1. THE 6 TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS Prospects for Ending the HIV Epidemic among Persons who Inject Drugs in Haiphong Vietnam Don C Des Jarlais PhD 1, Huong Duong Thi MD 2, Oanh Khuat Thi Hai MD 3, Khuê Pham Minh MD 2, Giang Hoang Thi MD 2, Thanh Nham Thi Tuyet BA 3, Kamyar Arasteh 1, Jonathan Feelemyer 1, Theodore Hammett PhD 4, Marianne Peries 5, Laurent Michel 6, Vinh Vu Hai 7, Marie Jauffret Roustide PhD 8, Jean-Pierre Moles PhD 5, Didier Laureillard MD 5,9, and Nicolas Nagot MD 5 for the DRIVE Study Team 1 Mount Sinai Beth Israel, New York City, USA 2 Hai Phong University of Medicine and Pharmacy, Hai Phong, Viet Nam 3 Supporting Community Development Initiatives, Hanoi, Viet Nam 4 ABT Associates, Boston, USA 5 Inserm U1058, University of Montpellier, France 6 Pierre Nicole Center, Red Cross, Paris, France 7 Infectious Diseases Department, Viet Tiep Hospital, Hai Phong, Viet Nam 8 Inserm, Paris, France 9 Infectious Diseases Department, Caremeau University Hospital, Nîmes, France

2. The 6 th National Scientific Conference on HIV/AIDS CONTENT OF REPORT  Presentation of HIV situation in Vietnam, specifically Haiphong, and harm reduction response  Methodology for respondent driven sampling (RDS) and data collection of persons who inject drugs (PWID) in Haiphong  Presentation of sample characteristics, HIV prevalence by years injecting, and HIV incidence of new injectors (using two methods)  Comparisons of HIV Epidemic, Interventions in Haiphong and New York City, USA from 1995 to 2020  Recommendations for continued interventions for ending the HIV epidemic among PWID and policy implications

3. The 6 th National Scientific Conference on HIV/AIDS  200,000 PWID in Vietnam-focal population for HIV epidemic in country  Framework: harm reduction and substance abuse treatment  Transition to voluntary, community based treatment  Rapid expansion of methadone in 2008-2015  Decriminalization of drug use  Legal policy framework still remains inconsistent  Law on Drug Prevention and Control remains in effect Background

4. The 6 th National Scientific Conference on HIV/AIDS Background  Haiphong has led movement towards evidence based substance abuse treatment and HIV prevention in Vietnam  High prevalence of HIV among PWID as high as 66% in 2006  “06” centers for drug users and “05” centers for commercial sex workers still exist  Methadone pilot programs begun in 2008: 3,200 patients  Needle/syringe programs implemented in 2005  Antiretroviral treatment offered free for HIV+ persons

5. The 6 th National Scientific Conference on HIV/AIDS Methods-RDS Recruitment  Three community support groups participated  Included PWID, with focus on female commercial sex worker (FCSW)-PWID, and men who have sex with men (MSM)-PWID  Participants recruited using RDS methodology  Twelve seeds initially used.; each seed received 3 coupons to recruit PWID into study  Target sample size: 600 PWID  Oversampling of MSM-PWID and FCSW-PWID

6. The 6 th National Scientific Conference on HIV/AIDS Methods-Data Collection  Questionnaire examining drug use and sexual behavior. HIV and HCV testing and counseling  Estimation of HIV incidence among non-MSM male new injectors (injecting < 2 years) using two methods:  HIV+ new injectors/years injecting among new injectors  Slope of HIV prevalence by years of injecting using ordinary least squares (OLS) regression

7. The 6 th National Scientific Conference on HIV/AIDS Results-RDS Recruitment  Recruitment from 9/6/2014 through 10/7/2014  603 total participants included in sample  581 PWID recruited through RDS  22 additional MSM-PWID and FCSW-PWID recruited through direct staff recruitment

8. The 6 th National Scientific Conference on HIV/AIDS Characteristics of Total Sample N (%) Gender: total (%)603 (100) Female61 (10) Male492 (82) MSM49 (8) Drug Injection Characteristics603 (100) Heroin (alone)602 (~100) Heroin (with other drugs)3 (<1) (Meth)amphetamine3 (<1) Receptive Sharing32 (5) Distributive Sharing19 (3)

9. The 6 th National Scientific Conference on HIV/AIDS Characteristics of Total Sample (continued) N (%) Sexual Risk Behaviors603 (100) Unsafe sex with primary partner172 (29) Unsafe sex with casual partner15 (2) Exchanged sex for money75 (12) Average Age (SD)37 (8) HIV and HCV Serostatus603 (100) HIV Seropositive152 (25) HCV Seropositive403 (67) N (%) Sexual Risk Behaviors603 (100)

10. The 6 th National Scientific Conference on HIV/AIDS Characteristics of New PWID N (%) Gender: total (%)178 (100) Female21 (12) Male136 (76) MSM21 (12) Drug Injection Characteristics178 (100) Heroin (alone)178 (100) Heroin (with other drugs)0 (0) (Meth)amphetamine0 (0) Receptive Sharing14 (8) Distributive Sharing7 (4)

11. The 6 th National Scientific Conference on HIV/AIDS Characteristics of New PWID (continued) N (%) Sexual Risk Behaviors178 (100) Unsafe sex with primary partner64 (36) Unsafe sex with casual partner7 (4) Exchanged sex for money31 (17) Average Age (SD)33 (8) HIV and HCV Serostatus178 (100) HIV Seropositive9 (5) HCV Seropositive76 (43) N (%) Sexual Risk Behaviors178 (100)

12. The 6 th National Scientific Conference on HIV/AIDS HIV by Years Injecting Years InjectingN HIV- (%) All451 (74.79) Less than one year44 (97.78) 1-2 years62 (93.94) 3-4 years63 (94.03) 5-6 years59 (84.29) 7-10 years83 (69.17) 11 years or more140 (59.57) Years InjectingN HIV- (%) All451 (74.79) Less than one year44 (97.78)

13. The 6 th National Scientific Conference on HIV/AIDS HIV Incidence-Non-MSM Male New Injectors Estimate of HIV incidence by prevalence among non-MSM male “new injectors” 1.2/100 person years (PY) at risk (95% CI: 0.24-3.4) Estimate of HIV Incidence using slope of prevalence by years injecting 0.8/100 person years (PY) at risk (95% CI: 0.9-2.5)

14. The 6 th National Scientific Conference on HIV/AIDS Measurement of HIV in Population and Interventions in NYC and Hai Phong, 1995- 2020 NYCHai Phong 19952005201420201995200520142020 Measurement of HIV in Population HIV Prevalence50%10% 60%25%10%? HIV Incidence2/100 PY1/100 PY0.1/100 PY ?1/100 PY0.1/100PY? Intervention MMTPYes NSPYes ARTNoYes NoYes TasPNo Yes No Yes?

15. The 6 th National Scientific Conference on HIV/AIDS Discussion-Declining Epidemic  Study found 25% HIV prevalence, a decrease from 68% (2006) and 48% (2009) among PWID  Low HIV prevalence (2.2%) among new PWID suggest further decline in new HIV infections  Compared to NYC Haiphong is approximately 10-15 years behind in ending the HIV epidemic among PWID  Time lag consistent with interventions for PWID

16. The 6 th National Scientific Conference on HIV/AIDS Limitations  Data primarily from large RDS survey  Possible social desirability bias and recall error in self-report data  Not enough MSM and FCSW to estimate HIV incidence for these groups

17. The 6 th National Scientific Conference on HIV/AIDS Conclusions and Recommendations  Maintaining current interventions in Haiphong would eventually lead to an end of the HIV epidemic among PWID  Scale up of TasP should greatly accelerate decline in HIV infections, and an end to the HIV epidemic among PWID would occur 5 to 10 years earlier