Efficacy of a Multi-level Intervention to Reduce Injecting and Sexual Risk Behaviors among HIV-Infected People Who Inject Drugs in Vietnam: A Four-Arm Randomized Controlled Trial

Vivian F Go, Constantine Frangakis, Nguyen Le Minh, Carl Latkin, Tran Viet Ha, Tran Thi Mo, Teerada Sripaipan, Wendy W Davis, Carla Zelaya, Pham The Vu, David D Celentano, Vu Minh Quan, Vivian F Go, Constantine Frangakis, Nguyen Le Minh, Carl Latkin, Tran Viet Ha, Tran Thi Mo, Teerada Sripaipan, Wendy W Davis, Carla Zelaya, Pham The Vu, David D Celentano, Vu Minh Quan

Abstract

Introduction: Injecting drug use is a primary driver of HIV epidemics in many countries. People who inject drugs (PWID) and are HIV infected are often doubly stigmatized and many encounter difficulties reducing risk behaviors. Prevention interventions for HIV-infected PWID that provide enhanced support at the individual, family, and community level to facilitate risk-reduction are needed.

Methods: 455 HIV-infected PWID and 355 of their HIV negative injecting network members living in 32 sub-districts in Thai Nguyen Province were enrolled. We conducted a two-stage randomization: First, sub-districts were randomized to either a community video screening and house-to-house visits or standard of care educational pamphlets. Second, within each sub-district, participants were randomized to receive either enhanced individual level post-test counseling and group support sessions or standard of care HIV testing and counseling. This resulted in four arms: 1) standard of care; 2) community level intervention; 3) individual level intervention; and 4) community plus individual intervention. Follow-up was conducted at 6, 12, 18, and 24 months. Primary outcomes were self-reported HIV injecting and sexual risk behaviors. Secondary outcomes included HIV incidence among HIV negative network members.

Results: Fewer participants reported sharing injecting equipment and unprotected sex from baseline to 24 months in all arms (77% to 4% and 24% to 5% respectively). There were no significant differences at the 24-month visit among the 4 arms (Wald = 3.40 (3 df); p = 0.33; Wald = 6.73 (3 df); p = 0.08). There were a total of 4 HIV seroconversions over 24 months with no significant difference between intervention and control arms.

Discussion: Understanding the mechanisms through which all arms, particularly the control arm, demonstrated both low risk behaviors and low HIV incidence has important implications for policy and prevention programming.

Trial registration: ClinicalTrials.gov NCT01689545.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Consort index participant flow diagram…
Fig 1. Consort index participant flow diagram (n = 455).
Chronological schematic diagram showing number approached, screened, eligible, enrolled, randomized and lost to follow-up by arm at 6, 12, 18, and 24-month visits. Retention rates were calculated excluding those who died or were incarcerated from the denominator.

References

    1. UNODC. World Drug Report 2013. Vienna: United Nations (Sales No. E. 13.XI.6), 2013.
    1. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651):1733–45. 10.1016/S0140-6736(08)61311-2
    1. Go VF, Frangakis C, Nam le V, Bergenstrom A, Sripaipan T, Zenilman JM, et al. High HIV sexual risk behaviors and sexually transmitted disease prevalence among injection drug users in Northern Vietnam: implications for a generalized HIV epidemic. J Acquir Immune Defic Syndr. 2006;42(1):108–15.
    1. Hammett TM, Johnston P, Kling R, Liu W, Ngu D, Tung ND, et al. Correlates of HIV status among injection drug users in a border region of southern China and northern Vietnam. J Acquir Immune Defic Syndr. 2005;38(2):228–35.
    1. Des Jarlais DC, Chamberland ME, Yancovitz SR, Weinberg P, Friedman SR. Heterosexual partners: a large risk group for AIDS. Lancet. 1984;2(8415):1346–7.
    1. Panda S, Chatterjee A, Bhattacharya SK, Manna B, Singh PN, Sarkar S, et al. Transmission of HIV from injecting drug users to their wives in India. Int J STD AIDS. 2000;11(7):468–73.
    1. Marks G, Burris S, Peterman TA. Reducing sexual transmission of HIV from those who know they are infected: the need for personal and collective responsibility. Aids. 1999;13(3):297–306.
    1. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985–1997. Am J Public Health. 1999;89(9):1397–405.
    1. Wolitski RJ, MacGowan RJ, Higgins DL, Jorgensen CM. The effects of HIV counseling and testing on risk-related practices and help-seeking behavior. AIDS Educ Prev. 1997;9(3 Suppl):52–67.
    1. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological, and medical findings. Aids. 2002;16(2):135–49.
    1. Deren S, Beardsley M, Tortu S, Goldstein MF. HIV serostatus and changes in risk behaviors among drug injectors and crack users. AIDS and Behavior. 1998;2(2):171–6.
    1. Metsch LR, McCoy CB, Lai S, Miles C. Continuing risk behaviors among HIV-seropositive chronic drug users in Miami, Florida. AIDS and Behavior. 1998;2(2):161–9.
    1. Ministry of Health of Vietnam. Results from the HIV/STI intergrated biological and behavioral surveillance (IBBS) in Vietnam, Round II, 2009 Hanoi, Vietnam: Ministry of Health; 2011. Available: . Accessed 12 October 2014.
    1. Socialist Republic of Viet Nam. Vietnam AIDS Response Progress Report 2014. Following up the 2011 Political Declaration on HIV/AIDS. Reporting period: January 2012-December 2013. Hanoi, Vietnam: National Committee for AIDS, Drugs and Prostitution Prevention and Control. 2014. Available: Accessed 13 October 2014.
    1. Hong KT, Anh NTV, Oanh KTH, Kidd R, Brady L, Nyblade L, et al. Understanding and challenging stigma toward injecting drug users and HIV in Vietnam: Toolkit for Action Washington, D.C.: International Center for Research on Women, 2011.
    1. UN Country Team. Reduction of HIV/AIDS related employment discrimination in Viet Nam, Discussion Paper No. 5. Ha Noi: 2005.
    1. Khoat DV, Hong LD, An CQ, Ngu D, Reidpath DD. A situational analysis of HIV/AIDS-related discrimination in Hanoi, Vietnam. AIDS Care. 2005;17 Suppl 2:S181–93.
    1. Nguyen TH, Nguyen TL, Trinh QH. HIV/AIDS epidemics in Vietnam: evolution and responses. AIDS Educ Prev. 2004;16(3 Suppl A):137–54.
    1. Rudolph AE, Davis WW, Quan VM, Ha TV, Minh NL, Gregowski A, et al. Perceptions of community- and family-level injection drug user (IDU)- and HIV-related stigma, disclosure decisions and experiences with layered stigma among HIV-positive IDUs in Vietnam. AIDS Care. 2012;24(2):239–44. 10.1080/09540121.2011.596517
    1. National Assembly. Socialist Republic of Vietnam No. 64 2006 Q11. Law on HIV/AIDS Prevention and Control. No. 05/2006/L-CTN. July 12, 2006. 2006.
    1. Salter ML, Go VF, Minh NL, Gregowski A, Ha TV, Rudolph A, et al. Influence of Perceived Secondary Stigma and Family on the Response to HIV Infection Among Injection Drug Users in Vietnam. AIDS Educ Prev. 2010;22(6):558–70. 10.1521/aeap.2010.22.6.558
    1. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int J Drug Policy. 2009;20(3):193–201. 10.1016/j.drugpo.2008.10.003
    1. Blankenship KM, Friedman SR, Dworkin S, Mantell JE. Structural interventions: concepts, challenges and opportunities for research. J Urban Health. 2006;83(1):59–72.
    1. Rhodes T, Simic M. Transition and the HIV risk environment. Bmj. 2005;331(7510):220–3.
    1. Strathdee SA, Shoptaw S, Dyer TP, Quan VM, Aramrattana A. Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention. Curr Opin HIV AIDS. 2012;7(4):320–5. 10.1097/COH.0b013e32835369ad
    1. Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet. 2010;376(9737):285–301. 10.1016/S0140-6736(10)60742-8
    1. Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376(9737):268–84. 10.1016/S0140-6736(10)60743-X
    1. Fonner VA, Denison J, Kennedy CE, O'Reilly K, Sweat M. Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev. 2012;9:Cd001224.
    1. O'Connell AA, Reed SJ, Serovich JA. The Efficacy of Serostatus Disclosure for HIV Transmission Risk Reduction. AIDS Behav. 2014.
    1. Thai Nguyen Provincial HIV/AIDS Control Center. Bi-annual Report of the Provincial HIV/AIDS Control Center, Thai Nguyen, Vietnam. 2014.
    1. Go VF, Frangakis C, Le Minh N, Latkin CA, Ha TV, Mo TT, et al. Effects of an HIV peer prevention intervention on sexual and injecting risk behaviors among injecting drug users and their risk partners in Thai Nguyen, Vietnam: a randomized controlled trial. Soc Sci Med. 2013;96:154–64. 10.1016/j.socscimed.2013.07.006
    1. Koblavi-Deme S, Maurice C, Yavo D, Sibailly TS, N'Guessan K, Kamelan-Tano Y, et al. Sensitivity and specificity of human immunodeficiency virus rapid serologic assays and testing algorithms in an antenatal clinic in Abidjan, Ivory Coast. J Clin Microbiol. 2001;39(5):1808–12.
    1. Turner JC. Social comparison and social identity: Some prospects for intergroup behaviour. European Journal of Social Psychology. 1975;5(1):5–34.
    1. Rogers E. Diffusion of innovations (5th ed.). 2003.
    1. Ministry of Health of Vietnam. Voluntary HIV Counseling and Testing (VCT) Guidelines (Promulgated at the Decision No. 647/QD-BYT dated February 22, 2007 by the Minister of Health). Hanoi: Ministry of Health, 2007.
    1. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705–14.
    1. D'Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17(19):2265–81.
    1. Achy-Brou AC, Frangakis CE, Griswold M. Estimating treatment effects of longitudinal designs using regression models on propensity scores. Biometrics. 2010;66(3):824–33. 10.1111/j.1541-0420.2009.01334.x
    1. Wu Z, Frangakis CE, Louis TA, Scharfstein DO. Estimation of treatment effects in matched-pair cluster randomized trials by calibrating covariate imbalance between clusters. Biometrics. 2014;70(4):1014–22. 10.1111/biom.12214
    1. Des Jarlais DC, Kling R, Hammett TM, Ngu D, Liu W, Chen Y, et al. Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project. Aids. 2007;21 Suppl 8:S109–14. 10.1097/01.aids.0000304705.79541.34
    1. Latkin CA, Donnell D, Metzger D, Sherman S, Aramrattna A, Davis-Vogel A, et al. The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA. Soc Sci Med. 2009;68(4):740–8. 10.1016/j.socscimed.2008.11.019
    1. NIMH Collaborative HIV/STD Prevention Trial Group. Results of the NIMH collaborative HIV/sexually transmitted disease prevention trial of a community popular opinion leader intervention. J Acquir Immune Defic Syndr. 2010;54(2):204–14. 10.1097/QAI.0b013e3181d61def
    1. Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. Am J Public Health. 2007;97(10):1762–74.
    1. Coates TJ, Kulich M, Celentano DD, Zelaya CE, Chariyalertsak S, Chingono A, et al. Effect of community-based voluntary counselling and testing on HIV incidence and social and behavioural outcomes (NIMH Project Accept; HPTN 043): a cluster-randomised trial. Lancet Glob Health. 2014;2(5):e267–77. 10.1016/S2214-109X(14)70032-4
    1. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Lancet. 2000;356(9224):103–12.
    1. Mazhnaya A, Andreeva TI, Samuels S, DeHovitz J, Salyuk T, McNutt LA. The potential for bridging: HIV status awareness and risky sexual behaviour of injection drug users who have non-injecting permanent partners in Ukraine. J Int AIDS Soc. 2014;17:18825 10.7448/IAS.17.1.18825
    1. van Empelen P, Kok G, van Kesteren NM, van den Borne B, Bos AE, Schaalma HP. Effective methods to change sex-risk among drug users: a review of psychosocial interventions. Soc Sci Med. 2003;57(9):1593–608.
    1. Crawford ND, Vlahov D. Progress in HIV reduction and prevention among injection and noninjection drug users. Journal of acquired immune deficiency syndromes (1999). 2010;55 Suppl 2:S84–7.
    1. Li L, Tuan NA, Liang LJ, Lin C, Farmer SC, Flore M. Mental health and family relations among people who inject drugs and their family members in Vietnam. Int J Drug Policy. 2013;24(6):545–9. 10.1016/j.drugpo.2013.06.007
    1. Nyblade L, Hong KT, Anh NV, Ogden J, Jain A, Stangl A, et al. Communities Confront HIV Stigma in Viet Nam: Participatory Interventions Reduce HIV Stigma in Two Provinces Washington, D.C.: International Center for Research on Women; Hanoi: Institute for Social Development Studies, 2008.
    1. Quan VM, Go VF, Nam le V, Bergenstrom A, Thuoc NP, Zenilman J, et al. Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study. AIDS Care. 2009;21(1):7–16. 10.1080/09540120802017610

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