JOINT STUDY ON RISKS OF HIV TRANSMISSION AT VIETNAM-LAOS BORDER: CURRENT SITUATION AND SOLUTIONS
To help provide evidence to effectively carry out Prime Ministerial Decision 38/QD - TTg dated 8/1/2008 on “Regulations on cooperation in prevention cross-border HIV/AIDS transmission”, the Health Strategy and Policy Institute (HSPI), MOH Vietnam cooperate with the HIV/AIDS/STDs Prevention and Control Centers, Department of Preventive Medicine, Ministry of Health of Laos to conduct the joint study “Risks of HIV transmission in some localities along Viet Nam – Laos border: Current situation and solutions”. The study is carried out in Mar to December 2009 with funding by the Coordination Office of the Infectious Diseases Prevention and Control Project in Sub-Mekong Region.
1. To evaluate the risks of cross-border HIV transmission among most-at-risk populations (MARPs)
2. To recommend intervention solutions to change knowledge, attitude and behaviors, and increase MARPs accessibility to preventive and curative services to minimize cross-border HIV transmission
3. To improve capacities for study partners and establish long-term cooperation in research and implementation of interventions among stakeholders.
III. TARGET GROUPS, LOCATION AND STUDY METHODS
Study methods: cross-sectional descriptive survey, using qualitative data collection method (in-depth interview), collect and analyze available data, direct observation in hot spot of sex work and drug injection along the border.
Target groups: include both Laos and Vietnamese populations in 3 groups: leaders and managers at border areas, MARPs along the border and other related groups. In total there are 409 in-depth interviews, including 90 interviews with management group, 237 with MARPs and 82 with other related groups.
Study location: The study is conducted in 6 provinces around 3 international border gate along Vietnam – Lao border: Bờ Y–Phù Cưa border gate in Kon Tum (Vietnam) and Attapư (Laos), Cầu Treo-Nam Phao in Ha Tinh(Vietnam) and Bolykhamsay (Laos) and Tây Trang- Panghok in Điện Biên (Vietnam) and Phongsaly (Laos).
1. Hot spots around border areas:
Ø Demographic and social features of migrant groups
ü Sex workers: Most sex workers in this study are female, aged 25-30 years old. The Laos female sex workers (FSWs) are younger than the Vietnamese. Their education is at average good level and most are single or divorce or separated. The majority are not local, born in families with special circumstances (poor, orphan, parent divorce, lack of care, cheated by spouse or lover, abandoned, raped, etc.)
ü Injecting drug users (IDUs): The majority of IDUs are male however female IDUs tend to increase in some areas. The average age of Laos IDUs is 16-37, lower than Vietnamese side (19-62). Their education is at average good level. Main professions are farming, small trading and self-employed. Most of them are married and living with their wives and children.
ü Long-distance drivers: Most of them are men, aged 30-50 years old. Common education level is secondary and primary. Mostly they transport wood, fruits and electronic commodities from Thailand. Incomes depend on job (5-8 million VND/month). Most of them are married. Most of them share some hobbies like sexual relationship, entertainment services (karaoke, relaxed hairdressing), card playing, etc.
ü Other migrant groups: They are mainly men, working as construction workers, workers, contractors, employees. They are in 20-50 age group with low education. Married men account for the majority but due to working conditions they often stay away from wives and relatives. They have stable incomes, 4-5 million VND/month. Working and living in remote areas make them easily attracted to risky behaviors.
Ø Most-at-risk behaviors and accessibility to HIV prevention and treatment services
+ Sexual relationship: The Vietnamese FSWs have first sexual relationship when young (16-25 years old) but the Laos FWSs experience it even when younger (13-25 years old). Clients are diversified (Vietnamese, Laos, Cambodian, Thais, Chinese, etc.). Besides clients, FSWs have 1-3 regular partner. Average years of experience of FSWs are 1-5 years. The main type of sexual relationship is vaginal track. On the average the Laos FSWs have 2-4 clients/week while that in Vietnamese FSWs is 2-3 clients/day or even 7-8 times/day. Safe sex practice (condom use) by FSWs remain low, especially with partners or regular clients. However, with clients FSWs tend to use condom more frequently (97% among Laos FSWs and 80% among Vietnamese FSWs). Despite such fact, most FSWs do not know how to use condom in a right way. Their understanding of HIV transmission path and prevention ways remains limited.
+ Drug use: Some FSWs and clients use drugs before sexual relationship (Amphetamine or heroine inhale/injection). In the beginning the Laos FSWs often take synthetic drugs while the Vietnamese one inhale heroin and then injection. The resonance of HIV transmission risks among this group is very high.
+ Drug use: The IDU groups (both Laos and Vietnamese) start using drugs after 1990, at the age of 16-39 (majority from 18-25 years old). Common drug use type is inhale then injection. Drug injection places keep changing and difficult to identify. Each injection spot in Laos often has 3-5 persons, including men and women (mainly FSWS). The lowest consumption is 1-2 times/day, each time cost 50,000 VND, medium at 3-5 times/day and highest 10 times/day. All interviewed IDUs say they shared or reused syringes and needles without cleaning.
+ Sexual behaviors: Most IDUs enter into sexual life at young age (20 years old). Their partners are often school mates, lovers or FSWs. Safe sex practice is normally at low level. All do not use condom when having sex with their wives and rarely use condom with FSWs. They have rather complete understanding of HIV prevention but their safe behavior indicator remains low among their group. There are many limitation in access to HIV/AIDS care and treatment services.
ü Long distance drivers in the Vietnam-Laos border areas do not only regularly have many sexual partners, especially with FSWs but also have members using drugs. This is the resonance of risky behaviors, consisting factors to increase HIV transmission.
ü Other migrant groups’ sexual relationship behaviors (especially with FSWs) are similar to the long-distance driver groups but with less frequency due to working conditions, mobility and instability. Drug injection among construction and road workers is higher than the long-distance drivers. Resonance of risky behaviors and potential factors of HIV transmission among this group is of concern.
Ø The operation orbit in sexual relation and drug inject among migrant groups are diversified and complicated, not only in Laos and Vietnam but also neighboring countries like China and Cambodia.
Ø Social and sexual relation networks
a) Social relation network: The FSWs group have their social relationships limited within the same group or directly related ones (brothel owner, shop owners, pimp, clients, etc.). Most IDUs only relate with family members and peer IDUs. Notable the relation of long-distance drivers and other migrant groups are very diversified and complicated (likewise hobby friends, partners, shop owners, hotels, pimps, FSWs, etc.)
b) Sexual relation network: Migrant groups around Vietnam – Laos border areas have quite large openness to sexual relation. FSWs, long-distance drivers and other migrant groups have more complicated sexual relation networks than that of IDUs.
Ø Inter-relationships among MARPs: It is visible that FSWs and long-distance drivers are the two groups with close relationships with great potential risks of increasing HIV transmission
2. Current situation of cross-border HIV transmission control in study locations
In the border area of Vietnamese side, the capacities of VCT and STDs service delivery in all 3 provinces remain limited. At present, there is no collaboration between relevant agencies and local government authorities along border line in implementing, discovering and providing HIV/AIDS care and treatment.
In the border area of Laos side, the surveyed provinces have insufficient capacities to deliver STDS examination and treatment services as well as HIV testing. At the study time, there are some harm reduction interventions among FSWs along Laos border but only limited within communication activities.
V. CONCLUSIONS AND RECOMMENDATIONS
- This is the first study on HIV transmission risks in the border areas implemented joint by researchers of two countries with new approach.
- Social evil hot spots, especially disguised entertainment facilities keep appearing around the border areas.
- FSWs in Vietnam-Laos border areas normally have higher age, longer working experiences and worked in different areas. This is a potential risks of STDs and HIV transmission.
- The highest risks of cross-border HIV transmission is seen in FSWs (especially the Vietnamese FSWs), long-distance driver, construction workers. The indigenous people along the border line are also a potential group with high risks of cross-border HIV transmission.
- Capacities of access to information on HIV/AIDS prevention and control among migrant groups in Vietnam-Laos border areas remain limited. Thus their perception of HIV transmission paths and prevention measures is vague.
- The risks of STIs and STDs contraction among FSWs, especially the Vietnamese FSWs working in Laos and street FSWs are extremely high in the context of limited access to examination and treatment services in both border sides.
- There are difficulties in accessibility to HIV/AIDS testing and treatment services among migrant groups. Interventions for preventing HIV transmission are initially carried out at small scales and among some specific groups.
- There is no collaboration between the two countries in controlling and monitoring epidemic situation as well as implementing HIV/AIDS preventive, care and treatment activities.
* Recommendations to the joint studies of two sides in the future: Study results should be widely disseminated to localities. This study should be replicated to other areas along Vietnam-Laos border. In this study location, repetition should be made (in 2-3 years) to update new changes.
* Solutions to strengthen cross-border HIV transmission:
- Invest resources to enhance IEC activities and harm reduction interventions for migrant groups, vulnerable to HIV along both border sides. Invest resources to enhance IEC activities and harm reduction interventions right in residential areas close to the border line.
- Improve capacities for health personnel in charge of performing HIV/AIDS prevention and treatment along both border sides, especially health care professionals at district level in Laos.
- Invest equipment to enable border localities to have sufficient capacities of STDs examination, diagnosis and treatment
- Invest to strengthen and expand VCT sites to help different populations to easily access and at the same time enhance HIV testing capacities for Vietnamese provinces to provide support for Laos neighboring provinces when needed.