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JOINT STUDY ON RISKS OF HIV TRANSMISSION AT VIETNAM-LAOS BORDER: CURRENT SITUATION AND SOLUTIONS

Vũ Thị Minh Hạnh, Chansy Phimphachanh*, Hoàng Thị Mỹ Hạnh, Trần Thị Hồng Cẩm, Trần Vũ Hiệp, Tường Duy Trinh, Vũ Văn Hoàn, Hoàng Ly Na, Vũ Thị Mai Anh, Phan Hồng Vân, Ketmala Banchongphanith*, Sisavath Manivong*, Phengphet Phetvixay1, Khanti Thongkham*

*Center for HIV/STIs Prevention and control,Department of Preventive Medicine, 
Ministry of Health of Laos
 
Place of Publication: Health Strategy and Policy Institute
               Asian Development Bank (ADB) in Vietnam
Year of Publication:  2009
 
Background 
 
To provide evidence for the effective implementation of the Prime Ministerial Decision 38/QD-TTg dated 8/1/2008 on “collaboration and cooperation in prevention cross-border HIV transmission”, the Health Strategy and Policy Institute (HSPI), MOH Vietnam cooperated with the Center for HIV/AIDS/STDs Prevention and Control, Department of Preventive Medicine, Ministry of Health of Laos to conduct the joint study “HIV transmission in Viet Nam – Lao PDR border area: Current situation and solutions”. The study was carried out in March to December 2009, funded by the Coordination Office of the Greater Mekong Sub-Region Communicable Disease Control Project..

Objectives 
1. To evaluate the risks for cross-border HIV transmission among high-risk populations 
2. To make recommendations for knowledge and behavior change interventions, and improving accessibility to HIV/AIDS prevention, care and treatment to reduce cross-border HIV transmission.
3. To Strengthen capacity and establish long-term cooperation among the participating organizations in conducting joint research and implementing interventions.
 
Methods 
Study methods: cross-sectional descriptive survey, using qualitative data collection method (in-depth interview), collecting and analyzing available data, direct observation in hot spot of sex work and drug injection along the border.
Target groups:  both Laos and Vietnamese people belonging to 3 groups: leaders and managers of responsible institutions at border areas, high-risk groups along the border and other related groups. In total 409 in-depth interviews were done, including 90 interviews with managerial staff, 237 with high-risk individuals and 82 with other relevant persons. 
Study location:  The study was conducted in 6 provinces located in 3 pairs of international border entry points along Vietnam – Lao border, including Bo Y–Phu Cua of Kon Tum (Vietnam) and Attapeu (Lao PDR), Cau Treo-Nam Phao of Ha Tinh (Vietnam) and Borikhamxay (Laos) and Tay Trang-Panghok of Dien Bien (Vietnam) and Phongsaly (Lao PDR).
 
Results 
Risks for cross-border HIV transmission among mobile groups in the border areas.
Demographic and social features of migrant groups
Sex workers: Most sex workers in this study were female, aged 25-30 years old. The Laos female sex workers (FSWs) were younger than the Vietnamese. Their education was at average good level and most were single or divorced or separated. The majority were not local, born in families with special circumstances (poor, orphan, parent divorce, lack of care, cheated by spouse or lover, abandoned, raped, etc.)
Injecting drug users (IDUs): The majority of IDUs were male however female IDUs tended to increase in some areas. The average age of Laos IDUs was 16-37, lower than Vietnamese peers (19-62). Their education was is at average good level. Main occupation were farming, small trading and self-employed. Most of them married and were living with their wives and children.
Long-distance drivers: Most of them were male, aged 30-50 years old. Most of them finished was secondary and primary school. Mostly they transported wood, fruits and electronic commodities from Thailand. Incomes depend on job (5-8 million VND/month). Most of them married. Most of them shared some hobbies like sexual relationship, entertainment services (karaoke, relaxed hairdressing), card playing, etc.
Other mobile groups: They were mainly male, working as construction workers, workers, contractors, employees. They were in 20-50 age group with low education. Married men were dominant. Due to working conditions they often stayed away from their wives and relatives. They had stable incomes, 4-5 million VND/month. Working and living in remote areas made them easily engage in risky behaviors.
High-risk behaviors and access to HIV prevention and treatment services
Female sex workers
Sexual relationship: The Vietnamese FSWs had the first sexual relationship when they were young (16-25 years old) but the Laos FWSs experienced it even when younger (13-25 years old). Their clients were diversified (Vietnamese, Laos, Cambodian, Thais, Chinese, etc.). Besides clients, FSWs had 1-3 regular partner. Average years of experience as FSWs was 1-5 years. The main type of sexual relationship was vaginal track. On average, the Laos FSWs had 2-4 clients/week while Vietnamese FSWs had 2-3 clients/day or even 7-8 times/day. Safe sex practice (condom use) by FSWs remained low, especially with partners or regular clients. However, with clients FSWs tended 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 remained limited.
Drug use: Some FSWs and clients used drugs before working as commercial sex workers (Amphetamine or heroine inhale/injection). In the beginning the Laos FSWs often tooke synthetic drugs while the Vietnamese ones inhaled heroin and then injection. The resonance of HIV transmission risks among this group was very high.
Injecting drug users
Drug use: The IDUs groups (both Laos and Vietnamese) started using drugs after 1990, at the age of 16-39 (majority from 18-25 years old). Common drug use type was inhale then injection. Drug injection places were  changed often, therefore, difficult to identify. Each injection spot in Laos often had 3-5 persons, including men and women (mainly FSWS). The lowest consumption was 1-2 times/day, each time costed 50,000 VND, medium at 3-5 times/day and highest 10 times/day. All interviewed IDUs said they shared or reused syringes and needles without cleaning.
Sexual behaviors: Most IDUs entered into sexual life at young age (20 years old). Their partners were often school mates, lovers or FSWs. Safe sex practice was normally at low level. All reported having not used condom when having sex with their wives and rarely used condom with FSWs. They had rather complete understanding of HIV prevention but their safe behavior indicator remained low. Access to HIV/AIDS care and treatment services was limited. 
Long distance drivers in the Vietnam-Laos border areas  not only regularly had many sexual partners, especially with FSWs but  used drugs also. This was the resonance of risky behaviors, consisting factors to increase HIV transmission. 
Other mobile groups’ sexual relationship behaviors (especially with FSWs) were similar to that of the long-distance driver groups but with less frequency due to working conditions, mobility and instability. Drug injection among construction and road workers was higher than the long-distance drivers. Resonance of risky behaviors and potential factors of HIV transmission among this group was of concern.
The trajectory of mobility among FSWs, IDUs and other mobile groups were diversified and complicated, not only in Laos and Vietnam but also neighboring countries like China and Cambodia.
Social and sexual networks 
Social  network: The FSWs group had a limited social relationships within their peers or directly related ones (brothel owner, shop owners, pimp, clients, etc.). IDUs mainly contacted only with family members and peer IDUs. Notably,  the relation of long-distance drivers and other mobile groups were very diversified and complicated (likewise hobby friends, partners, shop owners, hotels, pimps, FSWs, etc.)
Sexual network: Mobile groups around Vietnam – Laos border areas had quite large openness to sexual relation. FSWs, long-distance drivers and other migrant groups had a more complicated sexual relation networks than that of the IDUs. 
Interaction among high-risk groups: It was visible that FSWs and long-distance drivers were the two groups with close relationships, facilitating  great potential risks of HIV infection and transmission
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 remained limited. At present, there was no collaboration between relevant agencies and local government authorities along border line in implementing and providing HIV/AIDS care and treatment. 
In the border area of Laos side, the surveyed provinces had insufficient capacities to deliver STDS examination and treatment services as well as HIV testing. At the study time, there were some harm reduction interventions among FSWs along Laos border but only limited within communication activities.
 
Conclusions
This was the first study on HIV transmission risks in the border areas implemented jointly by researchers of two countries, using the same methods. .
Social evil hot spots, especially disguised entertainment establishments kept appearing along the border areas. 
FSWs in Vietnam-Laos border areas normally were older and had longer sex work duration and prior experience in selling sex in other areas, facilitating potential risks  fore STDs and HIV transmission.
The highest risks of cross-border HIV transmission was seen among FSWs (especially the Vietnamese FSWs) followed by long-distance driver and construction workers. The indigenous people along the border areas were also at risk of cross-border HIV transmission.
Mobile population groups in the Vietnam-Laos border areas had limit access to information on HIV/AIDS prevention and control. Thus their perception of HIV transmission paths and prevention measures was very vague.
The risks of STIs and STDs contraction among FSWs, especially the Vietnamese FSWs in Laos and or street based FSWs  was extremely high. However, they have a very limited access to examination and treatment services in both border sides. 
Its was difficult for mobile groups in the border areas to access HIV testing and treatment services. Interventions for the prevention of HIV transmission were initially carried out at small scale and among some specific groups.
There have not yet been any collaboration between the two countries in implementing programs for surveillance, control and prevention, care and treatment of HIV/AIDS..
Recommendations 
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, the study should be repeated every 2-3 years to update new changes.
Solutions to strengthen cross-border HIV transmission control and prevention:
Invest resources to enhance information - education - communication (IEC) activities and harm reduction interventions for mobile groups vulnerable to HIV along both border sides. Allocate resources to enhance IEC activities and harm reduction interventions for residential areas close to the border line.
Strengthen the capacity of local health personnel providing HIV/AIDS prevention and treatment services along both border sides, especially those at district level in Laos.
Invest more in improving equipment to enable localities in the border area to have sufficient capacity for STDs examination, diagnosis and treatment
Invest to strengthen and expand voluntary counseling and testing  sites to help different populations to easily access to and at the same time enhance HIV testing capacity for provinces in the Vietnam border areas so that they would support Laos neighboring provinces when needed.
 

10/12/2013
Health Strategy and Policy Institute  
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