thực trạng nhiễm hiv và các nhiễm trùng lây qua đường tình dục ở phụ nữ bán dâm 4 quận hà nội và hiệu quả một số biện pháp can thiệp bản tóm tắt tiếng anh

Ministry of Education and Training Ministry of Health National Institute of Epidemiology and Hygiene PHAM THI MINH PHUONG HIV AND SEXUALLY TRANSMITTED INFECTIONS IN FEMALE SEX WORKERS

Ministry of Education and Training Ministry of Health

National Institute of Epidemiology and Hygiene

PHAM THI MINH PHUONG

HIV AND SEXUALLY TRANSMITTED INFECTIONS IN FEMALE SEX WORKERS

IN 4 DISTRICTS OF HA NOI AND THE EFFECT OF SOME INTERVENTION

ACTIVITIES

Specialization: Epidemiology Code: 62 72 01 17

ABSTRACT OF PhD DISERTATION

Ha Noi - 2014

The work is completed in:

National Institute of Epidemiology and Hygiene

Thesis advisor:

1 Ass.Prof TRẦN HẬU KHANG, PhD

2 Ass.Prof NGUYỄN ANH TUẤN, PhD

Opponent 1: Prof Dao Van Dung, PhD

The Central Department of Propaganda and training

Opponent 2: Ass Prof Ho Ba Do, PhD

The Military Medical Insitute

Opponent 3: Ass Prof Tran Dang Quyet PhD

The Military Medical Insitute

The thesis will defensed at Institutional commitee in National Institute of Epidemiology and Hygiene at , date month year

Full disertation could be found at

- National Library

- The library of National Institute of Epidemiology and Hygiene

Scientific articles published

1 Pham Thi Minh Phuong, Tran Hau Khang, Nguyen Anh Tuan (2012), “HIV prevalence and risk related behaviors

in female sex workers in Hanoi, Vietnam 2005-2006”,

Journal of Preventive Medicine 6(133), pp.55-63

2 Pham Thi Minh Phuong, Tran Hau Khang, Nguyen Anh Tuan (2013), “Assessment of intervention to reduce HIV/ STI risk among female sex workers in Hanoi 2005-2010”,

Journal of Preventive Medicine 3(139), pp.66-73

3 Pham Thi Minh Phuong, Tran Hau Khang, Nguyen Anh Tuan (2013), “Chlamydia prevalence and behavioral risk among community female sex workers in Hanoi 2005-

2006”, Journal of Preventive Medicine 7(143), tr.56-63

INTRODUCTION

1 Justification for the study

Sexually transmitted infections (STI) including HIV are big publichealth issue Prostitution plays an important role in transmittingHIV/STI, therefore HIV/STI prevention for sex workers is one of the keyactivities in HIV program In Vietnam, National strategy on HIV/AIDSprevention and control claims that STI counseling and management forhigh risk group need to be strengthen A study on HIV/STI epidemiologyand intervention for female sex workers is necessary for making

HIV/STI prevention plan Therefore, the study “HIV/STI situation in

Acronym

AIDS Acquired Immuno-Deficiency Syndrome

FSW Female sex worker

HCM City Ho Chi Minh City

HIV Human Immunodeficiency Virus

PCR Polymerase Chain Reaction

RPR Rapid Plasma Reagin

STI Sexually Transmitted Infection

TPHA Treponema Pallidum Haemagglutination Assay

female sex workers in 4 districts of Ha Noi and the effect of some intervention activities” was implemented

3 New findings of the dissertation

The dissertation has provided new information about HIV/STIprevalence of FSW in 4 districts in Ha Noi at 2005-2006 and at 2009-

2010 and about HIV/ Chlamydia infection related factors among FSW at2005-2006 The dissertation has also evaluated some interventionactivities aiming to HIV/STI control in FSW group

4 Scientific and confident issue in the thesis

The study used quasi-experimental study with pre and postintervention comparison The sampling and sample size, data collectioninstrument including questionnaire and laboratory tests, data analysiswere relevant, thus the results are scientifically confident

5 Outline of the dissertation

The dissertation is 123 page length excluding table of content, list

of tables, list of figures, appendix and 131 references The dissertationincludes: introduction, literature review, methodology, results,discussion, conclusion and recommendation part, 32 tables and 15figures

CHPATER ONE: LITERATURE REVIEW 1.1 Prostitution situation in the world and in Viet Nam

Commercial sex worker group is stigmatized over the world.Prostitution is considered illegal, therefore it is very difficult to accessand trace them Female sex worker (FSW) group is considered one of thehigh risk group and they play an important role in HIV epidemic Thereare 2 type of FSW: direct and indirect FSW Direct FSW income comesfrom selling sex activity only They sell sex on streets and brothels.Indirect FSW income comes from selling sex and from other jobs such asmassage girl, hair dresser and waitress in hotel/restaurant

In Viet Nam, prostitution is illegal and considered as a social evil.Police and local authorities carry out campaign to attack FSW Ifarrested, FSW will be brought to rehabilitation center where they getSTI/HIV checking/ treating and vocational education

1.2 HIV/STI situation and related factors in FSW

1.2.1 HIV/STI situation in FSW

HIV: Africa is the place having very high HIV prevalence in FSW

(19%) In Asia, HIV epidemic is concentrated in some specialpopulations such as intravenous drug user and sex worker In China, HIVsentinel surveillance reveals that HIV prevalence in sex worker isincreasing In India, HIV prevalence in FSW is 5% In Viet Nam, HIVprevalence in FSW is higher than 10% in some cities/provinces and tends

to increase in some other provinces In the period of 2003-2011,according to HIV sentinel surveillance, the HIV prevalence in this groupwas around 3-5% However, in some place, HIV prevalence was veryhigh such as in Lang Son (17.6%), Can Tho (10.67%) and was low such

as in Da nang (0.6%) and Khanh Hoa (1.1%)

Gonorrhea: Gonorrhea prevalence in FSW in Yunnan (China) was

37.8%, in Cambodia was 12%, in Indonesia was 28.6% In Viet Nam,gonorrhea prevalence was 3% in Ha Noi, 0.5% in HCM city, 5.3% in Hai

Phong, 20.2% in Lai Chau, 24.8% in Quang Tri, 7.3% in Dong Thap,5.7% in An Giang, 9.4% in Kien Giang and 14.9% in Soc Trang.

Syphilis: Syphilis prevalence in FSW was 8% in Quang Dong,

2.3% in Cambodia In Viet Nam, the prevalence in street based FSW and

in venue based FSW was 9.1% and 7.3% in HCM city, 5.5% and 5.8% in

An Giang, 3.0% and 5.4% in Da Nang, 5.6% and 0.3% in Can Tho, 3.2%and 2.2% in Hai Phong

Chlamydia: Chlamydia prevalence in FSW in Yunnan (China) was

58.6%, in Cambodia was 14% Some studies inViet Nam showed thatChlamydia prevalence in FSW was 48.4% in Soc Trang, 5% in Ha Noi,3.3% in Hai Phong, 3% in Quang Ninh, 6.5% in HCM city and 3.5% in

Da Nang

1.2.2 The association between some behaviors and HIV/STI

A study in Quang Dong (2010) showed that high education leveland good STI knowledg were protective factor that could reduce the risk

of STI The behavior of inviting clients on street or in hotel, getting moremoney for selling sex was associated with higher risk of STI According

to a study in Jamaica, age, using drug, not using condom in the last sexwere high risk behaviors of getting HIV in FSW

A study in HCM city, Can Tho, An Giang revealed that the ageunder 30, genital ucer, inconsistent condom use were associated withhigher risk of HIV A study in Hai Phong showed that good STIknowlegd was a protective factor while having more than 4 clients perweek, self STI treatment, poor knowlegd on condom use associated withhigher risk of STI A study in Hue in 2008 also proved that loweducation level and incorrect condom use were considered high riskbehavior

1.3 Some interventions to reduce HIV/STI in FSW

In Thailand, interventions including information educationcommunication activities, strengthening condom use and STImanagement helped to increase consistent condom use and decreasedSTI prevalence in FSW, HIV prevalence in community got stable andfinally decreased In 2003, an intervention in India includingcommunication for bahavior change, increasing condom use, regular STIscreening, periodical STI check also increased condom use with regularclients, decreased HIV and some STI prevalence

A study in Vinh Long showed that after 2 year intervention,knowlegd on how to prevent HIV got increased, consistent condom usewith regular clients and husband/boyfriend got improved However, HIVprevalence did not decreased after the intervenion Another interventionfor FSW in Ha Tay showed that after intervention, consistent condomuse with regular and irregular clients did not change, but with boyfriendgot increased In venue based FSW, consistent condom use with irregularclients and with boy friends got improved, but with regular clients didnot The percentage of people who knew STI symptoms did not improve(p>0.05) After intervention, prevalence of genital discharge, lowerabdominal pain and genital ulcer syndrom decreased significantly

1.4 Some information about Ha Noi

HIV prevalence in FSW in Ha Noi is very high in comparison withthat of the whole country According to HIV sentinel surveillance, HIVprevalence in FSW group was around 3-5% during the period of 2003-

2011, but that of Ha Noi was 13-16% during the period of 2003-2005.The cumulative HIV number at the end of each year in this period ofThanh Xuan and Cau Giay were lowest and that of Hai Ba Trung andDong Da were highest in compare with other districts In Ha Noi,prostitution situation is complicated Karaoke bar is one of the places ofprostitution activities A master often hires a place to gather 10-15

FSWs, prints name cards to distribute to entertainment places such askaraoke bars, restaurants, hotels The heads of these entertainment placeswill call the master if necessary Each FSW carries a number for easyand confidential contact Prostitution brings much profit, therefore manyentertainment places get involved in In addition, the monitoringactivities of local authorities do not strong enough; many tourists go toViet Nam for prostitution leading to complicated prostitution situation.

CHAPTER 2 METHODOLIGY 2.1 Study subjects

The subjects of the study were FSWs in community of Ha Noi,including 2 groups: street based and venue based FSW

2.2 Place and time

The study was implemented in 4 districts of Ha Noi: Dong Da, Hai

Ba Trung, Thanh Xuan, Cau Giay

Study was carried out from 2005 -2010 Pre intervention surveywas from 2005-2006 and post intervention survey was from 2009-2010;Intervention was implemented from 2006-2009

2.3 Study design

This is an quasi experimental study with pre/ post interventioncomparision Pre intervention and post intervention survey were crosssectional survey with cluster sampling

2.3.1 Sample size

Formular for sample size calculation:

Stage 2: Study subject selection If in a cluster, the number of FSW atthe time of selection was larger than 10, the subject has been chosenrandomly If the number was less than 10, all of the FSW at that time havebeen selected and the investigator had to come back later to select moreFSW until geting 10 FSW

2.4 Study activities

Questionnaire development and piloting

The questionnaire was developed by experienced expert and tested/adjusted before being used

Interviewer selection and training

All of interviewers were experienced staff and they had been trained

on mapping technique and how to implement a survey

Data collection

After getting to the interview place, study subjects got registered atreception area, and then were interviewed After interview, urine and bloodsamples were collected The urine samples were used for gonorrhea andChlamydia detection by PCR at National Institution of Epidemiology and

Hygiene (NIHE); Blood sample was used for HIV and syphilis detectiontest at Hanoi HIV/AIDS Center

2.5 Intervention

Intervention activities were carried out by Women Health careCenter The activities included STI services at the Center, mobile STIservices, counseling on HIV/STI, condom use promotion, condom andclean syringe/needle provision

The questionnaire was developed by experienced experts and tested

to ensure it was clear, understandable for FSWs, and the answersreflected the truth

All of the subjects were coded, anonymous so that they feltcomfortable to give the right answers

All of the lab test including HIV test, syphilis test and PCR forgonorrhea and Chlamydia detection were implemented in standardlaboratory with high sensitivities and specificities Therefore, the results

of lab tests are trustable

2.7 Human subject

All of the subjects participated into the study voluntarily Theirpersonal information was kept confidentially The intervention activitieswere safe and were not harmful for them The study was approved byNIHE institution reviewing board

CHAPTER 3: RESULTS

Pre intervention survey recruited 499 FSW (275 venue based FSWand 224 street based FSW) Post intervention survey recruited 600 FSW(300 venue based FSW and 300 street based FSW)

3.1 HIV/STI situation and related factor in FSW in 4 districts of Ha Noi 2005-2006

3.1.1 HIV/ STI prevalence in FSW

Street FSW

Venue FSW

use drug

not use drug

inject drug

not inject drug

%

Figure 3.4 HIV prevalence by FSW type and by drug use behavior

The survey 2005-2006 showed that 16.6% FSW got HIV infected.According to figure 3.4, HIV prevalence of street based FSW was higherthan that of venue based FSW (p=0.0001), HIV prevalence of peoplewho used drug was higher than of people who did not (p=0.0001) and ofwho injected drug was higher than who did not (p=0.0001)

0,4 1,1

2 FSW group street based Venue based

Figure 3.5 STI prevalence in FSW of Ha Noi before intervention

According to figure 3.5, syphilis prevalence in street based FSWwas 1.1% and in venue based FSW was 0.4% (p=0.39) Gonorrheaprevalence in both FSW groups was 1.8% Chlamydia prevalence instreet based FSW was 17.5 and in venue based FSW was 8.5%(p=0.003)

3.1.2 HIV/STI related factors

3.1.2.1 Age of selling sex, duration of being prositution and the number

of clients of investigated FSWs

FSW started to sell sex when they got around 24 years old Themean age of selling sex of street based FSW was higher than of venuebased FSW (25.2 vs 22.9; p=0.0001, t test) The mean of duration ofselling sex was 4,1 year, that of street based was 4,4 year, longer than ofvenue based FSW (3.7 years) (p=0,047, t test) FSWs had around 21.7clients monthly including 14.8 irregular and 5.5 regular clients Thenumber of regular and of irregular clients monthly of street based FSWsdid not different with that of venue based FSWs

3.1.2.2 HIV/STI knowledge of FSWs before intervention

Pre intervention study showed that 87.2% of FSW had heard aboutHIV/AIDS The proportion of FSW who considered themselves at highrisk of being HIV infected was 25.7% That of street based FSW was29.8%, higher than that of venue based FSW (20.5%) significantly(p=0.018) The proportion of FSWs who had sufficient HIV knowledgeaccounted for 43.1%, that of venue based FSW was higher than of streetbased FSW (51.3% vs 36.4%, p=0.001)

Regarding to STI knowledge, 63.7% of FSWs recognized genitaldischarge as a STI sign Other signs such as pain at passing urine, genitalulcers/warts and lower abdominal pain were less recognized (accountedfor 28.3%, 14.4% and 20.2% of surveyed FSW, accordingly) Thepercentage of FSW who did not know any common STI signs accountedfor 17.8% The proportion of FSW knowing 4 STI signs was 3.6%among street based FSWs and was 0.4% among venue based FSW

3.1.2.3 STI history of FSW in Ha Noi before intervention

Figure 3.8 STI history of FSW in Ha Noi before intervention (n=499)

According to figure 3.8, 46.5% of FSW had genital discharge and 12.8% had genital ulcer/ warts in the year before the pre intervention survey The history of genital discharge in the 2 groups of FSW did not different significantly (p=0.22), but the history of genital ulcer/wart of