ASSESSMENT OF HIV, AFB (+) TB CONTRACTION AND EFFICACY OF INTERVENTION MEASURES ON INTRAVENOUS DRUG USERS IN DAKLAK PROVINCE, 2011 2012

Scientific evidence had revealed that intravenous drug users IDUs had higher risk of HIV infection, implicating opportunistic infections among which was TB.. However, in Vietnam, and par

MINISTRY OF TRAINING AND EDUCATION

MINISTRY OF HEALTH

NATIONAL INSTITUTE OF HYGIENE AND

EPIDEMIOLOGY

- - - * - - -

PHAM THO DUOC

ASSESSMENT OF HIV, AFB (+) TB

CONTRACTION AND EFFICACY OF

THE ISSUE IN QUESTION

1 The imperative of thesis

HIV/AIDS and TB are and were two troubling public health issues With two agents, two transmission mechanisms, exposed subjects pose different infected symptoms; however, the conditions of the two health issues go hand in hand HIV was the main cause of failure in the preventive strategy of TB and vice versa, TB was the main cause of fatalities among HIV infected persons Scientific evidence had revealed that intravenous drug users (IDUs) had higher risk of HIV infection, implicating opportunistic infections among which was TB The increase of TB infections might create a boost on increase of HIV/TB coinfection

There had been tremendous researches on the prevalence

of HIV infections among IDUs and TB infected group in several areas in the nation However, in Vietnam, and particularly Daklak Province, there had not been many specific study on HIV infections, AFB (+) TB and HIV/TB coinfection among IDUs, in order to obtain scientific evidence which shall

in turn be helpful for planning preventive strategy on IDUs in particular and the community health in general On that basis,

we conducted this study with the following goals:

1 Determining the prevalence of HIV and AFB (+) infections among IDUs in Daklak Province, 2011

2 Providing descriptions of several related factors of HIV/TB coinfections on study subjects

3 Determining the efficacy of community intervention measures to prevent HIV and TB infections among IDUs during the period 2011 – 2012

2 Further contributions by thesis

This thesis was the first systematic study on the prevalence of HIV, AFB (+) TB and HIV/TB coinfection among IDUs in Daklak This study provided descriptions on several risk factors which might increase HIV/TB coinfection The preliminary study roll-out had accurately assessed the efficacy of community intervention measures against HIV, TB infections among IDUs in Daklak Province

3 Scientific significance and practicality of thesis

3.1 Scientific significance:

Thesis adopted the cross-sectional study model of pre- and post- community intervention Adopted methods on sample collection and data analysis were accurate and creditable From the collected data and result interpretations, the thesis had determined certain indices of prevalence of HIV, AFB (+) TB, HIV/TB coinfection, HIV/TB coinfection risk factor index and efficacy index of community intervention measures among IDUs on study areas in Daklak Province

3.2 Practicality of thesis:

The study results provided preliminary scientific data which contribute to proposal of intervention measures model, and control of HIV, AFB (+) TB and HIV/TB coinfection among IDUs

The study results provided practical data serving teaching purposes and being the prerequisite for further follow-up studies

4 Outline of thesis: the body of thesis consisted of 126 pages

(excluding appendices, table of contents, glossary) and was divided into: Issues in question (3 pages); Chapter 1 – General (43 pages); Chapter 2 – study subjects and approach (17

pages); Chapter 3 – study results (28 pages); Chapter 4 – Discussion (31 pages); Conclusion (2 pages); Recommendation (1 page) and Portfolio of publicized research papers (1 page) Thesis had 45 tables, 07 graphs, 04 maps and

01 figure The appendices consisted of 120 references (37 in Vietnamese, 83 in English), surveys (commitment on study participation and survey questions); blood collection slip; oral fluid collection slip;

CHAPTER 1: GENERAL 1.1 The situation of HIV/TB coinfection

1.1.1 The situation of HIV/TB coinfection on a global scale

According to WHO, by the end of 2012, there were approximately 34 million cases of HIV infections globally Among HIV infected persons, one third of them had high risk

of TB infection, therefore, increased the number of TB infected persons HIV infected persons had 20-30 times risk of contracting active TB in compared with HIV non-infected persons An estimation of 1.4 million deaths were caused by

infected with HIV was 26% in compared with 2% among HIV (-) patients

From the first 5 cases detected of HIV infections in 1993 until the end of December, 2010, Daklak Province had recorded 1,520 cases of HIV infection among which 623 were advanced to AIDS, 351 were deceased because of AIDS; the rate of HIV infection among TB patients was 3.1%

1.2 Factors relating to HIV/TB coinfection

1.2.1 Socio-economic and living condition factor

Factors such as: social integrity, degrading behaviors, ethnic groups, financial problems, poverty, illiteracy, unemployment, domestic violence or sexual discrimination, etc might affect the risk of HIV/TB coinfection in a community, especially among high risk groups (Intravenous drug users (IDUs), prostitutes, and MSM)

1.2.2 Knowledge and behavior

Lack of knowledge, negative behaviors and action against the norm such as drug abusing which might lead to sharing of needles and unsafe sexual intercourse are among factors that affected the increase of HIV infections HIV infections shall weaken the immune system which implicated opportunistic infections, among which was TB

2.2.2 Group of intravenous drug users

Intravenous drug users were the group of highest risk of HIV infection due to sharing of needles and unsafe sexual intercourse

2.2.3 Group of female prostitutes

Female prostitutes were faced with risk of HIV infections, unstable financial conditions, social discrimination and domestic issues HIV infection among female prostitutes

fluctuated from 0.3% to 23% depending on geography and areas

2.2.4 Group of men who have sex with men (MSM)

Currently, MSM was the main route of HIV transmission

in most of countries in Latin American

3 Several intervention measures on HIV/TB coinfection

Programs about sharing needles Replacement/opposition treatment of opium-like substance; voluntarily HIV consultation and test

ARV treatment and caring for HIV infected persons; Information, education and risk reduce consultation; giving out condoms and control on sexual transmitted diseases

Coordination in HIV and TB surveillance acitivities; HIV/TB supervision and assessment; HIV/TB preventive activities; HIV/AIDS diagnosis and treatment for TB infected persons and coordinated diagnosis, TB treatment for HIV/AIDS patients; Control on TB and HIV infected persons

CHAPTER 2: STUDY METHODS

2.1 Study subjects

Study subjects were males of age above 18 who had been

an IDUs for at least 6 months and were residences of Daklak Province Subject must volunteer to participate in study and perform all 3 steps of study: (i) completed the survey without skipping any information; (ii) provided blood sample and (iii) provided 3 samples of oral fluid

2.2 Date and location of study

2.2.1 Date of study: from January 2011 to December 2012 2.2.2 Location of study

Selected areas were those whose IDUs record showed higher numbers and prevalence of HIV infected persons, which were: Buon Me Thuot City, EaHLeo District and Krong Pac District

2.3 Design of study

Cross-sectional descriptive inquiry

Non-testimonial assessment study of community intervention measures

2.4 Sample size and sample collection method

Full size sample was selected

Year 2011: 298 IDU subjects were studied intervention

pre-Year 2012: 301 IDU subjects were studied intervention

post-2.5 Variables and indices: were subjected to study

objectives

2.6 Means of study: participation agreement, survey

questionnaire, collection slip and collecting equipment for blood and 03 samples of oral fluid

2.7 Data collection method

Cross-sectional inquiry: phase 1 (July ~ October 2011) and phase 2 (12 months after intervention) Study subjects were interviewed by questionnaire and taken 3ml venous blood and

03 oral fluid sample on 3 different time

Collected samples were preserved and transported as stipulated with biological safety ensured to the laboratory within the same day

2.8 Testing methods

HIV tests were conducted at Prevention of HIV center of Daklak and Institute of Hygiene and Epidemiology of Tay Nguyen

Test of AFB in 3 oral fluid samples were conducted in Tuberculosis and Lung disease Hospital of Daklak Province All tests were completed as stipulated by Ministry of Health

2.9 Main contents of community intervention measures on HIV prevention

Building outreach group approaching community and deploy peer education, reaching to target subjects

Holding media activities: different types of media material, group discussion

Deploying peer education, reaching to target subjects: giving out needles, condoms, and holding infected group clubs Announcing locations providing medical and social service, health care for subjects

2.10 Data processing and analysis

Data was cleaned before entered and processed in computers by SPSS software for Windows 15.0 and applied the Medical – Biological algorithm to deduce the results by 2test or OR; if occurrence frequency was less than 5, Fisher test was adopted for calibration Single variable analysis technique was adopted for assessment and determination of related factors affecting the prevalence of HIV and AFB (+) infections, HIV/TB coinfection

Efficacy of intervention measures was determined according to following formula:

EFFICACY

INDEX =

Post-intervention ratio – intervention ratio x 100 Pre-intervention ratio

pre-2.11 Ethics issue during study

Study was approved by Ethics Council of National Institute of Hygiene and Epidemiology

CHAPTER 3: RESULTS OF STUDY

3.1 Prevalence of HIV and AFB (+) TB infection among IDUs in Daklak, 2011 was determined

3.1.1 Basic information about study subjects

Study subjects were 298 IDUs cases, in which there are

131 subjects in Buon Ma Thuot City (43.9%), 100 subjects in EaHleo District (33.6%) and 67 subjects in Krong Pac District (22.5%) The average age is 26.9 years old in which the majority is from 20 to 29 years old (54.4%); The majority graduated middle school (62.1%); single (57.1%); living with family (56.4%); currently employed (87.2%); of E De ethnic group (1%); of Tay Nung ethnic group (6.1%); of Kinh ethnic group (92.9%)

Intravenous drug injection behaviors of study subjects

Table 3.1 The prevalence of intravenous drug injection behaviors

Intravenous drug

injection behaviors

n No of subjects

Ratio (%)

Age started

to use

drugs

< 20 years of age

> 20 years of age

20 years of age was 42%; sharing needles were 59.7%;

injection frequency ≤ 1 time/day, 2-3 times/day and ≥ 4

times/day are in respective order of 56.1%; 23.8%; and 20.1%; majority of addictive drug in use was Heroin which accounted for 85.6%, others 14.4%

3.1.2 The prevalence of HIV infections, AFB (+) TB infections and HIV/TB coinfection

Table 3.2 The prevalence of HIV, TB infections and HIV/TB coinfection

HIV/TB coinfection with AFB (+) 8 2,7

TB infection with AFB (+)/HIV (-) 3 1,2

In 2011, the current prevalence of HIV (+) infection among IDUs group was 12.8%; prevalence of TB with AFB (+) was 3.7%; HIV/TB coinfection was 2.75% and TB infection among IDUs had not contracted HIV was 1.2%

3.1.3 Distribution of HIV and AFB (+) TB injection according to locations

Table 3.3 Prevalence of HIV and AFB (+) TB infection according to locations

Locations Type of

infection

No of subjects

All three selected locations were detected of HIV (+) and AFB (+) TB, and HIV/TB coinfection In which, Buon Ma Thuot City had high rate; the follow-ups are EaHLeo District and Krong Pac District (Table 3.3)

3.1.4 Distribution of HIV infection and AFB (+) TB infection among to ethnic groups

Chart 3.1 Distribution of HIV and AFB (+) TB infection

among ethnic groups

Result of Chart 3.1 showed the HIV and AFB (+) TB infection pre-intervention distribution in all ethnic groups (Kinh and minority)

3.2 Several factors relating to HIV/TB coinfection

3.2.1 Relation between HIV (+) infection and AFB (+) TB infection

Ratio %

Table 3.4 Relation between HIV (+) and AFB (+) TB

AFB

HIV

AFB (+)

AFB (-)

OR (CI 95%)

3.2.2 Age group factor relating to HIV/TB coinfection

Table 3.5 Age group factor relating to HIV/TB coinfection

Age group Coinfection

3.2.3 Ethnic factor relating to HIV/TB coinfection

Table 3.6 Ethnic factor relating to HIV/TB coinfection

Ethnic group Coinfection

3.2.4 Sharing needles and injection frequency factors relating to HIV/TB coinfection

Table 3.7 Sharing needles and injection frequency factors relating to HIV/TB coinfection

Sharing

needles Coinfection

coinfection χ

3.3 Assessment on efficacy of community intervention measures on HIV infection among IDUs, 2011-2012

3.3.1 Efficacy on change of prevalence of HIV (+), AFB (+)

TB and HIV/TB coinfection post-intervention

Table 3.9 showed the comparison of current HIV infection and AFB (+) TB, HIV/TB coinfection among IDUs group

3.3.2 Efficacy of post-intervention knowledge exchange

Table 3.10 showed the change in understanding about the agents, transmission routes, HIV/AIDS preventive methods and behaviors towards HIV infected persons

Ratio % (n) Full understanding

about agents and

transmission routes

71,1 (212)

83,4 (251)

66,1 (195)

18,5

p < 0,05

Post-intervention information showed that the information about agents, transmission routes as well as positive behaviors towards HIV infected persons provided to IDUs group had created better tendency for HIV prevention as well as statistic meaning (Table 3.10)

3.3.3 Efficacy of post-intervention intravenous drug injection behaviors

Table 3.11 Comparison of changes in intravenous drug injection behaviors

59,9

p < 0,001 Injection 2-3

times/day 23,8% 14,6

38,7

p < 0,001 Injection ≥ 4

3.3.4 Efficacy of post-intervention changes in sexual intercourse behaviors

Table 3.12 Comparison of changes in sexual intercourse behaviors