A cross-sectional survey was conducted among male and female drug users under age 25 recruited from drug treatment centers N = 560 and the community N = 240 in Ho Chi Minh City, Dong Nai
Trang 1Abstract Vietnam is in the midst of an expanding
HIV epidemic, primarily driven by an increase in
injection drug use in young people This study was
conducted to understand the patterns and initiation of
drug use, and the sexual risk behavior among youth in
three provinces in southern Vietnam A cross-sectional
survey was conducted among male and female drug
users under age 25 recruited from drug treatment
centers (N = 560) and the community (N = 240) in Ho
Chi Minh City, Dong Nai and Ba Ria-Vung Tau The
majority of those surveyed (82%) began by smoking
heroin; after a year, 57% were injecting heroin and/or
opium Initiation of drug use frequently occurred in
entertainment venues Among injectors, 23% shared
needles; 71% of all users were sexually active of whom
77% had unprotected sex More than half of those
recruited from treatment centers had previously been
in drug treatment Public health programs to prevent
and treat the dual epidemics of HIV and drug abuse
must be able to access and respond to the needs of
youth, many of whom are unemployed and exposed to
drug traffic
Keywords IV Drug Users Æ Risk-taking Æ Sexual Behavior Æ Heterosexual Transmission Æ Vietnam Æ Asia
Introduction Since the first AIDS case was reported in Ho Chi Minh City (HCMC) in 1990, the HIV epidemic in Vietnam has spread rapidly, primarily due to the expansion of injection drug use throughout the country (Hien, Long,
&Huan, 2004) The estimated total number of HIV infections in Vietnam is 263,000 (Ministry of Health Vietnam 2005), 51% of which are attributed to injec-tion drug use (Hien et al., 2004) The greatest number
of reported HIV infections occur in the north, where drug use proliferates along trafficking routes and the borders of China and Laos (Beyrer et al., 2000; Hammett et al., 2005) However, all provinces in Vietnam currently report persons with HIV infection and an increase in the number of cases due to sexual transmission The southern city of Ho Chi Minh accounts for a quarter of the total national reported and estimated cases of HIV (UNAIDS and WHO, 2005) In 2004, the HIV prevalence among injection drug users in HCMC was 53% and 16% among female sex workers (Hien et al., 2004)
During the past 10–15 years, the epidemiology of drug use in Vietnam has changed, providing new challenges for the control of narcotic use, as well as HIV transmission Prior to 1996, narcotic drug abuse occurred primarily among older men who smoked or injected blackwater opium (Lindan et al., 1997; Reid and Costigan, 2002) By 2002, approximately 80% of registered drug addicts were under age 35
L T L Thao Æ L T Giang
Ho Chi Minh City Provincial AIDS Committee, Ho Chi
Minh City, Vietnam
C P Lindan Æ D B Brickley (&)
Institute for Global Health, University of California,
50 Beale Street, Suite 1200, San Francisco,
CA 94105, USA
e-mail: dbain@psg.ucsf.edu
L T Giang
Ho Chi Minh City Health Department, Ho Chi Minh City,
Vietnam
DOI 10.1007/s10461-006-9138-y
O R I G I N A L P A P E R
Changes in High-Risk Behaviors Over Time Among Young Drug
Users in South Vietnam: A Three-Province Study
Le Thuy Lan Thao Æ Christina P Lindan Æ
Deborah B Brickley Æ Le Truong Giang
Published online: 20 July 2006
Springer Science+Business Media, Inc 2006
Trang 2(‘‘Vietnam: Country profile’’, 2002) This increase in
drug use among youth largely accounts for the
dra-matic rise in the proportion of reported HIV infections
among young people: 16% of all HIV infections in
1995 were among those less than 30 years of age,
compared to 69% in 2004 (Hien et al., 2004)
Control of HIV infection is linked to control of drug
abuse in Vietnam; both are managed within the
Committee for AIDS and for Control of Drug Abuse
and Prostitution In Ho Chi Minh City, a pilot program
was established in which 22 drug treatment centers
(also known as rehabilitation centers) housing more
than 30,000 drug users provided detoxification,
educa-tion, vocational training and health care Although
there are rehabilitation centers elsewhere in Vietnam,
the HCMC program had by far the greatest number
Identified drug users remain in treatment for up to and
in some cases more than 2 years Approximately
two-thirds of these clients are now being released as their
mandated rehabilitation time has been completed
(‘‘3,097 drug addicts in Ho Chi Minh City finish
rehab’’, 2005) HCMC is grappling with ways to
inte-grate these young people into society
Effective strategies to prevent initiation of drug use
among youth need to be developed and evaluated The
public health approach to HIV and illicit drug use has
been based primarily on using peer outreach to provide
education, some needle exchange and counseling
(Khoat, West, Valdiserri, & Phan, 2003) Methadone
treatment is not yet available, but it is anticipated that
it will soon become legal (JVnet, 2005) High
unem-ployment rates, injecting as well as smoking practices,
and sexual risk behavior with multiple partners are
issues that need to be addressed to successfully prevent
HIV infection in this population
In order to learn more about patterns of drug use
and sexual and injecting behaviors among young drug
users, this study was conducted by the HCMC AIDS
Committee in three different provinces in the southern
region of the country
Methods
Setting
Subjects were recruited from three cities in southern
Vietnam, chosen to represent different urban settings:
a metropolis, a suburb, and a smaller resort town Ho
Chi Minh City is the largest city in Vietnam, with a
population of 7 million and the commercial and
industrial center of the country Dong Nai is a rapidly
developing industrial zone in the suburbs of HCMC
Ba Ria-Vung Tau is a beach resort about 120 km from HCMC that attracts both domestic and foreign tourists
Study Subjects Subjects were recruited both from drug rehabilitation centers and community venues A sample size of 400 participants from HCMC, and 200 from each of the two other cities was based on feasibility and cost It was planned that approximately 75% of subjects would be recruited from drug rehabilitation centers and 25% from the community, based on the belief that the majority of identified drug users would be in treatment
In addition, the feasibility of recruitment from drug rehabilitation centers was expected to be easier In HCMC, where large numbers of drug users in both the community and rehabilitation centers could easily be identified, this sampling approach was taken In the other two locations, however, the total number of drug users was much smaller, and the ability to recruit subjects was limited by the size of the rehabilitation centers and/or the availability of identified users in the community Thus, 88% of study participants from Dong Nai and 43% from Ba Ria-Vung Tau were re-cruited from treatment centers
At the time of the study, there were eight govern-ment rehabilitation centers in HCMC, and participants were recruited from each, proportional to the per-centage of total drug admissions received by that site For example, a total of 300 subjects were to be re-cruited from rehabilitation centers in HCMC, and 100 from the community If center A received 20% of all drug rehabilitation admissions in the city, then 20% of the 300 subjects were enrolled from that site Both Dong-Nai and Vung-Tau had only one drug center each, and all eligible residents at the time of the study were asked to participate
Recruitment was conducted by experienced social workers and counselors who were employed and trained by the HCMC AIDS Committee In the drug treatment centers, health and social workers who were familiar with young drug users conducted the inter-views Recruitment and interviewing of community based drug users were carried out by peer educators currently working in those communities All study personnel had experience in counseling drug users; they also received additional training in interviewing and in research methods as part of this study Recruitment occurred from October 1999 to March 2000
Trang 3Subjects were self-identified users of opiate drugs
and < 25 years in age Because all users in treatment
could not be enrolled, participants were selected by
systematic sampling Counselors described the study
protocol and procedures and received verbal consent
from the subjects Participation was voluntary and
study staff made clear that refusal to participate would
not influence ability to receive treatment or services
Subjects received a small gift (value less than US$1) to
compensate for their participation All questionnaires
were anonymous and no identifying information was
collected; names of the subjects were not recorded or
linked with the survey in any way
Measures
Questionnaire items and methods of approaching drug
users were explored during focus group discussions
with peer educators The questionnaire was
adminis-tered by trained study staff in Vietnamese using lay
language and common terms Areas addressed
in-cluded basic demographic characteristics of
respon-dents, drug use behaviors (both at the beginning of
drug use and currently), sexual behavior, condom use,
and knowledge and attitudes related to HIV There
were four questions about HIV transmission regarding
whether HIV could be transmitted from mother to
child, by sharing needles or injection equipment,
through sex, or via mosquitoes or insects There were
three questions asking whether it is possible to prevent
HIV transmission by using condoms during sex, using
clean needles/injection equipment, and by not touching
or eating with persons who have AIDS There were
five additional questions regarding the utility of
con-doms Discriminatory attitudes towards persons with
HIV/AIDS (PLWHA) were identified by asking five
questions: whether PLWHA should be fired from jobs
and isolated; whether their identity should be provided
to the public; whether they should be allowed to work
and live as usual; whether their identity should be
hidden to avoid discrimination; and whether their
health and psychological well-being should be
sup-ported
Analysis
Data were entered onsite into EpiInfo 6 and analyzed
using Intercooled Stata 7.0 Distribution of responses
were evaluated using proportions, mean and median
values Data was initially stratified by city, gender,
recruitment venue (community or treatment center),
age, employment status, and financial status to identify
relationships of interest Differences were evaluated
using v2-test for differences in categories, or student’s t-test for differences in mean values Data are presen-ted stratified by recruitment site (drug rehabilitation centers versus the community)
Ethical Review The study was reviewed and approved by the Provin-cial AIDS Committee of Ho Chi Minh City before an Institutional Review Board (IRB) was established An IRB and NIH Federal Wide Assurance are currently in place The Committee on Human Research at UCSF provided approval for UCSF co-authors to participate
in data analysis and manuscript writing
Results Demographics Table 1 shows the demographic profile of subjects by type of recruitment site (community versus treatment center), which varied by city Approximately 19% of participants were women The median age was 20 (range 13–24), and 19 subjects were between 13 and
15 years of age The majority had only elementary or primary education, and 5% were illiterate Of those older than 18 years, only 34% had achieved a high school education (data not shown) About one-half were employed, 17% were students, and the remainder had no job Three quarters of all subjects described their families as poor or struggling with just enough to live on The vast majority (87%) of subjects lived with their families and 65% were completely financially dependent upon them; 55% reported that their family was a main source of drug money Of the 560 recruited from treatment sites, 37% had entered voluntarily, 20% had been sent there by their families, and 43% had been arrested and were undergoing mandatory treatment There were some notable differences between those interviewed from the community compared to treat-ment centers Those in treattreat-ment tended to be younger (less than 22 years old) and to have higher levels of education and be students They were more likely to be financially dependent on families, and those families were better off financially—only 6% were described as poor compared to 21% of families of community participants In addition, a greater proportion in treatment (62% vs 40%) relied on the family as the source of drug money
Across provinces, subjects recruited from the treat-ment centers were similar demographically, whereas there were some differences among those recruited
Trang 4from communities (data not shown) Unemployment
was higher among participants from Vung Tau
compared to the other two cities (56% vs 36% in Ho
Chi Minh City and 31% in Dong Nai, P < 0.001); those
recruited from Ho Chi Minh City were more likely to
be financially independent from their families (39% vs
22% in Vung Tau, and 4% in Dong Nai, P < 001)
Men and women in the study were similar in age,
education and employment status; however, more
women lived on their own without financial support
(data not shown) They were more likely to be married
(19% vs 10% of men, P < 01), live apart from their
families (22% vs 11% of men, P < 01) and be
financially independent of them (24% vs 15% of men,
P < 01) The economic status of their families was also lower—82% of women were from poor or finan-cially struggling families compared to 74% of the families of men surveyed (P < 05)
Drug Use Behaviors Table 2 highlights the drug use patterns of subjects recruited from rehabilitation centers and the commu-nity The mean length of time using drugs was 2.7 years (median 3 years, range 1–12 years); those in treatment had been using for slightly longer—about half had
Table 1 Demographic characteristics of 800 young drug users by recruitment site
Recruitment site
City***
Age, years***
Educational level***
Employment***
Financially dependent on family***
Family economic status***
Sources of drug moneya
Reason for being in treatment
P-values refer to differences between recruitment sites across categories, using v2statistics ***P < = 001
a Categories are not mutually exclusive
Trang 5been using drugs for more than 2 years, and some up to
12 years Nearly all those in treatment were using
heroin and only 1% used opium, whereas 32% of those
from the community were using opium There were
some differences in sharing practices by city of
recruitment (data not shown): 24% of injectors in
HCMC reported sharing, compared to 22% in Vung
Tau and 19% in Dong Nai Almost 80% stated that
peer pressure was their main reason for using drugs
initially, and most began using with friends Many,
52% of those recruited from treatment centers and
32% of those in the community, had previously been in
treatment, and roughly similar proportions believed
they could eventually give up drugs (65% of those in
treatment vs 37% from the community) Only 11
participants reported selling drugs (data not shown)
At initiation of drug use, the majority (87%) of
subjects smoked and only 9% injected (Table 3) This
changed significantly over time—when surveyed, the
majority of users (57%) reported injection practices
Among those who had switched method of use, the
mean time to change was 14.1 months Sharing needles
or drug paraphernalia was reported by only one-quarter of injectors, and was the same at drug initiation (26%) and at the time of the survey (23%) Heroin was
by far the most commonly used substance; at drug initiation, 94% used heroin: 88% exclusively and 6% mixed it with other drugs; only 2% were using opium and 8% marijuana By the time of the study, 90% overall were using heroin, and the proportion of opium users had increased slightly (10%) In general, those using heroing continued to do so—only 7% of heroin users switched to opium, whereas among those using opium initially, 67% continued to do so Among marijuana users, 83% were smoking or injecting heroin when surveyed (data not shown) Overall, 17% had changed their primary drug since initiation Frequency
of drug use increased from a mean of 1.6 to 2.5 times per day
More than half the survey participants (53%) began using drugs at an entertainment place such as a cafe´, restaurant or karaoke bar There was a general trend from initially smoking heroin at entertainment venues,
to injecting heroin at home or with friends Even so, a
Table 2 Drug use patterns among 800 young drug users by type of recruitment site
Current Age 13–18 (N = 196) **
Current age 19–24 (N = 604)*
Current methods of drug usea
Drugs used currentlya
Reason for initiating drug use
Used drugs with whom initially***
P-values refer to differences between recruitment sites across categories, using v 2 statistics *P < = 05 **P < = 01 ***P < = 001
a
Not mutually exclusive categories
Trang 6significant proportion (28% of injectors, 40% of
smokers, and 35% of heroin users) continued to use
drugs at entertainment sites (Table 4) Opium was
used most commonly at shooting galleries (54%) All
drugs, including opiates, marijuana and other drugs
were purchased primarily at shooting galleries
Sexual Risk Behaviors
Table 5 describes the sexual behaviors of study
sub-jects Most, but not all, were sexually experienced: 82%
of women, 71% of men, and 67% of those who had
never been married Among the 586 who had had sex,
20% had sex with friends in their drug-using group,
37% with friends outside of their using group, and 24%
with casual partners About twice as many women
(41%) as men (20%) reported sex with casual partners
We did not ask women whether they had engaged in commercial sex, although 32% of men had visited fe-male sex workers About half of respondents reported never using condoms, and this was not significantly different between men and women Condom use with spouses was low—6% reported always using them Among those who were married and had other relationships, 32% never used condoms with extra-marital partners (data not shown)
Knowledge and Attitudes about HIV/AIDS Participants in the study were generally knowledgeable about HIV/AIDS (Table 6) Most (86%) could cor-rectly answer all questions about HIV transmission,
Table 3 Change in drug use: at drug initiation and currently, among 800 young drug users
Method of use a
Drug used and methoda
No times/day use drugs
Primary location of usea
Purchase drugs wherea
a
More than one response possible
b Proportion smoking, injecting etc are calculated using the entire cohort (800) as the denominator
c
Entertainment places include restaurants, cafes, karaoke bars, etc
Trang 7and 80% could correctly answer all questions about
means of preventing HIV However, only 43% of
injectors and 21% of non-injectors believed they were
at risk for HIV Most had favorable attitudes about
how society should respond to people living with HIV/
AIDS Eighty-four percent believed the identity of
those with HIV infection should not be disclosed in
order to avoid discrimination, and an equal number
believed that people living with HIV should be allowed
to work and live as usual Almost all (97%) believed
that family and health services should provide care and
support for people living with HIV Those in treatment
were more than twice as likely to have undergone HIV
testing than participants from the community (67% vs 28%) A very small number of those who reported having been HIV tested (440), indicated that they were HIV infected (8%), and was higher (12%) among injectors compared to non-injectors (1%)
Discussion This study provides important information about how youth in southern Vietnam begin using drugs and how this changes over time Heroin was by far the drug of choice, and opium use was comparatively uncommon
Table 4 Current primary location of drug use and purchase among those who used heroin and/or opium (N = 800)
Method of intake and drug used Primary location of drug use
Shooting gallery
Entertainment place a
Friend’s house Own house
Method
Drug
Current drug used Primary place of purchase
Shooting gallery
Entertainment place a
Drug
a
Entertainment places include restaurants, cafes, karaoke bars, et al.
Table 5 Marital status and sexual risk behaviors of 800 young drug users
Sex with whom?a,b
Frequency of condom use c (N = 532)
a
Includes sexually active single persons, as well as those who were married, divorced, or separated
b
Categories are not mutually exclusive
c Condom use among 108 women and 424 men who were single and sexually active, or married with non-marital partners
Trang 8This is in contrast to a decade ago, when opium use was
more prevalent, particularly in the southern part of the
country One study from the mid-1990s reported that
96% of drug users in treatment were using opium
(Tran, Williams, Truong, & Do, 1998) Most young
people in our study reported smoking drugs initially,
with one-half transitioning to injection within a year
This quick transition to injection likely results from
increasing addiction, the need for more drug per dose,
and the fact that injection is comparatively cheaper
Other studies of drug users have found that transition
to injection occurred within 7 months to 1.85 years
(Hien et al., 2004; Nguyen, Hoang, Pham, & Detels,
2001) Needle sharing in our study was reported by
only one-quarter of those injecting drugs, and is
con-siderably less than in other surveys in which up to 70%
of injectors in urban settings reported sharing
equip-ment (Hien et al., 2001; Nguyen et al., 2001; Tran et al.,
1998) Other reasons for varying rates of sharing may
be related to cost, availability of clean needles and
concerns about arrest if caught with injection
equipment
Until now, a policy of sending drug users to large
treatment centers for up to 2 years of detoxification
and ‘‘rehabilitation’’ has been widely pursued (Rekart,
2002; Vu, 2001) Vast resources have been dedicated to
expanding existing drug treatment centers and building
new ones At the time of this study there were 8 such
sites in HCMC; by 2005, there were 22, mostly run by
the government with a few private clinics, and housing
30,000 users Previous data show that upon leaving a
rehabilitation center, at least 90% of clients begin
using again (International Narcotics Control Strategy
Report, 1999) This is consistent with reports of prior
treatment among participants in our study—55% of
those in treatment and one-third of those in the
community had previously been in rehabilitation Because the maximum 2-year detention has now expired for many with mandatory sentences, large numbers of drug users are being released into the community, up to 16,000 in 2006 in HCMC alone (‘‘3,097 drug addicts in Ho Chi Minh City finish rehab’’, 2005) This poses a large challenge in finding ways to support abstinence, education, and reintegra-tion into society A step-down program of 1–3 years in which former drug users can be employed and live in more controlled settings is being pursued
With the large efflux of drug users from treatment, information about initiation of drug use will be important for prevention programs and outreach We found that drug use was most often initiated at enter-tainment venues, such as karaoke bars or cafes, and occurred under peer pressure Even over time, both purchase and use of drugs continued to occur in these public venues, although most drugs were obtained at shooting galleries even if they weren’t used there Developing peer outreach at these sites may be very important in preventing recidivism as well as reducing experimentation with highly addictive drugs
We were somewhat surprised to find many young drug users were fairly well-educated, middle class and typically living with and/or receiving financial support from their families This was particularly true of drug users in treatment, who in many cases were sent to treatment by family members Many families were also a source of money for buying drugs This may occur because relatives would rather provide funds than have children steal and bring shame to the family Because of this involvement, an important role may exist for families in supporting prevention, harm reduction and drug abstinence However, this also poses a dilemma for families, many of whom are reluctant to have former drug users return home following rehabilitation
Despite concerns about the use of rehabilitation centers, the HIV prevalence rates in HCMC declined significantly in the several years during which the majority of drug users were in treatment Data from HCMC sentinel surveillance show that HIV prevalence among drug users dropped from 83% to 48% from
2002 to 2005, concomitant with reductions in HIV among other at-risk populations As the majority of HIV infected persons were in rehabilitation centers, HIV transmission both sexually and parenterally was reduced In addition, the presence of drug mafia and dealers declined Unfortunately, as former drug users re-enter society, HCMC may witness a return of a ready drug supply as well as the emergence of meth-amphetamine use
Table 6 Knowledge and attitudes about HIV (N = 800 drug
users)
HIV transmission knowledgea
Knowledge about HIV preventiona
No discriminatory attitudes towards PLWHAa
Perceive oneself at risk for HIV
Previously tested for HIV
Recruited from community (N = 240) 67 28
Recruited from treatment centers (N = 560) 373 67
a Items are described in the Methods section of the text
Trang 9We did not perform HIV testing and counseling as
part of this study By self-report, only 55% of
partici-pants claimed to have undergone HIV testing The
greater proportion in treatment who had been tested
may be a result of national HIV sentinel surveillance
which is performed primarily in rehabilitation centers
A very small number, only 8% of the sample, admitted
to being HIV seropositive This likely reflects
und-erreporting and fear of disclosure due to stigma
Sentinel surveillance data among injection drug users
indicates that 65% of surveyed injection drug users in
HCMC and 20% in Dong Nai were HIV infected
during the period when this study was performed (Hien
et al., 2004) Even though half of those recruited in our
study were injecting drugs, high HIV prevalence rates
among non-injecting heroin users have been noted in
many reports In a study of 500 drug users in Hai
Phong, HIV prevalence among non-injectors was 46%
(Nguyen et al., 2001) In HCMC, 25% of surveyed
heroin smokers were HIV infected in 2000
(unpub-lished surveillance data, HCMC AIDS Committee)
The reasons for high rates among non-injectors may
be due to sexual transmission and the overlap among
drug users, their sexual partners, and female sex
workers (National AIDS Committee Bureau of
Viet-nam, 2001) Overall, one-half of those who were
sexually active in our study never used condoms with
their partners, and one-third of men had visited
female sex workers Although we didn’t ask women
whether they sold sex, a large proportion, 41%,
admitted to having casual sex partners It is possible
that many of these women were trading sex for drugs
or money
The HIV prevalence among sex workers has risen
steadily in Vietnam, particularly in the southern part
of the country Concomitantly, drug use among
female sex workers is a growing problem Studies of
sex workers in HCMC and in Hanoi have indicated
that 25–45% of them inject drugs, and among them
HIV rates are close to 50% (Bain et al., 2003; Tran,
Detels, Long, & Lan, 2005) Thus, HIV among
female sex workers may be due to injecting drug use
and sexual transmission from drug using sex partners
It is not clear whether many women identified as sex
workers and detained in rehabilitation centers, are
primarily addicted to drugs and compelled to sell sex
to support a habit; or whether they are female sex
workers who have become addicted to drugs This
distinction may only be relevant in pointing out
that women who sell sex may be in need of harm
reduction programs
There were several limitations to this study Use
of peer educators as interviewers may have biased
responses of participants toward socially desirable answers, particularly from among those who were in treatment However, all efforts were made to main-tain confidentiality and encourage clients to respond accurately The representativeness of the community-based sample may be reduced because participants were recruited from among networks of drug users already known to peer outreach workers Likewise, participants enrolled from rehabilitation centers may not be representative of drug users in general We
do not have information about whether risk behav-ior, related to drugs or sexual relationships, was taking place during rehabilitation Because males and females are separated and centers are inpatient facilities, it is assumed that drug use and heterosex-ual sex are infrequent; however, to our knowledge this has not been formally evaluated Questionnaire items were not designed to identify specific recall periods, and we have assumed that ‘‘current’’ drug use refers to the period prior to entry in rehabilita-tion centers In addirehabilita-tion, recall periods were not specified for questions relating to sexual activity and condom use
This study and many others point to the need to address the growing population of young drug users in Vietnam who are fueling and most likely to succumb to the HIV epidemic (Giang, Luyen, Thao, & Narimani, 1999; Hien et al., 2004) Many of those in our study were less than 18 years of age, and some had started using drugs by the time they were 13 Innovative prevention programs need to be developed, such as conducting outreach at entertainment sites where young people smoke and exchange drugs Recent evidence shows that community-based interventions for drug users are effective in reducing risk behaviors, yet there remains a gap in the number who could benefit from such interventions and those who actually receive them (Needle et al., 2005) Young users are sexually active and do not use condoms regularly This puts them at additional risk of HIV acquisition, and requires that interventions also promote fewer episodes of unprotected sex (Des Jarlais & Semaan, 2005; Go, Quan, Yoytek, Celentano, & Nam, 2006; Nguyen et al., 2001) The recent official recognition of needle exchange and drug substitution as valid components of harm reduction and its inclusion into law will be a big step in moving Vietnam’s HIV prevention programs forward (JVnet, 2006) However, this will only be successful if drug users can obtain clean paraphernalia without fearing arrest, and if methadone becomes available to those who need it Until then, high rates of drug use could spell disaster for many of Vietnam’s youth
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