Research paperSocial injecting and other correlates of high-risk sexual activity among injecting drug users in northern Vietnam
Introduction
The majority of HIV infections among injecting drug users (IDUs) initially was attributed to parenteral exposures; however, research has increasingly highlighted the importance of sexual behaviours for HIV infection among IDUs, especially among women (Kral et al., 2001, Strathdee et al., 2001). Additionally, in areas where HIV infections are primarily in IDUs, high-risk sexual behaviours among IDUs may serve as a catalyst for progression from a concentrated epidemic to a generalized one (Grassly et al., 2003, Saidel et al., 2003; Wiessing & Kretzschmar, 2003).
In Vietnam, IDUs account for over 65% of all reported HIV infections (UNAIDS, 2004). National HIV prevalence among IDUs increased from 9.4% in 1996 to 29.3% in 2002 and from 0.6% in 1994 to 6.6% among female sex workers (FSWs). Among STD patients and army conscripts, HIV prevalence increased from 0.5% and 0% in 1994 to 2.0% and 0.7% in 2002, respectively and from 0.03% in 1995 to 0.4% in pregnant women (Subcommittee on HIV/AIDS Surveillance, 2003; United Nation General Assembly Special Session on HIV/AIDS: UNGASS, 2003). Between 2000 and 2005, the total number of persons living with HIV/AIDS more than doubled to an estimated 260,000 (UNAIDS, 2006).
Injecting drug use has increased substantially in recent years. The Vietnamese government reported 170,400 recorded drug users in Vietnam, an increase of 6% from the previous year. Approximately 93% of all drug users in Vietnam are men, 70% use heroin, and injecting heroin has become the primary route of drug administration (United Nations Office on Drugs and Crime Country Office Vietnam, 2005). Additionally, studies among Vietnamese IDUs have reported high frequencies of multiple sex partners, sex with sex workers and low rates of condom use with all sex partners (Thao le, Lindan, Brickley, & Giang, 2006; Tran et al., 2006, Tung et al., 2001). Among male IDUs in 5 Vietnamese provinces, only 28–56% reported consistent condom use with commercial sex workers in the past year, and even fewer (15–28%) used condoms consistently with regular partners (Tung et al., 2001). With the rising prevalence of HIV, a large pool of IDUs, and high rates of risky sexual behaviours, there is potential for the epidemic to spread from IDUs to the general population via sexual transmission (Go et al., 2006a, Hammett et al., 2005; Tran, Detels, Long, Van, & Lan, 2005).
Understanding sexual activity and the characteristics of sexual activity among IDUs is paramount to designing effective prevention strategies to avert a large-scale HIV epidemic in Vietnam. Investigating predictors of high-risk sex among IDUs may allow public health officials to identify pockets of IDUs who engage in high-risk sexual behaviours for targeted interventions. We have previously found that sexual risk and STDs are relatively high among IDUs. In Bac Ninh province, 88% of IDUs had ever had sex, 1/3 reported having had sex with a sex worker during their last sexual encounter, and 30% were diagnosed with at least 1 sexually transmitted infection other than HIV. Our previous qualitative findings indicated that some IDUs injected in groups and then visited sex workers together (Go et al., 2006a; Go, Quan, Voytek, Celentano, & Nam, 2006).
We sought to determine the characteristics of sexually active IDUs, as well as the correlates of high-risk sexual practices among IDUs. Based on our previous findings, we hypothesized that injecting behaviours indicative of injecting in groups, or social injecting, were associated with high-risk sexual practices.
Section snippets
Methods
We conducted a community-based cross-sectional survey among active IDUs in Bac Ninh, Vietnam. Active IDUs were recruited from Bac Ninh Province, a small semi-urban province 45 km north of Hanoi, between August and September 2003, through snowball sampling using peer recruiters who were current or former IDUs. Two districts, Bac Ninh town centre and Tu Son, a rural district 10 km from the town centre, were purposively selected based on the highest reported number of out-of-treatment IDUs. IDUs
Results
Of the 393 IDUs approached by outreach workers, 309 (79%) eligible participants completed interviews. Of these, we excluded 10 women (3%), 80 men who were not sexually active in the past year (20%) and 3 men who declined to divulge the number of sex partners they had in the past 12 months (1%). One third (33%) of the remaining 216 participants had engaged in high-risk sex within the past year.
Overall, the average age of sexually active IDUs was 28.5 (median: 27.5), and just over half reported
Discussion
IDUs who inject socially may be a key bridge group for HIV transmission in Vietnam. Having drugs injected by someone else, and sharing needles in the past 6 months were independently associated with recent risky sexual behaviour—having sex with more than one partner and inconsistently using condoms in the past year. Our results highlight the importance of sexual behaviour as a risk factor for HIV infection among IDUs in Vietnam, as well as the potential for the HIV epidemic to spread via
Acknowledgement
Sources of support: This research was supported by the US National Institute of Mental Health (grant 1 R01 MH 64895-01).
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