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July 15, 2004 - The Wall Street Journal (US)

Trying to Arrest HIV's Spread

Officials Encouraged By Needle Exchange In China And Vietnam

By Gautam Naik, Staff Reporter of the Wall Street Journal

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BANGKOK, Thailand -- Public-health workers around the world are closely watching the promising results of an innovative program in China and Vietnam that suggests the spread of the AIDS virus can be contained among intravenous-drug users -- a high-risk, hard-to-reach group that threatens to hasten the disease's march across a wide swath of the globe.

Drug use is especially fueling the spread of AIDS in Eastern Europe, Central Asia and Russia. The worry for these countries is that unless they quickly find ways to lower HIV infection rates among drug users, the virus could proliferate via sexual contact from this high-risk group to the general population. The worst-case outcome: new HIV epidemics to rival the one that is devastating Africa. In China, about 70% of existing infections are needle-related, and in Vietnam, it is about 60%, according to Abt Associates, Cambridge, Mass., research firm that set up the program.

Of the 40 million people world-wide infected with the human immunodeficiency virus, about four million contracted it by sharing needles, according to Abt.

As part of the China-Vietnam program, a trained cadre of peer educators, who themselves are drug users, hands out vouchers to other drug users. The vouchers can be exchanged at local pharmacies for clean needles and syringes, and in some cases, other medicines and condoms. Police have agreed not to interfere with the program; pharmacists and local health authorities have been cajoled into supporting it.

Results from the first 12 months of the project showed that "while transmission of HIV has not been stopped, the number of new infections has gone down," said Ted Hammett of Abt.

The U.S. National Institutes of Health funded research and data collection for the program. The Ford Foundation funded the remainder, including the cost of needles and syringes. The project will run for another year. It reported its initial data yesterday at the International AIDS Conference here.

Needle-exchange programs have been started in dozens of places around the world, but progress so far has been limited. "Drug users are very unpopular, so there's been a tremendous failure of political leadership in preventing HIV in this group," said Don Des Jarlais of the Beth Israel Medical Center in New York, an expert on HIV and drug use and co-investigator of Abt's project.

Abt initiated the project three years ago in the remote mountains that straddle northern Vietnam and southern China. The cross-border area has become a major shipment route for heroin, and HIV prevalence among drug users is close to 20% on the Chinese side and as high as 47% on the Vietnamese side. In the fight against HIV, crossborder regions have proved a special problem because of the difficulties of predicting and monitoring the movement of people.

The early days weren't easy for Abt. The firm wanted to locate part of its program in Hunan, China, but officials balked because they were hosting a major horticultural fair "and didn't want to call attention to the HIV problem," Mr. Hammett said. Eventually, Abt chose the border region of China's Guangxi province and Vietnam's Lang Son province. On the Vietnamese side, a provincial leader at first objected to the program, fearing it would encourage drug use, recalled Doan Ngu, a doctor who is a consultant with Abt's project. The official eventually was won over.

Abt started by training local pharmacists, doctors and women's unions about how the program would work. While the local police retained their right to arrest drug users, they signed agreements promising not to interfere with Abt's program -- and so far have kept their word, Mr. Hammett says. The key step was the hiring of about 30 drug users on each side of the border as "peer educators." In exchange for a salary, these educators hand out vouchers and collect used needles and syringes from other drug users. Abt says the program reaches more than 60% of all drug users and hands out a total of about 25,000 needles and syringes a month.

"Drug users have a built-in credibility" when it comes to reaching other drug users, Mr. Hammett says. But, he adds, the peer educators "can be difficult to manage. Some have even been arrested."

Based on data collected over an initial 12-month period, the program has yielded some encouraging results. In China 22% of drug users surveyed said they had accepted a previously used needle, down from 46% a year earlier. Twenty-six percent said they had handed out a used needle, down from 52% a year earlier. In Vietnam, the self-reported rate for receiving needles fell to 2% from 5%; the figure for handing out needles fell to 1% from 6%. Mr. Hammett says he is skeptical about the accuracy of the Vietnamese figures, which he says seem suspiciously low.

Nonetheless, HIV prevalence among drug users remained stable in Vietnam and China over the 12-month period. Preliminary results of an 18-month survey show that the HIV rate in Vietnam fell to 37% from 47%, according to Abt. "We think we can conclude that, at this stage, the intervention is working," Mr. Hammett says.

Not everything has gone as predicted. In China the vouchers have fallen out of favor with drug users, so they instead are supplied with clean needles and syringes directly by the peer educators. Separately, a survey by Abt of community attitudes toward the needle-exchange program showed that 30% of people believed that HIV can be transmitted by eating alongside an HIV-positive person, while more than 30% of people said that Abt's program would encourage drug use.

"We've got some more education to do in this area," Mr. Hammett says.

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