Ending an HIV epidemic among persons who inject drugs in a middle-income country: extremely low HIV incidence among persons who inject drugs in Hai Phong, Viet Nam

Abstract

Objective: To determine whether it is possible to ‘end an HIV epidemic’ among persons who inject drugs (PWID) in a low/middle income country. Design: Serial cross-sectional surveys with a cohort of HIV seronegative participants with 6-month follow-up visits recruited from surveys. Methods: Surveys of PWID using respondent driven and snowball sampling were conducted in 2016, 2017, 2018, and 2019 (N = 1383, 1451, 1444, and 1268). HIV recency testing was used to identify possible seroconversions in the window period prior to study entry. Structured interviews covering drug use histories, current drug use, and use of HIV-related services were administered by trained interviewers. Urinalysis was used to confirm current drug use. HIV and hepatitis C virus testing were conducted. Electronic fingerprint readers were used to avoid multiple participation in each survey and to link participants across surveys. A cohort of HIV seronegative participants with 6-month follow-up visits was recruited from the surveys, 480 from 2016, 233 from 2017, and 213 from 2018. Results: Participants were predominantly male (95%), mean age approximately 40, all reported injecting heroin, HIV prevalence ranged between 26 and 30%. We had three seroconversions in 1483 person-years at risk (PYAR) in the cohort study, and 0 in 696 PYAR among repeat survey participants, and 0 seroconversions in 1344 PYAR in recency testing. Overall HIV incidence was 0.085/100 PYAR, 95% confidence interval 0.02–0.25/100 PYAR. Conclusion: The data from Hai Phong clearly demonstrate that it is possible to achieve very low HIV incidence – ‘end an HIV epidemic’ – among PWID in a middle-income country.

Ongoing HIV transmission following a large outbreak among people who inject drugs in Athens, Greece (2014-2020)

“…An important question is why HIV transmission did not decline further after 2013. In other settings with increased transmission among PWID, such as HaiPhong and Bangkok, HIV incidence declined in the recent years to <1/100 PYs 32,33 Our analysis has some limitations. First, estimates of HIV prevalence in 2012-2013 and 2018-2020 were based on a sample of PWID participating in both programs.…”

“…An important question is why HIV transmission did not decline further after 2013. In other settings with increased transmission among PWID, such as HaiPhong and Bangkok, HIV incidence declined in the recent years to <1/100 PYs 32,33 . In Athens, as soon as the HIV outbreak was recognized in 2011, several interventions were implemented; NSP coverage increased from 16 syringes/PWID in 2010 34 to 216 in 2013 35 and OST coverage from 21% in 2010 to 35% in 2012 36 .…”

Using large-scale respondent driven sampling to monitor the end of an HIV epidemic among persons who inject drugs in Hai Phong, Viet Nam

“…We enrolled 4279 individual PWID in the 4 surveys, or 61% of the estimated PWID population during the period of the surveys. PWID who did not participate in the study would have to had a much higher rate of HIV incidence (approximately 6 times higher than the rate among PWID who did participate in the study) for the total incidence to be greater than 0.5/100 person-years in the population as a whole [ 3 ].…”

“…When implemented at high coverage levels, combined prevention and care has been quite effective in achieving very low HIV incidence rates (< 1/100 person-years), thereby effectively “ending HIV epidemics” among PWID in many high-income settings [ 2 ]. Additionally, the DRug use and Infections in ViEtnam (DRIVE) study recently observed a very low HIV incidence rate of 0.085/100 person years at risk (PYAR)(95% CI 0.02–0.25/100 PYAR) among PWID in Hai Phong, Vietnam, a middle-income setting [ 3 ].…”

A cohort study revealed high mortality among people who inject drugs in Hai Phong, Vietnam

“…In addition, free universal antiretroviral treatment was provided to PWID since 2005. Altogether, these interventions led to reduce the HIV incidence down to 0.085/100 personyears (95%CI, 0.02-0.25) [15] . This incidence is below the threshold set at 0.5/100 person-years that we previously defined for ending the HIV epidemic among PWID in LMIC [16][17][18][19] .…”