Long-term Follow-up of Community-based Drug and HIV

Prevention Intervention in Yunnan, China

Debby Lee OhUCLA Department of Epidemiology

Funded by the National Institute on Drug Abuseand the UCLA Global Health Training Program

To investigate the long-term effectiveness of a multi-component community-based

drug and HIV prevention interventionimplemented in Yunnan, China in 1997.

OBJECTIVE

Specific aims

1. Identify and characterize the components of the 1997 drug abuse intervention that are still in operation.

2. Describe the current drug use situation.

3. Measure knowledge, attitudes, and behaviors related to drug use and HIV/AIDS.

Overview

PHASE I• Qualitative study – May 2007• 30 in-depth interviews with village and county

level leadersPHASE II• Quantitative study – June 2008• Cross-sectional questionnaire of 15-39 year old

males (n=774) and small subset of 15-39 year old females (n=107)

BACKGROUND

700, 000 PLWHA (0.05%)

50,000 new infections in 2007

44.7% heterosexual activity 42.0% injection drug use 12.2% homosexual activity1.1% mother-to-child

617 methadone clinics729 needle and syringe exchange sites

HIV in China (2007)

71.3% PLWHA are male

Injection drug use (IDU) in China

• Estimated 2.35 million IDU• 12.3% of IDU infected with HIV• Concentrated in south and west near

Golden Triangle and Golden Crescent

• China relatively drug-free 1950’s-1980’s• “Open door” policy opened country to drug

trade

Longchuan County

Longchuan statistics

• Population 173,000• Over half are ethnic minorities

– Jingpo– Dai

Longchuan

• Adjacent to Golden Triangle• Drug trafficking from Myanmar across the

Chinese border• First indigenous cases of HIV in China were found

in 1989, in a county neighboring Longchuan

Longchuan statistics (2006)

• 4,600 IDUs• 59.7% of IDUs infected with HIV• Of HIV+, 75% infections associated with IDU• 3,700 PLWHA, 89.1% male

1994 study

• In 1994, Dr. Zunyou Wu and colleagues conducted a cross-sectional study of 1,548 males 18-29 year olds in 82 high risk villages.

• Found that initiation of drug use associated with:

– having premarital or extramarital sex– having a family member who used drugs– being unmarried

• Found the incidence of drug use increased from 10% in 1991 to 30% in 1994.

1997 intervention

• In response, local leaders worked together with Dr. Wu and Dr. Roger Detels to implement a community-based drug prevention intervention.

• 19 high risk villages in one cluster were randomly allocated to the intervention, 19 similar villages were selected to serve as a control group.

1997 intervention

• Games• Videos• Agricultural classes• School curriculum• Skits• Activity center• Youth work core

1998 Follow-up

• In October 1998, all males 15-49 in the 38 villages were invited to participate in a follow-up questionnaire.

– 559 males in control villages (91% participation)

– 748 males in intervention villages (88% participation)

1998 Follow-up

• Intervention villages had a 2.7-fold greater decrease in incidence of new drug users compared to control villages

• Greatest reductions were observed in those most at risk:– Youngest age groups– Single individuals– Jingpo minority people– Illiterate and semiliterate

PHASE I - Qualitative study

May 2007

Phase I• 30 in-depth interviews

– 9 in control villages– 17 in intervention villages– 4 with county level government

• Key informants– Government officials– School teachers– Youth leaders– Women’s federation leaders– Health workers

Phase I - Analysis

• Atlas.ti software used for analysis• Data transcribed in Chinese• Grounded theory

– Made initial notes– Open, axial, and selective coding– Conditional matrix of data built– Visual model created

• Key quotes translated into English

Knowledge

“At that time, there were a lot of drug users and a lot of people were dying--there were too many people dying of AIDS. If there were no prevention activities, we wouldn’t know the danger of these things to families and individuals.”

-45 year old woman, intervention village

Knowledge

“At the time, we were all scared of AIDS. We didn’t really understand how HIV was transmitted. If you just said ‘HIV’ people would get scared. But after the training, we gradually understood that HIV infection is preventable.”

--52 year old woman, intervention village

Motivation

“Through the HIV/AIDS education, everyone’s knowledge about prevention increased. We also treated those who were infected with HIV with more loving care. The knowledge touched us deeply--we also realized how precious life is. We all became motivated to do something.”

--43 year old man, intervention village

Motivation

“…in 1997 we decided to form the Village Protection Committee to carry out prevention activities--we thought of this solution ourselves. At the time we thought, if our group of leaders could take the initiative on controlling the drug situation, it could make the drug users quit. While we were developing this, every household gave five yuan.”

--39 year old male, intervention village

Motivation (lack of)

“Relatively, our village has a lot of drug users, but higher level leaders very rarely come to do prevention activities or any kind of work. If the government doesn’t support or pay attention to us, our drug prevention won’t work well. They just tell our village leaders that they need to develop activities, but I think that without higher level government support, we can’t do these things well.”

--48 year old male, control village

Educational programs

“Yes, every one of our schools has [a drug and HIV/AIDS prevention curriculum]. These sort of activities have become a regular thing….we just took it and made it part of our daily work.”

--38 year old male teacher, intervention village

Activity room

“You see, these countryside youth, after they got organized, at night after work and after dinner, they would go to the cultural activity room to rehearse programs, play poker, play chess. They didn’t have an opportunity to come into to contact with drug users.”

--60 year old male, Longchuan County official

Village protection teams

“The government also doesn’t know who is doing drugs where. If the drug users hear of any sort of disturbance, they will immediately run and hide, so it’s very difficult for the police. The village protection team lives here in the village, so they understand the situation clearly. They know exactly what time the drug users are coming and where they are hiding.”

--42 year old male, intervention village

Fear of the law

“Now there are 7-8 old drug users--there are no new drug users. In the past two years, the government policy has been stricter. So a few of them controlled their own problem and quit themselves. Since the policy has ben so strict in the past few years, they all got scared, they didn’t want to go to labor camp, so they quit themselves at home.”--46 year old male, control village

Government role

“There were effects, then once in a while the government wasn’t as strict, and it wasn’t as effective. The past two years have been good, government work groups have come here to help us and everything has gotten better. Before our farming equipment would all be stolen, in the past two years there has been no theft. The public safety situation has been better too.”

--46 year old male, control village

Fewer drug users

“So now things are relatively strict. Drug users in Longchuan have gone down a lot. One reason is because the government is focusing on it, another reason is because we have more awareness programs. Before it used to be that before the old drug users died, there were new drug users, it was very difficult to do work. Now with these few years of awareness and education programs, there are fewer and fewer drug users.”

--60 year old man, Longchuan County official

Economic improvement

“…sugar cane production has gone up. Before since there were a lot of drug users, there was less sugar cane planting done on the farmland, and there was little output. After these programs, sugar cane planting went up.”

--43 year old man, intervention village

Increased public security

“There are less drug users now. Before there were a lot of drug users, they would do nothing at home, all they could do was rely on the help of their family. Before there was also a lot of theft, if you put anything down at home, it would be stolen in a second, you couldn’t even relax when you were doing things at home. Those drug users don’t do drugs anymore, they’ve also built homes and their lives are much better. Their quality of life has improved.”

--40 year old woman, intervention village

Phase I - Discussion

• In general, stronger emphasis on enforcement

• Chinese policy toward drug users has changed (starting June 2008)

• Social desirability bias• No interviews with drug users

PHASE II - Quantitative study

June 2008

Phase II - Participants

• 774 males 15-39 years old from 18 intervention villages and 16 control villages

• 107 females 15-39 years old from two randomly selected control villages and two randomly selected intervention villages

*one participant was excluded for being too intoxicated after partially completing the survey

Phase II – Data collection• Village headmen notified all potential

participants.• Interviewer administered questionnaire

– door-to-door OR– at a pre-determined location and time

• Anonymous questionnaire– Demographics– HIV knowledge/attitudes– Tobacco and alcohol use– Sexual behavior– Drug behaviors/attitudes

Phase II - Analysis

• Descriptive – χ2 test– t-test

• Univariate– PROC GLIMMIX

• Multivariate– PROC GLIMMIX– PROC MIXED

Phase II – Analysis

• Primary outcomes– Drug initiation after May 1997– HIV knowledge

• Secondary outcomes– HIV/AIDS in Longchuan– Attitudes toward drugs and HIV/AIDS– Drug prevention programs

Drug use

Intervention(n=412)

Control(n=362)

Χ2

p-value

n % n %

Frequency of drug use

Never used drugs 286 69.8 303 83.7 <0.0001

Used drugs regularly 52 12.7 47 13.0

Occasionally used drugs 72 17.6 12 3.3

Drug initiation

Never used drugs 286 70.4 303 83.9 <0.0001

Started drugs before May 1997 53 13.1 21 5.8

Started drugs after May 1997 67 16.5 37 10.3

DemographicsIntervention

(n=412)%

Control(n=362)

%

χ2

p-value

Age15-19 16.0 21.6 0.134620-29 42.0 38.130-39 42.0 40.3

Marital StatusMarried 58.7 63.2 0.3469Unmarried 39.8 34.9Divorced/Other 1.5 1.9

Ethnic groupHan 16.8 24.3 <0.0001JingPo 56.7 33.4Dai 25.8 37.3Other 0.7 5.0

Education statusIlliterate 5.1 15.2 <0.0001Elementary school 38.0 42.8Middle school 52.3 39.8>Middle school 4.6 2.2

Drug initiation and demographics

OR 95% CI p-value

Age15-19 0.03 (0.01, 0.12) <0.000120-29 0.59 (0.41, 0.85) 0.004630-39 1.00 - -

Marital StatusMarried 1.00 - -Unmarried 0.31 (0.20, 0.48) <0.0001Divorced/Other 8.32 (2.71, 25.5) 0.0002

Ethnic groupHan 1.00 -JingPo 3.57 (1.93, 6.61) <0.0001Dai 1.50 (0.77, 2.94) 0.2308Other 3.80 (1.38, 10.48) 0.0099

Education statusIlliterate 3.47 (1.97, 6.11) <0.0001Elementary school 1.53 (1.03, 2.26) 0.0345Middle school 1.00 - ->Middle school 1.22 (0.44, 3.41) 0.6987

Risk Behaviors

Intervention(n=412)

Control(n=362)

χ2

p-value

n % n %

Has smoked cigarettes in past 30 days

No (<1 cigarette/day) 105 25.5 114 31.5 0.0642

Yes 307 74.5 248 68.5

Had alcohol in past 30 days

No 92 22.3 101 27.9 0.0480

Yes 320 77.7 261 72.1

Had sex with non-spouse in past year

No 326 79.7 307 86.7 0.0101

Yes 83 20.3 47 13.3

Drug initiation and Risk Behaviors

OR 95% CI p-value

Has smoked cigarettes in past 30 days

No (<1 cigarette/day) 1.00 - -

Yes 8.92 (4.49, 17.70) <0.001

Had alcohol in past 30 days

No 1.00 - -

Yes 3.44 (2.04, 5.78) <0.0001

Had sex with non-spouse in past year

No 1.00 - -

Yes 2.12 (1.40, 3.22) 0.0004

Multivariate model for drug initiation after May 1997

Controlling for intervention group, age, marital status, ethnicity, education, smoking, alcohol use, and pre/extra-marital sex.

OR 95% CI p-value

Intervention group 1.78 (0.96, 3.28) 0.0672

Age 15-19 0.10 (0.02, 0.45) 0.0027

Unmarried 0.35 (0.19, 0.66) 0.0011

JingPo ethnicity 3.04 (1.52, 6.09) 0.0017

Illiterate 1.89 (0.98, 3.63) 0.0578

Smoking 6.90 (2.98, 15.95) <0.0001

Drinking 1.89 (1.02, 3.51) 0.0431

Extra/pre-marital sex 3.81 (2.11, 6.87) <0.0001

HIV knowledge

Intervention(n=412)

Control(n=362)

p-value

Answered all questions correctly on HIV knowledge

43.5 14.4 <0.0001*

Average HIV knowledge score (out of 16)

13.6 10.3 <0.0001**

*Chi-squared test**t-test

Multivariate model for HIV knowledge

Correctly answering all questions on HIV knowledge HIV score

OR 95% CI p-value β p-value

Intervention group 4.66 (2.63, 8.24) <.0001 2.19 <.0001

Age 15-19 0.62 (0.36, 1.07) 0.0883 -1.57 0.007

Illiterate 0.18 (0.09, 0.37) <0.0001 -5.35 <.0001

Elementary school education

0.39 (0.28, 0.53) <0.0001 -1.95 <.0001

Controlling for intervention group, age, marital status, ethnicity and education.

HIV/AIDS data

1989-2007Intervention

(n=4404)Control

(n=4731)

Cumulative cases of HIV/AIDS 352 192

AIDS deaths 179 94

Prevalence of HIV (end of 2007)* 3.9% 2.1%

*No significant difference (t-test p-value=0.1302)

Attitudes

Intervention(n=412)

Control(n=362)

χ2

p-value% agree

Drug use is a severe problem in my village* 46.6 47.8 0.5715

Drug use affects me or my family* 82.7 72.9 0.0034

HIV/AIDS is a severe problem in my village* 37.8 40.1 0.7087

HIV/AIDS affects me or my family* 63.8 51.4 0.0006

Government should be responsible for preventing drug use** 94.2 97.5 0.0218

We should work together to help drug users** 95.6 96.4 0.5819

*Responses were recorded as “Agree,” “Disagree” and “Don’t know”**Responses were recorded as “Agree” and “Disagree”

Prevention programs

Intervention(n=412)

Control(n=362)

χ2

p-value

Is aware that village has Village Protection Team 87.4 83.4 0.2716

Is aware that village has cultural activity room 60.4 62.2 0.0783

Phase II – Discussion• Information on drug users scarce• Response rates relatively low• Disparity in response rates

• Results suggest that intervention affected knowledge without affecting behavior

CONCLUSIONS

Conclusions

• Improvements in knowledge• Overall decrease in drug use• Some programs remain• Current focus is on law

enforcement

Conclusions

• Rapid change in China makes it difficult to determine long-term effects

• Need for long-term follow-up on prevention programs

• Need better strategies to investigate drug use in community

THANK YOU!