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

1. Long-term Follow-up of Community-based Drug and HIV Prevention Intervention in Yunnan, ChinaDebby Lee OhUCLA Department of Epidemiology Funded by the National Institute on Drug Abuse and the UCLA Global Health Training Program

2. To investigate the long-term effectiveness of a multi-component community-based drug and HIV prevention intervention implemented in Yunnan, China in 1997. OBJECTIVE

3. Specific aims • Identify and characterize the components of the 1997 drug abuse intervention that are still in operation. • Describe the current drug use situation. • Measure knowledge, attitudes, and behaviors related to drug use and HIV/AIDS.

4. Overview PHASE I • Qualitative study – May 2007 • 30 in-depth interviews with village and county level leaders PHASE 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)

5. BACKGROUND

6. HIV in China (2007) 700, 000 PLWHA (0.05%) 50,000 new infections in 2007 71.3% PLWHA are male 44.7% heterosexual activity 42.0% injection drug use 12.2% homosexual activity 1.1% mother-to-child 617 methadone clinics 729 needle and syringe exchange sites

7. 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

9. Longchuan County

10. Longchuan statistics • Population 173,000 • Over half are ethnic minorities • Jingpo • Dai

11. 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

12. 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

13. 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.

14. 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.

15. 1997 intervention • Games • Videos • Agricultural classes • School curriculum • Skits • Activity center • Youth work core

16. 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)

17. 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

18. PHASE I - Qualitative studyMay 2007

19. 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

20. 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

22. 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

23. 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

24. 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

25. 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

26. 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

28. 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

29. 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

30. 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

32. 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

33. 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

35. 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

36. 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

37. 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

39. 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

40. PHASE II - Quantitative studyJune 2008

41. 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

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

43. 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

44. Phase II - Analysis • Descriptive • χ2 test • t-test • Univariate • PROC GLIMMIX • Multivariate • PROC GLIMMIX • PROC MIXED

45. 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

46. Drug use

47. Demographics

48. Drug initiation and demographics

49. Risk Behaviors

50. Drug initiation and Risk Behaviors