Fuzhou market workers get comfortable with condoms. (Photo courtesy of Stephanie Sun and Sheng Wu)
Fighting HIV in the Golden Triangle
UCLA researchers find grassroots approaches to curbing the spread of HIV in China and Vietnam.
The Golden Triangle contains border regions of Myanmar, Thailand, Vietnam, and southeastern China. UCLA Professor Roger Detels said that the "extraordinary valley" was one of the most beautiful places he had ever seen.
"But they have a huge drug problem," Detels explained. And with that drug problem has come a rampant spread of HIV, the virus that causes AIDS.
Detels, a former chair of UCLA's Department of Epidemiology, spoke Nov. 8 at a colloquium put on by the Center for Southeast Asian Studies. It was the first of two UCLA events in two days about interventions designed to curb the spread of HIV in China and Vietnam.
In a Nov. 9 presentation sponsored by the Center for Chinese Studies, Sheng Wu and Stephanie Sun, researchers at the UCLA Semel Institute's Center for Community Health, explained that the stigma attached to HIV infection in China made it even more difficult to address the problem. The Chinese government reports that, in the whole country, 840,000 people live with the virus, a number that could grow to 10 million by 2010, according to some experts.
In a one-year span in the late 1990s, high rates of HIV infection spread from the southern part of Vietnam, near Ho Chi Minh City, to the north and across the Chinese border. The epidemic was striking younger victims, particularly male injected-drug users (IDUs).
Although Detels would move on to Vietnam, at the time he was refining his strategies in the southeastern Chinese province of Yunnan. His 1998–99 community intervention study was based in China's portion of the Golden Triangle, one of the first places to see HIV spread by syringes.
Intervention in drug use has taken many forms, including rehabilitation and chemical replacement, or the weening of IDUs off injections and onto pills in order to reduce the chances of spreading the virus. Detels' study focused on the effectiveness of education and community involvement. "One thing China does well," he explained, "is imposing the will of the community on the individual."
Detels and his team watched two villages, one as a control for comparison. In the other, Detels worked with village leaders to educate the community about curbing the use of injected drugs. He brought together healthcare leaders, workers' leaders, teachers, and police, telling them, "We understand that you have a problem."
Then Detels and his team simply listened. The leaders began to open up about HIV in their village. For two hours, they talked about not having enough resources and support from Beijing to combat the problem. Then one woman, Detels recounted, said, "These are our kids. We should do something for them."
"When she said that, I knew [the intervention] would work," said Detels. "We had overcome the first and the most important step in any community intervention. We had gotten the community to accept the responsibility to do something about this problem."
The team then set out to develop culturally appropriate intervention methods with the leaders' help. Members developed videos and posters, meetings, and discussion programs. They performed skits and engaged youth groups. They got young villagers to perform service such as repair work and to build a recreation center with ping pong tables.
"I think that the impact of that wasn't so much what they did, but the fact that they did it and had a visible impact gave them self-esteem," said Detels. "And I think self-esteem is a very key factor in trying to reduce problems like drug use."
Village leaders even introduced an elementary-school program that discussed HIV and drugs, a novelty in their culture. The program reached students in a village where children often do not attend high school. It was "a little too successful," Detels said facetiously. The control village, which was not supposed to have any intervention, found out about the curriculum and adopted it in their own schools.
A year and a half later, Detels conducted a retrospective survey. He found that in the village with purposeful intervention, the incidence of new drug users went down significantly in men, particularly among people 15 to 19 years in age (a 4.8 percent reduction), illiterate villagers (over 6 percent), and in an ethnic minority known as the Jingbo (about 3 percent).
Replicating Results in Vietnam
One of Detel's former students, now an epidemiologist at the Hanoi Medical School in Vietnam, found out about what his teacher had accomplished in Yunnan. The Vietnamese government soon asked Detels to do for the northern Vietnamese city of Halong—also part of the Golden Triangle and also hugely affected by the spread of HIV through injected-drug use—what he had accomplished in China.
"I must admit that I had some misgivings," said Detels. "I didn't think the communes [of Vietnam] had the same sense of community" as Yunnan villages. Halong was much more urban than the village of his last study.
Nonetheless, Vietnam's need for intervention was as dire. By 2002, the country had 45,000 known IDUs and over 45,000 people living with HIV, mostly young men and largely in the 15- to 25-year-old age group.
Detels approached his work in Halong with the same strategy he had used in Yunnan. Most enthusiastic about taking on the problem, recounted Detels, were the police and Communist Party and Social Evils Department representatives.
These leaders, like those in Yunnan, came up with intervention strategies. The idea was to change community norms, to reduce the stigma associated with drug use and HIV. "Instead of looking down on drug users, the community is trying to do something to solve the problem," Detels said.
He recalled a skit the Halong group put together. A poor, young man and his sweet girlfriend were approached by a drug pusher who was wearing a tall black hat and a handle bar moustache. "It was hysterical. And it was really overacted," Detels laughed. But it was also effective: The audience cheered the young man's resistance and booed the drug pusher away.
"Here you are on a Saturday morning listening to La Traviatta"—Detels is an opera fan—"and you come up with this idea. Three years later, here you're seeing a hysterical play that's a product of your idea," Detels recounted. "And to see it actually come to life 8 or 10,000 miles away is extremely exciting."
Although the follow-up survey to measure the impact of intervention in Halong will not happen until next year, Detels has already seen improvements. Community leaders asked him to start replacing injected drugs with oral pills, a pragmatic program that they were initially against.
Reducing Stigma, Infection
Semel Institute researchers Wu and Sun are taking note of cultural mores that hinder efforts to curb the spread of HIV in China.
Discrimination against people living with HIV is prevalent in China, said Sun, making it difficult for patients to get effective care. The National Institute of Mental Health funded Wu and Sun's three-year study of how this stigma affects healthcare workers in Yunnan province. Their research group has interviewed 1,100 healthcare workers from provincial, city, and county hospitals, as well as township and village clinics, to collect data about how stigma comes about and what effects it has on the quality of health care.
Now the team, at UCLA and in China, is designing its intervention plan based on the data.
Sun said the study so far has shown that "family is very important in helping HIV-positive individuals to deal with the disease."
The pair's other study in China is informed largely by Detels' work. With funding from the National Institute of Mental Health, Sun and Wu are measuring the effectiveness of intervention by people identified as leaders of community opinion in reducing high-risk behaviors, such as unprotected extra-marital sex. The work is being carried out in the southeastern Fuzhou province.
Sun describes Fuzhou's capital as a developing city that combines older structures with modern buildings. The research group, which began its work in 1999 in collaboration with the Research Triangle Institute, Johns Hopkins University, and the Medical College of Wisconsin, focuses its work on markets. Team members are collecting information from 4,500 stall workers, 15 percent of whom they identified, with locals' help, as community opinion-makers. Sun, Wu, and their colleagues taught this smaller group about safe sex, open communication, and the importance of regular health checkups.
"The layout of the market allows frequent interactions between people, among people," said Sheng, "and so they have conversations every day working in the market."
The intervention seeks to change attitudes through these conversations, with the leadership group influencing others' behaviors. The opinion leaders also initiate social events to encourage discussion and act out scenarios in skits. One skit showed a market worker expressing anxiety about his extra-marital unsafe sex and a community leader telling him he should be checked at a clinic and use condoms. Sheng said that such interventions are effective in reducing high-risk behaviors because "friends influence friends" more successfully than outsiders judging or preaching.
Sun and Wu are still collecting data from markets they have added to their study, going back to the sites about every two months. The results will be analyzed when that project concludes in 2007.
Published: Friday, November 18, 2005