HIV/AIDS and other Infectious Diseases.

Addiction and infectious diseases are closely linked regardless of the type of addiction (drugs, alcohol, sexual). Injection of drugs such as heroin, cocaine, and methamphetamine accounts for a big proportion of HIV cases in Vietnam and is a major driver for the spread of Hepatitis. Drugs and alcohol affect judgment and behaviour, thus increasing the likelihood for partaking in high-risk activities such as unprotected sex and needle-sharing. As a result, common infectious diseases among addicts include HIV, Hepatitis B & C and Sexually Transmitted Diseases (STDs).

Human Immunodeficiency Virus & Acquired Immune
Deficiency Syndrome (HIV/AIDS)

HIV must be transmitted directly from one person to another through human body fluids that contain HIV infected cells, such as blood, semen, vaginal secretions, or breast milk. It cannot survive outside the human body for long periods of time.

The most effective way of transmitting HIV is by direct contact between the infected blood of one person and the blood supply of another, this makes sharing of needles the most effective mode of transmission since the virus goes directly into the bloodstream in a short period of time. A person is about 5 times more likely to contract HIV through anal intercourse than through vaginal intercourse. Studies have shown that circumcised men have up to 60% reduced chance of acquiring HIV through vaginal sex, however male circumcision does not protect women from acquiring HIV from an infected partner.

HIV is spread via unprotected sex, needle sharing/ needle stick injuries, through mother to child during pregnancy, delivery of breast feeding, by tattoos/piercings as well as blood transfusions and organ transplants.

HIV/AIDS is a large and increasing problem in Vietnam putting a heavy burden on the national health system and with severe adverse affects on the patient, his or her family and society as a whole.

The latest epidemiological data indicates a more serious epidemic could be on the way and if the response is not swift enough it could threaten the long-term socio-economic stability of the country. Today one in 50 households in Vietnam has a person living with HIV. According to revised official statistics, it is estimated that the number of people affected is above 310,000, and projections suggest that the number to increase to around 500,000 by 2015.

The number one reason for contracting the disease in Vietnam is the sharing of needles or syringes – in other words the spreading of the disease is closely linked to drug addiction.

Vietnam’s HIV epidemic is at a concentrated phase, meaning that the majority of cases are found among high-risk groups, and fewer cases in the general population. The main driving force behind HIV transmission at the moment is through needle sharing practices by IDUs, followed by commercial sex work.

HIV is an infection for life. There is no cure, but anti-HIV drugs (ARVs) can keep HIV in check for years. This makes it a chronic but treatable disease. As a result of better treatment, deaths from AIDS have declined almost 60 % since 1995 globally.

NGO Fontana closely follows the development of disease, and forms alliances with organizations combating and informing about the disease.

A number of patients in treatment at centers with which NGO Fontana has been collaborating suffer from the disease, and a number of dedicated HIV/AIDS clinics have a large number of infected people with addiction problems. Working together to combat both addiction and HIV transmission therefore benefits both groups dealing with HIV and drug/alcohol abuse prevention.

The only current treatment method for addiction provided by the Vietnamese government is punitive via “06 and 05 centers”. Sadly, incarcerating addicts for years is not an effective way to treat them of their addiction, causing the vast majority to relapse within the first year upon release. Conditions in these centers infringe their human rights and deny them of adequate care. Furthermore, such centers act as incubators of disease, increasing HIV and hepatitis transmission rates. Those held at centers are not told their HIV status when tested and do not receive ARV or counseling. As a result, many go on to pass the infection when released into the community.

HIV and alcohol are common denominators when it comes to sexual violence, for victims and perpetrators.

NGO Fontana works hard to advocate for scientifically proven treatment methods to be used in Vietnam. Previous projects have included training of counselors on the 12-step program working in HIV/AIDS and outpatient clinics in Ho Chi Minh City, so as to reduce relapse rates and counsel them on HIV issues. It is our belief that effective alcohol and drug treatment are key to HIV prevention & treatment, and should be included in HIV programs.

What are the treatments?

Treatment with combinations of drugs can keep people with HIV from getting full-blown AIDS. It is absolutely essential to take the drugs at the right time of day, every day. Sometimes the drugs’ side effects make this hard to do.

Because HIV is constantly mutating, no two people are infected with exactly the same virus. Treatment must be planned and adjusted for each individual.

Most doctors recommend postponing treatment until a persons’ immune system starts to fail. This decision is based on the CD-4T cell count the best measure of HIV disease. Another factor is how much HIV is in the blood, a measure called the viral load.

As HIV mutates quickly it becomes resistant to any single treatment, which is why doctors use combinations, or cocktails of ARVs. Over time, a virus resistant to multiple drugs may appear. At this point a physician will switch to another drug combination.

Once a person is infected with HIV, alcohol and other drug use hastens the development of AIDS, and use of drugs and alcohol may interfere with drugs given to fight HIV infection.

A person who first learns that he or she has HIV will typically experience a vast range of emotional responses. At first he or she may be in denial. A perfect example of this is the thought that maybe the doctor is looking at the wrong chart. Later a person may become angry at himself or herself, at the virus, or perhaps at the person, place, or situation they hold responsible. Another typical response is bargaining, where a person may say to himself or herself, “ I’ll be real good from now on if God makes this not true”. Most people experience a period of depression following diagnosis, which may include feelings of hopelessness and despair and suicidal thoughts. Eventually, many people reach a level of acceptance and begin to take responsibility for fighting back. The people who reach this stage seem to share one common characteristic: They are involved in some sort of support group.

Hepatitis C

The Hepatitis C virus (HCV) is most commonly spread by contact with infectious blood, via sharing of needles, cuts on skin, blood transfusions, organ transplants, needle stick injuries in health care settings and mother to child at birth. It is rarely transmitted through sexual contact with an infected person. It is not spread through breast milk or sharing of food/water. Recently-infected individuals usually go through a symptomatic acute phase, although some may show no symptoms of disease. An average of 20% clears the infection within 6 months; the remaining 80% go on to develop chronic infection. Hepatitis C in the chronic stage causes liver damage but can also affect other areas of the body such as the digestive system, lymphatic system and brain.

The risk of infection is highest when sharing contaminated needles since blood has the highest levels of virus, it is the most direct way of entry for the virus, and it can survive for up to 4 days in dried blood. Due to this, Hepatitis C is sometimes considered an IDU disease and those infected subjected to stigma. Studies have shown a prevalence of 46% HCV infection among heroin injecting groups in Vietnam.

Although a vaccine for Hep C is not available, it is possible to get treatment to help clear the infection although not everyone responds to it. The best thing to do is prevent infection by always using sterilised equipment and having safe sex.

Hepatitis C and STD/HIV co-infection

HIV-HCV co-infection is common due to the shared modes of transmission, 50-90% of IDUs have both infections. HIV is thought to increase infectiousness of HCV and can accelerate liver disease progression in patients. In addition, alcohol consumption is also associated with accelerated disease due to the damage it causes to the liver. End-stage liver disease is now a leading cause in AIDS deaths, which makes screening and treating HCV imperative to HIV positive individuals.

There is evidence of an increased risk of HCV sexual transmission among non-injecting MSM. The main risk factors were noted as high-risk sexual behaviours (multiple partners, receptive sex) whilst on drugs; in particular, methamphetamine was significantly related to acquiring HCV.

HCV transmission appears to be facilitated by STDs. Given that HCV is spread by contact with contaminated blood, ulcerative diseases such as herpes and syphilis can facilitate sexual transmission of HCV among individuals.

Hepatitis B

Hepatitis B is a preventable disease as a vaccine is available and is recommended for everyone; in particular to high risk groups such as IDUs. It is estimated that 15-20% of the adult population in Vietnam has chronic HBV. Transmission occurs through contaminated body fluids such as blood and semen, via sharing of contaminated needles, unprotected sex, mother to child transmission by birth, sharing of toothbrushes/razors with an infected individual and needle sticks associated with healthcare settings. HBV can be infectious more than seven days outside the body, and is 50 to 100 times more infectious than HIV.

Given that Hepatitis leads to inflammation of the liver, and can lead to cirrhosis (as can alcoholism) it is important to address these infections as early as possible to avoid them becoming chronic.

Sexually Transmitted Infections (STIs)

It must be noted that although the terms STDs and STIs are used interchangeably, there are in fact differences between them. An infection relates to the presence of an infectious agent in the body, but not necessarily leading to symptoms. A disease refers to the state where a person is symptomatic; they may or may not be infectious.

STIs are infections of bacterial, viral or parasitic nature acquired by sexual contact. The most common are Chlamydia, Gonorrhoea, genital Herpes and Syphilis. The best mode of prevention is by practising safe sex (monogamous relationships and consistent condom use) or abstinence. Although treatment is available for some STIs, transmission is facilitated by several important factors. These are; many people are asymptomatic for a long time (thus passing on an infection they are not aware of having), are reluctant to get tested (and therefore treated), some groups have significant barriers to and antimicrobial resistant is beginning to be a problem, particularly for Gonorrhoea. Herpes is a life-long disease which can be managed, but not cured.

Drugs and alcohol increase the chance of acquiring/giving STIs by the way it decreases cognitive restraint and increased risk-taking, this affecting judgment and behaviour. A person who is under the influence is more likely to make risky decisions around sex such as having unprotected sex, having sex with a stranger and/or commercial sex worker, increased number of sexual partners, in addition to undermining condom negotiation and correct use. The context in which people drink, and drinking practices themselves strongly determine sexual behaviour. Studies have shown increased HIV infection rates among people who excessively drink alcohol at once (for example, heavy drinking over the weekend, furthermore the problem is increased when a lot of bars and drinking venues sell sex too.

Addiction has severe effects on disease prevention and treatment for various reasons. Firstly, drug taking is affected if people under the influence forget to take their medication thus affecting drug adherence. This is particularly important in cases of HIV where drug regiments are strict and life-long. On a biomedical level, alcohol has also been shown to increase the receptiveness of cells to HIV, affect the production of T-cells and thus impact the immune system.

Rehabilitation is a crucial part of infectious disease prevention which has not been adequately addressed and should be included in prevention programmes. The effect drugs and alcohol have on the spread of HIV and other infectious diseases should not be underestimated, and must be more openly addressed.