Rapid assessment of the drug-injecting situation at Hanoi and Ho Chi Minh City, Viet Nam
Ho Chi Minh City
Recommendations and findings
Author: R. POWER
Pages: 35 to 52
Creation Date: 1996/01/01
This paper describes a rapid assessment of the drug-injecting situation in Viet Nam. The study, which was carried out over a five-week period during October and November 1993, focused on the cities of Hanoi and Ho Chi Minh City. A multi-indicator inductive methodoIogy was adopted that mixed qualitative and quantitative measures. As only limited background epidemiologic and official statistics were available, the study involved the generation of original data, through, for example, the construction of "cognitive maps" describing broad patterns of drug use, semi-structured interviews (for the collection of baseline data), focus groups, in-depth interviews and ethnographic observations.
The study revealed that the injection of "blackwater" opium proliferated, often in combination with a range of pharmaceutical preparations. High-risk injecting practices were common at both Hanoi and Ho Chi Minh City, drug scenes and congregation sites being more public and visible at Ho Chi Minh City. The implications for policy and practice are discussed, emphasis being placed on the need for outreach and peer intervention.
The main purpose of the study was to conduct a qualitative rapid assessment of patterns of drug use by injection at Hanoi and Ho Chi Minh City, Viet Nam, with reference to the implications for the spread of the human immunodeficiency virus (HIV), in particular:
To examine drug-use practices at Hanoi and Ho Chi Minh City, with reference to injecting, and to recommend intervention strategies to prevent the spread of HIV infection;
To train assistants in basic rapid assessment techniques in collaboration with relevant officials in each city;
To assess the drug-abuse situation in the two cities by conducting interviews with drug users, covering:
Which drugs were being used and how;
The cost and availability of drugs;
The cost and availability of injecting equipment;
The attitudes of drug users towards injecting;
Estimates of how many drug users shared the same injecting equipment and the social connotations of such sharing;
To examine present policy responses to the HIV problem;
To submit a report to the United Nations International Drug Control Programme, including an analysis of actual and potential risk of HIV and recommendations on intervention strategies aimed at persons who inject drugs.
It has been recognized worldwide that the sharing of injecting paraphernalia among drug users is an effective conduit for the spread of infection [ 1] . In November 1993, figures of the National AIDS Committee showed that, in 94 per cent of the 926 confirmed HIV cases in Viet Nam, injecting drug use was the prime risk factor. Although these figures partly reflect the testing procedures used (drug users were apprehended by law enforcement agencies and, upon entering treatment, were compulsorily tested), no studies had been undertaken to examine the social context of drug injecting. It was crucial to obtain research information in order to develop appropriate community-based strategies aimed at altering high-risk behaviour.
A multi-indicator approach was followed in the study in order to make optimum use of the time and resources available. Training of interviewers, research design, piloting of research instruments and fieldwork in the two cities took place between 19 October and 11 November 1993. The duration of the rapid assessment was between 17 October and 19 November 1993.
The overall approach was that of inductive analysis. The following methodology was used:
A "cognitive map" was constructed to describe the main congregation sites and broad patterns of drug use;
To collect baseline data (socio-demographic information; history of drug use; injecting behaviour), semi-structured interviews were conducted using carefully recruited, trained and supervised indigenous fieldworkers, some of whom were themselves recovering drug injectors [ 2] . Slight modifications were made to the questionnaire to take into account the needs and profiles of the two cities. After two pilot sessions at each site, a total of 120 completed questionnaires were collected (60 at each site).
Ethnographic and participant observation took place at sites (such as "shooting-galleries") where drug users congregated to buy and consume drugs;
Focus and discussion groups were held to investigate issues that arose in the course of the study. The focus groups comprised both active drug users and key individuals such as social workers and treatment centre personnel;
In-depth interviews were conducted with drug users and drug dealers in order to clarify issues and to provide illustrative case-studies.
In the present section, the profiles of drug use in both cities are described and data from all stages of the study are used to present an overall picture.
Of the 60 survey respondents at Hanoi all were injectors of opium. Forty-eight per cent of the respondents injected opium with both Dolargan and Seduxen and occasionally with morphine; 18 per cent used opium and Dolargan; and 15 per cent combined opium with Seduxen. Only 17 per cent of the respondents restricted their use to opium alone. One respondent (2 per cent) used morphine only.
The findings were confirmed by ethnographic and qualitative research, which suggested that opium use was the most common form of drug abuse at Hanoi. The opium originated in the provinces bordering the Lao People's Democratic Republic. It was prepared either from raw opium or, more commonly, from "blackwater" opium, a concoction made from the residue of opium that had been prepared for smoking. At Hanoi, it was common to mix the two solutions together.
Both solutions were processed and refined for injecting by boiling in water. The black residue from opium smoking ("blackwater") went through a number of repeated stages before it was ready for injecting. Initially it was boiled in water. Once boiled the first time, the residue was filtered through a muslin cloth and then reboiled. The process was repeated up to three times and then all the solutions were mixed into one. That solution was poured into a smaller container, or "pot" (a cup or mug with a capacity of 100-500 cc), for distribution to injectors.
Heroin use at Hanoi was extremely rue and had not been a factor in the drug scene since 1975. However, one heroin abuser had recently been treated at the Hanoi Treatment Centre. Both officials and drug users found it hard to identify heroin and cocaine and referred to those drugs as "white powder". However, a recent seizure of 5 kilograms of heroin, interdicted at the airport at Ho Chi Minh City en route to Frankfurt, demonstrated the potential for supplying heroin in Viet Nam. Drug users had heard of heroin use at Hanoi (from among other things, media reports) but had not come into contact with it themselves, as its high cost was prohibitive. No cocaine use was reported or observed during the study.
The pharmaceutical preparation Dolargan (pethidine), used as an anaesthetic in hospitals, but unavailable over the counter, was popular among drug injectors. It was often mixed with the opium solution. There were reports of theft of Dolargan from local hospitals. It was available on the black market and was often sold by dealers at "shooting-galleries".
All illicit drug use took place at private addresses and there was no "street scene" at Hanoi. Indeed, 88 per cent of survey respondents reported buying their drugs from "shooting-galleries". Drug injecting also took place in "shooting-galleries" (called "lo chich" at Hanoi), which were indistinguishable (except for the volume and traffic of people) from other residences in the city. Each "shooting- gallery" was controlled and managed by a dealer (the "chu"). In the Dong Da district alone, an estimated 15 "shooting-galleries" were in operation at any given time.
The price for 5 cc of injectable opium tended to be standard in the "shooting- galleries" throughout the city: 7,500 dong. However, in some "shooting-galleries" the price ranged from D 1,500 to D 2,500, depending on the concentration of opium. One ampoule containing 2 cc of injectable Dolargan cost D 18,000 and was commonly shared among three or four Nectors. By comparison, rice retailed at D 2,000 per kilogram.
The daily expenditure of the respondents averaged D 26,700 and ranged from D 2,000 to D 120,000, skewed by two drug dealers, who reported their daily expenditure for personal use to be D 80,000 and D 120,000 respectively. The mode, a more useful measure, was D 15,000 (or approximately US$ 1.50). The mean price per injection (including the cost of any pharmaceutical drug) was D 8,900 and ranged from D 1,000 to D 25,000. Again, that figure was skewed by two drug dealers, who used doses costing D 25,000 and D 30,000 respectively. The mode in this case was D 5,500.
In addition to selling to "shooting-gallery" customers, the dealer commonly had a hidden supply of prepared injectable optium That was often kept in a cupboard in the house and was served to persons who came to the location to buy the prepared drug for their own use or for resale. The most common container was a 0.75-litrc beer bottle (though some containers were as small as 100 cc or 200 cc). The injectable opium was measured from it, often into an ampoule with a rubber stopper that held 7 cc, which retailed for D 1,500 per cubic centimetre. Only individuals known to the dealer or recommended by a regular customer could avail themselves of that service. There was evidence that such buyers also received a free injection from the common "pot" of injectable opium, heightening the risk and multiple transmission of viral infection. That was particularly the case where buyers travelled from outside of the city and returned to their own towns and villages, where they injected within a small network of other drug users.
The venues for "shooting-galleries" were private enterprises and many injectors aspired to own and control them The majority of the managers of "shooting-galleries" were dealers who ran their operations to maintain their own drug habits. Due to police enforcement and surveillance, such operations were constantly shifting, their addresses opening and closing in tandem.
Drug users provided each other with information regarding the latest (and best quality) locations. In the Dong Da district, it was estimated that a highly reputed "shooting-gallery" serviced upwards of 100 injectors per day; one with an acceptable reputation for quality drug products serviced about 30 drug injectors per day.
Opium injecting was commonplace among the drug users at Hanoi. During discussions with injectors it was estimated that the ratio of females to males using that route of administration was approximately 1:30. The age of the respondents averaged 31.4 years and ranged from 19 to 63 years. There were 58 males (97 per cent) and 2 females (3 per cent); 20 per cent had been recruited from treatment centres and the remainder had come from the community, including 12 per cent who were recruited directly from "shooting-galleries".
Reports suggested that most females who injected opium were also sex workers. Some were as young as 16.
Males raised money for their drug use by a range of both legal and illegal activities. Forty-three per cent of the respondents were gainfully employed in a wide range of occupations, including "cyclo-drivers", porters, traders, carpenters and jewellers. A further 45 per cent were unemployed and 12 per cent stated that they were drug dealers.
At the "shooting-galleries" it was common for the dealer to provide the syringe (made from glass and manufactured in China) and perform the injections. A number of factors had led to that practice:
Drug injectors were able to hide needles on their person in an attempt to keep knowledge of their drug use from family members and fellow workers. A number of injectors stated that they were concerned that if they had their own syringes then their families would know that they were drug injectors. That was also a disincentive for buying syringes. One fourth (25 per cent) of the persons in the sample gave that reason for not possessing their own syringes;
Drug injectors were concerned that if they carried syringes on their person, the potential for breakage would be high. Over one fourth (28 per cent) of the persons in the sample gave lack of convenience as the main reason for not carrying their own syringes;
Due to the proliferation of "shooting-galleries", drug injectors could easily locate one at any time of the day and therefore had no need to inject at home. Nearly one third (30 per cent) of the respondents stated that they did not carry their own syringes because they knew that syringes would be provided by the dealers.
Although some injectors (13 per cent) stated that dealers allowed them to keep syringes at the "shooting-galleries", that practice was uncommon. The main reason behind the reluctance of the dealers to do so was that multiple syringes would be regarded by the police as clear evidence of drug-injecting activity on their premises;
By controlling the syringes, the dealers also controlled the amounts of injectable opium being distributed to customers.
Responses to the survey, as well as observations and group discussions, confirmed the key role of the dealer in injecting practices. Asked about their last injecting incident, 74 per cent of the respondents stated that it had taken place in a "shooting-gallery"; the remainder (26 per cent) reported that it had taken place in a private home. On that last occasion, 72 per cent of the respondents had been injected by the dealer, 17 per cent had injected themselves and 12 per cent had been injected by another drug injector.
It was common in the "shooting-gallery" for the dealer to take control of all the drug-injecting paraphernalia. That included cotton wool soaked in alcohol; a syringe (with a capacity of 10-15 cc, to contain enough drugs to be used for a number of injections); a small pan for boiling water; and a small stove. The drug solution was mixed and kept in a glass jar covered with a rubber lid. The drug solution was drawn up directly into the syringe by putting the needle through the lid. If the drug solution was contained in a larger "pot", then the dealer would cover the needle point with a piece of absorbent cottor4 which acted as a filter when the solution was drawn up into the syringe.
Case study 1: a dealer from a "shooting-gallery"
Nyg was 72 years old. He had lived at Hanoi all his life and his parents had died of cholera when he was 10 years old. His father had worked as a porter in a rice milling factory. After the death of his parents Nyg had gone to live with his aunt and uncle and after a short period of time had begun working in a factory. He had first smoked opium at the age of 35; he had been introduced to injecting "blackwater" opium one year prior to the interview. Like many dealers in the "shooting-galleries", he kept a set of injecting equipment for his own use and did not share it (or his supply of drugs) with others, though he provided a syringe to be shared among his customers.
Customers would bring their own needles or buy them from the dealer. Questioned about their last sharing incident, 32 per cent of the persons in the sample replied that they had used their own needles. At most "shooting-galleries", needles were replaced at the request of the customer. If drug users did not have their own needles, "new" ones could be bought from the dealer; the newly bought needles were needles that had been "recycled" (i.e. washed in water and sharpened if necessary). After the dosage and mixture were agreed on, the dealer performed the injection. Before and after the injection the dealer wiped the injection area with a piece of cotton wool soaked in alcohol. The same piece of cotton wool was used for many injections.
Owing to the monopoly that dealers exercised over syringes and the drug consumption in the "shooting-galleries", the sharing of injecting equipment and paraphernalia was commonplace. Though a substantial proportion of injectors used their own needles, the vast majority shared the dealer's syringe. Eighty-one per cent of the persons in the sample stated that they had shared a syringe with unknown drug users on their last sharing occasion and 18 per cent stated that they had shared a syringe with friends.
Once the opium solution was prepared for consumption, approximately 200 cc of it was placed in a "pot". The common dose per injection was 3 cc, although a heavy or regular user would draw 5-7 cc per dose. If 4 cc could be taken to be an average dose, each "pot" would yield 50 individual doses. Thus, it was possible that around 50 individuals would share the same "pot". That figure is likely to be an overestimation, as a number of users returned to the same "shooting-gallery" for a number of injections.
Seventy-five per cent of the persons in the sample stated that on their last sharing occasion, the drug solution had been drawn from a shared "pot".
A heavy user would inject three or four times per day, though not necessarily from the same "shooting-gallery". Many drug users reported injecting at specific times of day, such as at 7 a.m. and then at 5 p.m. Thus, both user and dealer would often know the expected time of purchase and injection. To protect their veins and limit the number of injections per day, some heavy users reported that they restricted themselves to two injections of 5 cc or more. However, as noted above, the majority would inject smaller quantities three or four times daily. Such patterns varied from day to day according to finances and supply.
The number of daily injections averaged 2.7 and ranged from one to six. Ninety- five per cent of the persons in the sample were able to stipulate specific times of day at which they injected.
The sharing of ampoules of Dolargan was common in the "shooting-galleries", as few could afford to purchase a single ampoule for their own use. Because of the constant fear of police raids, activity at the "shooting-galleries" tended to be purely functional with few if any social connotations. However, most injectors knew each other and mixed socially outside the context of the "shooting-gallery".
Case study 2: drug use in an "shooting-gallery"
Dom was a 30-year-old male, the youngest of five children. His parents had retired and his father had worked as a shop assistant in a cooperative meat retail outlet. All Dom's siblings worked as government officers. He felt rejected by his parents, who by the time of his birth had been having difficulties in their marriage. He had left home in his early teens and had led a rough life with other street children.
It was during that period that he had begun smoking opium. About three years prior to the interview he had injected the drug for the first time, having been encouraged to do so by a close friend who had told him of the heightened effect. His first injection Had been administered by the dealer of a "Shooting-gallery", who had used the common needle, syringe and "pot". Since that time, although he had know on of the dangers of acquired immunodeficiency syndrome (AIDS) from television and newspaper campaigns, he had never carried his own needle or syringe and had shared injecting paraphernalia at the "shooting galleries" that he had attended. He reported that the desire for the drug hat superseded his fear of the risks. His most common pattern was to inject 2 cc of opium once or twice per day. If he had sufficient money he would pool his resources and purchase an ampoule of Dolargan, which he would mix with 1 cc of opium and would share with four friend.
He had never attended a treatment centre. For two months in the previous year he had stopped taking drugs altogether by staying at home for two weeks and enduring the withdrawal symptoms. During that time his drug-using friends had been supportive and encouraging of his attempt to cease taking drugs. He was currently living at home with his aged parents and his older brother. They were unaware of his drug habit and he never used drugs at home. He often travelled across the city to "shooting-galleries" away from his neighbourhood in order to maintain his anonymity. He said that he was doing whatever was necessary to raise money for his drug use. His long fingernails were painted red, indicating the likelihood that he was operating in the sex industry.
Except for the few who had their own syringes (7 per cent of the persons in the sample described boiling syringes the last time that they had injected at home), the injector had no control over syringe hygiene in the "shooting-galleries". Some dealers sluiced syringes in boiled (though not boiling) water, which was poured from a flask. Of the persons in the sample, 53 per cent reported that that had been done on their last injecting occasion. The water would be used for multiple "cleaning" episodes and would rarely be changed before it became a dark pink colour. Others would flush the syringe plunger two or three times in the same water. Observations were recorded where shared needles were dipped (not rinsed) in water that had been warmed and cooled. Needles were often repeatedly sharpened for reuse. However, injectors in "shooting-galleries" were not able to insist upon any form of syringe cleaning. Many visited the "shooting-gallery" for the minimum amount of time necessary to purchase and inject their drugs and therefore had no knowledge of the preceding injecting episodes or the cleaning methods.
Drug users who injected at home reported various strategies for cleaning injecting equipment. Most reported sluicing the needle and syringe in boiled water for two or three minutes. No use of bleach was reported.
Of the persons in the sample, 69 per cent relied totally on the dealer for hygiene related to injecting practices, 12 per cent generally boiled equipment, 13 per cent used boiled water and 6 per cent did nothing.
As at Hanoi, opium was the most commonly used drag at Ho Chi Minh City. Cannabis was easy to obtain and that made Ho Chi Minh City attractive to some foreign drug users. Occasionally, cocaine was also available, but it was too expensive for local people.
The opium used for injecting originated in the northern provinces. As at Hanoi, two different preparations of opium were injected by the drug users: "blackwater" opium and raw opium Only a minority purchased the latter as it was deemed to be weaker, and few people had sufficient privacy and technical resources to prepare and refine the drug for injecting at home. Drug injectors also noted that injecting raw opium provided an acceptable initial "hit", but subsequent injection produced diminishing effects. Raw opium residue was sold in a variety of units. For example, the "chi" (approximately 2.6 grams) retailed at D 28,000 and the "goc tu" (one quarter of a "chi") cost D 7,000.
"Blackwater" opium was valued for its strength, as the refining process eradicated most of the impurities. It was sold in the "shooting-galleries" (called "dong chich" at Ho Chi Minh City). The residue was bought by the drug dealer from a variety of opium smoking dens around the city. It was then prepared for injecting and diluted by the "chu" and sold to the drug users. As at Hanoi, the opium solution was sold from a common "pot" in various units. At Ho Chi Minh City, 3 cc of the solution cost D 3,000.
It was common for users to mix the opium solution with pharmaceutical preparations to enhance the effect Most "shooting-galleries" provided a wide selection of such drugs. The range of pharmaceutical preparations available at Ho Chi Minh City. was greater than that at Hanoi. The preparations were always in ampoule form, already prepared for injection. The pharmaceuticals were mixed in the syringe with the opium solution. Many of the preparations could be easily purchased from normal retail outlets and the popular Dolargan was freely available on the black market. The most commonly mentioned pharmaceuticals were Seduxen (diazepam), Valium, Dolargan and Gardenal (phenobarbital). A variety of other tranquillizers were available; some were simply known among drug users as "Chinese tranx" or "Thailand tranx", depending on their country of origin.
A number of drug-injecting respondents noted the common preference for purchasing pharmaceutical preparations (especially Valium) whose expiry dates had elapsed. Drug users commented that such drugs produced a different and more powerful effect. A number of pharmacies kept ampoules of such preparations to be sold to drug users. For instance, ampoules containing 2 cc of Valium were sold to the public for D 5,000 each; those sold after their expiry dates had elapsed would be sold to drug injectors for D 7,000 each. Drug users noted that they could recognize preparations with elapsed expiry dates as their colour was a darker yellow than that of freshly stocked preparations.
Virtually no heroin had been available in Viet Nam since 1975. Many older drug users reported having used and injected heroin prior to that time, but since the withdrawal of the United States troops, its importation had been severely reduced and may have even ceased altogether. There was limited evidence of cocaine use among the 6hte and rich, but no "crack" use. The cocaine use had been observed at parties where foreigners had been present.
All 60 of the persons in the sample were current injectors; 92 per cent of them injected opium. Thirty per cent had been recruited from treatment centres and the remaining 70 per cent had been interviewed at congregation sites, including "shooting- galleries". Of the 18 persons reporting past heroin use, none reported having commenced such use after 1975. There were no reports of cocaine use. Fifty per cent reported having mixed and injected opium with other drugs (primarily morphine, Dolargan and Valium).
The majority purchased their drugs most often from "shooting-galleries" (47 per cent) or street scenes (38 per cent). Only 1 5 per cent stated that they most often bought drugs from other places, such as private homes. Daily expenditure on drugs ranged from D 2,000 to D 55,000. Three fourths (78 per cent) of the respondents spent D 10,000 (US$ 1) or less each day. Just over one fourth (28 per cent) of the respondents were employed and the remainder (72 per cent) were unemployed. Of the 60 respondents, 92 per cent (55) were male and 8 per cent (5) were female.Their ages ranged from 23 to 68. Twenty per cent were under 31 years of age, and 77 per cent were under 42.
The official population of Ho Chi Minh City in 1993 was 4.5 million. However, many people had migrated to the city from outlying and rural areas; thus, a more realistic estimate was 6 million. That led to a broad social diversity of the populace and heightened potential for anonymity. There were a number of networks of drug users that rarely overlapped. Those social networks were based on a complexity of factors, including such variables as class, education, parents' occupation, accommodation status, employment and allegiance in the conflict with the United States. One such group of drug users was the "thanh nien hu hong" (spoilt youths), who came from relatively wealthy families, met together for recreation and were often associated with powerful motor cycles.
Owing to the size of the city and the greater opportunities for anonymity, the drug scene at Ho Chi Minh City was more open than that observed at Hanoi. Injectors congregated and used drugs in parks, under bridges and on the streets themselves. However, a recent crackdown by the police had reduced the public nature of the drug scene, forcing groups of drug injectors to use more private and semi-public locations, as described below.
Ethnographic observation 1: Street scene
One street scene was on a busy side road in District One, which comprised many small shops and restaurants. Leading off the road was a labyrinth of narrow streets and alley-way six injectors (two of whom were women) were observed in various stages of intoxication. Some lay on makeshift beds; others leaned against the wall waiting for their turn to be injected. On a small table in the alley-way was a blue plastic mug (the "pot"), which contained the prepared opium solution. Only own syringe was observed, which the dealer used to inject his customers with the solution from the "pot". The opium itself was prepared in a separate room about 10 meters away, in a house in the next alley-way. None of the injectors endeavoured to hide what they were doing while everyday activity took place around them. Recent police activity had closed many of the outdoor "shooting-galleries" that had been commonplace in the city parks and other open areas on roadsides and side streets. Consequently, the drug scene had retracted into more secluded sites, such as the archways under the roadway near the Bach Dang river.
Ethnographic observation 2: Bach Dang river
An open-air "shooting-gallery" was situated in a series of arches under the road that flanked the Bach Dang river. The conditions were extremely unhygienic and it appeared that the drug injectors were using water from the river for the preparation of the solution. Two injectors were observed to be injecting into their groins (probably the femoral vein) using the same injecting equipment. About ten injectors (both male and female) congregated in the tiny cavity under the road, awaiting their turn to be injected. An informant commented that a stream of drug users had been going to the site since 7 a.m. At noon, the site was a bustle of activity. In an adjacent area there were a number of jetties where small boats ferried people across the river. A number of the small boats that served the area ferried prostitutes to the ships that were moored in the river and port. From the disproportionate number of women injectors at the site, it might be assumed that some of the injectors also worked as prostitutes, servicing the sailors from the ships, which came from a variety of countries. At such areas, the drug dealer kept everything needed for drug injecting inside a bag. That included a syringe, a box of second-hand needles, some new needles when ordered, a glass pot of water used for cleaning needles and syringes, cotton soaked with alcohol and filtered "blackwater" opium in a small glass jar. Usually a dealer carried only one "pot" of opium solution and one syringe made of plastic which would be thrown away if there was any danger of being stopped by the police. At Ho Chi Minh City it was common for a dealer to set up on open-air "shooting-gallery" by the roadside and quickly inject addicts until all the opium solution was expended.
The majority of the respondents reported that they would go to the "shooting- galleries" in order to hide their drug use from their families. Due to cramped living conditions, preparing the drugs in privacy was not an option for most injectors. Also, few had sufficient resources or contacts to buy opium in bulk. The semi-secluded "shooting-galleries" also afforded a degree of security from apprehension by the police. Some respondents noted that even when they used drugs on their own or with a group of friends, they often went to the park to avoid detection by their families.
A minority did use drugs at home. They were often individuals who were aware of the danger of infection from sharing injecting equipment; a number of them had been concerned about hepatitis infection prior to the emergence of HIV. One described how he would prepare raw opium. He would then seal a 20-30 cc "pot" (a small medicine phial or other container) with a rubber stopper into which he would insert two needles: one to aerate the solution and the other to draw it into the syringe. He would then attach a syringe to the one needle in order to measure out the required dosage. Occasionally, he would share his drugs with selected friends, but only if they had their own syringes and needles for injecting.
Case study 3: drug use in private
Li was a 38-year-old male from a wealthy family of jewellery merchants. He had lived all his life at Ho Chi Minh City. His father had been killed during the conflict with the United States in 1975 and he had two brothers and one younger sister. He had first used illicit drugs at the age of 15 in 1970 and had progressed from smoking to injecting heroin until 1975, when it had ceased to be available. He stated that he had been encouraged to inject by friends who had told him about the greater effects. He ran the family jewellery store and, because of his role as main economic provider, his drug use was tolerated. His business produced sufficient income to provide for all the needs of his family and to support his drug habit. He purchased his opium in ready-to-inject solutions, which he commonly mixed with pharmaceutical drugs such as Valium and phenobarbital. He injected twice daily (at 10 a.m. and 5 p.m.) 5 cc of liquid opium and 6 cc of pharmaceutical drug. He always used his own syringe and needle and never shared them. On the advice of one of his brothers, ad doctor in California, he had had an HIV test a couple of years prior to the interview. The test results had been negative.
One injector from Da Lat described how he would travel to Ho Chi Minh City to purchase "blackwater" opium. While in the city he would also visit the "shooting- galleries" to inject drugs. In his hometown there was a single "shooting-gallery" that was used by 15 injectors. Although they provided their own needles, only one syringe was used and all shared the same "pot".
Complete sets of needles and syringes were available at many outlets at Ho Chi Minh City, including market places and pharmacies. There was also a black market in syringes and needles. One doctor who disposed of his used syringes by placing them in garbage containers at his clinic noted that the refuse collectors sorted through the rubbish, cleaned the syringes and sold them to drug users.
Although plastic syringes were available, most drug users stated that they were not prepared to pay the retail price of D 5,000 and that dealers in the "shooting- galleries" (for many of the same reasons given at Hanoi) did not encourage them to do so.
The vast majority of injectors attended "shooting-galleries" where syringes and the drug solution were shared. At Ho Chi Minh City some drug users had their own needles, but the drug dealers controlled the syringes. Injectors stated that the "pots" from which the drug solution was drawn and measured into the syringe ranged from 500 cc to 1,000 cc. Assuming that an average dose was 4 cc, each "pot" could provide between 125 and 250 equipment-sharing episodes. Many commented that the solution in the "pot" became a dark pink before it was expended.
About one half (48 per cent) of the persons in the sample injected doses of 2 cc, though the doses ranged from 1 cc to 10 cc. The number of injections per day was evenly spread: 28 per cent reported one injection, 20 per cent reported two injections, 23 per cent reported three injections and 28 per cent reported four injections. Although 18 per cent reported injecting at set times of the day, the majority (82 per cent), stated that they injected at any time of the day, depending on their resources and the opportunity. That was somewhat different from the situation at Hanoi, where the majority reported regular injection times. Nearly one half (48 per cent) of the respondents reported that they used their own needles but not their own syringes when injecting. Twenty-six per cent reported that they did not carry their own syringes because they were concerned about being detected by their families or the police.
The majority (58 per cent) believed that by having their own needles they sufficiently reduced their risk of HIV infection and that they did not need to purchase their own syringes. Nearly two thirds (63 per cent) stated that a friend or a drug dealer always gave them the injection and 76 per cent routinely shared the "pot" of opium solution.
The situation at Ho Chi Minh City regarding the cleaning of injecting equipment was similar to that at Hanoi. In the "shooting-galleries", the dealers controlled all activities, including the level of general and injection-specific hygiene.
Just under one half (47 per cent) of the persons in the sample reported occasions where the syringe was cleaned in boiled (but not boiling) water from a flask, a further 29 per cent reported that the syringe was cleaned with unboiled water.
The main recommendations, and findings of the rapid assessment study, which were used to develop community-based intervention strategies in seven sites in Viet Nam, are summarized below.
Recommendation 1. Knowledge and awareness of the human immunodeficiency virus should be increased through the mass media and peer education
Precise information needs to be disseminated regarding the risk of HIV infection through the sharing of all injecting paraphernalia (including needles, syringes, the common "pot" and cleaning material). Although 72per cent of the 120 respondents from the two cities were aware that sharing injecting equipment (and sex without condoms) increased the risk of such infection, many drug users equated high-risk activity solely with the sharing of needles. Similarly, the majority were unclear about effective means of sterilizing injecting equipment.
The majority of both samples (67 per cent at Hanoi and 70 per cent at Ho Chi Minh City) noted that their main sources of information about HIV and acquired immunodeficiency syndrome (AIDS) were the mass media and drug-using friends. Both the media and health advocates should be utilized to provide appropriate information. Clear reference should be made to specific activities such as syringe- sharing in "shooting- galleries" and sharing from the "pot". Not only would that dual approach target particular types of behaviour, but it would also make apparent to drug injectors that the health advocates are cognizant of their lifestyle, thereby increasing their openness to the message being delivered.
Outreach teams and peer educators need to be trained in AIDS prevention work in order to deliver appropriate health information. Such groups should include health and social professionals, but also workers with first-hand experience in drug use and the drug scene where the outreach work is to take place. A number of studies have shown the value of using recovering and former drug users in that context [ 3] , [ 4] .
Given the important role of the drug dealers and managers of the "shooting- galleries" in both cities, outreach workers, especially indigenous fieldworkers, should endeavour to contact and work with them. The drug dealer and "shooting-gallery" manager are key figures and opinion leaders in the injecting community and have a high status. If only from a purely pragmatic point of view, drug dealers could be encouraged to promote low-risk injecting practices in "shooting-galleries". Such work is difficult and much effort is required to gain the trust and respect of such individuals. The selection and training of appropriate indigenous fieldworkers are crucial to the success of such an initiative.
Whereas work in treatment centres to encourage drug-free and healthy lifestyles and to promote reductions in high-risk behaviour among injecting drug users is to be applauded, it is imperative that community-based intervention strategies are developed to reach active drug injectors on their own territory. Such work is particularly useful in cities such as Ho Chi Minh City, where the drug scene is visible and drug users congregate at easily identifiable semi-public sites.
Community-based intervention strategies that target injecting drug users should be coordinated; non-governmental organizations and other agencies should work together to plan activities in order to avoid duplication. In a number of countries, various agencies have initiated outreach work without collaborating with other interested parties and that has led to a multiplicity of initiatives (often in the same city) and duplication of both resources and efforts.
Recommendation 6. Action research programmes should be implemented to promote behavioural changes and evaluate and monitor intervention strategies
Given the mechanics of drug injecting in the "shooting-galleries", it is likely that levels of high-risk sharing activity will persist for some time. It is recommended that a number of action research programmes should be put in place. The main focus should be on outreach work, but targeted intervention strategies should also be initiated.
The viability of the use of bleach as a disinfectant in Viet Nam should be investigated. Many of the "shooting-galleries", especially at Ho Chi Minh City, are in semi-public and public areas, where the boiling of injecting equipment is difficult. Additionally, many of the syringes on the market lack the robustness to be boiled. Therefore it is recommended that full-strength household bleach (5.25 per cent sodium hypochlorite) should be promoted [ 5] . Intervention strategies should be initiated to provide bleach and educate drug dealers and drug users in its effective use. It should be possible to provide small, inconspicuous plastic bottles that can contain sufficient bleach solution for one cleansing operation. Larger containers should be placed in "shooting-galleries" for more general use. Simple before-and-after action research studies should be undertaken to evaluate the effectiveness and uptake of this form of intervention, plotting the incidence of new HIV cases among that population. Ideally, evaluation should be an integral component of any new intervention strategy and should be included in the design stage.
The present rapid assessment project illustrates two main points. First, useful data can be collected within a relatively short period and with limited human resources by closely collaborating with relevant agents from the host country and other interested parties, such as experienced non-governmental organizations. Secondly, adopting a multi-indicator approach facilitates the gathering of data that can be used to determine the appropriate form of intervention.
It should be emphasized that the spread of HIV infection takes place in the context of specific social environments and that certain social behaviour leads to high- risk activity that facilitates the spread of infection. Thus, by recognizing and recording the precise nature of drug patterns and high-risk social activity and milieux (such as the sharing of injecting paraphernalia) appropriate intervention strategies can be developed to arrest the spread of HIV and other infectious diseases. The spread of such infectious diseases can be reduced by providing information and otherwise promoting the desired change in social behaviour. In many countries throughout the world, introducing needle and syringe exchange schemes, promoting the disinfection of injecting equipment and educating drug injectors about low-risk practices have reduced the sharing of injecting equipment and, in turn, the incidence of infection [ 6] .
Where intervention strategies are introduced, there are two prerequisites for success. First, politicians and policy makers need to accept that HIV and AIDS are greater threats to the well-being of individuals and to society than illicit drug use per se. For many countries this means a pragmatic shift in the policies and practices aimed at illicit drug users, a shift away from law enforcement and towards a public health agenda. Some have described it as a harm minimization approach to dealing with the issue of drug injecting and HIV infection. In practical terms, and without condoning illicit drug use, it means accepting that some individuals will continue to use drugs and will continue to inject. Advice must be given to such individuals to reduce the likelihood of their becoming infected with HIV or passing the infection on to others. Groups such as drug users are often seen as spreading HIV infection to society at large through sexual transmission. Preventive measures not only protect the individual, but also are in the broader interests of society.
The second prerequisite for success is that interventions are appropriate to the target population and the prevailing social, political and economic climate. It may be politically and economically inadvisable to recommend wholesale needle and syringe exchange programmes in a country where, because of serious shortages in medical supplies, such injecting equipment is not available for routine hospital work. Suggested interventions must also be sensitive to the social behaviour and daily routine of the target group. In that context, ethnographic and qualitative research are crucial in describing the precise nature of social behaviour, the context in which it takes place and its social meanings [ 7] . Armed with that knowledge, intervention strategies can be devised that fit into the daily lives of the target group and that are more likely to be accepted by them. It is important to provide drug injectors with both appropriate knowledge and the practical means to effect behavioural change.
The data from the present study show that despite differences, there are a number of factors common to both cities, such as the practice of syringe sharing at "shooting- galleries", the control exercised by the drug dealer, the sharing of the common "pot" and ineffective hygiene; consequently, some foals of intervention are likely to be applicable to drug injectors in Viet Nam as a whole.
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R. Power, "Methodological and practical implications of employing drug users as research workers", Challenge and Innovation: Methodological Advances in Social Research on HIV/AIDS, M. Boulton, ed. (London, Taylor and Francis, 1994), pp. 97-111.03
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J. Kelly, J. St. Lawrence and T. Brasfield, "Community AIDS/HIV risk reduction: the effects of endorsements by popular people in three cities", American Journal of Public Health, No. 80, 1992, pp. 1483-1489.05
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World Health Organization, Programme on Substance Abuse, WHO Collaborative Study Group, "An international comparative study of HIV prevalence and risk behaviour among drug injectors in 13 cities", Bulletin on Narcotics (United Nations publication), vol. 45, No. 1 (1993), pp. 19-45.07
R. Power and others, "Drug user networks, coping strategies, and HIV prevention in the community", Journal of Drug Issues, No. 25, 1995, pp. 565-581.