28
LIST OF CANDIDATE’S SURVEYS ASSOCIATED
WITH THESIS PUBLISHED
1. Nguyen Tien Hoa, Nguyen Tran Hien, Nguyen Thi Lan
Anh, Le Anh Tuan (2010), Status of HIV, HBV, HCV
infections and risk factors among injecting drug users and
female sex workers in Hanoi, 2008, Journal of Preventive
Medicine, Volume XIX, No 8 (116), pp. 50-56.
2. Nguyen Tien Hoa, Nguyen Van Luyen, Nguyen Thuy
Linh, Bui Thi Lan Anh, Đo Huy Duong, Vu Thi Hong
Duong, Nguyen Thanh Binh, Le Anh Tuan, Nguyen Tran
Hien (2011), HIV, HBV, HCV prevalence and risk factors
among injecting drug users and female sex workers in Hanoi,
2008-2010, Journal of Preventive Medicine, Volume XXI, No 7
(125), pp. 140-147.
1
MINISTRY OF EDUCATION- TRAINING - MINISRY OF PUBLIC
HEALTH
NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY
NGUYEN TIEN HOA
SITUATION OF HIV, HBV, HCV
Thesis is protected at the assembly point of thesis at Level
of Institute, meeting at the National Institute of Hygiene
and Epidemiology, at last….now… dated… 2012 year.

Thesis can find out at:
1. National library
2. Library of National Institute of Hygiene and
Epidemiology

27
3. To enhance further researchs of the molecular epidemiology of blood
borne viruses order to surveillance and determine molecular epidemiological
characteristics of HIV, HBV, HCV infections in Vietnam.
4. It should be having measures to strengthen hepatitis B vaccination for high
risk subjects.

26
For HBV/HCV co-infection among IDUs and FSWs, HCV-6 and HCV-1
genotypes ware similar.
3. Several influencing factors increase the transmission of HIV, HBV,
HCV among IDUs, FSWs, HDPs and MTPs in Hanoi, 2008-2010:
+ Risks for HIV, HBV, HCV infection among IDUs and FSWs was drug
injecting. The longer time of drug injecting, the higher rate of HIV, HCV
infections; Risks for HIV, HBV, HCV infections among HDPs and MTPs,
Duration of heamodialysis lasts many years and HDPs receives blood

Coinfection is modified the natural history of monoinfection. Further,
coinfection with viral hepatitis may complicate the delivery impacting the
selection of ART by increasing the risk of drug-related hepatoxicity and of
specific agents. Owing to characteristics of disease transmission like that those
agents has very high potentially transmission among special population groups
which has behaviors or conditions increases transmission as injecting drug use,
female sex worker, heamodialysis patients, multi-transfusion patients (at high
risk groups). Those high risk groups has very important role among the
epidemiology and public heath for the dangerous communicable diseases
spreaded to the famillies and the general population. Based on those problems,
we had searched thesis: “Situation of HIV, HBV, HCV infection and
associated factors in some high risk populations in Hanoi, 2008-2010”.

OBJECTIVES:
1. Determine the rate of HIV, HBV, HCV infection among Injecting drug
users, female sex workers, heamodialysis patients and multi-tranfused patients
in Hanoi, 2008-2010.
2. Determine genotypes of HIV, HBV, HCV among at high risk several
subjects in Hanoi, 2008-2010.
3. Describe several risk factors increasring of HIV, HBV, HCV transmission
among Injecting drug users, female sex workers, heamodialysis patients and
multi-tranfused patients in Hanoi, 2008-2010.
4

NEW CONTRIBUTIONS OF THESIS

- To determine prevalence of HIV, HBV, HCV among some at high risk groups
CONCLUSIONS

1. The rate of HIV, HBV, HCV infection among IDUs, FSWs, HDPs and
MTPs in Hanoi (2008-2010):
1.1. Among Injecting drug users: HCV prevalence was highest (60.0%,
57.3%, 69.3%) and had an increasing tendency (p<0.05). HIV prevalence was
high (43.0%, 37.7%, 30.5%) but had an decreasing tendency (p<0.05) and
HBV prevalence (16.5%, 15.1%, 12.5%) was decreasing. HIV/HCV co-
infection was highest (86.0%, 92.0%, 100%), then HIV/HBV co-infection
(15.1%, 6.7%, 16.4%) and HIV/HBV/HCV co-infection (10.5%, 6.7%,
16.4%).
1.2. Among Female sex workers: prevalence was highest (45.0%, 39.0%,
25.5%) but was decreasing (p<0.01) then HCV prevalence (24.6%, 27.0%,
21.5%) và HBV prevalence(14.5%, 9.0%, 9.5%). HIV/HCV co-infection was
highest (32.2%, 32.1%, 52.9%) and had an increasing tendency (p<0.05) but
HIV/HBV co-infection (12.2%, 9.0%, 7.8%) và HIV/HBV/HCV co-infection
(3.3%, 3.8%, 2.2%) had an decreasing tendency.
1.3. Among Haemodialysis patients: HCV prevalence was highest (45.0%,
28.7%, 31.3%) and had an decreasing tendency, then HBV prevalence(12.0%,
11.3%, 10.7%). HBV/HCV co-infection was small.
1.4. Among Multi-transfused patients: HBV prevalence(7.0%, 6.7%, 5.4%)
and HCV prevalence (13.0%, 5.3%, 3.3%) were the same and had an
decreasing tendency .

2. HIV genotype of injecting drug users and female sex workers was

identified among the injecting drug user, according to us, may be associated
with complicated and high risk of the injecting drug user. They infected HCV
by many transmittable modes, as shared needles and syringes, water of inject,
absorbent cotton, unprotected sex with others,…

5

CHAPTER 1. OVERVIEW

1.1. Prevalence of HIV, HBV, HCV
- Chronic hepatitis B is one of the most common causes of hepatocellular
carcinoma (HCC) in the world. More than 400 million people are chronically
infected with HBV globally. Thus, HBV infection is one of the most important
infectious diseases worldwide. The majority of cases occuring in regions of
Asia (predominant in East and Southest Asia) and Africa. It is estimated that 10
to 15 million people in Vietnam are living with HBV.
- Approximately 180 million people world are infected with hepatitis C virus
(HCV) and are at risk of developing serious hepatic complications such as
cirrhosis, HCC or decompensation. Disease progression is more rapid in
patients who are coinfected with HBV and HIV.
- According to UNAIDS, about 40 million people are infected with HIV world
and the majority of them live in Asia and Africa. Approximately 10% of them
has concurrent chronic HBV and 4-5 million has chronic HCV. With the
increased availability of antiretroviral therapy, the number of people surviving
with HIV and presenting with HBV, HCV is increasing.
1.2. Molercular epidemiological characteristic
- Analyses of the divergence of HBV genomic sequences has led to the

1.3.1. The Injecting drug users (IDUs):
Injecting drug user is an important public health issue around the
world: 16 millionpeople injected drugs in 2007 (range 11-21 million). IDUs has
at high risk of blood-borne viral infections (include HIV, HBV, HCV).
Injecting drug use plays a critical role in the trensmission of HIV in Vietnam.
The predominant source of infections is unsafe drug injection. Hepatitis B and
C viruses are even more effectively spread by this practive than is HIV. Up to
half of injection drug uers infected with HIV are coinfected with HBV. In
countries where HBV are highly endemic, the rate can be as high as 25%. In a
study of 309 IDUs in Northern Vietnam, the prevalence of HBV infections was
80,9%.
1.3.2. Female sex workers (FSWs):
FSWs associated drug use were high upward tendency and considered
popular event in Vietnam. The high risk of FSWs were not only sexually
focused but also injecting-related.According to previous survays show that HIV
prevalence among the injecting FSWs is even higher than among male IDUs .

23 DISCUSSION
+ HIV prevalence among IDUs
According to this survey result, the rate of HIV infection among IDUs was
higher than result of Nguyen Anh Tuan survey in Hanoi in duration 2005-2006
but it was lower than this rate in Hai Phong (65.5%), Quang Ninh (58.7%) and
equal to rate of HIV infection in Ho Chi Minh city (34.0%), Can Tho (36.6%),
Bac Ninh (21.4%) at moment. However, this rate have downward tendency in

with p>0.05.
The rate of HBV infection among hepatitis B vaccinated HDPs (6.0%)
are lower significantly than the rate of HBV infection HB unvaccinated HDPs
(16.6%) with p<0.01.
The rate of HBV infection among hepatitis B vaccinated MTPs (3.9%)
are lower than the rate of HBV infection HB unvaccinated HDPs (7.2%) but
no significant difference with p>0.05.

7

1.3.3. Multi-transfused patients (MTPs):
The risk of acquiring post-transfusion hepatitis B, C and HIV depends

n =
2
2
2
1
.
e
pq
Z



8
Description: n: required sample size. p: the expected frequency value,
expressed as decinal. q: 100-p, e: expected exact level. Z
(1- /2)
: confidence
value based on  statisticant level, If:
1. Required sample size for IDUs and FSWs:
p= 0.23 (the rate of HIV infected of IDUs and FSWs, according to
sentinel surveillance results in Hanoi for 2 groups).
e= 0.059,  = 0.05 for value Z
(1-

/2
=1.96, with 95% confidence level.
Required sample size: n= 200. Sample size selected in 3 years equal 600

controlled by running quality control sera (Virotrol I, Bio-rad) together with
specimens.
2.3.5.2. For genotyping HBV, HCV and HIV was based on the polymerase
gene, NS5B gene and Protease-Reverse transcriptase gene, respectively.
Sequencing was carried out with BigDye terminator v3.1 on Genetic Analyzer

21
HIV infected FSWs were treatment more low than IDUs and difference
between 2008-2010 were not significantly (p>0.05).
3.4.8. The relation between the rate of HBV, HCV and history of hepatitis
among study objects

Table 3.32 The relation between the rate of HBV, HCV and history of
hepatitis
History of
hepatitis
HBV infection HCV infection
n % n %
Yes 32 34.0 59 62.8
No 157 10.0 529 33.8
P < 0,01 < 0.01
OR 4.63 3.30
95%CI 2.9 – 7.3 2.1 – 5.1
- 34.0% HBV infected people have history of hepatitis diagnosed and 10.0%
objects are unknowledge of their B hepatitis status. Those difference has
significantly statistical evidence (p<0.01).
- 62.8% HCV infected people have history of hepatitis diagnosed and 33.8%

higher than of unmarried people (57.2%) with p<0.05.
3.4.7. Knowledge about the status of HIV infection of IDUs and FSWs
Table 3.29. The rate of positive HIV infected IDUs and FSWs knew their
HIV infected status
Subject 2008 2009 2010 p
n % n % n %
IDUs 40 62.5 40 59.7 27 56.3 > 0.05
FSWs 31 42.5 32 46.4 8 19.5 < 0.05
Over half of HIV infected IDUs knowledged their infection status and those
rate were not significantly difference between 2008-2010. Otherwise, HIV
infected FSWs knowledged their infection status lower than IDUs and
significantly downward tendency (p<0.05).
Table 3.30 The rate of HIV cared IDUs, FSWs when they knowledged of
their HIV infected status
Subject 2008 2009 2010 p
n % n % n %
IDUs 34 85.0 28 70.0 12 52.2 < 0.05
FSWs 19 61.3 20 62.5 2 50.0 > 0.05
9
ABI 3130. The sequences were edited and contiguously assembled by
software Seqman DNA Star Lasergene – Seqman. The sequence of HBV
polymerase gene, HCV NS5B gene and HIV Protease-Reverse transcriptase
gene are analyzed on-line by bioinformatic tools at websites,

and respectively to determine genotype.
2.3.6. Statistical analysis:
Data was entered using the Winpath software computer program after
which this data was transferred to the SPSS version 11.5 software program for
analysis. Data analysis performed by use of Chi-square statistics and the Fisher
Exact test. Variables with p values of 0.05 or less were considered statistically

n % n % n %
IDUs 327 54.6 207 34.6 65 10.9 599
FSWs 149 24.8 219 36.5 232 38.7 600
HDPs 71 17.8 301 75.3 28 7.0 400
MTPs 158 39.5 241 60.3 1 0.3 400
Total 705 35.6 968 48.4 326 16.3 1999
- Majority of IDUs (54.6%) has unmarried. FSWs has 38.7% specilized
conditions (seperation, divorce, widow).
- Majority of HDPs and MTPs in this study has private family; 75.3% of HDPs
and 60.3% of MTPs has married. However, MTPs has 39.5% of unmarried.
3.2. The rate of HIV, HBV, HCV infected and coinfected in Subjects
3.2.1. The rate of HIV infected subjects
Table 3.5 The rate of HIV infected subjects
Subjects 2008 2009 2010
n (+) % n (+) % n (+) %
IDUs
200 86 43.0 199 75 37.7 200 61 30.5
FSWs
200 90 45.0 200 78 39.0 200 51 25.5
HDPs
100 1 1.0 150 0 0.0 150 0 0.0
MTPs
100 0 0.0 150 0 0.0 150 4 2.7
- The rate of HIV infected IDUs has to show downward tendency in 2008-2010
period with p<0.05.
- The rate of HIV infected FSWs has to show downward tendency in 2008-
2010 period with p<0.01.
3.2.2. The rate of HBV infected subjects
Table 3.6 The rate of HBV infected subjects
Subjects 2008 2009 2010

≤ 19 20 - 29 30 - 39 40 - 49 ≥ 50
n % n % n % n % n %
IDUs 5 10.9 122 56.0 192 75.6 45 69.2 7 58.3 <0.01
FSWs 3 9.7 60 24.7 75 31.3 6 9.0 0 0.0 <0.01
HDPs 2 22.2 19 29.7 25 29.8 30 44.1 59 33.7 0.30
MTPs 4 6.3 8 6.8 1 1.4 6 10.9 7 7.4 0.30
3.4.6. Relations between marital status and the rate of HIV, HBV, HCV
infection:
Table 3.26 The relation between the rate of HIV infection and marital
status of study subjects
Sub. Unmarried Married* Divorce, Separarion, widow p
n % n % n %
IDUs 112 34.3 78 37.7 32 49.2 0.07
FSWs 35 23.5 76 34.7 108 46.6 < 0.01
HDPs 1 1.4 0 0.0 0 0.0 0.10

18

Table 3.21 Relations between condom use and HIV, HBV, HCV prevalence
Condom use
*

HIV infect. HBV infect. HCV infect.
n % n % n %
Non-consistent 270 24.0 110 12.9 402 35.8
Consistent 115 48.3 30 13.8 109 45.8
p < 0.01 0.8 < 0.01

IDUs 4 8.7 80 36.5 119 46.9 4 8.7 80 36.5 <0.01

11
MTPs
100 7 7.0 150 10 6.7 149 8 5.4
The rate of HBV infected subjects has downward tendency but no
difference in 2008-2010 period.
3.2.3. The rate of HCV infected subjects
Table 3.7 The rate of HCV infected subjects
Subjects 2008 2009 2010
n (+) % n (+) % n (+) %
IDUs
200 120 60.0 199 114 57.3 199 138 69.3
FSWs
199 49 24.6 200 54 27.0 200 43 21.5
HDPs
100 45 45.0 150 43 28.7 150 47 31.3
MTPs
100 13 13.0 150 8 5.3 150 5 3.3
- The rate of HCV infected IDUs has upward tendency.
- The rate of HCV infected FSWs is high but no significant difference in 2008-
2010 period (p>0.05).
- There are a difference of 3 years duration (2008-2010) about the rate of HCV
infected HDPs. They has downward tendency. Compared 2008-2009 and 2009-
2010 was a difference statistically significant (p<0.01 and p< 0.05).
- The rate of HCV infected MTPs ( 13.0% (2008); 5.3% (2009); 3.3% (2010)
was lower than other subjects and also has downward tendency in 2008-2010
duration having statistically significant vith p<0.05.
3.2.4. The rate of HIV, HBV, HCV coninfected subjects
3.2.4.1. The rate of HIV, HBV, HCV coinfected IDUs:

difference (p>0.05). Those rates were not equal the rate of HIV/HCV
coinfected FSWs from 2008 to 2010.

3.2.4.3. The rate of HBV/HCV coinfection among HDPs and MTPs:
The rate of HBV/HCV coinfected HDPs from 2008 to 2010 were 4.0%, 4.0%,
2.67%, respectively. The rate of HBV/HCV coinfected MTPs from 2008 to
2010 were 1.0%, 0.0%, 0.0%, respectively. Those rate were low and in HDPs
higher than MTPs. Difference of those rate within 2008-2010 were not
statistically significant (p>0.05). 17
n % n % n %
IDUs 118 69.4 121 68.8 103 56.3 < 0.05
FSWs 190 95.5 178 90.8 189 95.5 > 0.05
Number of IDUs shared needles was rather high but has significantly
downward tendency (p<0.05). But on the Contrary, shared needles of FSWs
was very high and has not significantly difference in the survey duration.
3.4.3. Sexual relations and condom use of IDUs and FSWs
Table 3.19 Percentage of subjects who had sex with over a partner in the
12 months prior survey
Subjects 2008 2009 2010 p
n % N % n %
IDUs 95 51.1 89 48.6 91 46.4 > 0.05
FSWs 194 99.5 176 92.6 187 97.9 < 0.05
HDPs 0 0.0 0 0.0 0 0.0
MTPs 2 3.4 0 0.0 8 38.1 < 0.05

Injecting
HIV infection HBV infection HCV infection
n % n % n %
Yes 69 44.8 28 18.2 88 57.1
No 28 31.8 4 4.5 12 13.8
P < 0.05 < 0.01 < 0.01
OR 1.73 4.67 8.33
95%CI 1.1 - 3.0 1.6 - 13.8 4.2 - 16.6
The rate of HIV, HBV, HCV infected FSWs associated with drug
injecting (44.8%) was higher significantly FSWs unassociated with drug
injecting.
Table 3.17 The relation between duration of drug injecting and rate of
HIV, HBV HCV infection among FSWs
Duration of
drug injecting
HIV infection HBV infection HCV infection
n % n % n %
< 2 years 7 41.2 2 11.8 6 35.3
2-5 years 12 38.7 5 16.1 16 51.6
> 5 years 48 46.6 20 19.4 64 62.1
p

0.71 0.72 0.09
HIV, HBV, HCV prevalence among FSWs has upward tendency based
on duration of drug injecting. However, those difference was not significantly
statistical
3.4.2. Shared needles of IDUs and FSWs:
Table 3.18 Percentage of IDUs and FSWs reporting needle sharing in the a
month prior survey
Subject 2008 2009 2010 p

6a
5 10M00327 pos pos pos
CRF01_AE 1b
6 10M00332 pos pos pos KPT
1a
7 10M00346 pos pos pos KPT
1a
8 10M00384 pos pos pos KXĐ
1a
9 10M00390 pos pos pos KXĐ KXĐ
10 10M00392 pos pos pos KPT
1b
11 10M00235
neg
pos pos KPT
12 10M00237
neg
pos pos KXĐ
13 10M00269
neg
pos pos
6a
14 10M00318
neg
pos pos
1a
15 10M00338
neg
pos pos
6e

HCV
genotype
HIV HBV HCV
1
10M00058 pos pos pos
CRF01_AE
KPT
2

10M00005
neg
pos pos
6a
3
10M00121
neg
pos pos
1a
4
10M00126
neg
pos pos KXĐ
5

10M00006

pos
neg neg
KPT



11 10M00101
pos
neg neg
KPT

12 10M00127
pos
neg neg CRF01_AE

13

10M00139

pos
neg neg CRF01_AE

14 10M00186
pos
neg neg
KXĐ

+ Analysis genotypes of FSWs:
- HIV genotype: HIV subtypes were determined that CRF01_AE subtype
- HCV genotype: only 2 subtypes: HCV-1a and HCV-6a
- HBV genotype: Survey sample has viral load at low level, which can not
determine genotypes.
3.4. Several influencing factors on trasmission of HIV, HBV, HCV among
survey objects
3.4.1. Duration of drug injecting of IDUs and FSWs:

co-infection
n % n % n %
< 2 years
2 2.8 10 14.1 1 1.4
2-5 years
3 4.6 18 27.7 7 10.8
> 5 years
22 6.5 162 47.6 44 12.9
p
0.44 < 0.01 < 0.05
- The rate HIV/HCV, HBV/HCV co-infection was significantly upward
tendency in duration of drug injecting.
- The rate of HIV/HBV co-infection also was increased in duration of drug
injecting. The highest rate of infection among subject has duration of drug
injecting over 5 years. However, this difference was not enough statistical
evidence.
3.4.1.2.Dug use behavior of FSWs:
Table 3.15 The relation between drug using and HIV, HBV, HCV infection
among FSWs
Drug
using
HIV infection HBV infection HCV infection
n % n n %
Yes 98 40,0 33 13.5 101 41.4
No 121 34.2 33 9.3 45 12.7
P 0.15 0.11 < 0.01
OR 1.28 1.51 4.85