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      The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia

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          Abstract

          Background

          In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country.

          Methods

          A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment.

          Results

          We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area.

          Conclusions

          Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.

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          Most cited references 35

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          Cost-effectiveness of methadone maintenance treatment for HIV-positive drug users in Vietnam.

          Methadone maintenance treatment (MMT) is efficacious in reducing drug use that may improve HIV/AIDS care and treatment outcomes. This study evaluated the incremental cost-effectiveness of MMT for HIV-positive drug users from the perspective of health service providers. A sample of 370 HIV-positive drug users (age: mean ± SD: 29.5 ± 5.9 years; 95.7% male) taking MMT in multi-sites was assessed at baseline, three, six and nine months. Costs of MMT services were analyzed and converted to the year 2009. Quality-adjusted life years (QALYs) were modeled from changes in health-related quality of life of patients using the modified World Health Organization Quality of Life - Brief Version (WHOQOL-BREF). Inverse probability-of-treatment weights, constructed using propensity score of non-responses, were applied to adjust for potential confounding. Over nine months, MMT substantially improved QALYs of HIV/AIDS patients (0.076 QALY [0.066-0.084]). The increments in QALY were large and stabilized in those patients taking antiretroviral treatment and abstinent to drug use. For one QALY gained, the MMT program would cost US$3745.3, approximately 3.2 times Vietnam GDP per capita in 2009. The cost-effectiveness of MMT intervention was robust against HIV advanced status or co-morbidity, e.g., TB treatment, but it might not be cost-effective for those patients who continued to use drug. Findings of this study indicate that providing MMT for HIV-positive drug users is a cost-effective intervention in Vietnam. Integrating MMT to HIV/AIDS care and treatment services would be beneficial in injection-driven HIV epidemics.
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            Compulsory drug detention in East and Southeast Asia: evolving government, UN and donor responses.

            According to official accounts, more than 235,000 people are detained in over 1000 compulsory drug detention centers in East and South East Asia. Individuals in such centers are held for periods of months to years, and can experience a wide range of human rights abuses, including violation of the rights to freedom from torture and cruel, inhuman and degrading treatment; freedom from arbitrary arrest and detention; a fair trial; privacy; the highest attainable standard of health; and freedom from forced labor. Since 2010, an increasing number of United Nations agencies, human rights experts, and others have expressed concerns about rights abuses associated with compulsory drug detention centers, and since 2012, called for their closure. Although they do not represent a complete break from the past, these calls mark a significant shift from past engagement with drug detention, which included direct and indirect funding of detention centers and activities in detention centers by some donors. However, the lack of transparent governance, restrictions on free speech and prohibitions on monitoring by independent, international human rights organizations make assessing the evolving laws, policies and practices, as well as the attitudes of key governments officials, difficult. Looking specifically at publicly announced reforms and statements by government officials in China, Cambodia, Vietnam and Lao PDR reveals possible improvements in respect for the rights of drug users, and on-going challenges. Copyright © 2013 Elsevier B.V. All rights reserved.
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              Prior opiate injection and incarceration history predict injection drug use among inmates.

              To describe injection drug use among inmates, and to identify correlates of drug injection while incarcerated. Cross-sectional survey. Six provincial correctional centres in Ontario, Canada. Face-to-face interviews were conducted with a random sample of 439 adult males and 158 females. Inmates were asked about drug use in their lifetime, outside the year prior to their current incarceration, and while incarcerated in the past year. Among the 32% (189 / 597) with a prior history of drug injection, independent correlates of injection while incarcerated in the past year were identified using multiple logistic regression. Among all inmates while incarcerated in the past year, 45% (269 /597) used drugs and 19% (113 / 596) used non-cannabis drugs. Among those with a prior history of injecting, 11% (20 / 189) injected while incarcerated in the past year. Rates of injection with used needles were the same pre-incarceration as they were while incarcerated (32%). Independent correlates of drug injection while incarcerated were injection of heroin (OR = 6.4) or other opiates (OR = 7.9) and not injected with used needles (OR = 0.20) outside in the year prior to incarceration, and ever being incarcerated in a federal prison (OR = 5.3). The possibility of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) or other blood-borne diseases exists in Ontario correctional centres. In this setting, drug injection while incarcerated is primarily related to opiate use prior to incarceration. The correlation between injecting and extensive incarceration history suggests missed opportunities to improve inmates' health.
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                Author and article information

                Contributors
                huongthuhanoi@gmail.com , thu.vuong@unsw.edu.au
                tonhu@fhi360.org
                leminhgiang@hmu.edu.vn
                m.shanahan@unsw.edu.au
                robert.ali@adelaide.edu.au
                alison.ritter@unsw.edu.au
                Journal
                Harm Reduct J
                Harm Reduct J
                Harm Reduction Journal
                BioMed Central (London )
                1477-7517
                11 January 2017
                11 January 2017
                2017
                : 14
                Affiliations
                [1 ]The National Drug and Alcohol Research Centre/UNSW Australia, Sydney, Australia
                [2 ]FHI360 Vietnam, Hanoi, Vietnam
                [3 ]Hanoi Medical University, Hanoi, Vietnam
                [4 ]University of Adelaide, Adelaide, Australia
                Article
                130
                10.1186/s12954-016-0130-1
                5226106
                28077147
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100004426, Atlantic Philanthropies;
                Award ID: 18634
                Award Recipient :
                Funded by: Australian Government Endeavour Postgraduate Scholarship
                Funded by: NDARC PhD Scholarship
                Funded by: National Health and Medical Research Council (AU) Senior Research Fellowship
                Award ID: APP1021988
                Award Recipient :
                Funded by: Australian Substance Misuse Prevention and Service Improvements Grants Fund
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

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