A new analytical framework of 'continuum of prevention and care' to maximize HIV case detection and retention in care in Vietnam

Abstract

BackgroundThe global initiative ‘Treatment 2.0’ calls for expanding the evidence base of optimal HIV service delivery models to maximize HIV case detection and retention in care. However limited systematic assessment has been conducted in countries with concentrated HIV epidemic. We aimed to assess HIV service availability and service connectedness in Vietnam.MethodsWe developed a new analytical framework of the continuum of prevention and care (COPC). Using the framework, we examined HIV service delivery in Vietnam. Specifically, we analyzed HIV service availability including geographical distribution and decentralization and service connectedness across multiple services and dimensions. We then identified system-related strengths and constraints in improving HIV case detection and retention in care. This was accomplished by reviewing related published and unpublished documents including existing service delivery data.ResultsIdentified strengths included: decentralized HIV outpatient clinics that offer comprehensive care at the district level particularly in high HIV burden provinces; functional chronic care management for antiretroviral treatment (ART) with the involvement of people living with HIV and the links to community- and home-based care; HIV testing and counseling integrated into tuberculosis and antenatal care services in districts supported by donor-funded projects, and extensive peer outreach networks that reduce barriers for the most-at-risk populations to access services. Constraints included: fragmented local coordination mechanisms for HIV-related health services; lack of systems to monitor the expansion of HIV outpatient clinics that offer comprehensive care; underdevelopment of pre-ART care; insufficient linkage from HIV testing and counseling to pre-ART care; inadequate access to HIV-related services in districts not supported by donor-funded projects particularly in middle and low burden provinces and in mountainous remote areas; and no systematic monitoring of referral services.ConclusionsOur COPC analytical framework was instrumental in identifying system-related strengths and constraints that contribute to HIV case detection and retention in care. The national HIV program plans to strengthen provincial programming by re-defining various service linkages and accelerate the transition from project-based approach to integrated service delivery in line with the ‘Treatment 2.0’ initiative.

Challenges and potential barriers to the uptake of antiretroviral-based prevention in Asia and the Pacific region

“…23 First, HTC uptake is very limited among key populations, with only 31% of IDU, 40% of female SWs and 39% of MSM reported that they had received HTC in the past 12 months and knew their test results in 2012 (Table 2). 69 An analysis of the new HIV diagnosis and the clinic enrolment data at national 70 and provincial levels 70 suggests that a substantial number of people diagnosed with HIV infection are lost to follow-up and are not effectively linked to care. People are also starting ART late, 70,71 with a median CD4 count of 93 cells mm -3 in 2010, associated with a higher attrition rate.…”

“…69 An analysis of the new HIV diagnosis and the clinic enrolment data at national 70 and provincial levels 70 suggests that a substantial number of people diagnosed with HIV infection are lost to follow-up and are not effectively linked to care. People are also starting ART late, 70,71 with a median CD4 count of 93 cells mm -3 in 2010, associated with a higher attrition rate. 72 Attrition was defined as discontinuation of ART due to death or loss to follow-up, or discontinuation of ART medications while remaining in care.…”

“…Importantly, stigma, discrimination and punitive policies on drug use and sex work have posed significant structural barriers to timely and safe access to the HIV testing and treatment services for key populations. 72 The large number of peer educators (6300) and partners (11 800) involved in HIV prevention outreach 70 could facilitate earlier uptake of HIV diagnosis and treatment, and support retention across the cascade in these populations. The government of Vietnam plans to expand methadone maintenance therapy to 80 000 IDUs by 2015, 70 which could serve as an effective platform to offer periodic HTC and ART among IDUs.…”

“…72 The large number of peer educators (6300) and partners (11 800) involved in HIV prevention outreach 70 could facilitate earlier uptake of HIV diagnosis and treatment, and support retention across the cascade in these populations. The government of Vietnam plans to expand methadone maintenance therapy to 80 000 IDUs by 2015, 70 which could serve as an effective platform to offer periodic HTC and ART among IDUs. Studies suggest that once IDU start ART, they have equally good responses to ART in achieving CD4 increase 74 and viral suppression 75 compared with non-IDUs.…”

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study

“…In 2014, the Joint United Nations Program on HIV/ AIDS released goals for HIV engagement and treatment by 2020: that 90% of all people living with HIV will know their status; 90% of all people diagnosed with HIV will receive antiretroviral therapy; and 90% of those on antiretroviral therapy will be virally suppressed [4]. Recent literature highlights systems-level factors that impact this care continuum in Vietnam, including the cost of treatment [5], care coordination, chronic disease management, and peer networks [6]. However, little is known about patient level factors that contribute to engaging in the HIV care continuum in Vietnam.…”