Improving the HIV Cascade of Services in Vietnam
ICAAP BangkokNovember 2013
Outline
• Current Response to the HIV epidemic in Vietnam
• Impact of recent research in stimulating major changes to program approaches
• The Cascade Framework
– Vietnam cascade
– Provincial rapid assessments
– Findings and actions
• Implications for planning/investments
Response to HIV epidemicin Vietnam
• Nearly 72,000 on ART
• More than 14,500 on MMT (Target 80,000 by 2015)
• Number of newly reported HIV diagnoses has declined
• New generation of well trained, experienced leaders emerging
• Country leadership on HIV/AIDS is gaining in strength
• New mountainous province initiative
Response to HIV epidemic in Vietnam
Concerning trends in Vietnam
1. Substantial, local HIV epidemics occurring in underserved areas.
2. Many PLHIV often not seeking testing or not linked to care after testing positive.
3. Number newly initiating ART not growing or declining in many sites.
4. Many clients are dying, dropping out of treatment or lost to follow-up
5. Coordination of service systems is fragmented and project-focused.
6. Donor resources declining and service system costs too high to be sustained by the GVN.
7. Epidemic of injection drug use continues with >215,000 estimated PWID.
Concerning trends in Vietnam
Injection Drug Use Trends in Vietnam
“At present, 51% of people start treatment at a CD4 cell count below 100 cells/mm3, underlining the urgency of expanding access to treatment, regardless of its prevention benefit.”
Dr Bui Duc Duong, Deputy Director-GeneralViet Nam Authority of HIV/AIDS Control
7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Kuala Lumpur, Malaysia (July 2013)
Late Entry to ART
Research findings are stimulating new program approaches
Recent Studies of MMT and ART
• MMT - Systematic review found that recipients reduce their HIV risks by 54%.
Macarthur, et. Al., October 2012
• Cost Effectiveness:
– HIV counseling and testing with “immediate” ART targeted to PWID can greatly reduce new infections and be “cost saving”
Kato, et. al., 2013
– Systematic review of 36 studies in developing countries found ART and MMT to be cost effective in all.
West and Nguyen, 2013 Report
Research is making program goals clearer
• “Knowing HIV positive status ” will lead to reduced individual behavioral risk.
• Viral load (VL) is directly related to increased HIV transmission risks.
• Suppressing VL through ART substantially reduces HIV transmission risks.
• Methadone maintenance reduces HIV risks (HIV positive and negative) among PWID.
• Priority goals include: 1) increasing the number of PLHIV who know their status, 2) reducing viral load through sustained ART and 3) increasing access of PWID to MMT.
The Cascade Framework in Vietnam
The Cascade framework is…
• Old, but new
• Improvement on older methods for presenting data &illustrating program performance
• Simple, easy to communicate with powerful impact
• Scalable from province to national
• Easily adaptable to different programs, strategies and populations
• Promotes different interventions targeted to different phases of - or gaps in - the cascade
The Cascade is…
• Based on a set of available core indicators
• A logic model that links prevention outreach, testing & treatment services across a continuum of care (CoPC)
• Reveals how individuals move, don’t move, through the CoPC or are lost to follow-up
• Identifies areas where “plugging” leaks will lead to higher performing service systems with more impact
The Cascade Framework: Patching a Leaky Pipe
- Extension of life- Reduce transmission
The Cascade Framework
Preliminary Cascade for Vietnam, June 2012
80%
77%
51%
89%
77%
100%
79%
40%32%
27%
0%
20%
40%
60%
80%
100%
HIV Infected* HIV Diagnosed Linked to HIV Care**
HIV Retained in HIV Care
On ART*** Suppressed viral load (<500 copies/ml)
248,500
197,335
98, 668
78,934
67,000
Vietnam AIDS Response Progress Report 2012. National Committee for AIDS, Drugs and Prostitution Prevention and Control. March 2012. ** Assumes 70% uptake from HTC to OPC (nationally) *** Current estimate based on verbal report from SCMS
?
51,165 potential PLHIV not diagnosed
118,401 PLHIV not engaged and retained in care
Cascade of HIV diagnosis, care and treatment in Vietnam, Dec, 2012
138166
53979 47926
63537
2826224785
0
50000
100000
150000
200000
250000
Diagnosed PLHIV In care at OPC On ART
Pe
rso
n
Female Male
39%
44%
87%
88%
Source: VAAC report, D28
Cascade for Hanoi, December 2012
13543
4470 3599
3514
21071743
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Diagnosed PLHIV In care On ARV
Pe
rso
n
Female Male
33%
83%
80%
60%
Source: Hanoi PAC, D28, 2012; HIV INFO/VAAC, 10/2013
Rapid Assessments and Responses
• Four provinces assessed: Nghe An, Lao Cai, Dien Bien and An Giang (three more scheduled)
• Cascade framework coupled with service mapping used to assess CoPC performance and needs.
• Targeted, time limited assistance plan rapidly implemented (in phases)
• Cost assessment and analyses being added
Cascade for Nghe An, Dec 2012
3088
1234 1176
1583
562 538
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Diagnosed PLHIV In care On ARV
Pe
rso
n
Female Male
35%
95%
40% 95%
Source: Nghe An PAC, 2012
Cascade for Lao Cai, 6/2013
1778
477 381
1390
276232
0
500
1000
1500
2000
2500
3000
3500
Diagnosed PLHIV In care On ARV
Pe
rso
n
Female Male
20%
84%
27% 80%
Source: Lao Cai PAC, 10/2013
7782
6364
1741 1616
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Accumulative HIV reported cases
PLHIV still alive Retain in care Currently on ARV
27.36% 92.82%
Cascade for Dien Bien, 6/2013
81.78%
Dien Bien Dong District, Aug 2013
597 555
131
183
0
100
200
300
400
500
600
700
800
900
H+ cumulative HIV+ Managed on ARV
Death
PLHIV
Tua Chua District, Aug 2013
57
38
6
35
0
10
20
30
40
50
60
70
80
90
100
H+ cumulative HIV+ Managed on ARV
Death
PLHIV
Muong Bang Commune, Aug 2013
28
16
2
20
0
10
20
30
40
50
60
H+ cumulative HIV+ Managed on ARV
Death
PLHIV
Tua Chua Town-ship, Aug 2013
1714
2
10
0
5
10
15
20
25
30
H+ cumulative HIV+ Managed on ARV
Death
PLHIV
Other Cascades
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
IDU's MMT ART
ARV 71.4%
13,000
121‘06 Centers
25-35,000
60MMT Clinics
13,000HIV+ 22.5%
HIV-Negative
77.5%
2,925
Data Source: VAAC 2012
MMT Retention:Haiphong1 Year 90%2 Years 80%
Drug Users
Estimated:217,000
Recorded:171,000
Methadone Maintenance
MMT – HIV – ART Cascade, Dec 2012
Implications for planning and investment
The Cascade Framework in Vietnam…
• A useful planning/diagnostic tool,
• Easily used at the provincial level
• Rapid assessments/responses can lead to closing of service gaps/leaks
• Useful for monitoring/evaluating introduction of new tools/approaches and a wide range of health issues
Investments in ….
• Use of the cascade framework coupled with service mapping and cost assessment can be very effective.
• Addressing targeted gaps and leaks will substantially Improve system performance.
• Supporting local use of the cascade framework can increase sustainability.
• Investment in the framework is well justified.
THANK YOU!
Nghe An Mineral Deposits
Source:
http://idm.gov.vn/Nguon_luc/Ban_do/Khoang_san/
Khoang_san_tinh/Nghean/NgheAn_index.htm
New TB/HIV Cases in Quy Chau
2012 First half of 2013
56% of cases with SS-
or extrapulmonary TB
with 20% HIV+ rate
HTC test in Dien Bien
4642
15424
12602
10199
6360
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
2009 2010 2011 2012 Aug-13
Number of HTC test decreased from 2010 to August 2013 and HIV+ trend also decreased
Number of HIV test
HIV+ through HTC
Case reporting
% of HIV+