Adapting Treatment 2.0 in Viet Nam - Toward Universal and Sustainable Access - Associate Professor, Bui Duc Duong, MD, Ph.D. Deputy Director General, Ministry of Health Socialist Republic of Viet Nam
HIV epidemic and response in Viet Nam Statistics Estimated HIV population (2010) 254,400 Estimated adult ART needs (2010) 102,000 Reported HIV cases (2010) 183,938 People receiving ART (2010) 49,492 HIV prevalence in IDUs (2009) 18.4% Number of people receiving ART in Viet Nam Concentrated epidemic: Injection drug use being major driver. Comprehensive harm reduction: needlesyringe, condom, methadone maintenance. Successful ART scale-up: 18 times increase in the in past five years (2005-2010) 2
Challenges for HIV treatment and care in Viet Nam Late treatment initiation common (average baseline CD4 count<100). Late diagnosis; Lost-to-follow-up between diagnosis and care. Mortality high in early phase of ART Limited access and retention Limited access in closed settings and remote mountainous provinces Stigma, discrimination, punitive laws against MARPs - barriers for access Burden of TB, viral hepatitis and drug dependence high Highly verticalized HIV, TB, MCH programs limited collaboration and linkages. Limited availability and complex procedures of drug dependence treatment. Sustainability challenges 90% of HIV treatment and care budget funded by external donors. HIV services delivered through donor projects. 3
Adapting Treatment 2.0 into Viet Nam - What we want to achieve? - Maximize ART s survival and preventive benefits through achieving universal access and earlier treatment initiation (CD4 350) Enhance synergy between HIV prevention and treatment Address co-morbidities, especially TB, viral hepatitis and drug dependence Contribute in virtual elimination of MTCT Ensure program efficiency and sustainability. 4
Adapting Treatment 2.0 into Viet Nam Pilot implementation in two provinces (Can Tho, Dien Bien) with focuses on: Expanding HIV testing and counseling; application of rapid test algorithm. Simplifying, decentralizing and integrating service delivery. Mobilizing PLHIV and MARP peer educators. Phased expansion Priority given to provinces with high HIV burden. Dien Bien Can Tho Optimize policy framework and guidance 5
Adapt delivery systems Expand HIV testing and counseling Apply rapid test algorithm. Expand HIV testing and counseling to primary care sites (commune health station) and through mobile/outreach teams. Integrate PITC into health services (e.g. ANC, TB, STI, methadone maintenance). Simplify and decentralize Simplify ART and methadone procedures. Pilot and expand ART and methadone provision/ follow-up at commune health station and closed settings Integrate Promote one-stop service delivery model. Ensure referral among the services: From HIV diagnosis (CITC, PITC) to HIV prevention, treatment and care. Among HIV-TB, HIV-methadone and HIV-MCH 6
Mobilize communities. Optimize drug regimens. Point-of-care diagnosis. Mobilize communities Support PLHIV and MARP peer educators to take active roles in HIV treatment, care and support. Enhance treatment literacy among MARP peer educators (benefits of early diagnosis and treatment initiation). Promote public-private partnership. Optimize drug regimens Shift towards less-toxic regimens (from d4t to TDF) Promote use of fixed dose-combinations Promote point-of-care diagnosis. Develop rapid test-based algorithm for HIV diagnosis. 7
Reduce costs: Promote program approach and sustainability Finalize costing study and resource needs estimation. Standardize service packages. Analyze cost-effective strategy. Strengthen national health insurance system to cover standard HIV treatment and care package. Maximize efficiencies Shift from project approach to program approach Integrate HIV service and laboratory function into health system Promote earlier treatment initiation (CD4 350) Reduce cost for hospitalization and OI treatment Preventive benefits of ART on HIV and TB 8
Monitoring and Evaluation, Operational researches Learning by doing Implement, review and optimize Facilitative supervision Quality improvement HIV drug resistance prevention and surveillance Operational researches Impact of integration and decentralization on health outcomes, health system and cost. 9