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+