Center for Studies of Addiction, University of Pennsylvania, USA Integrated substance use disorder and HIV care in Vietnam: Effectiveness and cost Cecile Denis, PhD Center for Studies of Addiction, University of Pennsylvania, USA

Disclosures Project funded by NIDA grant R01- DA033671 (C. P. O’Brien, MD, PhD, PI) AUG- 01- 2012 to JUL- 31-2017 Buprenorphine/Naloxone (Suboxone®) was donated to the research by Indivior® (former Reckitt Benckiser®)

Vietnam 271,000 people using drugs (UNAIDS 2015) 14,000 new HIV infections in 2015, and most of them are driven by drug users 2006: Scale up of HIV prevention programs targeting people who inject drugs (PWID) (Giang et al., 2013) Sterile injection equipment, the introduction and expansion of methadone treatment, and increased access to antiretroviral therapy (Government of Vietnam, 2014) Although the proportion of HIV infections among PWID has declined from 30% in 2005 to 22% in 2013, PWID remain the largest risk group living with HIV infection (Vietnam Administration of HIV/AIDS Control, 2013)

Go Vap Integrated Treatment Clinic Integrated Treatment provided A pharmacological opiate maintenance treatment with methadone (MET) or buprenorphine/naloxone (BUP/NX) Introduction of BUP/NX (Suboxone®) in January 2015 First time in Vietnam Counseling: 12 weekly sessions and 10 monthly sessions thereafter HIV screening and HIV treatment if needed HCV screening Structured and manual-based standardized counseling sessions Rooted in cognitive behavioral therapy Sessions assess the need for intervention in six areas of functioning: 1) Adherence to SUD, HIV, TB; 2) continued drug use and related drug and sex risk; 3) cravings for drug use; 4) psychological status (depression, anxiety, symptoms of psychiatric disorder); 5) confidence in and satisfaction with SUD treatment; and, 6) strategies for the next month Data recorded and available for review with the participant as a clinical tool to show progress and promote self-monitoring.

Participant characteristics (n=448)

Treatment retention High retention in treatment at 12 months (78.0%) MET > BUP/NX MET: 89.9% BUP/NX: 57.0% Daily BUP/NX: 40.0% Thrice weekly BUP/NX: 69.8% Wilcoxon chi2= 110.9, p<0.0001

Change in heroin use Significant decrease of heroin use regardless of the treatment (F(12,277)=21.8, p<0.0001) BUP/NX > MET First 3 months of treatment (F(12,702)=0.69, p<0.0001)

HIV Prevalence 34.2% (n=153) Viral load CD4 count Newly diagnosed 7.2% (n=11) Viral load Baseline range: 0-400,000 Reported ART adherence: 78% reported taking >90% of the time Suppressed viral load 82.8% at 6 months 90.5% at 12 months VL suppression was Not associated with the type of OMT neither the type of ART Linked to a better observance of ART (Pearson=7.18, p=0.007) and to the decrease of heroin use over 12 months (F(12,32)= 2.20, p=0.03) CD4 count Baseline Mean 326 (SD=202, range 57 - 1099), and >500 cells/mm3 = 37% 12-month < 350 cells/mm3 = 32% Not associated with the ART observance or the type of OMT

Cost of 6 months of integrated Tx program Daily MET US$1204.08 (SD=160.21) < daily BUP/NX US$2865.31 (SD=480.36) Daily MET < BUP/NX thrice weekly US$1880.37 (SD=168.56) (F(2,122)=374.21, p<0.0001)

Conclusion Integrated treatment strategy showed significant positive impact on Drug use HIV detection Access to HIV care Integration of opiate maintenance treatment and HIV care in the same setting Not significantly increase the cost of the addiction treatment Decrease cost for HIV-positive participants by preventing them from having to travel to different locations However, still potential HIV reservoir that needs to be eliminated By improving the monitoring of treatment efficiency, and a better treatment adherence

PI: Charles O'Brien, MD, PhD - UPenn Co-PI: Le Truong Giang, MD, PhD – HCMC, Vietnam Jean-Pierre Daulouède, MD, France Investigators David Metzger, PhD, UPenn, Marc Auriacombe, University of Bordeaux, France Gilles Raguin, MD, Expertise France Lisa Huang, MD, Expertise France Trung Nguyen, Expertise France, HCM Medical Univ. Vincent Trias, Expertise France Project director: Cecile Denis, UPenn Expertise France Research staff in HCMC Expertise France Staff in Vietnam Expertise France Staff in Paris, France Go Vap Center Staff in Ho Chi Minh City PAC Ho Chi Minh City Ministry of Health of Vietnam, Hanoi VAAC, Hanoi