HIV/AIDS Epidemiology in the World and Vietnam HAIVN Harvard Medical School AIDS Initiative in Vietnam HAIVN basic training for nursing N1-01-Epidemiology in the world and Vietnam-EN Revised 9/2013

Learning Objectives By the end of this session, participants will be able to: Explain HIV epidemiology in the world, Asia, and Vietnam Describe characteristics of the HIV epidemic in Vietnam Explain the current and planned future national strategy on HIV/AIDS

Global HIV/AIDS Epidemiology EXPLAIN that the next few slides is about the global HIV/AIDS epidemiology

Global Prevalence of HIV, 2009 Không dữ liệu Việt Nam EXPLAIN that the dark red color represents the highest prevalence rate by country. Prevalence is the number of people that have a given disease in a given place at a certain point in time. The prevalence presented here explains the percentage of people that have HIV and AIDS at the end of 2009. SHOW participants that sub-Saharan Africa has the highest rates in the world. IDENTIFY Vietnam on the map for participants. Sahara 2.2

Adults and Children Living with HIV, 2009 DEMONSTRATE the magnitude of the HIV pandemic in the world by explaining this map. EXPLAIN that the majority of persons living with HIV (PLHIV) reside in sub-Sahara Africa and South and Southeast Asia Background Information: An estimated 33.2 million people were living with HIV in 2009. Sub-Saharan Africa remains the region most heavily affected by HIV worldwide, accounting for two thirds (22.5 million) of all people living with HIV and for three quarters of AIDS deaths in 2009. In Asia, an estimated 4.9 million people were living with HIV in 2009. Total: 33.2 million Adults: 30.8 million Children 2.5 million Source: WHO/UNAIDS 2010

Tóm tắt dịch AIDS toàn cầu giai đoạn 2001-2009 Adults and Children Living with HIV 28,6 million 33,3 Adults and Children newly Infected with HIV 3,1 2,6 % Adult Prevalence (15-49 years) 0,8% AIDS-related Deaths Among Adults and Children 2,0 1,8 ASK participants to look closely at this table. In what categories have there been improvements? No change? ASK participants “Why has the number of people living with HIV worldwide increased even though the number of new infections per year has gone down?” EXPLAIN that the overall growth of the global AIDS epidemic appears to have stabilized. The annual number of new HIV infections has been steadily declining since the late 1990s and there are fewer AIDS-related deaths due to scale up of antiretroviral therapy. Although the number of new infections has been falling, levels of new infections overall are still high. This coupled with significant reductions in mortality explains why the overall number of people living with HIV worldwide has increased. REFER participants to Handout 1.1: Global HIV Epidemiology for further information. Nguồn: UNAIDS, cập nhật dịch AIDS, 2010

HIV/AIDS Epidemiology in Asia

HIV Epidemic in Asia 2001 2009 People living with HIV 4,2 triệu People Newly Infected with HIV 450 000 360 000 Children living with HIV 100 000 160 000 AIDS-Related Deaths 250 000 300 000 ASK participants to look closely at this graph. In what categories have there been improvements? Setbacks? EXPLAIN that the HIV epidemic in Asia is also relatively stable. There are estimated 4.9 million people were living with HIV in Asia which is about the same as five years earlier. There were 360 000 people newly infected with HIV in 2009, 20% lower than the 450 000 in 2001. Source: UNAIDS: AIDS Epidemic Update, 2010

HIV Prevalence (%) in Adults (15–49) in Asia, 2009 Vietnam EXPLAIN that the dark red color represents the highest prevalence rate by country. The prevalence presented here explains the percentage of people that have HIV at the end of 2009. POINT OUT Thailand on the map and EXPLAIN that it is the only country in this region with a prevalence above 1% IDENTIFY Vietnam on the map for participants and EXPLAIN that the adult HIV prevalence in Vietnam is .4% REFER participants to 1.2: HIV Epidemiology in Asia for further information. Thailand UNAIDS: AIDS Epidemic Update, 2010

HIV/AIDS Epidemiology in Vietnam ASK participants “What do you know about the HIV epidemic in Vietnam?” ALLOW time for them to answer before moving on to the next few slides.

HIV và AIDS ở Việt Nam First case of HIV in Vietnam was diagnosed in 1990 HIV cases have been reported in 100% of provinces and 97% of districts (VAAC, 2011) National prevalence rate among adults is 0.45% (MOH, 2011) HIV is concentrated in certain high risk populations EXPLAIN that the national prevalence of .44% is for the population age 15-49 in Vietnam. EXPLAIN further that although the national HIV prevalence is low, the prevalence among certain high risk populations including intravenous drug users, commercial sex workers, and men who have sex with men (MSM) is much higher. MENTION that this will be discussed in more depth in later in this session.

Reported Cumulative Cases of HIV, AIDS and Deaths in Vietnam, by Year *Accumulation cases - MOH 6/2012 EXPLAIN that the number of new HIV cases detected every year has risen steeply. As of October 2010, a cumulative total of 180,312 people were diagnosed HIV positive in Vietnam. As of 30/06/2012, number of people living with HIV is 204.019, number of AIDS patient is 58.569 and number of death is 61.856 (MOH 2012) REFER participants to Handout 1.3: Cumulative Cases of HIV, AIDS, and Deaths in Vietnam by Year so that they can read this graph more closely. REFER participants to Handout 1.4: HIV Prevalence and Incidence in Vietnam for further information.

Số trường hợp HIV theo tỉnh EXPLAIN that this chart shows the 10 provinces/cities with the highest number of live HIV cases detected. MOH 2012

HIV Prevalence by Province HIV cases per 100,000 population EXPLAIN that this chart shows the 10 provinces/cities with the highest number of PLHIV per 100,000 population. POINT OUT that the last column shows the HIV cases per 100,000 population for the entire country. Sơn La Điện Biên HCMC Yên Bái Thái Nguyên BR-VT Bắc Cạn Cao Bằng Hải Phòng Quảng Ninh Việt Nam VAAC – MoH, 2010 VAAC – Bộ Y tế, 2010

Số liệu ước tính nhiễm HIV/AIDS EXPLAIN that there are 2 types of data: Detected number: the statistics of the health department (the tip of the iceberg) Estimated number: apply the scientific method to estimate the number of HIV infected people (the whole iceberg) EMPHASIZE that the estimated number is almost 3 times of the detected number Proof: If there is 1 AIDS patients, there are about 5 to 10 HIV infected people who have symptoms and 50-100 people have no symptoms Pic 1: Image of an iceberg 1a: The tip of the iceberg: visible ( Number of HIV infected people as reported) 1b: the whole iceberg (number of HIV infected people in reality)

Distribution of HIV Infection in Vietnam, by Age EXPLAIN that this slide demonstrates the percentage of HIV infections in Vietnam by different age groups in the first 6 months of 2011 and 2012. The majority of people living with HIV in Vietnam are < 40 years old. EXPLAIN further that over time HIV is affecting younger populations. There has been an increase in the percentage of HIV infections among persons aged 20-29 and 30-39 and a decrease among those > 40 years old. (Source: VAAC – MoH, 2010) MOH 2012

Distribution of HIV Infection by Gender EXPLAIN that the majority of PLHIV in Vietnam are male. This is related to the fact that intravenous drug use is the most common route of transmission in Vietnam and most intravenous drug users are men. However, the percentage of HIV infections in women is increasing. In 2004, more than 80% of PLHIV were male. The increasing proportion of women infected is related to a shift in the primary mode of transmission from intravenous drug use to heterosexual transmission. EXPLAIN that this will be discussed in more depth in later in this session MOH 2012

Distribution of HIV Infection by Transmission EXPLAIN that numbers on the graph are based on studies and reports of VAAC 9% unknown cases: patient have more than one risk behavior such as IDUs and unsafe sex… MOH 2012

Xếp loại các trường hợp HIV theo nhóm nguy cơ EXPLAIN that in Vietnam, HIV is concentrated in certain high risks groups including intravenous drug users, sex workers, and increasingly men who have sex with men (MSM). EXPLAIN that about 50-60% of all HIV infections in Vietnam are transmitted by IDU. REFER participants to Handout 1.5: HIV Among Risk Groups in Vietnam for more information. Cục phòng chống AIDS - Bộ Y Tế, T6/2012)

Who will the Patients be in the Future Who will the Patients be in the Future? New HIV Infections by Sub-population Số ca mắc mới HIV EXPLAIN that this graph is from an analysis of the HIV epidemic in HCMC. The analysis attempted to predict which populations in Vietnam would be most affected by HIV in the future The model predicted that in the future most new transmission of HIV will not by related to intravenous drug use because the majority of drug users will have been infected already. Most new transmission will be in male clients of commercial sex workers and in the wives and girlfriends (low-risk females) of the male clients. MSM (Men who have Sex with Men) are also becoming a high-risk group and account for more transmission than intravenous drug users. Source: Analysis and Advocacy, The HIV Epidemic in HCMC: Where is it going? 2006. Thanh niên TCMT Nam nguy cơ thấp KH nam TCMT NĐN GMD Nữ nguy cơ thấp

Characteristics of HIV Epidemic in Vietnam (1) The number of people living with HIV in Vietnam is increasing The epidemic is concentrated in high risk groups Two concurrent epidemics: IDU transmission in concentrated areas Heterosexual transmission predominant in Mekong delta area EXPLAIN that the concentrated areas where a lot of HIV transmission is occurring includes Hanoi, Hai Phong, Quang Ninh, Khanh Hoa, HCMC and surrounding provinces. EXPLAIN that the heterosexual transmission, often related to commercial sex work and their clients, is more common in provinces bordering with Cambodia. EXPLAIN that Mekong delta area included An Giang, Kien Giang, Long An…

Characteristics of HIV Epidemic in Vietnam (2) Shift in the HIV epidemic toward: Young people from <29 year olds Female Non-IDUs General community (heterosexual transmission) Men who have sex with men (MSM) EXPLAIN that in the future, we expect to see continued HIV transmission among IDU, but that sexual spread (both heterosexual and homosexual) will increase to become the most common risk factor for transmission.

National Strategy on HIV/AIDS Prevention and Control Overall objectives: Reduce national HIV prevalence to 0.3% Reduce adverse impact of HIV/AIDS on social-economic development 3 main groups of solutions: Social solution Technical expertise solution Resources and international cooperation solution EXPLAIN to participants that to obtain the objectives, there are 9 National Action Programs and 4 Future Priority Activities for Vietnam. REFER participants to Handout 1.6: Future HIV Prevention, Care, and Treatment Activities in Vietnam for more information. INTRODUCE that in the next slides, we focus on Future Priority Activities for Vietnam.

9 National Action Plan (1) Education and Communication to change behavior for HIV/AIDS prevention Enhance harm reduction interventions Care and support people living with HIV/AIDS Monitoring and evaluation HIV/AIDS program ASK participants the following questions: Describe some programs have been implemented where you live and work ? Explain the contents of harm reduction intervention? USE the answer for discussion and lead into the slide.

9 chương trình hành động QG (2) Access to HIV/AIDS treatment Provision of HIV/AIDS from mother to child transmitted Management and treatment of STI Safe blood transfusion Capacity building and international cooperation to prevent and control HIV/AIDS

Future Priority Activities for Vietnam Strengthen Information, Education and Communication (IEC) activities to change unsafe behaviors Enhance harm reduction interventions Increase HIV counseling, care, treatment Build capacity in program management, monitoring and evaluation NOTE that IEC stands for: Information, Education and Communication for HIV/AIDS prevention and control.

Key Points HIV epidemic continues to expand globally Increasing in Vietnam, particularly: Concentrated in high risk groups (IDUs, sex workers, MSM) Among young people and women through IDU, unsafe sex National HIV prevention and control strategies include: Focus on IEC to change risk behavior Increase harm reduction Scale up access to ARV care and treatment

Thank you! Question?