1. PREVALENCE OF HIV/HBV/HCV CO-INFECTION AMONG PWID, FSW, MSM IN VIETNAM
Ass. Prof. Nguyen Anh Tuan, MPH, PhD
National Reference Laboratory - HIV/AIDS Department
National Institute of Hygiene and Epidemiology

2. Global Context
Viral hepatitis is a leading communicable cause of death (GBD, Lancet 2015)
World Health Assembly Hepatitis Resolutions passed in 2010 and 2014
Hepatitis listed alongside HIV, TB, and malaria in post-2015 sustainable development goals
“End the epidemics of AIDS, TB, malaria and .. combat hepatitis, water-borne diseases and other communicable diseases”
New medicines sparking treatment ‘revolution’

3. Estimated 6 million with chronic HBV infection by 2020
Vietnam Epidemic
Viral hepatitis 3rd leading cause of death in Vietnam; HBV and HCV major causes (GBD, Lancet 2015)
High prevalence of HBV: 6 – 25% in general population (Van TTN, APJPH ).
HCV concentrated among PWID (Nadol et al. Plos One 2015)
Estimated 6 million with chronic HBV infection by 2020

4. Viral Hepatitis Strategic Information
Viral hepatitis strategic information has many purposes and methods
Viet Nam currently uses case reporting to detect outbreaks
Viet Nam also exploring sustainable approaches for estimating disease burden nationally, regionally, and in different populations using surveys
Purpose of surveillance
Methods
Detect outbreaks and monitor incidence
Case reporting
Laboratory-based surveillance
Assess prevalence of chronic hepatitis infection (disease burden)
Seroprevalence surveys (general and special populations)
Assess incidence and mortality of disease outcomes
Cancer registry
Chronic liver diseases registry
Vital registration systems
Evaluate implementation and impact of prevention, care, control and treatment programmes
Seroprevalence surveys
Hospital-based studies
Ambulatory care data
Pharmacy data
Vietnam has experience with red boxes
Wiktor. 2015

5. Hepatitis Case Reporting System
Policy
Viral hepatitis is one of the 28 notifiable diseases in Viet Nam
Circular 13/2013/TT-BYT provides guidance on infectious disease surveillance, including viral hepatitis
System provides estimates of cases detected and reported in health facilities
Challenges
Specificity: Current case definition does not have biomarkers, so Hepatitis A-E currently grouped together
Non-viral hepatitis (e.g. alcohol abuse) may also be included
Validity: Limited financial and human resources for systematic implementation and quality assurance
Generalizability: Data only representative of symptomatic cases
Completeness: Severe underreporting
# reported cases through surveillance < 20% of # estimated deaths through Global Burden Disease

6. Hepatitis and HIV case reporting
Viral hepatitis
HIV
General Department of Preventive Medicine (MOH)
Viet Nam Administration of HIV/AIDS Control (MOH)
E-report
Provincial Preventive Medicine Centre (63)
Provincial AIDS Centre (63)
E-report
District (~1,100)
Include HIV and Hepatitis
Paper-based
reporting
Commune (> 10,000)

7. HIV Surveillance System*
07/16/96
HIV Surveillance System
Vietnam has an HIV epidemic concentrated in: PWID, FSW, and MSM
System of HIV/AIDS case reporting (1992) in all 63 provinces.
The first HIV positive case was detected in 1990.
Cumulatively ~245,000 people living with HIV reported
Integrated Behavioral-Biological Survey (IBBS) was implementing 3 rounds (2005, 2009, 2013) among PWID, FSW, and MSM in 12 provinces of the most serious epidemic in Vietnam.
Measures risk and preventive behaviors including sexual and drug-used behaviors as well as exposure to HIV/AIDS intervention programs
System of HIV sentinel surveillance - HSS (1994) (now reaches 40 provinces) in PWID, FSW, and MSM. HSS integrated with priority behavioral indicators (HSS+) started in 2010.
Ministry of Health has guidance on national implementation through circular 9/2011/TT-BYT *

8. Hepatitis Testing in IBBS
In the first two rounds of IBBS (2005 and 2009), only biological indicators from different populations were collected:
HIV prevalence
STI prevalence: syphilis, chlamydia, and gonorrhea
In IBBS III (2013), some more biological indicators were decided to add in for IBBS II and IBBS III:
CD4 count
Viral load
HIV drug resistance
HBV, HCV
Why hepatitis testing was added
Key populations at high risk for HCV and HBV transmission
HCV related liver disease become leading cause of mortality among those co-infected with HIV
No existing laboratory-based hepatitis surveillance

9. IBBS Hepatitis Methods - 2009
Approximately 3000 PWID, 2500 FSW, and 1500 MSM tested for viral hepatitis in 2009 IBBS round
Algorithm for HBV testing:
Monolisa-Abbott (1)
Pos
Equipvocal/WeakPositive
Negative
Re-test (1)
Pos - Recent
Monolisa Anti- HBc Plus (2)
(1): Neg
(1): Equipvocal
(2): Neg
(2): Pos
(2): NEG, Equiv, POS
-> Neg
-> POS past
->INDETERMINATE
Base on what was used in IBBS

10. IBBS Hepatitis Methods - 2009
Algorithm for HCV testing:
Monolisa-HCV
Ag/Ab Ultra (1)
Pos
Equipvocal/WeakPositive
Negative
Re-test (1)
Base on what was used in IBBS

11. IBBS Hepatitis Methods - 2013
Approximately 1422 PWID, 1863 FSW, and 1266 MSM tested for viral hepatitis in 2013 IBBS round
Algorithm:
Base on what was used in IBBS

12. Preliminary Results: PWID, 2009-2013
Indicators
Hanoi
Hcmc
2009
2013*
HIV
20.7
25.9
46.1
37.4
HBV
14.0
14.2
24.2
15.0
HIV+
15.9
15.2
HIV-
17.6
13.6
22.8
14.8
HCV
37.3
52.7
69.0
68.7
91.1
97.2
97.8
47.1
39.2
44.9
52.0
HIV/HBV
4.1
11.9
5.1
HIV/HCV
23.6
44.8
32.9
HIV/HBV/HCV
3.0
4.9
Pie chart
* RDS

13. Preliminary Results: FSW, 2009-2013
Indicators
Hanoi
Hcmc
Haiphong
2009
2013*
HIV
18.1
12.2
15.1
11.0
17.5
19.4
HBV
13.9
12.4
9.1
10.1
14.3
12.6
HIV+
17.4
23.0
8.8
9.0
9.5
11.8
HIV-
13.2
10.9
9.2
10.2
15.4
12.8
HCV
14.2
10.3
4.0
20.8
56.2
72.5
54.8
22.9
60.7
8.5
5.0
11.2
HIV/HBV
3.2
2.8
1.3
0.9
1.7
2.3
HIV/HCV
6.8
5.7
11.7
HIV/HBV/HCV
0.7
0.8
0.5
1.9
Pie chart
* TLS

14. Preliminary Results: MSM, 2009-2013
Indicators
Hanoi
Haiphong
2009
2013*
HIV
17.3
4.0
16.5
5.4
HBV
29.1
12.6
12.3
9.8
HIV+
49.3
16.3
16.7
18.9
HIV-
24.8
12.4
11.4
9.3
HCV
20.6
10.5
43.5
9.7
90.0
98.5
94.1
7.2
32.6
4.9
HIV/HBV
8.5
0.7
2.8
10.2
HIV/HCV
3.6
5.0
HIV/HBV/HCV
Pie chart
* RDS

15. Conclusions
HIV prevalence were varied by provinces and by high-risk populations (highest in PWID, second in FSW, and third in MSM)
Proportion of HCV+/HIV+ in PWID was very high ( %)
Proportion of HCV+/HIV+ was highest in PWID ( %), MSM ( %), and FSW ( %)
Proportion of HCV+/HIV+ was always higher proportion of HBV+/HIV+ in all three populations
Proportion of HIV+/HCV was high in PWID ( %)

16. Recommendations
Study on HIV/HCV/HBV among general population will be needed
HBV/HCV surveillance system in high-risk populations need to be set up
ARV programme need to be urgently put HCV and HBV treatments in the programme

17. Lessons Learned from IBBS
Advantages
Used existing surveillance system-> saves money from collecting new specimens
Good domestic capacity for serological testing allows identification of HBsAg and anti-HCV
Using existing staff and infrastructure from HIV surveillance was feasible for HBV and HCV
Challenges
Requires substantial financial and human resources -> HSS may be more affordable than IBBS?
Procuring test kits come from different sources takes time -> Central procurement may be more efficient
Did not have enough equipment domestically for confirming chronic HCV infection with PCR -> maybe use DBS or Gene Xpert in future

18. Unresolved issues Appropriate frequency for HBV and HCV surveys?
Focus populations?
HCV burden largely mirrors HIV in key populations while HBV has higher prevalence in general population
Integration with existing efforts?
HSS for key populations? General Statistic Office household surveys for general population?
Funding?
Viet Nam government? Bilateral partners (e.g. US Government)? Global Fund?
Improving quality of case reporting data?
Essential for measuring cascade of viral hepatitis services

19. Acknowledgments We would like to express our sincere thank to:
Supervisors, laboratory staffs of PACs,
Peer educators, other persons who worked in the surveys from participated provinces
We especially thank to organizations who supported finance and technique to implementing the surveys:
CDC Atlanta and in Vietnam
Family Health International – FHI
Abbott company who supported a part of test kits for this study

20. Cảm ơn!