1. 1 Scaling-up ARV therapy in Vietnam HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 Learning Objectives At the end of this lecture, each trainee should understand: - the Care and Treatment situation in Vietnam: management and technical aspects - Current ARV therapy in Vietnam and role of international agencies in the treatment program. - The challenges of the ART program in Vietnam - The future plan for the ARV program in Vietnam

3. 3 Contents 1.Review the HIV/AIDS situation in Vietnam 2.Introduce the current care and treatment situation 3.Update on the ARV therapy program 4.List the challenges of ART program 5.Draft coordination plans in the next few years

4. 4 HIV/AIDS situation in Vietnam HIV cases reported nationwide*: - HIV infections: 185,623 - AIDS cases: 44,701 - Deaths due to AIDS: 49,912 Infections have been detected in**: - 96% of districts - 66% of wards/communes *Data up to 03/2011- MOH source. **The third country report on following up the implementation to the Declaration of commitment on HIV/AIDS, Socialist Republic of Vietnam, 2008

5. 5 Estimates of HIV/AIDS epidemic in Vietnam between 2004 - 2012 20042006200820102012 HIV179,244208,403231,422254,387280,113 AIDS Deaths 5,2367,2587,7947,6538,239 Need ARV 24,10239,10256.87077,826100,547 Viet Nam HIV/AIDS Estimates and Projections 2007-2012, VAAC, 2009

6. 6 Characteristics of HIV epidemic in Vietnam The epidemic is spreading and is still concentrated in the high risk groups. Blood transmitted HIV cases account for (45%) but sexually transmitted HIV cases also are increasing (43%). Most PLWHA are men (73.5%) and young, between 20- 39 years old. The epidemic is spreading out to the community: Transmission by sex, both heterosexual and homosexual, is increasing. There is a growing need for HIV/AIDS care and treatment due to the increase of number of patients with HIV/AIDS. To date, the drug supply doesn’t meet the needs of ARV treatment.

7. 7 Number of persons on ARV in low and middle income countries, December 2008 (estimated need in 2008: 9,500,000) WHO, Towards Universal Access Progress report, 2009

8. 8 Care and Treatment Objectives by 2010 1.70% of AIDS patients are on ARV treatment 2.100% HIV/AIDS infected & affected children receive care, treatment and management 3.At least 50% of provincial AIDS clinics are equipped with diagnostic & treatment facilities 4.70% of Districts establish outpatient clinics (OPC) and comprehensive care, treatment and support systems for HIV/AIDS patients 5.100% of technical staff receive adequate training (Source: National strategy on HIV/AIDS control till 2010 and a vision 2020– MoH,2005)

9. 9 HIV/AIDS Care & Treatment in Vietnam VAAC was established in August 2005 Health system provides care and treatment services: –Central level: 3 Centers –Provincial level: care & treatment of in-patient & out- patient –District level: QCT Program (Management, Care and Counseling) ARV treatment support from International Organizations (GFATM, PEPFAR, WB, ESTHER,...) Source: MOH-Bases for Building up the Action Plan 3

10. 10 ARV Programs in Vietnam Vietnam MOH: - delivers ARV to all 63 provinces, PEPFAR (President Emergency Plan for AIDS Relief): - delivers a Comprehensive model of Treatment and Care for PLHA including ART and referral network in 18 provinces (Ha Noi, Hai Phong, Quang Ninh, Cao Bang, Bac Ninh, Son La, Hoa Binh, Thai Binh, Nam Dinh, Nghe An, Da Nang, Ho Chi Minh, Can Tho, An Giang, Vinh Long, Long An, BR-VT, Soc Trang). Global Fund: - supplies OI drugs and supports ART program in 20 provinces. Bill Clinton Foundation: - supplies ARV for HIV infected children.

11. 11 PEPFAR support: 7 Focus Provinces and 11 additional ARV provinces Hai Phong Quang Ninh Ha Noi Can Tho An Giang TP Ho Chi Minh Nghe An Ba Ria-Vung Tau Soc Trang Cao Bang Nam Dinh Son La Hoa Binh Thai Binh Bac Ninh Da Nang Long An Vinh Long

12. 12 Global Fund Supported 20 provinces/cities Qu¶ng Ninh Hải Phòng TP HCM An Giang Hà Nội Lạng Sơn Cao Bằng Khánh Hòa Thanh Hóa Nam Định Th¸i Nguyªn Phú Thọ Đắc Lắ c Tây Ninh Kiên Giang Cà Mau Sóc Trăng Cần Thơ Nghệ An Hải Dương 100 districts/ 578 communes

13. 13 Number of patients receiving ARV

14. 14 ART program in Vietnam (as of 2/2009) Project Number of ART sitesNumber of patients (approximations) MOH National program 94 sites/63 prov.2,500 GF on AIDS 64 sites/20 prov.5,200 PEPFAR 39 sites/7 prov.19,000 Clinton Foundation and National Program for children 8 sites/6 pro.1,300 Total 28,000 (Source: Vietnam Administration of HIV/AIDS Control – MoH)

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16. 16 Current ART regimens: (at PEPFAR sites) - 97% patients on the 1 st line regimens - 3% patients on the 2 nd line regimens Treatment target reported by MOH: –70% of adults needing treatment on ARV by 2010 ~ 49,000 adults (70% X 70,000) –100% of children needing treatment on ARV by 2010 ~ 2,200 Children ART program in Vietnam

17. 17 Successes of ARV Treatment program in Vietnam Rapid scale –up of ARV treatment from 2005 to 2010 ARV now available in every province in Vietnam. Expansion of treatment for children and availability of pediatric drug formulations. Expansion of new OPC’s in districts in many provinces Second-line ARV available in many provinces through the PEPFAR program. Expansion of capacity for CD4 testing in many provinces. Coordination between national programs and international donors by VAAC.

18. 18 ARV are still not yet universally available for all patients who need it in Vietnam. The major limitation in providing ARV is the infrastructure to deliver care and treatment to patients: the number of clinics and trained medical staff. Many staff in OPC to not yet have adequate training. OPC staffing is not stable: many staff turn over, work part-time, have responsibilities in other clinical sites, and leave to work in other departments. The referral system and coordination between services at the local and provincial level needs to be improved Challenges in the scale-up of ARV Treatment in Vietnam

19. 19 Most HIV patients in Vietnam are also IDU and have many social, economic, and legal problems as a result of drug use. Adherence is difficult for patients who take ARV for long periods of time, especially for IDU. Lab capacity for OI diagnosis remains very limited in the hospitals. No Third-line or salvage ARV available in Vietnam yet PLWHIV support groups have few resources and limited capacity in most provinces. Challenges in the scale-up of ARV Treatment in Vietnam

20. 20 Thank you Questions?