The document discusses Vietnam's response to the HIV epidemic and improving their cascade of services. It outlines Vietnam's cascade and findings from provincial rapid assessments. Key findings include that many PLHIV are not seeking testing or linking to care after testing positive, ART initiation is not growing in many sites, and coordination of services is fragmented. The cascade framework is being used to identify gaps where interventions can have the most impact, like increasing testing and linkage to care and reducing viral loads through sustained ART. Investments in applying the cascade approach at local levels can substantially improve the performance of Vietnam's HIV response system.

1. Improving the HIV Cascade of
Services in Vietnam
ICAAP Bangkok
November 2013

2. 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

3. Response to HIV epidemic
in Vietnam

4. Response to HIV epidemic in 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

5. 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.

6. Concerning trends in Vietnam
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.

7. Injection Drug Use Trends in Vietnam

8. Late Entry to ART
“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-General
Viet Nam Authority of HIV/AIDS Control
7th International AIDS Society Conference on HIV
Pathogenesis, Treatment and Prevention. Kuala
Lumpur, Malaysia (July 2013)

9. Research findings are stimulating
new program approaches

10. 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

12. 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.

13. The Cascade Framework in
Vietnam

14. 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

15. 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

16. The Cascade Framework: Patching a Leaky Pipe

17. The Cascade Framework
- Extension of life
- Reduce transmission

18. Preliminary Cascade for Vietnam, June
2012
100%
51,165 potential PLHIV not
diagnosed
248,500
118,401 PLHIV not
engaged and retained in
care
197,335
80%
80%
60%
77%
98, 668
100%
40%
51%
78,934
79%
40%
20%
32%
89%
67,000
77%
27%
0%
HIV Infected*
HIV Diagnosed
Linked to HIV
Care**
HIV Retained in
HIV Care
On ART***
?
Suppressed viral
load (<500
copies/ml)
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

19. Cascade of HIV diagnosis,
care and treatment in
Vietnam, Dec, 2012
250000
200000
Female
Person
63537
Male
150000
100000
44%
138166
28262
50000
39%
53979
87%
88%
24785
47926
0
Diagnosed PLHIV
Source: VAAC report, D28
In care at OPC
On ART

20. Cascade for Hanoi, December 2012
18000
16000
3514
14000
Person
12000
Female
Male
10000
60%
8000
6000
13543
2107
83%
4000
33%
2000
4470
1743
80%
3599
0
Diagnosed PLHIV
Source: Hanoi PAC, D28, 2012; HIV INFO/VAAC, 10/2013
In care
On ARV

21. 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

22. Cascade for Nghe An, Dec 2012
5000
4500
4000
1583
Person
3500
Female
Male
3000
2500
2000
35%
3088
1500
1000
562
40%
1234
500
95%
95%
538
1176
0
Diagnosed PLHIV
Source: Nghe An PAC, 2012
In care
On ARV

23. Cascade for Lao Cai, 6/2013
3500
3000
Person
2500
1390
Female
Male
2000
1500
1000
1778
20%
276
500
27%
84%
477
80%
0
Diagnosed PLHIV
Source: Lao Cai PAC, 10/2013
In care
232
381
On ARV

24. Cascade for Dien Bien, 6/2013
9000
8000
7000
7782
81.78%
6364
6000
5000
4000
3000
27.36%
2000
1741
92.82%
1616
1000
0
Accumulative HIV
reported cases
PLHIV still alive
Retain in care
Currently on ARV

25. Dien Bien Dong District, Aug 2013
900
800
700
183
600
500
Death
400
300
PLHIV
597
555
200
100
131
0
H+ cumulative
HIV+ Managed
on ARV

26. Tua Chua District, Aug 2013
100
90
80
35
70
60
50
Death
40
PLHIV
30
57
20
38
10
6
0
H+ cumulative
HIV+ Managed
on ARV

27. Muong Bang Commune, Aug 2013
60
50
40
20
30
Death
PLHIV
20
28
10
16
2
0
H+ cumulative
HIV+ Managed
on ARV

28. Tua Chua Town-ship, Aug 2013
30
25
10
20
15
Death
PLHIV
10
17
14
5
2
0
H+ cumulative
HIV+ Managed
on ARV

29. Other Cascades

31. MMT – HIV – ART Cascade, Dec 2012
40,000
Data Source: VAAC 2012
Estimated:
217,000
35,000
Recorded:
171,000
30,000
121
Drug
‘06 Centers
25,000
Methadone Maintenance
Users
25-35,000
MMT Retention:
Haiphong
1 Year 90%
2 Years 80%
20,000
15,000
10,000
5,000
13,000
60
MMT
Clinics
HIVNegative
77.5%
13,000
HIV+ 22.5%
2,925
ARV 71.4%
0
IDU's
MMT
ART

32. Implications for planning and
investment

33. 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

34. 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.

35. THANK YOU!

36. Nghe An Mineral Deposits
Source:
http://idm.gov.vn/Nguon_luc/Ban_do/Khoang_san/
Khoang_san_tinh/Nghean/NgheAn_index.htm

37. New TB/HIV Cases in Quy Chau
56% of cases with SSor extrapulmonary TB
with 20% HIV+ rate
2012
First half of 2013

38. HTC test in Dien Bien
Number of HTC test decreased from 2010 to August 2013 and
HIV+ trend also decreased
18000
100.0%
90.0%
15424
16000
80.0%
14000
12602
70.0%
12000
10199
60.0%
Number of HIV test
10000
50.0%
8000
6360
40.0%
6000
30.0%
4642
4000
20.0%
2000
10.0%
0
0.0%
2009
2010
2011
2012
Aug-13
HIV+ through HTC
Case reporting
% of HIV+