Service availability including geographical distribution and decentralization
Organization of local health facilities follows the administrative divisions of 63 provinces, 697 districts and 11,112 communes [28
]. TB diagnosis (smear) and delivery services were noted to be available in all districts. All communes were charged with providing TB treatment and antenatal care services.
HIV prevention for MARPs and HIV care and treatment has been rapidly expanded since 2004. Evolution of HIV health services are summarized in Table [29
]. By 2010 HIV prevention targeting MARPs included needle and syringe programs for IDUs. These programs were implemented in 3,333 communes in 352 districts or 51% of all districts in 43 provinces mainly by 1,792 peer educators (Table ) (VAAC: Unpublished report; 2010). Condom use program targeting SWs involved 3,123 peer educators. In addition, voluntary counseling and testing (VCT) and ART services co-existed in the same districts in most cases. That is, 175 districts had VCT and 167 of these districts had ART sites. At the provincial level, both VCT and ART were present in all provinces. PMTCT services involving antiretroviral prophylaxis were available in 133 districts in 63 provinces. Methadone maintenance therapy (MMT) was available in 11 districts in 4 provinces.
Evolution of HIV health services in Vietnam
Strengths and constraints of HIV health service delivery in improving HIV case detection and retention in care
The density of ART sites in the provinces (number of ART sites / number of districts × 100) was 66% in the high, 29% in the middle, and 15% in the low burden provinces (Table ). It was noted that a number of high and middle burden provinces had mountainous remote areas where a substantive portion of MARPs and PLHIV had limited physical access to health facilities.
Availability of ART sites according to different levels of HIV burden in 2009
1) Hub and heart of continuum
a) Local coordination mechanisms
Mechanisms for local coordination of HIV and other related health services were stipulated in several official documents from the Ministry of Health and its donor-funded projects. These documents included national guidance on HIV care and treatment, TB/HIV, PMTCT as well as project guidance on HIV prevention for MARPs [33
]. Consequently, a variety of coordination committees for HIV-related services were formed in some areas, while none were formed in other areas. Most provinces lacked coordination mechanisms for HIV-related services between districts. That is, districts providing ART/VCT services rarely coordinated with districts without such services (Bui DD: Unpublished presentation; 2010).
b) HIV outpatient clinic ‘plus’
The national guidance on HIV care and treatment stipulated the responsibilities undertaken in the HIV outpatient clinics [33
]. These stipulations included the provision of clinical services, health education, prevention services, and psychosocial support. Other stipulations included the provision of linkages with other relevant health services and the involvement of PLHIV as members of care teams and local HIV treatment committees.
Large donor funded initiatives supported expansion of HIV outpatient clinics mainly in high and middle burden provinces (Table ). In addition to the clinical services, several functions were added consistent to support the concept of the HIV outpatient clinic ‘plus’. These functions included: (i) facilitating HIV positive MARPs to access HIV outpatient clinics; (ii) involving HIV positive MARPs in HIV prevention initiatives targeting MARPs; (iii) supporting treatment adherence in collaboration with commune health stations, peer educators and CHBC teams; (iv) linking with TB and MCH services as well as closed settings; (v) establishing patient referral procedures to specialized hospitals [38
]. Despite these initiatives, however, some HIV outpatient clinics were known to be only providing clinical services, especially in low burden provinces where limited donor funded projects were operating.
2) Chronological continuum
National guidance documents stipulated case management procedures and provided standardized longitudinal registers for pre-ART care and ART [41
]. These documents were in line with the chronic care principles including self-care, peer support, and patient follow-up information systems [42
HIV outpatient clinics tended to actively prepare and track patients for ART by mobilizing PLHIV peer support and CHBC. Program data indicated the percentage of adults and children with HIV still alive and known to be on treatment 12 months after initiation of ART was 84.2% [43
]. HIV drug resistance early warning indicators indicated good adherence to appointment schedule and low level of lost-to-follow-up despite a large proportion of the patients being IDUs (Figure -a) [44
]. Furthermore, a study conducted a 2-year prospective cohort analysis of patients taking ART in two HIV outpatient clinic ‘plus’ sites in Ho Chi Minh City. It revealed the change of median CD4 count over the 24-month follow-up period among patients who ever injected illicit opiates was similar to that for those who reported never having injected [46
]. In another study in Hanoi [47
] viral suppression was not statistically different among the patients who used drug in the previous six months versus those who did not use it after at least six months of ART initiation.
Outcomes of people diagnosed HIV-positive and initiated ART.
To meet palliative care needs [48
], the Ministry of Health [49
] developed the guidelines on palliative care for cancer and AIDS patients in 2006. The ministry also improved opioid prescribing regulations in 2008 and trained over 400 physicians by early 2010 [50
]. As a result, palliative care services have started in both hospitals and communities [51
Patient follow-up and tracking for pre-ART care appeared to be considerably less operational than for ART. Results from an ad hoc assessment indicated that a substantial number of PLHIV might be dying or lost-to-follow-up during the pre-ART period (Figure -b) (Hanoi Health Services HIV/AIDS Center: Unpublished record review; 2010). In 2009, monitoring of attrition from pre-ART care started as part of HIV drug resistance early warning indicators monitoring [52
Existing referral forms were not used extensively to facilitate the referral process from VCT to pre-ART care. An ad hoc assessment in one province indicated a large gap between the number of people diagnosed as HIV positive at VCT and the number of people enrolled in pre-ART care (Figure -c) (Kato M: Unpublished presentation; 2010). No specific national guidance or patient tracking system was established for this process.
3) Horizontal continuum
Collaborative activities between HIV and TB services and HIV and MCH services (PMTCT) were expanded mainly through donor funded projects. These collaborative efforts were consistent with the national guidance developed by concerned national programs [35
] (Table ).
However, these projects tended to support specific districts rather than a provincial network. In districts without donor-funded VCT/ART, scarcely any health workers were charged with providing HIV health services (COPC review group: Unpublished report, 2010). In these districts, TB and antenatal care services were rarely equipped to implement provider-initiated testing and counseling for TB cases and for pregnant women. As a result, in 2009 the percentage of estimated HIV-positive incident TB cases that received treatment for TB and HIV was as low as 27.5% [43
]. Similarly, the percentage of HIV-positive pregnant women who received antiretroviral medicines to reduce the risk of mother-to-child transmission was 32.3%.
Standard TB registers included a section for recording HIV status. However, antenatal care registers did not include a space to record HIV status among pregnant women. Pre-ART and ART registers did not have a section for recording TB diagnosis and treatment or for pregnancy status. Patient-held records provided this additional information but were used in only a limited number of sites.
All the methadone maintenance therapy (MMT) sites were located in districts where VCT/ART was present [53
] (VAAC: Unpublished report; 2010). Some of the current MMT sites were stand-alone and physically separate from HIV outpatient clinics while others were co-located with HIV outpatient clinics. Efforts were made to strengthen linkages between MMT and other HIV health services as part of the MMT scale-up.
4) Vertical continuum
a) Linkages across different levels of health services
PLHIV suspected of active TB were often required to travel long distances across the community, district, and provincial levels. Diagnosis of smear-negative and extra-pulmonary TB was mostly performed at the provincial level. Similarly, a number of PMTCT services were provided mainly at the provincial level. These services included planned delivery of HIV positive women, early infant diagnosis and pediatric treatment. In addition, the provincial level was responsible for confirmation of HIV treatment failure and prescription of second line ART regimens in most provinces [41
All of these patient flows required robust referral systems including patient information sharing across the different levels. Commonly, a doctor simply instructed a patient to go to another facility often without a referral form (Table ). There were no routine mechanisms to monitor the functioning of the referral process (COPC review group: Unpublished report; 2010). Respect for administrative boundaries and the hierarchy of authority were reported to often make health workers reluctant to contact their peers in other health facilities.
b) Community response and its linkage with health services
Peer educators for condom use and needle and syringe program were encouraged to systematically refer their clients to VCT (Table ). An increasing number of MSM peer educators were also recruited particularly in large cities. However, the coverage of HIV prevention programs for male IDUs, female SWs and MSM was only 15.4%, 47.3% and 24%, respectively in 2009 [43
]. Similarly, the coverage of HIV testing and counseling among IDUs, female SWs and MSM was low at 17.9%, 34.8% and 19.1%, respectively. Consequently, majority of PLHIV accessed HIV care and treatment services at an advanced stage of HIV infection. Program monitoring data from 2009 indicated 64% of PLHIV started ART at CD4 100/cm3
or lower [52
Alternatives to the peer education approach were reported to be emerging to serve hard-to-reach populations. These alternatives included mobilization of pharmacies, street vendors, self-service boxes and commune health stations for needle and syringe and condom use programs [54
]. Civil society partners also began to extend their reach to MSM through internet connections and cruising hot spots.
In most districts, peer educators for prevention and those for care were reported to be managed and supported separately by different donor funded projects. However, there were growing examples of synergy between the activities of the two different peer educator groups [54
]. These examples included drop-in-centers for IDUs managed by PLHIV with support from district HIV outpatient clinics, and needle and syringe program activities performed by PLHIV.