Providing HIV & AIDS Treatment to High-Risk Groups in Vietnam
Vietnam is one of the target countries included in the US President's Emergency Plan for AIDS Relief (PEPFAR) program. The Government of Vietnam's response to HIV & AIDS prevention is guided by a national strategic plan, one that calls for mobilizing government and community-level organizations across multiple sectors.
The Supply Chain Management System (SCMS), funded by USAID PEPFAR through the Partnership for Supply Chain Management, a nonprofit organization established by the JSI Research & Training Institute and Management Sciences for Health, is working with the Vietnam Administration for AIDS Control (VAAC) at the Ministry of Health to improve HIV & AIDS efforts by strengthening the supply chain for HIV & AIDS medicines and supplies. SCMS is also working with dispensers through training workshops and follow-on monitoring to shore up their role as key providers of drug treatment and patient information.
In addition, SCMS has worked with the Government of Vietnam and other stakeholders to design and pilot a methadone treatment program in an effort to prevent the spread of HIV and hepatitis C in the injecting-drug-user population.
MSH spoke with Juanita Folmsbee, SCMS Country Director in Vietnam, to discuss the complex challenges of targeting high-risk groups in Vietnam.
What are the major health challenges in Vietnam?
Vietnam has a huge population for its land size – almost 86 million people—that is quickly developing into a middle income country. It is also a country with a very young population. The Government of Vietnam is grappling with the challenge of how to give health care to such a large population. There is only a small private health care sector in Vietnam; the public sector is still the main provider of health care.
Vietnam is faced with a number of infectious diseases including HIV & AIDS, avian influenza, malaria (in the southern area), and tuberculosis. At the same time chronic diseases, such as cancer and heart disease, are growing as the population begins to age.
The country is struggling with limited resources and a lack of professional and support staff trained to provide care for its people.
How many people are affected by HIV & AIDS in Vietnam?
It is estimated that 180,000 people are HIV-positive in Vietnam, being concentrated in three high-risk groups: sex workers, men who have sex with men, and injecting drug users (IDU) and their sexual partners. Within these groups the epidemic is having a large impact. For example, although only 0.43% of the general population is infected, within the IDU population, the prevalence rate is between 12 and 56%.
Currently, there are about 45,000 people are on antiretrovirals (ARVs) in Vietnam, with SCMS providing ARVs for 28,000 of these individuals who receive treatment through PEPFAR funded programs.
How do you target high-risk population in Vietnam?
Besides providing ARVs, procurement of commodities to support prevention in high-risk groups plays a big role in the SCMS program here.
The Government of Vietnam, with PEPFAR support and funding through SCMS, started a methadone treatment program about two years ago. This marked the first time Vietnam used methadone as a treatment method. Before this program, the Government put IDUs in detention centers with almost no detoxification processes in place. Since there was a high concentration of drug users with clandestine drug use and needle sharing occurring in these centers, HIV rates in this population continued to increase.
As part of the pilot, methadone treatment centers were established as part of a comprehensive approach to addressing drug addiction. In supporting the pilot program, Vietnam's Ministry of Health is taking a step away from compulsory drug treatment programs, common throughout Asia, which are often found to be ineffective. This approach focuses on treating heroin addiction as a disease and providing critical interventions, including counseling and psychosocial support to help recovering heroin users manage their addiction and reintegrate into their families and communities. Because methadone is taken by mouth, need for injections and needle sharing is eliminated and the risk of HIV infection is decreased.
There are currently 3,000 people in the methadone program. SCMS provides all the drugs and trains all the dispensers. SCMS makes site visits to follow up to make sure the dispensers are following proper narcotic dispensing methods.
Now the government has set a new target – they want to have 80,000 people on methadone treatment by 2015. There are a lot of constraints that we will have to work on with the government to reach this goal.
What other efforts are taking place to control HIV & AIDS in Vietnam?
The US Government works with the Government of Vietnam in focusing its prevention efforts on the three high-risk groups and their partners and of course providing care and treatment to these groups. When HIV-positive people are on treatment, it helps decrease their viral load, and they become less likely to transmit HIV on to their partners.
Through other partners, the US Government has supported other HIV & AIDS prevention programs in Vietnam. For example, PSI, with funding from the U.S. Agency for International Development (USAID), has a condom program. Other donors focus on needle exchange programs.
The Government of Vietnam is grappling with these efforts because there is not a unified approach to HIV prevention and treatment. While the Vietnam Ministry of Health is supporting needle exchange and "friendly pharmacies", a program where IDUs can get clean needles late at night, the police department targets these programs and arrest patrons for illegal activity. There is not a harmonized approach to HIV & AIDS policy and prevention/treatment at this point.
What results has SCMS achieved in Vietnam?
We are providing quality ARVs for 28,000 of the 45,000 people on treatment, with no stock outs to date. We have a great staff that monitors the supply system. We work closely with the VAAC to provide methadone for 3,000 patients. SCMS is training and supporting health workers in relation to pharmaceutical management at over 150 ARV and 8 methadone sites.
An important step forward occurred when the Government of Vietnam recognized the need to take ownership of ARV distribution. The Government wants to develop a national distribution system that is owned by the government. This country leadership and ownership will make the SCMS work sustainable after the end of the SCMS program. SCMS is now helping the Government look at how this new distribution process will work. This has not come easily. Vietnam has a decentralized health system, in fact provinces have their own budgets and for drug management that means that hospitals go out and buy their own drugs. The idea of centralized procurement followed by drug distribution from a centralized warehouse is not standard for Vietnam.
What role do you play in the Partnership's work?
I am the country director of the SCMS program – I have been in Vietnam for two years. My major role is being the advocate and spokesperson for our project with donors, other implementing partners and the Government of Vietnam. I work with my staff and all other stakeholders to ensure the strategy within our program is in line with national strategies and priorities as well as donor strategies and priorities. Within my office, I work with my staff to ensure that our workplans reflect the strategic objectives that we have set and that we have in place the system to monitor our progress toward those objectives.
The success of our work in the areas of ARV and methadone supply chain management has been noted by our funder and as a result, the SCMS program has recently been asked by USAID to increase help for the National TB Program work on developing the supply chain for second-line TB drugs. Supply planning for these drugs present challenges due to the short shelf life and variations in protocols for multi drug resistant TB drugs. SCMS has been asked to bring its expertise in supply chain management in order to ensure that these life-saving drugs are available to those who need them in Vietnam.
For me, the big goal is to make life for those Vietnamese people affected by HIV & AIDS better and more productive. Secondly, to make the work we are doing sustainable so the support for these people will continue into the future.
My focus is how to make sure whatever is funded by PEPFAR, the American people, and supported by SCMS, is something that will last and benefit the Vietnamese people long after we are gone.