A prospective “test‐and‐treat” demonstration project among people who inject drugs in Vietnam

Abstract

IntroductionModelling suggests that early diagnosis and immediate antiretroviral therapy (ART) among key populations would have a substantial impact in reducing HIV transmission and mortality in Vietnam. An implementation research project of “test‐and‐treat” among people who inject drugs (PWID) was developed to inform effective roll‐out of such interventions.Methods“Test‐and‐treat” was offered to PWID in two high burden provinces, Thai Nguyen and Thanh Hoa. The interventions comprised the offer of biannual HIV testing and immediate ART, irrespective of CD4 count. PWID were enrolled between April 2014 and July 2015 and followed up for 12 months, and retention, HIV viral load (VL) and risk behaviours were assessed. Retention in care of this prospective cohort was compared with the retention among men enrolled in care in the preceding period (April 2012 to March 2013) at the same clinics when ART was initiated at CD4 cell count ≤350 cells/mm3.ResultsIn total, 287 HIV positive PWID started immediate ART. The majority (98%) were men; median age was 34; and median (interquartile range) CD4 count was 199 (50 to 402) cells/mm3. After 12 months, 238 participants (83%) were retained on ART, and 205 achieved viral suppression (<1000 copies/mL) (92% among those in whom VL was measured, 71% overall). Baseline CD4 count ≤100 cells/mm3 and history of imprisonment were associated with lower retention and viral suppression, while engagement in methadone maintenance was associated with higher retention. Retention in care was higher in the “test‐and‐treat” cohort (83%) compared with men enrolled in care in the preceding period (78%), primarily because lost‐to‐follow‐up during pre‐ART care was eliminated. No decline in consistent condom use and clean needle use was observed.ConclusionsEarly ART initiation resulted in successful treatment outcomes among PWID, with no observed increase in self‐reported risk behaviours, suggesting feasibility and potential effectiveness of “test‐and‐treat” approach. The results also call for differentiated care for PWID, including promoting early diagnosis and engagement in methadone maintenance therapy while enhancing care for those with advanced HIV disease and history of imprisonment.

Feasibility of dried blood spots for HIV viral load monitoring in decentralized area in North Vietnam in a test-and-treat era, the MOVIDA project

“…As a probable consequence of the test-and-treat strategy, CD4 measurements were no longer measured systematically prior to ART initiation, indeed only 28% of the patients had a CD4 measurement. In this group, the median (IQR) CD4 level was 287 (83-449) cells/mm 3 , which is higher than in previous reports in Vietnam [24,29] and in line with the global increase of CD4 level at ART initiation observed in resource-limited settings [30].…”

“…In terms of virological results, the proportion of patients with a viral load <1000 copies/mL at 6 months was 84.2%. This is lower than other evaluations which took place at later time points [23,24,31], but similar to the proportion observed in a test-and-treat evaluation study in PWID performed in Vietnam [29]. At later time points, the higher rate of virological success could be explained by a survival bias effect as those who were not fully adherent are no longer in active care.…”

“…However, the technique used for viral load measurement on DBS, which is CE-marked, performed well in an evaluation in the same laboratory [14]. Of note, another evaluation in PWID in Vietnam reported a very similar virological failure rate [29].…”

Intersecting Stigmas among HIV-Positive People Who Inject Drugs in Vietnam

“…Recent studies in Vietnam have also suggested that enacted and anticipated stigma was common among PWID, and that stigmatization by health care providers was an important barrier for PWID to access services. [48][49][50] For example, health care providers often described patients using terms like lazy, unreliable and viewed PWID as unable to prioritize HIV treatment and care. 49 While our participants rarely reported explicit stigmatization from health care providers, many reported providers being silent, cold, or not allowing questions from patients.…”

Time to treatment initiation and retrospective analysis of antiretroviral therapy outcomes among HIV-positive methadone maintenance therapy clients in primary health-care centers, Kuantan, Pahang

“…It is supported by a few studies that showed that the mortality rate in HIV-positive MMT clients was low with early ART initiation, and the combined treatment increased the retention rate in the MMT program. [ 2 4 , 17 18 ]…”