Structural Barriers to Timely Initiation of Antiretroviral Treatment in Vietnam: Findings from Six Outpatient Clinics

Abstract

In Vietnam, premature mortality due to AIDS-related conditions is commonly associated with late initiation to antiretroviral therapy (ART). This study explores reasons for late ART initiation among people living with HIV (PLHIV) from the perspectives of health care providers and PLHIV. The study was undertaken in six clinics from five provinces in Vietnam. Baseline CD4 counts were collected from patient records and grouped into three categories: very late initiators (≤100 cells/mm3 CD4), late initiators (100–200 cells/mm3) and timely initiators (200–350 cells/mm3). Thirty in-depth interviews with patients who started ART and 15 focus group discussions with HIV service providers were conducted and thematic analysis of the content performed. Of 934 patients, 62% started ART very late and 11% initiated timely treatment. The proportion of patients for whom a CD4 count was obtained within six months of their HIV diagnosis ranged from 22% to 72%. The proportion of patients referred to ART clinics by voluntary testing and counselling centres ranged from 1% to 35%. Structural barriers to timely ART initiation were poor linkage between HIV testing and HIV care and treatment services, lack of patient confidentiality and a shortage of HIV/AIDS specialists. If Vietnam’s treatment practice is to align with WHO recommendations then the connection between voluntary counselling and testing service and ART clinics must be improved. Expansion and decentralization of HIV/AIDS services to allow implementation at the community level increased task sharing between doctors and nurses to overcome limited human resources, and improved patient confidentiality are likely to increase timely access to HIV treatment services for more patients.

Determinants of virological failure after 1 year's antiretroviral therapy in Vietnamese people with HIV: findings from a retrospective cohort of 13 outpatient clinics in six provinces

“…In Vietnam, a low baseline CD4 cell count is also an independent predictor of early mortality and LTFU 8. Furthermore, recent research has reported that 69% of people with HIV in a similar cohort did not initiate ART until their CD4 cell count dropped to <50 cells/mm 3 17. Having a baseline WHO stage IV was not significantly associated with virological failure in our study although patients with a baseline WHO stage IV generally had low baseline CD4 cell counts and more advanced immune deficiency.…”

Linkage, initiation and retention of children in the antiretroviral therapy cascade

“…Convoluted registration processes and complex patient routing through health facilities worsen delays further [38]. Since patients and caregivers often travel long distances to access facilities providing pediatric care, clinic visits can take up an entire day of a child’s and caregiver’s time [36].…”

Cost-Effectiveness of Antiretroviral Therapy Expansion Strategies in Vietnam

“…The main barrier for reaching this level is the poor access to targeted testing, the limited linkage between HIV care and ART clinics. 23 Our study, therefore, underscores the need to remove barriers to HIV testing, and ART accessibility to facilitate more timely recruitment of HIV patients into ART. Additionally, high risk groups (IDUs, sex workers, or males who have sex with males) should be encouraged to have routine, voluntary, and anonymous HIV testing, and PLHIV should be referred to ART clinics when they have been identified as meeting the eligibility criteria for ART initiation.…”

“…Increasing access from 19% to 30% is likely to be achievable, but it would require substantial effort to address the significant structural barriers to accessing HIV testing and treatment, including a lack of confidentiality, poor linkage between HIV care and ART clinics, and human resources shortages, as well as socio-cultural factors, such as punitive laws against drug users and female sex workers, along with the associated stigma and discrimination against PLHIV. 23 The next two most cost-effective strategies are highly unlikely to be practical because the increased costs are prohibitive in a resource poor country like Vietnam. This study has estimated, for example, that it would cost $100 million to have ART initiation at 500 and 100% access (Fig.…”

“…21 In Vietnam, for example, only an estimated 53% of PLHIV in Vietnam had access to ART and, among those currently receiving ART, 59% sought treatment at a late stage of disease progression. 22,23 Provision of ART in Vietnam currently costs an estimated US $33.4 million. 24,25 There is an important question about whether it would be more cost-effective for Vietnam to improve ART treatment outcomes by increasing ART initiation threshold to a CD4 cell count £ 500 cells/mm 3 or treating all PLHIV regardless of CD4 cell counts at ART initiation versus by increasing the number of PLHIV accessing ART at the current threshold.…”