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

Dam Anh Tran,David P Wilson,Christopher Doran,Lei Zhang,Anthony Shakeshaft,Anh Duc Ngo,John Rule,D William Cameron

doi:10.1371/journal.pone.0051289

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.

Highlights

Late access to antiretroviral therapy (ART) substantially increases the incidence of opportunistic infections and mortality associated with HIV infection
CD4 count test equipment was only available in Quang Ninh and Binh Duong clinic
The results show that late ART initiation is relatively common and may result from poor linkage between HIV testing and treatment services, a shortage in human resources, and lack of confidentiality in the provision of services at ART clinics

Summary

Introduction

Late access to antiretroviral therapy (ART) substantially increases the incidence of opportunistic infections and mortality associated with HIV infection. In low income countries in 2005– 2006, an estimated 51% to 78% of people who needed lifesustaining ART presented late to ART clinics [1]. Despite a WHO recommended threshold for ART initiation at a CD4 cell count of 350 cells/mm3 [2], and a rapid increase in the number of sites providing free ART from 74 in 2005 to 287 in 2009 [3], an estimated 41% of people living with HIV (PLHIV) in Vietnam in 2010 initiated ART very late, at a median CD4 cell count below 50 cells/mm, placing them at high risk of premature mortality [3]. ART clinics in Vietnam are organized in parallel with the HIV treatment system. HIV clinics are located inside central hospitals in Hanoi in the North and Ho

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Discussion

Conclusion