Over the past several decades, Vietnam has been among a group of nations that has achieved unprecedented gains in population health through a synergistic process of socioeconomic development and strategic investment in health systems.

Despite this considerable progress, there remain important opportunities for improvement and innovation in the health sector in order to meet emerging needs based on epidemiological and demographic trends, and to build a system capable of sustainably, efficiently and equitably delivering on the promise of health for all Vietnamese citizens. While there is substantial and admirable infrastructure for health care delivery in the form of clinics, hospitals, and trained health care workers in Vietnam, there is an opportunity to deploy these resources more effectively to optimize health outcomes, return on investment, and the experience of care for Vietnamese citizens. In particular, evidence detailed in this report suggests a lack of capacity to tackle the non-communicable disease (NCD) epidemic and to provide highly responsive, longitudinal, integrated care that is accessible to individuals and families in their communities and homes. Thus, bolstered by the track record of decades of success in health and strategic investment, comes the chance to build and execute a bold new vision for strengthening primary health care systems in Vietnam, further strengthening its reputation as a world leader in providing social services to citizens.

The purpose of this report is threefold: 1) to review achievements and challenges in primary health care (PHC) in the last 30 years since Doi Moi; 2) to analyze relevant evidence on PHC in LMICs; and, 3) to provide recommendations for an innovative, high-functioning primary health care system based on both 12 the unique strengths and context of the  ietnamese social sector as well as global best practices.  

Introduction: HIV viral load (VL) testing is recommended by the WHO as the preferred method for monitoring patients on antiretroviral therapy (ART). However, evidence that routine VL (RVL) monitoring improves clinical outcomes is lacking.

Commune health centers (CHCs) in Vietnam have made significant strides in managing acute infectious diseases and implementing national disease-specific vertical programs. However, in the context of socioeconomic development, the burden of disease in Vietnam has transitioned such that there is a far greater prevalence of non-communicable diseases (NCDs), which require an integrated, longitudinal approach to care. This study identified that CHCs in Vietnam have limited capacity to prevent, diagnose, and treat NCDs in 3 provinces in northern Vietnam, especially among less wealthy and ethnic minority areas.

High HIV viral load (VL >100,000 cp/ml) is associated with increased HIV transmission risk, faster progression to AIDS, and reduced response to some antiretroviral regimens. To better understand factors associated with high VL, we examined characteristics of patients presenting for treatment in Hanoi, Vietnam. We examined baseline data from the Viral Load Monitoring in Vietnam Study, a randomized controlled trial of routine VL monitoring in a population starting antiretroviral therapy (ART) at a clinic in Hanoi. Patients with prior treatment failure or ART resistance were excluded. Characteristics examined included demographics, clinical and laboratory data, and substance use. 

Objectives:We sought to determine the rate of response to hepatitis B (HBV) vaccination among HIV-infected adults in Vietnam.

Methods:We retrospectively abstracted data from a cohort of HIV-infected adults who had received HBV vaccine at an HIV clinic in Hanoi. We examined demographic, clinical and laboratory factors for associations with development of a protective antibody (Ab) response following vaccination (defined as ‘responders’ with anti-HBs>10 IU/L).

Results:Out of 302 HIV-infected patients who completed the vaccine series and follow-up serology testing, 189 (62.6%) had a positive protective Ab response. Female patients had a higher response rate compared to male patients (71.4%vs 56.8%,P=0.01). Among responders, mean CD4 T cell count was 309 cells/μL as compared to 204 cells/μL in  non-responders (P<0.0001). On multivariable analysis, CD4 T cell count prior to vaccination was the only factor independently associated with a positive Ab response. Compared to patients with a count less than 100 cells/μL, those with a CD4 T cell count between 100 and 200 cells/μL were 20% more likely to be responders (relative risk [RR] 1.20, 95% confidence interval [CI] 0.77–1.87), those with a CD4 T cell count between 200 and 300 cells/μL were 61% more likely to be responders (RR 1.61, 95% CI 1.05–2.45), and those with a CD4 T cell count greater than 300 cells/μL were 89% more likely to be responders (RR 1.89, 95% CI 1.26–2.83).

Conclusions:We found that the CD4 T cell count at the time of vaccination to be the sole predictor of response to HBV vaccination among HIV-infected Vietnamese adults. Our findings highlight the importance of vaccinating HIV-infected adults prior to advanced immunosuppression

As antiretroviral therapy (ART) coverage for HIV-infected patients in Vietnam continues to increase, data on the prevalence and patterns of transmitted drug resistance (TDR) mutations are important to guide national ART strategies. TDR was evaluated in 345 antiretroviral-naïve patients consecutively initiating first-line ART in the clinical trial of Virological Monitoring in Vietnam (VMVN) at Bach Mai Hospital in Hanoi between April 2011 and October 2013. TDR mutations were identified by Sanger sequencing of HIV pol gene and were  defined based on the 2009 World Health Organization surveillance drug resistance mutation (SDRM) list. 330  plasma samples were  successfully sequenced in both  protease and reverse transcriptase regions of HIV pol gene. 323 samples were subtype CRF01_AE; two were subtype A/CRF01_AE, two were subtype BC, one was subtype C; one was subtype F/C recombinant. SDRMs were identified in 16 (4.8%) patients. Among them 6  (38%)  patients carried  mutations conferring  resistance  to  nucleoside/tide  reverse  transcriptase inhibitors (NRTIs)  (K70E, V75M, K219N/E, T215S), 5 (31%) to non-nucleoside  reverse  transcriptase  inhibitors (NNRTIs) (K101E, K103N, Y181C, G190A), 4 (25%) to protease inhibitors (PIs) (M46I/L, I54L, L90M), and one to both NRTIs and NNRTIs (L74I, V75M, M184V, T215F, K101E, G190A). The level of TDR remains  low  despite  the  rapid  scale  up  of  ART in Vietnam over the past 10 years. TDR  to  PIs  was  identified  in  4  patients for the first time in Ha Noi. As PIs are the main component of 2nd-line therapy and the last resort for  patients with drug-resistant virus in Vietnam. The detection of TDR to PIs is of concern and requires further investigation.

We trained and mentored existing staff of the Son La provincial health department and provincial HIV clinic to work as a provincial coaching team (PCT) to provide Integrated coaching in clinical HIV skills and quality improvement (QI) to the HIV clinics in the province. Nine core indicators were measured through chart extraction by clinic and provincial staff at baseline and at 6 month intervals thereafter. Coaching from the team to each of the clinics, in both QI and clinical skills, was guided by results of performance measurements, gap analyses, and resulting QI plans. After 18 months, the PCT had successfully spread QI activities, and was independently providing regular coaching to the provincial general hospital clinic and six of the eight district clinics in the province.

The frequency and type of coaching was determined by performance measurement results. Clinics completed a mean of five QI projects. Quality of HIV care was improved throughout all clinics with significant increases in seven of the indicators. Overall both the PCT activities and clinic performance were sustained after integration of the model into the Vietnam National QI Program.  We successfully built capacity of a team of public sector health care workers to provide integrated coaching in both clinical skills and QI across a province. The PCT is a feasible and effective model to spread and sustain quality activities and improve HIV care services in a decentralized rural setting.

Links: http://www.biomedcentral.com/1472-6963/15/269/abstract

To inform the development of a new training curriculum on HIV for use in nursing universities in Vietnam, Nam Dinh University of Nursing and the Vietnam Administration for HIV/AIDS Control, with technical assistance from HAIVN, performed a survey with the following objectives: (1) To understand the current situation of HIV/AIDS teaching at universities that train full time bachelor nurses in Vietnam; (2) To identify the needs of HIV/AIDS training of full time student nurses in Vietnam; and (3) To recommend the development of a curriculum and course book for HIV/AIDS training for full time student nurses.

The People’s AIDS Committee of Ho Chi Minh City, Vietnam is leading an effort to transfer the care of patients who are clinically stable on ART, from district specialized HIV clinics to the ward health station level (WHS). The goal of the down-referral is 1) integrating care of these patients into the general health care system of Vietnam and 2) reducing the human resource burden at specialized HIV outpatient clinics (OPCs). This report describes the 12-month results from an ongoing program evaluation to assess quality of care, satisfaction and resource use in the citywide transition of HIV care to the community. The People’s AIDS Committee of Ho Chi Minh City, Vietnam is leading an effort to transfer the care of patients who are clinically stable on ART, from district specialized HIV clinics to the ward health station level (WHS). The goal of the down-referral is 1) integrating care of these patients into the general health care system of Vietnam and 2) reducing the human resource burden at specialized HIV outpatient clinics (OPCs). This report describes the 12-month results from an ongoing program evaluation to assess quality of care, satisfaction and resource use in the citywide transition of HIV care to the community.

As HIV prevention and treatment efforts expand around the globe, local capacity-building to update and maintain nurses' HIV competence is essential. The purpose of this project was to develop and sustain a national network of nurse-trainers who could provide ongoing HIV continuing education and training experiences to Vietnamese nurses. Over the course of 6 years, 87 nurses received training to become HIV trainers; their HIV knowledge increased significantly (p = .001), as did teaching self-confidence (p = .001 to .007). The 87 nurses subsequently reported training more than 67,000 health care workers. Recipients of train-the-trainer-led workshops demonstrated increased HIV knowledge (p = .001) and increased willingness to provide nursing care for HIV-infected patients (p = .001). The program demonstrated that including a substantial amount of instruction in pedagogical strategies and experiential learning could enhance knowledge transfer, expand education outreach, and contribute to sustainable HIV competence among nurses.

We describe the results of a study to determine the prevalence and characteristics of cytomegalovirus (CMV) retinitis among HIV-infected patients in Vietnam. We conducted a cross-sectional prospective study of patients with CD4 lymphocyte count ≤100 cells/mm³ recruited from public HIV clinics. The diagnosis was made by a trained ophthalmologist using slit lamp biomicroscopy and corroborated on fundus photography. A total of 201 patients were screened. The median age was 32 years, 77% were men, median CD4 count was 47 cells/mm³, and 62% were on antiretroviral treatment. Prevalence of CMV retinitis was 7% (14/201, 95% CI 4–11%).

CMV retinitis was not associated with age, gender, injection drug use, CD4 count, WHO clinical stage, or antiretroviral treatment status. Blurring of vision and reduced visual acuity <20/40 were associated with CMV retinitis, but only 29% of patients with the diagnosis reported blurry vision and only 64% had abnormal vision. On multivariate analysis, the sole predictor for CMV retinitis was decreased visual acuity (OR 22.8, p < 0.001). In Ho Chi Minh City, CMV retinitis was found in 7% of HIV-infected patients with low CD4. HIV-infected patients with a CD4 count <100/mm³ or who develop blurring of vision in Vietnam should be screened for CMV retinitis.m

Graduate Medical Education is a key stepping stone in transforming graduates from medical universities into independently practicing physicians. Recently, Vietnam initiated efforts to strengthen the clinical training of physicians through the requirement of a mandatory 18-month internship for all medical graduates. This report summarizes the findings of a landscape analysis of graduate medical education at 10 hospitals nationwide (3 central level, 7 provincial level) and provides recommendations for the development and implementation of a formal and standardized 18-month clinical internship program for Vietnam.