current conditions and assessment on the effects of the caring, supporting and treating activities for aids patients at adult outpatient clinics in 3 provinces of vietnam, 2009 - 2010

MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH CENTRAL INSTITUTE OF HYGIEN AND EPIDEMIOLOGY VU CONG THAO REAL SITUATION AND ACCESS THE EFFICIENCY OF AIDS PATIENT CARE, SUPPORT

MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH

CENTRAL INSTITUTE OF HYGIEN AND EPIDEMIOLOGY

VU CONG THAO

REAL SITUATION AND ACCESS THE EFFICIENCY

OF AIDS PATIENT CARE, SUPPORT AND TREATMENT AT OUTPATIENT CLINICS FOR ADULTS IN 3 PROVINCES OF

Major: Epicemiology Code: 62 72 01 17

SUMMARY OF MEDICAL DOCTOR THESIS

Hanoi, 11/2011

2The work is completed at: Central Institute of Hygiene and Epidemiology

The science supervisor:

Objection 1: Objection 2: Objection 3:

The thesis will be defenced at the State Council of thesis mark in Central Institute

of Hygiene and Epidemiology at , date month year

The thesis can be serached at:

1 National library

2 The library of National Institute of Hygiene and

Epidemiology

LIST OF THE AUTHORS’ ANNOUNCED RESEARCH

WORK RELATED TO THE THESIS

1 Vu Cong Thao, Nguyen Thanh Long, Ho Ba Do, (2011) “Some features and

demand of care, support and treatment of the infected at the non-resident clinics in

3 privinces of Vietnam in 2009”, Preventive Medical Magazine– Special issue for

Vietnam Teacher Day, November 20th and 2011’s postgraduate science conference

of postgraduate training bases, Central Institute of Hygiene and Epidemiology. File XXI, No 7 (125) pp 148 – 154

2 Vu Cong Thao, Nguyen Thanh Long, Ho Ba Do and et al (2011), “Some comments

on HIV/AIDS patient treatment by ARV at 3 outpatient clinics in Vietnam, 2010”, Vietnam Medical Megazine – File 388, No 1, December 2011 pp.30 – 34

INTRODUCTION

It has been 30 years since the world confronted with HIV/AIDS epidemic In spite of many achievements in medicine, biology, sociology, media education information, community mobilization, etc in the field of HIV/AIDS prevention, it is not strong enough to prevent the HIV/AIDS epidemic’s attack Especially, in the developing countries where the source for diagnosing, treating, monitoring and managing HIV/AIDS infected patients is limited, HIV/AIDS is still the issue of top concern of public and social health

To limit spreading the HIV/AIDS epidemic and prolong the life for the patients, a lot of methods such as education propaganda to increase the awareness, understading on HIV for the community, provision treatment, potential infection treatment, anti-retrovirus medicine (ARV) for infected persons were conducted Among above methods, caring, supporting and treating by ARV medicine play an important role Although ARV medicines do not completely treat HIV/AIDS, it significantly reduces the diseases and death, prolong and improve meaningful life for many patients with AIDS

In Vietnam, in order to meet HIV epidemic prevention, in 2000, Ministry of Health issued national instructions on HIV/AIDS dignosis and treatment, which were supplemented and amended in 2005, 2009 Ministry of Health also had the plan to classify the treatment by establishing outpatient clinic in provinces, cities HIV/AIDS infected people can register to be freely cared and treated at one of these clinics Treatment extension by ARV and treatment monitor in outpatient clinics have been conducted since March, 2006 with the support of the projects of global fund, American President’s urgent assistance fund (Pepfar), Bill-Clinton Fund, etc This treatment implementation brought the hope and future for a lot of HIV/AIDS infected persons, and timely prevent HIV infection for the potential subjects and community.At these clinics, HIV/AIDS infected persons are provided with a lot of essential services: Adequately consulted to ensure complying with the treatment with high efficiency, discrimination reduction, community intergration, etc and create conditions for HIV/AIDS infected persons to obtain many chances to live, self-work, self-care, reduce the burden for the family and society

After 6 years of outpatient clinic development, as of 30/6/ 2011, the whole nation had 54.637 AIDS patients who were managed and treated by anti-retrovirus medicine (ARV) It is very issential to evaluate the efficiency of AIDS patient care, support and treatment at the outpatient clinics and then extend the program to meet AIDS patients’ increasing demand of care, support and treatment

Starting from above base, in the framework of the project “ Provision and

care for the HIV/AIDS infected persons in Vietnam – Life-Gap” by Ministry of Health

and Department of HIV/AIDS prevention, we conduct to research the theme: "Real

situation and efficiency evaluation of AIDS patient care, support and treatment at the adults’ outpatient clinics in 3 provinces of Vietnam, 2009-2010” with the targes:

1 Describe real situation and some factors related to supplying the services

of AIDS patient care, support and treatment in the adults’ outpatient clinics

in 3 provinces/cities: Hanoi, Nghe An, Ho Chi Minh City

2 Assess the efficiency of AIDS patient care, support and treatment management in the adults’ outpatient clinics at the place of research

* New contributions of the thesis:

- Describe operation situation of outpatient clinic models and services supplied for the patients by outpatient clinics and efficiency of AIDS patient treatment

by anti-retrovirus medicine (ARV) as well as several factors related to the outpatient clinics’s care, treatment support

- The model of outpatient clinics associated with available medical bases is proved to obtain good efficiency, in appropriateness with the nations which have public health network like Vietnam The research result is the scientific base to support the State Agencies on HIV/AIDS prevention and for the projects, the donars have basses to adjust the activities more appropriate and effective

* The thesis’ structure: The thesis including 120 pages (excluding the appendixes,

table of contents, abbreviations) constitues into 4 chapters:

- Introduction: 2 pages

- Chapter 1 Overview: 33 pages

- Chapter2 Subject and research method: 21 pages

- Chapter 3 Result: 38 pages

- Chapter 4 Discussion: 23 pages

- Conclusion: 2 pages

- Recomendation: 1 page

- The thesis include: 37 tables, 10 maps

- Reference: 137

CHAPTER I OVERVIEW

1.1 Real situation of HIV/AIDS infection

According to the report at the end of year 2010 by UNAIDS and WHO, the whole world has about 70 million of infected people, 30 million of dead persons and currently, there are about 40 million persons with HIV/AIDS Each day, there is further about 7.000 new infected persons (of which, there are 6.000 adults and 1.000 children), 95% new infected cases occurs in slowly developing or developing nations, mainly in African nations nearly Sahara, then it extends to East-South countries HIV/AIDS ranks the fourth among the causes leading to the dealth in African countries The women accounts for over 50% of total persons infected with HIV in the whole world Among 70 million persons infected with HIV in the world, 45% are at the youth age of 15-24 years old

The first HIV/AIDS infected case in Vietnam is detected in December, 1990 in

Ho Chi Minh City As of 30/6/2011, according to the report of Vietnam HIV/AIDS Prevention Department, the number of detected HIV infected cases is 190.902 persons who are alive; of which, there are 46.056 AIDS patients and 108 persons died due to HIV/AIDS The current infection rate is 224,6/100.000 people

1.2 Situation of HIV/AIDS infected patient care, support and treatment

The HIV/AIDS infected patient care, support and treatment is considerred to be

the focus of AIDS control and prevention Care, support and treatment reduce the pain of physical and spiritual state, help to prolong the life and enhance life quality

for HIV/AIDS infected persons Zămbia is one of the first African nations which

implement the HIV infected patient care service at home This service was internationally recognized because of high quality Currently, it is estimated that the whole world has 32,3 HIV infected persons who are alive and mainly gather in developing countries High efficiency HIV virus resistance treatment medicine support (started to implement in 1996) opened new prospects, bringing the hope to prolong the life for HIV/AIDS infected persons Up to now, several other nations un the region of Thai Binh Duong’s west established the base for extending HIV resistance treatment with the Government’s strong commitment in steering, finance and active participation of boards, sectors, unions in the society

In Vietnam, currently, the system of HIV infected person care and support in the community which was initiated since 1996, with the program of management, care and consulting in 3 provinces, cities was implemented in the whole country The outpatient clinics, voluntary test room (VCT) were established in combination with consulting HIV test, including the provision for HIV infection from mother to children (PLTMC)

in 40 provinces In addition, to gain the target that HIV infected persons can get easy access to the services of care, support and treatment, with the support of Global Project

on HIV/AIDS, Ministry of Health conducted the model of care, treatment support in

100 districts of 20 provinces, of which, there are 60 outpatient clinics at the district level which conducted AIDS treatment by HIV resistance medicine

CHAPTER II RESEARCH SUBJECT AND METHOD

2.1 Research subject, place and time

2.1.1 Research subject

- AIDS infected adults (identified ≥ 18 years old)

- The Health staff directly participate in AIDS patient care and treatment at the outpatient clinics and in the community

- Colleagues, co-ordinators

- AIDS patient’s relatives: Father, mother, wife/husband, brothers, sisters

- Reports on HIV/AIDS by Ministry of Health of 3 research provinces/cities; AIDS’s medical document of AIDS patient participating in the research

2.1.2 Research place

The research is conducted with clear purpose in 3 outpatient clinics supplying the service of care, support and treatment for AIDS infected adults in 3 provinces, cities: Ha Noi, Nghe An and Ho Chi Minh

The outpatient clinics in researched provinces which are choosen to participate researching on the convient base are the ones supplying the ARV treatment services

at least 1 years At least, there are 300 patients who are cared, supported and treated with ARV medicine

2.1.3 Research time: Conduct to investigate, intervene for researched subjects from 6/2009 to 12/2010

- The first investigaiton: 6/2009 - 9/2009 (Research real situation description)

- The second investigation: 10/2010 - 12/2010 (Access after treatment intervention by ARV medicine)

2.2 Research method

2.2.1 Design research

Is the description research method including analysis (combine the quantitative and qualitative) and clinic intervention research in comparison with before and after-intervention

2.2.2 Research method

- Method of cross description investigation

- Method of secondary data analysis

- Method of deep interview, group discussion

- Method of clinic test with the comparison

2 sample design influence coefficient; it is estimated that the rate of research refuse

is 105 With above-mentioned parameters, sample size for research is 844, in reality, when conducting the research, 100 AIDS patients of each outpatient clinics are taken into the research; therefore, total number of research subjects is 900

Sample size for clinical trial study: Assess the effectiveness of intervention, the size was calculated basing on the form to calculate the radix of noncontrolled cohort study

[(1 – p1)/p1 + (1 – p2)/p2]

n2 = Z2(1-α/2)

[ℓn(1 – ε)]2

n2: sample size of clinical trial study; Z(1-α/2): confidence coefficient, with

desired reliability was 95% (Z(1-α/2) = 1,96); P1: Rate of AIDS patient being taken cared of, supported before intervention p1 = 35% = 0,35; P2: Rate of AIDS patient

being taken cared of, supported after intervention p2 = 80% = 0,8; ε: Relative accuracy (Acceptale error), at 10%; expecting the rate of patient reusing to take part

in the study is 10% With the above parameters, n2 = 730 as the common sample size calculated for all three outpatient clinic In studying, we took 300 AIDS patients from each outpatient clinic; total number of studying subjects was 900

2.2.4.2 Qualitative study

In each clinic, choose 5 subjects for intensice interview (total number of interview was 15) and 20 subjects for focused group discussion (each group included 8-10 people, one group of AIDS patient; 1 group for officers, medical staff in the clinic and caring people) In fact, there were 75 subjects taking part in this study

2.2.5 Sample choosing method

2.2.5.1 Desciption of studying subject

* Quantitive study: Choose sample intentionally, in each province or city, choose 1 outpatient clinic the number of AIDS being managed, cared and supported and treated >300, data was collected from a random sample of 300 patients In practical studying, because the sample was chosen on purpuse, outpatient clinic taking part in the study all have sufficient amount of AIDS patient of 300 Total number of patients taking part in the study is 900

* Qualitative study: Subjects taking part in group discussion were chosen intentionally, especially AIDS patients chosen among 300 subjects taking part in the quantitive study Subject taking part in the interview were chosen intentionally

2.2.5.2 Subject of clinical intervention study

Studying subjects are AIDS patients studied in stage were patient using ARV medicine of the management board of province, city and district choose until the sample size is 300 for each clinic and were minitored continuously in 1 year

2.2.6 Equipment to collect studying information, indexs and enrolls

Set of studying indexes includes 5 parts with 43 indexes in order to describe actual situation, related factors and assess effectiveness of AIDS patient caring, supporting and treatment managing activities before and after treatment with ARV Table of group discussion and intensive interview instruction

Table of equipment and facility checking

Effectiveness indicator, to compare increasing effectiveness before and after intervention in percent, calculated as following:

׀Indicator before intervention - Indicator before intervention ׀

Effectiveness indicator = x 100 Indicator before intervention

2.2.7 Data collecting method

The data was collected by: testing table, cross-sectional survey, medical record, AIDS monitoring and caring book, clinical test result of hematology, biochemical, microbiological basing on studying indexes

2.3 Data processing

The data were entered with EPI-Info software, SAS program were used to compare and deal with any dissimilarity between 2 data After data entering, data sets were transferred to STATA software version 8.2 (Stata Corp, 2004)

2.5 Limitation of the topic

2.5.1 Topic range

Studying location of the topic was chosen interntionally, not really representing provincces, citites, areas with morphological features as well as socio-economic condition of each area

Outpatient clinics chosen were clinics financed from projects; then the studying results may not reflect actual situation of HIV/AIDS patient caring, supporting and treating activities currently

2.5.2 Topic limitation

The topic is performed in narrow range, not representative, studying subjects were chosen interntionally without randomness The cohort studying was applied for clinical intervention studying but without control

2.5.3 Overcome topic limitation

- Investigators and supervisors were chosen and trained consistently in term of studying method, tested tools and practised investigating skills (trial investigating)

- The investigating process was supervised closely by field work supervision and quality control survey as well as medical records

2.6 Morality in studying

Only study subjects that agreed to take part in Information, data is ensured to

be confident and only support for studying purpose The studying result is used to

10built up and adjusted intervention content for HIV and AIDS patients more and more effectively, helping other HIV / AIDS patients in the studying territory to get benifits directly or indirectly from the program

CHAPTER 3 STUDYING RESULTS

3.1 Actual situation and some factors related to supplying of caring, supporting and treating services to AIDS patient in outpatient clinic for audults in studying location

3.1.1 Actual situation of supplying of caring, supporting and treating services to AIDS patients in in outpatient clinic for audults in studying location

Outpatient clinic for audults in studying location had sufficient working room

as regulated, including: welcoming room, examiniation room, blood testing room, medicine room, consulting room, administration room; in average, there wee 5,6 rooms/ outpatient clinic Officers, staff of outpatient clinics included: doctors, nurse, consultants, technicians, ppharmaceutical workers, supporting staff, other staff; in average, there were 16 officers , staff / outpatient clinic

Outpatient clinic in studying location were also supported by peers (HIV/AIDS patients, drug addictors, prostitutes) and coordinators In average, there were 27.3 peers and 28.3 coordinator supporting the outpatient clinics in studying location

8,2

85,6

6,2

0 20 40 60 80 100

Quantity 1-2 times 3-6 times >6 times

Rate (%)

Diagram 3.1 Number of times that AIDS patients taking part in the training

100% of studied patients were trained before taking part in the ARV treatment; in that 85.6% took part in the training 3-6 times, 6 took part in more than 6 times

3.1.2 Some factors related to supplying of caring, supporting and treating services

to AIDS patients in outpatient clinics for adults in studying location

3.1.2.1 Characteristics of studied patients before intervention

32.6% of AIDS patients at the age of 20-29, while those at the age of 30-39 are 54.5% Male patients still accounted for majority with 72.8% while female ones accounted for 27.2% Studied subject with low education (from primary school downward) accounted for 15.1% There was a difference between high school level, college and university between Nghe An and two cities of Ho Chi Minh city and Hanoi (High school in Hanoi 44.5%, Ho Chi Minh city 38.8%, Nghe An 16.4%) 54.5% of AIDS patients have had husband or wife, the rest (45.5%) was not married or divorced, widow or judicially separated 71.1% of studied subjects lived

with their parents, husband or wife; 28.9% lived with their friends, alone or homeless

Rate of unstable job or unemployment was high: 72.9%, driver accounted for 16.3%,

worker: 6.3%; officer: 4.5%

The rate of AIDS patients taking part in the study who did not define the risk of

infection was high at 25.2% 74.8% defined the risk, in which infection through grug

injecting was 43.4% and through sex was 29.4%

Table 3.8 Unit introduced patients to outpatient clinic

Studying location Introduction unit

- Community outreach group

- Other outpatient clinics

- Know – themselves

- Others

- Non-defined

6,3 23,7 35 21,7 4,0 0,0 3,3 2,4 18,3 21,7 12,7 17,6 62,0* 4,7** 35,7*** 34,1

8,0 44,3 7,0 19,8 1,3 5,7 6,3 4,4

*&**: OR = 33,3, 95%CI (18,2 - 64,4), p<0,01;

***&**: OR = 11,3, 95%CI (6,2 - 21,9), p<0,01 Result in table 3.8 shows that: AIDS patients were managed, cared and treated in

outpatient clinics introduced by consulting room; voluntary laboratory account for

about 21.7%, by other outpatient clinics accounted for 17.6%, this ratio shows the role

of outpatients to HIV/AIDS patients Up to 34.1% of patient came to outpatient clinics

voluntarily to be treated and there is a statistic difference between big city with

provinces (Hanoi and Nghe An: OR = 33,3 , 95%CI (18,2 – 64,4), p<0,01; Ho Chi

Minh city and Nghe An: OR = 11,3 , 95%CI (6,2 – 21,9), p<0,01), this also shows that

they were aware of self-caring and studying related information themselves

3.1.2.2 Understanding of studying patient before intervention

Table 3.9 Knowledge about ARV

Content Frequency

(n = 900)

Rate (%) Right

- At least from 3 drugs upward 835 92,8

96.9% of the research patients understood that ARV is HIV antiretroviral

medicine; 2.1% of the research patients thought that ARV is an antibiotic medicine,

and 1.0% did not understand what ARV was

12When we asked the patients about the composition of ARV, 92.8% the

research patients thought that it consisted of at least 3 types of medicines, 4.1%

thought that ARV consisted of 2 types of medicines, and 3.1% of the research

patients did not know about the composition of ARV

Table 3.10 Knowledge about Time of Treatment and way to take ARV

(n = 900)

Rate (%) Time of treatment with ARV

Way to take ARV

- Time between the 2 dosages: 12 hours 900 100.0

Almost all the research patients understood that ARV is for long-life treatment

(accounting for 96.9%) However, 2.1% of the research patients did not know about

the time of ARV treatment 1.0% thought that the treatment with ARV would finish

until their health got better 100% of the research patients understood that during the

ARV treatment, they should take the ARV 2 times/day and that the time between the

2 dosages is 12 hours

Table 3.11 Knowledge about the side effects of ARV

Knowledge about the side effects of ARV Frequency

(n = 900)

Rate (%)

Only 81.4% of the research patients understood the side effects of ARV and

showed the side effects during the ARV treatment The most mentioned symptom is

Rash (75.9%); Dizziness and vertigo (45.6%); Vomiting (36.7%)

Diagram 3.3 Knowledge about treatment compliance

Almost all the research patients understood that treatment compliance was to

take the ARV on time (94.8%), take ARV with specified amount (86.6%) and take

the right medicine (81.4%)

Table 3.12 Knowledge about treatment non-compliance

ARV treatment non-compliance Frequency

(n = 900)

Rate (%)

- Skip 1 dosage among the specified dosages 650 72.2

- Skip 1 day without taking the medicine 612 68.0

- Do not care about the time between the dosages 492 54.7

72.2% of the research patients considered treatment non-compliance as skipping

1 dosage among the specified dosages; skipping 1 day without taking the medicine

(68.0%), and Do not care about the time between the dosages (54.7%) Only 1% of

the research patients did not know what should be consider as treatment

non-compliance

Table 3.14 Knowledge about taking additional missed medicine and the

supporting measures for treatment compliance

(n = 900)

Rate (%) Take