Mobilization for HIV Voluntary Counseling and Testing Services in Vietnam Clients’ Risk Behaviors, Attitudes and Willingness to Pay

Latkin2 Published online: 12 September 2015 Ó Springer Science+Business Media New York 2015 Abstract A multi-site survey was conducted on a sample of 365 clients to assess their willingn

O R I G I N A L P A P E R

Mobilization for HIV Voluntary Counseling and Testing Services

in Vietnam: Clients’ Risk Behaviors, Attitudes and Willingness

to Pay

Long Hoang Nguyen1,3•Bach Xuan Tran1,2•Nhung Phuong Nguyen5•

Huong Thu Thi Phan4• Trang Thu Bui4•Carl A Latkin2

Published online: 12 September 2015

Ó Springer Science+Business Media New York 2015

Abstract A multi-site survey was conducted on a sample

of 365 clients to assess their willingness to pay for HIV

voluntary counseling and testing (VCT) services in Ha Noi

and Nam Dinh province, two epicenters of Vietnam By

using contingent valuation technique, the results showed

that most of respondents (95.1 %) were willing to pay

averagely 155 (95 % CI 132–177) thousands Vietnam

Dong (*US $7.75, 2013) for a VCT service Clients who

were female, had middle income level, and current opioid

users were willing to pay less; meanwhile clients who had

university level of education were willing to pay more for a

VCT service The results highlighted the high rate of

willingness to pay for the service at a high amount by VCT

clients These findings contribute to the implementation of

co-payment scheme for VCT services toward the financial

sustainability of HIV/AIDS programs in Vietnam

Keywords HIV testing
Willingness to pay
Contingent

valuation
Vietnam

Introduction

The HIV epidemic in Vietnam is among those with the fastest growth in Asia [1] HIV infection is primarily driven

by high-risk populations in the country (i.e., female sex workers, injecting drug users, men who have sex with men, and sexual intimate partners of drug users [2 6] Approx-imately 225,000 people were reported to have contracted HIV [7], but this rate was underestimated due to the fact that many people are unaware of their HIV-positive status [6] In such cases, widespread scale-up of HIV voluntary counseling and testing services (VCT) is critical to limit the transmission of HIV

VCT has been recognized as a cost-effective part of the overall control strategy of the HIV/AIDS epidemic [8 10] VCT supports an individual to make an informed choice about being tested for HIV through counseling [11]

A VCT procedure consists of 4 components: (1) Pre-test counseling; (2) HIV testing; (3) Post-test counseling; and (4) Follow-up counseling [12] Counseling reduce possi-bilities of HIV infection and transmission through inter-preting test results and initiating changes of risk behaviors, Furthermore, service users are provided referrals to addi-tional care, such as preventive, psychosocial, and other essential services [11] VCT is also considered as an entry point for other HIV/AIDS preventive and treatment including the prevention of HIV transmission from mother

to child [11, 13] VCT may lead to a decrease of risk behaviors among HIV-positive individuals, such as unprotected sex [14, 15] In addition, it enables early antiretroviral treatment, therefore improves health status and quality of life of people living with HIV/AIDS (PLWHA)

VCT service has been used widely in Vietnam through supports of international donors Currently, there are 485

Long Hoang Nguyen and Bach Xuan Tran have equally contributed.

& Bach Xuan Tran

bach@jhu.edu

1 Institute for Preventive Medicine and Public Health, Hanoi

Medical University, Hanoi, Vietnam

2 Johns Hopkins Bloomberg School of Public Health, Johns

Hopkins University, Baltimore, MD, USA

3 School of Medicine and Pharmacy, Vietnam National

University, Hanoi, Vietnam

4 Authority of HIV/AIDS Control, Ministry of Health, Hanoi,

Vietnam

5 Hanoi University of Pharmacy, Hanoi, Vietnam

DOI 10.1007/s10461-015-1188-6

VCT sites in 63 provinces nationwide [16] However,

there are small proportions of high-risk populations

undergoing HIV testing (e.g., 15–32.7 % of female sex

workers [17,18], 36 % of men who have sex with men

[19] ) Therefore, expanding HIV testing service coverage

to high-risk populations is a high-priority task of the

National HIV/AIDS Strategic Plan in Vietnam in the

period of 2020–2030 [20]

The Vietnamese government is currently confronting

the challenge of ensuring the financial sustainability of

HIV/AIDS programs (including VCT) According to the

projection for the period 2011–2015, the total cost of

HIV services will increase by 60 %, to approximately

US $150 million However, internal sources can

subsi-dize only 6–12 % of the total cost [21] In order to

reduce the deficit, the Vietnamese Ministry of Health has

identified potential strategies, such as decreasing cost,

improving efficiency, mobilizing resources [22], and

encouraging users’ co-payments [22] Accordingly,

information about willingness to pay (WTP) of clients

for VCT will help the government identify appropriate

financial allocations to ensure sustainability of HIV/

AIDS intervention services

WTP is defined as the largest sum of money that a

customer is amenable to pay in order to obtain a certain

good or service The measurement of willingness to pay

could be derived by revealed- or stated- preference

approaches In evaluation of health care intervention, a

stated-preference method that has been widely used is

contingent valuation (CV) [23] CV is defined as a

survey-based and hypothetical elicitation technique to

estimate WTP values of customers for a service they

receive through their evaluation of hypothetical

scenar-ios [23]

Currently, there has been a little research on WTP for

VCT [24,25] This paper aimed to determine the WTP for

VCT and identify the WTP-related factors among

Viet-namese clients through a multi-site survey Results from

the study may inform social mobilization policy for

sus-tainability of HIV/AIDS programs

Methods

Study Setting and Sampling

This study was a part of ‘‘HIV Service User Survey 2013’’

(HSUS 2013), which evaluated the effects of integrated

HIV-related service delivery models on health and

eco-nomic outcome of PLWHA in Vietnam The

cross-sec-tional study was conducted in Hanoi and Nam Dinh from

January to August 2013 These two cities are among the

areas with the largest HIV infection burden in northern

region in Vietnam, with 20,762 and 3781 PLWHA in Hanoi and Nam Dinh, respectively [16] VCT clinics were purposively selected based on several following criteria: (1) providing VCT services; (2) comprising provincial-; district- and commune-level; (3) implementing HIV-testing and consultation according to the official guideline of Vietnam Ministry of Health [26] and (4) representing for both urban and rural areas The list of all VCTs meet eli-gible criteria was prepared and we estimated that 6 sites are needed to derive a sample of 400 clients We selected 2 provincial and the only one commune VCT in the sample frame, and then randomly selected 3 district- VCT sites Accordingly, six VCT facilities were selected four sites in Hanoi, including in 1 provincial site (Hang Bai clinic), 2 district sites (Dong Anh and Hoang Mai district health centers) and 1 commune site(Truc Bach); two sites in Nam Dinh, including in 1 provincial site (Nam Dinh HIV/AIDS control center) and 1 district site (Xuan Truong district health center).The information of each clinic was described below:

Name Level Location Other services Nam Dinh Provincial

AIDS Center

Provincial Nam Dinh Methadone

Maintenance Xuan Truong District

Health Center

District Nam Dinh ART/MMT,

General Health Hang Bai Clinic Provincial Hanoi General Health Dong Anh District

Health Center

District Hanoi ART, General

Health Hoang Mai District

Health Center

District Hanoi ART, General

Health Truc Bach Commune

Health Station

Commune Hanoi General Health

The VCT clients were introduced about the study at the waiting room by a well-trained interviewer This could be either a master student at Hanoi Medical University or a counselor at the VCT site The inclusion criteria included: (1) visiting clinics during the study period; (2) being age from 18 years or above; and (3) having capacity and agreement to answer the question-naires The VCT clinics were organized following a national guideline so that they are similar in terms of service, procedure and facility Clients may decide to take VCT in any site if they would like to During the period of the study, it is estimated that each site had about 10–50 clients per month; therefore, we set a

3 months as a duration for data collection We approa-ched and invited all clients who visited the selected VCT for the study Before interviewing, we explained the

purpose of this study and obtained informed consents

from eligible subjects The selected individuals were

invited to designated counseling rooms for an interview

Respondents included both those clients who first come

to take the services or those who returned for taking the

results To examine if the test results would influence

patients’ preference, we included the HIV-status of

cli-ents in the statistical analysis

Measures and Instruments

A structured questionnaire was developed to collect the

data of interest Due to the lack of data about WTP for

VCT, we developed the conceptual framework through a

literature review to identify the determinants of WTP for

VCT services in previous studies For example, a study of

Ozochukwu underlined the positive role of socio-economic

characteristics (age, gender, education, etc.) and VCT

toward-knowledge and attitude in WTP for VCT

Mean-while, some studies suggested both positive and negative

relations among socio-economic status, risk behaviors

(sexual activities, condom use, drug use, etc.), health status

and VCT service utilization [18, 27, 28] The conceptual

framework was figured out in Fig.1 The variables of

interest were listed below:

Socioeconomic Status The socio-economic factors included age, gender, marital status, educational level, employment, and income Monthly household income per capita was calculated through all household members’ incomes Then, this income was categorized into five quintiles as ‘‘poorest’’,

‘‘poor’’, ‘‘middle’’, ‘‘rich’’ and ‘‘richest’’

Health-Related Quality of Life Health-related quality of life was measured by using EQ-5D-5L instrument, which was validated elsewhere [29] This instrument assessed five dimensions including mobility, self-care, usual activities, pain/discomfort and anxiety/depression [30], with five levels of response: no problems, slight problems, moderate problems, severe problems, and extreme problems

Sexual Behaviors Sexual behaviors, such as number and type of partners, condom use with last sex, and percentage of condom use in the last 12 months, were investigated Non-condom use with last sex was identified when the respondent did not

Socio-economic status

Health status

Knowledge and attitude

Risk behaviors

- Income

- Expenditure

- Age

- Gender

- Education

- Marital status

- Employment

- Health-related quality of life

- Mental health

- Physical health

- Knowing relatives with HIV-positive

- Benefits and roles of taking VCT

- Importance of VCT

- Referral for relatives

- Unsafe sex, condom use, sexual contact with sex workers

- Alcohol use

- Drug use: history, concurrent

Willingness to pay for VCT

Fig 1 Conceptual framework

to determine the associated

factors with WTP for VCT

use condom in the last sex (i.e., primary partners, casual

partners, and sex workers)

Opiate Drug Use Behaviors

Information about illicit opioid (comprising heroin and

other opiates) use included: lifetime opiate drug use,

life-time opiate drug injection, and current opiate drug use

Current opiate drug user was defined as a person currently

used illicit opioid at the time they took HIV testing and

counseling

VCT Use and Referral

In this study, metrics about total times of using VCT until

the interview, information about a person who referred

respondents to take initial VCT used and whether or not

respondents referred their partners/relatives to VCT

ser-vices were collected In addition, whether VCT clients

were willing to be voluntary peer instructors was also

considered in the study

To figure out the HIV/AIDS status of clients and their

family members, some approaches were utilized For

people went to clinics to take test and consultation, we

asked questions about HIV status of their family members,

provided codes to them and then the clients used their

codes to have HIV test This step would help to ensure the

confidential of clients When the test results were available,

we matched the codes for the correspond questionnaires

Otherwise, for people went to clinics to take test results, we

only asked them to report their HIV status without

pro-viding codes

Willingness to Pay for VCT

To support respondents in evaluating their WTP for VCT, a

scenario, containing general information about several

aspects of VCT in Vietnam, was provided to ensure that patients had sufficient background knowledge about VCT First, the interviewers reviewed the transmission pathways

of HIV and the benefit of VCT (e.g., knowing HIV/AIDS status, preventing risk of infection) [11] Then, they sum-marized the financial problem related to VCT in the future, and the national plan in confronting the issues and

scaling-up the coverage of VCT services [20] Specifically, sur-veyors explained that although VCT was current free-of-charge due to the donation of international sources, that funding will be decreased and that co-payment from VCT clients may be essential to maintain the VCT services For patients or clients who already used VCT services, they were asked to imagine that they would have a need to utilize VCT services in the future This assumption helped the participants selecting their options easier

To elicit WTP for VCT, double-bounded dichotomous-choice questions combined with an open-ended question were used in the study To select an initial price, we based

on previous studies about cost per client for VCT in Vietnam A study showed that the cost per client was from

US $28.4 to US $38.9 in 2007 [31], while another study reported a much lower cost of US $7.6 in 2012 [31, 32] The difference may explain by higher number of clients per setting in the latter study compared to the former one [32]

To adapt the results of those studies and adjust to the number of VCT clients per site, twenty US dollars (20,000 VND = US $1, 2013 exchange rate) were selected to be an initial price in the current study

After understanding the scenario described above, each patient was asked a number of Yes/No questions about their willingness to pay specific prices (see bidding process

in Fig.2) First, they were asked to whether they were willing to pay US $20 for VCT service Depending on their choice, interviewers presented two other bids: the double bid for respondents answering ‘‘Yes’’; and the half bid for respondents saying ‘‘No’’ The question was repeated until

Fig 2 Bidding process of the

contingent valuation method.

N an unwillingness to pay; Y a

willingness to pay

the last bid was equal to four times or one-eighth of the

initial price Finally, the respondents were asked an

open-ended question ‘‘What is the maximum price you would be

willing to pay for VCT service?’’

Statistical Analysis

STATA version 12.0 (Stata Corp LP, College Station,

United States of America) was used to analyze the data

Statistical significance set at p \ 0.05 To examine

differ-ences in various characteristics among participants across

three healthcare system levels (provincial, district and

commune), ANOVA, Kruskal–wallis and v2 tests were

used Data about WTP was mixed between censored and

uncensored data due to the combination of double-bounded

and open-ended questions An average amount of WTP for

VCT in different patient groups was estimated by using an

interval model [33] Multivariate interval regression was

used to determine factors associated with the amount of

WTP for VCT services In the model, the amount of WTP

was an outcome variable, while factors such as

socio-economic, health status (EQ-5D), risk behaviors, attitude,

and uses of VCT services were independent variables

Stepwise backward strategies based on log-likelihood ratio

test were used to construct the reduced model, in which

p values [0.2 was the threshold for exclusion

Ethical Approval

The research was approved by the Medical Ethical

Com-mittee of the Authority for HIV/AIDS Control at the

Vietnamese Ministry of Health

Results

A total of 365 VCT clients were recruited to the study,

including 38.1 % at provincial clinics and 32.6 % at

dis-trict ones Of these, 32.6 % were female, 58.6 % aged

under 35, 64.1 % lived with their spouse, and more than

70 % of the respondents completing high school or above

Almost all of them were workers/farmers or self-employed

(Table1)

Self-reported health-related quality of life of clients is

shown in Table2 Most of the respondents reported

prob-lems in Anxiety/Depression (68.2 %) Approximately

one-third of subjects reported suffering issues in Mobility and

Pain/Discomfort Meanwhile, only 8.2 % clients reported

having problems in Self-care

Regarding risky sexual behaviors, 46.6 % of

respon-dents had one partner in the last twelve months, and 39.2 %

reported more than one partner Among those who were

sexually active, the proportion of the participants not to use

condom in the last sex with their primary partners was the highest compared with casual sex partners or sex workers However, the frequency of using condom with main part-ners (spouse/beloved) was the highest (mean = 37.2 times out of 100; SD = 32.3) In addition, one out of ten had a history of illicit drug use, 6.9 % reported a history of drug injection, and 4.1 % reported currently use drugs (Table3)

Table4 shows attitude toward and uses of VCT amongst respondents The average frequency of VCT uses was 1.12, higher at the provincial level than at the com-mune level Peers and media were the most frequent referrers of the first VCT use amongst clients (25.6 and 26.1 %, respectively), while parents/relatives were the least frequent HIV prevalence was low in respondents (4.7 %) but high in their family members (64.7 %) More than half of the clients would refer to their partners or relatives to VCT services (60.3 and 51.5 %, correspond-ingly) However, only one-fourth of people would become voluntary peer instructors

The preference and WTP for VCT services is described

in Table 5 Overall, most of the respondents were willing

to pay for VCT (95.1 %) The mean amount they were willing to pay was 155 thousand Vietnam Dong per uti-lization (95 % CI 132–177 thousands Vietnam Dong), equivalent to US $7.75 in 2013, and varied across groups Female clients and those clients utilizing VCT at the dis-trict or rural clinics were willing to pay less than other client groups

Table6 shows the findings from reduced multivariate regression to determine factors related with the amount of WTP for VCT service Clients were willing to pay a smaller amount for VCT service if they were female, current drug users, and belonged to middle income Meanwhile, respondents completing university education were willing to pay a higher price for VCT compared to those being illiterate

Discussion

This study indicated the high prevalence of mental and physical health problems; and sexual risky and illicit drug use behaviors amongst VCT clients Most people using VCT services reported anxiety/depression symptoms This may be due to the fact that when someone went to VCT facilities, they were worried about their HIV status In many developing countries, people who are infected with HIV have to confront not only the decline of health status, but also the serious stigma and discrimination of the communities [34] Moreover, the prevalence of sexual risk behaviors among VCT clients was still high, while the

proportion of people reported using illicit drugs was low.

This finding corresponds the changing pattern of HIV

transmission—from injection drug transmission to sexual

transmission in Vietnam [16]

While investigating the attitudes towards VCT, the

study found that peers and media were the most popular

factors that facilitated initial VCT visit of clients

Fur-thermore, high rates of clients had already referred the

service to their relatives This finding was similar to other

studies conducted in Ethiopia [35, 36] and Nigeria [37],

indicating that those channels are potential approaches to

expand the benefits of VCT service to population In

addition, most respondents expressed a WTP for VCT services

The observations indicated the noteworthy agreements

of clients about WTP for VCT services, suggesting that they already perceived benefits of VCT and their respon-sibility of co-payment The mean amount of WTP for VCT

in this study was US $7.75 The result was much lower than the cost per client in the study of Hoang et al in 2007 (in facility-based VCT: US $30.3; in free-standin g VCT facility: US $38.9) [31], but approximately equal to the survey of Nguyen et al (with US $7.6) in 2012 [32] This amount of WTP accounted for 0.41 % GDP per capita in

Table 1 Characteristics of

VCT clients by level of services

administration

Characteristics Province District Commune Total p value*

Gender

Age

Marital status

Live with spouse 94 67.6 78 65.6 62 57.9 234 64.1 Live with partner 6 4.3 3 2.5 5 4.7 14 3.8

Educational attainment

Secondary 25 18.0 40 33.6 19 17.8 84 23.0

Vocational 49 35.3 22 18.5 18 16.8 89 24.4

Employment

Self-employed 46 33.1 52 43.7 40 37.4 138 37.8 White collars 43 30.9 10 8.4 24 22.4 77 21.1 Workers, farmers 27 19.4 34 28.6 20 18.7 81 22.2

Religion Cult of ancestors 96 69.1 96 80.7 101 94.4 293 80.3 \0.001

*Using Chi squared test

Table 2 Health-related quality

of life of VCT Clients Health status EQ5D profile Province District Commune Total p value*

Mobility Have problems 21 15.1 39 32.8 35 32.7 95 26.0 \0.05

No problems 118 84.9 80 67.2 72 67.3 270 74.0 Self-care

No problems 134 96.4 94 79.0 107 100.0 335 91.8 Usual activities

Have problems 10 7.2 37 31.1 2 1.9 49 13.4 \0.001

No problems 129 92.8 82 68.9 105 98.1 316 86.6 Pain/discomfort

Have problems 54 38.9 46 38.7 31 29.0 131 35.9 0.21

No problems 85 61.2 73 61.3 76 71.0 234 64.1 Anxiety/depression

Have problems 100 71.9 52 43.7 97 90.7 249 68.2 \0.001

No problems 39 28.1 67 56.3 10 9.4 116 31.8

*Using Chi squared test

Table 3 Risk behaviors of VCT clients

Number of sex partners (in the last 12 months)

Type of sex partner

Condom use with last sex

With primary sex partners (n = 305) 62 50 52 62.65 55 56.12 169 55.41 0.20 With casual sex partners (n = 60) 14 36.84 – – 9 42.86 23 38.33 0.66 With sex workers (n = 76) 8 30.77 16 100.0 11 32.35 35 46.05 \0.001

Percentage of condom use (in the last 12 months)

With primary sex partners 54.2 39.2 31.4 42.1 16.1 35.0 37.2 32.3 \0.001

*Using Chi squared test and ANOVA

Vietnam in 2013 (US $1910, according to the statistic of

World Bank) [38], making this amount being acceptable

for the clients to pay However, a study conducted in

Nigeria indicated that the mean amount of WTP was much

lower (US $3.2) [24], despite of a higher GDP per capita in Nigeria compared to Vietnam Additional research con-ducted in Kenya estimated another amount was US $2 [25] This can be explained by various factors First, the cost to

Table 4 Attitudes and Uses of VCT services

value* Mean 95 % CI Mean 95 % CI Mean 95 % CI Mean 95 % CI

VCT service utilization (total times) 1.45 1.03 1.88 1.07 0.77 1.37 0.75 0.60 0.89 1.12 0.93 1.31 \0.05

Referrer of the first VCT used

HIV status (positive)

Refer partners to HIV testing services 86 61.9 71 59.7 63 58.9 220 60.3 0.88 Refer other relatives to HIV testing services 75 54.0 58 48.7 55 51.4 188 51.5 0.7 Volunteer to be a peer instructor 28 20.1 29 24.4 38 35.5 95 26.0 \0.05

*Using Chi squared test and ANOVA

Table 5 Willingness to pay for

VCT service Variable N Willing to pay Amount of WTP (1000 Vietnam Dong

a )

Sex

Level

Area

a 1 USD = 20,000 Vietnam Dong

operate VCT centers in those areas was lower than in

Vietnam [25, 31] Second, respondents engaged in

high-risk behaviors in concentrated epidemics like Vietnam may

perceive importance and necessity of VCT than those in

generalized epidemics [39, 40] Finally, in reference

set-tings, respondents believed that these services should have

been provided without charge [24]

This study also identified differences of mean WTP

amounts in various health service system levels While the

clients were inclined to spend approximately US $10 at the

provincial and commune clinics, US $5 was the maximum

amount a customer was amenable to sacrifice at the district

levels It might reflect that the clients were not satisfied

with the quality of services (e.g., counseling procedure,

clinics’ facilities and/or the ability of health staffs, etc.) at

those centers and they did not want to pay more

Addi-tionally, the finding that male clients and people with

university education were willing to pay more than the

others is consistent with a previous study [24]

Nonetheless, the respondents with middle income per

capita were willing to pay less than the poorest group

Normally, people with higher income are willing to pay more [41, 42] Notably, when analyzing the data more deeply for the frequency of having HIV-test according to levels of income (data not shown), we observed the higher rate of people not taking HIV-test before the interview in the lowest income quintile compared to that in other levels When using contingent valuation approach, this phenomenon had to be concerned as a lack

of familiarity in VCT service utilization may lead to hypothetical bias Previous literature emphasized the role

of familiarity characteristic that people having insufficient experience for unfamiliar goods tended to overestimate their WTP [43]

The result also found that current drug users were willing to pay less than others Some current drug users may avoid using health care services including HIV testing Besides, a previous study reported that monthly spend of drug users for opiates were US $540, which were five times higher than their average income per capita [41] This expenditure places economic burden on households, which may affect the WTP of respondents

Table 6 Factors associated

with willingness to pay for VCT

services among Vietnamese

clients

Employment Unemployed (ref)

Income per capita Poorest (ref)

Condom use with Spouse/Partner Yes (ref)

Brother/Sister have HIV positive Yes (ref)

Referrer of the first VCT used Spouse (ref)

Gender (Female vs Male) Male (ref)

Education Illiterate (ref)

Current drug use

No (ref)

The study has several implications First, the high

prevalence of sexual-risk behaviors (e.g., multiple partners,

inconsistent condom use) implied the need for counseling

and education about the role of safe sex in preventing HIV

infection Second, clients themselves and media

(televi-sion, radio, etc.) were demonstrated as potential channels to

disseminate benefits of VCT service to this vulnerable

population Third, the study indicated the possibility of

co-payment implementation to ensure the sustainability of

HIV/AIDS programs regarding the proportion of

respon-dents accepting to pay for VCT and their mean WTP

amount [32] Finally, since the WTP of high-risk

popula-tions such as female [5] or current drug users was observed

to be lower than other subjects, a subsidy or incentives for

those populations should be taken into consideration

Apart from investigating WTP, some suggestions are

drawn to reduce the cost and to address the financial

sus-tainability of VCT services The government should set up

different VCT delivery models in appropriate locations,

such as stand-alone VCT units were placed in the areas

with a high prevalence of HIV/AIDS while integration

facilities were established in low-risk areas [41, 44] It is

noteworthy that freestanding VCT facilities required much

more resources than integration model [31] The study in

Kenya showed an amount of US $8 per client may be

reduced if general health staffs could play a role as HIV

counselor [25] Health insurance is also a considerable

approach to tackle the issue However, ensuring the equity

and financial balance for other chronic diseases are great

challenges [45]

The strengths of this study lie in various settings in two

Vietnamese epicenters Clients were provided basic

back-ground of VCT and the current situation of financial

problem for VCT before asking the WTP, thus their

responses may reflect their true opinions about the issue,

which lead to reliable results Additionally, contingent

valuation method and multivariate interval regression were

used appropriately to improve the estimation of WTP by

mixing censored and uncensored data [33] However, the

research has several limitations Firstly, the generalization

of our results was limited due to the convenience sampling

We acknowledge the limitation that we include only 2

provinces with a small number of clients in this study, and

would like to notice readers to be cautious in the

applica-tion of our research findings Secondly, a small sample size

was used in the study, which may result in the deficiency of

statistical power Finally, contingent valuation is a subject

measure, which may lead to the uncontrolled bias For

example, people regularly respond to the bids that are

benefit for them [46] To diminish this issue, the purpose of

study as well as the confidentiality of clients was clearly

explained before the interview

In conclusion, the rates of WTP and the amount that Vietnamese clients were willing to pay were higher, compared to other studies The findings are partly con-tributed to the implementation of co-payment policy toward the sustainability of HIV/AIDS interventions in Vietnam

Acknowledgments Dr Bach Tran received the joint fellowship of the International AIDS Society and the National Institute on Drug Abuse that encourages HIV and drug use research The study was funded by Vietnam Authority of HIV/AIDS Control We would also like to thank all research managers, staffs and health professionals in

Ha Noi and Nam Dinh Provinces for the tremendous supports in implementing the study.

Compliance with Ethical Standards Compete of interest None.

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