Co-authored by Caroline Francis
For those of us who work in the field of HIV, words like "eradication" or "elimination" are not commonly used. Yet, new evidence and tools suggest that getting to zero might just be possible if we look at HIV through a fresh lens and focus our limited resources in strategic ways. As World AIDS Day nears, an example in Vietnam shows one promising approach.
Vietnam is at a tipping point. The country is working hard to scale up methadone maintenance treatment for injecting drug users and to provide antiretroviral (ARV) treatment for those living with HIV. External resources, however, are declining and every dollar (or Vietnamese dong (VND)) makes a difference. The cascade of HIV care -- an approach that links prevention outreach, testing and treatment services across a continuum of care -- helps identify the key opportunities to improve services to stop the spread of HIV. This tool has come to Vietnam at a critical time. Vietnam's HIV epidemic is still in a concentrated phase, with the highest seroprevalence among populations at higher risk. These include injecting drug users, female sex workers and men who have sex with men.
Using the cascade -- in every facility, commune, district and province -- helps Vietnam monitor HIV service system performance and focus its remaining human, financial and programmatic resources on the ultimate aim of the HIV response: viral suppression. The cascade approach identifies "leaks" in the system to target resources on interventions that diagnose people with HIV, initiate ARV treatment quickly and sustain those individuals with continued care. Knowing where the drop-offs are most pronounced can assist decision makers and service providers in implementing system improvements and service enhancements that make the greatest impact on individuals, communities and Vietnamese society.
When officials in Nghe An province looked at their epidemic through the cascade, they found striking service and financial gaps, which they then used as leverage to press for progress. "We presented the information to the Nghe An People's Committee, and they increased the annual budget and Government personnel," explained Nguyen Van Dinh, Director of the Provincial AIDS Committee. "We will use the cascade every six months to monitor our HIV situation."
The improvements that result from using the cascade approach can make a tangible difference in people's lives. Vi Van Nam, a 24-year-old HIV-positive man in Nghe An, says his life changed when HIV services were extended to the remote district where he lives. "I used to get treatment 80 km away. It cost me 500,000 VND every month for travelling and one day off for reexamination and getting medicines. I was so tired from having to travel a long way. Now that the [health facility] is near my house, I can save my time and health from travelling, while I can still work normally. I can also come and meet with health workers whenever I don't feel well. I feel healthier and now have more time for my family work. My family members and myself feel very secure about my treatment."
FHI 360, through the Sustainable Management of the HIV/AIDS Response and Transition to Technical Assistance (SMART-TA) project funded by the U.S. Agency for International Development, is introducing the cascade to the Vietnamese government and civil society organizations across the country. (Watch this video to see one way we share the benefits of the cascade with our partners.) By supporting Vietnam in using the cascade and other tools in the fight against HIV, we believe that, together, we can achieve an AIDS-free generation in Vietnam and other countries.
Ward Cates, M.D., M.P.H., is President Emeritus with FHI 360
Caroline Francis, M.A., is the Deputy Country Director of FHI 360 Vietnam