This document discusses using the HIV cascade framework to improve HIV services in Vietnam. It provides examples of HIV cascades from several provinces that reveal gaps where people are lost at each step from diagnosis to treatment. Rapid assessments in provinces are using the cascade framework to identify targeted interventions. While Vietnam has made progress in HIV treatment, over 50% still start treatment late. The cascade framework is a useful planning and evaluation tool to monitor how well people move through prevention, testing, and treatment services and to close leaks in the system through strategic investments.

1. Improving the HIV
Cascade of Services
in Vietnam
ICAAP Bangkok
November 2013

2. Response to HIV epidemic in Vietnam
• Nearly 72,000 on ART
• More than 14,500 on MMT (Target 80,000 by 2015)
• Number of newly reported HIV diagnoses has declined
• New generation of well trained, experienced leaders
emerging
• Country leadership on HIV/AIDS is gaining in strength

3. Concerning trends in Vietnam
(and in other countries)
1. Substantial, local HIV
epidemics occurring in
underserved areas.
2. Many PLHIV often not seeking
testing or not linked to care
after testing positive.
3. Number newly initiating ART
not growing or declining in
many sites.

4. Concerning trends in Vietnam
4. Many clients are dying, dropping out of
treatment or lost to follow‐up
5. Donor resources declining and service system
costs too high to be sustained by the GVN.
6. Epidemic of injection drug use continues with
>215,000 estimated PWID.

5. Late Entry to ART
“At present, 51% of people start treatment at a
CD4 cell count below 100 cells/mm3, underlining
the urgency of expanding access to treatment,
regardless of its prevention benefit.”
Dr Bui Duc Duong, Deputy Director‐General
Viet Nam Authority of HIV/AIDS Control
7th International AIDS Society Conference on HIV
Pathogenesis, Treatment and Prevention. Kuala
Lumpur, Malaysia (July 2013)

6. The Cascade Framework
in Vietnam

7. The Cascade framework is…
• Old, but new
• Improvement on older methods for presenting data &
illustrating program performance
• Simple, easy to communicate with powerful impact
• Easily adaptable to different programs, strategies and
populations
• Promotes different interventions targeted to different
phases of ‐ or gaps in ‐ the cascade
• Based on a set of available core indicators

8. The Cascade is…
• A logic model that links prevention outreach,
testing & treatment services across a continuum
of care (CoPC)
• Reveals how individuals move, don’t move,
through the CoPC or are lost to follow‐up

9. The Cascade Framework: Patching a Leaky Pipe

10. The Cascade Framework
‐ Extension of life
‐ Reduce transmission

11. Cascade of HIV diagnosis, care and
treatment in Vietnam, December, 2012
250000
200000
Female
Person
63537
Male
150000
100000
44%
138166
28262
50000
39%
53979
87%
88%
24785
47926
0
Diagnosed PLHIV
Source: VAAC report, D28
In care at OPC
On ART

12. Rapid Assessments and Responses
• Four provinces assessed: Nghe An, Lao Cai, Dien Bien
and An Giang (three more scheduled)
• Cascade framework coupled with service mapping
used to assess CoPC performance and needs.
• Targeted, time limited assistance plan rapidly
implemented (in phases)
• Cost assessment and analyses being added

13. Cascade for Nghe An, Dec 2012
5000
4500
4000
1583
Person
3500
Female
Male
3000
2500
2000
35%
3088
1500
1000
562
40%
1234
500
95%
95%
538
1176
0
Diagnosed PLHIV
Source: Nghe An PAC, 2012
In care
On ARV

14. Cascade for Lao Cai, 6/2013
3500
3000
Person
2500
1390
Female
Male
2000
1500
1000
1778
20%
276
500
27%
84%
477
80%
0
Diagnosed PLHIV
Source: Lao Cai PAC, 10/2013
In care
232
381
On ARV

15. Cascade for Dien Bien, 6/2013
9000
8000
7000
7782
81.78%
6364
6000
5000
4000
3000
27.36%
2000
1741
92.82%
1616
1000
0
Accumulative HIV
reported cases
PLHIV still alive
Retain in care
Currently on ARV

16. Tua Chua District, Aug 2013
100
90
80
35
70
60
Death
50
PLHIV
40
30
57
20
38
10
6
0
H+ cumulative
HIV+ Managed
on ARV

17. Muong Bang Commune, Aug 2013
60
50
40
20
Death
30
PLHIV
20
28
10
16
2
0
H+ cumulative
HIV+ Managed
on ARV

18. Potential for Other Cascades

19. MMT – HIV – ART Cascade, Dec 2012
40,000
Data Source: VAAC 2012
Estimated:
217,000
35,000
Recorded:
171,000
30,000
25,000
121
Drug
‘06 Centers
Users
Methadone Maintenance
25‐35,000
MMT Retention:
Haiphong
1 Year 90%
2 Years 80%
20,000
15,000
10,000
5,000
13,000
60
MMT
Clinics
HIV‐
Negative
77.5%
13,000
HIV+ 22.5%
2,925
ARV 71.4%
0
IDU's
MMT
ART

20. Implications for planning
and investment

21. The Cascade Framework in Vietnam…
• A useful planning/diagnostic tool,
• Easily used at the provincial level
• Rapid assessments/responses can lead to closing of service
gaps/leaks
• Useful Evaluation tool
• Can monitor success in introducing new tools (i.e.,
Treatment for Prevention)

22. Investments in ….
• Use of the cascade framework coupled with service
mapping and cost assessment can be very effective.
• Addressing targeted gaps and leaks will substantially
Improve system performance.
• Supporting local use of the cascade framework can
increase sustainability.

23. Thank you!