This post is by Global Center Director Christine Lubinski.
Viet Nam was an fitting spot for last week’s meeting of the Stop TB Partnership Coordinating Board, since the country’s anti-TB efforts demonstrate both the challenges and the potential for progress in combating this deadly disease.
Viet Nam’s Vice Prime Minister and Minister of Health welcomed members of the Stop TB Partnership Coordinating Board and expressed pride about the pace of Viet Nam’s economic development, as it stands on the threshold of moving from status as a low-income country to a lower middle-income country.
Viet Nam is one of the world’s 22 high burden TB countries, with significant rates of HIV/TB co-infection that have contributed to an increase in TB prevalence in young adults. Viet Nam’s national TB manager outlined the dimensions of the TB problem in the nation, as well as the response that began with a nationwide expansion of DOTS coverage in the 1990s. That effort now includes responding to co-infection and officials have also started to address the 2.7 percent of TB cases that are drug-resistant. The country just began providing treatment to multidrug-resistant TB patients in 2009 and still only reaches a fraction of those infected with deadly resistant TB disease. He outlined a number of critical challenges that plague highburden developing countries:
- Human resources—about 50 percent of TB district staff are brand new and require additional training
- Inadequate regulation of TB drugs in the pharmacy market, leading to self-medication
- ART access for patients co-infected with HIV and TB has improved but remains inadequate. The 3 Is—Isoniazid preventive therapy, intensified case-finding, and infection control–also need to be strengthened.
- MDR-TB is an emerging threat and the supply mechanism for second-line TB drugs is insufficient
- Addressing TB in so-called “closed settings”—prisons and re-education centers–and the coordination of these institutions with the national TB program
- Strengthening the role of civil society in TB control
- Monitoring and evaluation
The TB manager identified scaling up TB/HIV activities, the response to pediatric TB, and responding to TB human resource needs as key next steps.
Viet Nam’s national TB program hosted a site visit to the Hanoi Hospital on Tuberculosis and Lung Disease, as well as a district health center making great strides in TB control with a burgeoning migratory population moving to the Hanoi area from rural areas of the country.
The hospital director described the hospital’s key role in patient care, training, scientific research and providing leadership to the network of 29 district level clinics and providers providing T B services.
Viet Nam treats TB patients for 8 months, with the first two months using the DOTS model at the clinic daily. After this, patients are given several weeks of medication and must check in with health providers frequently. There are more than 5,000 TB cases a year in Hanoi, and in 2009, almost 12 percent of these cases were TB/HIV co-infection. Only about half of the TB patients were actually tested for HIV, so the number of co-infected patients is likely to be higher. The mortality rate among the co-infected patients is 21 percent. Half of all deaths at this hospital occur among co-infected individuals. Notably, only 45 percent of the co-infected patients have access to ART.
Eligibility for ART in Viet Nam is a CD4 count of under 200 or clinical symptoms of WHO Stage IV HIV infection. Officials hope to move to a CD4 count of 250 soon for ART eligibility and to generally improve access to ART for co-infected individuals. They have been successful in providing ART to some HIV patients with pulmonary TB. It is also worth noting the CD4 diagnostic capability is not available everywhere.
Not all TB services are free in Viet Nam. Patients must pay for physician services, chest X-rays and medical care related to extra-pulmonary TB, which occurs much more frequently in persons living withy HIV infection.
A visit to a district health facility offered an inspiring picture of dedicated staff working to provide TB and HIV services to a growing population of migrants. This center has substantially ramped up screening of HIV-infected persons for tuberculosis and now ensures that nearly 100 percent of TB patients are screened for HIV infection. The staff have engaged peer educators in their work to support co-infected patients. The majority of persons living with HIV infection are injection drug users and center’s staff were excited to report that they are now offering methadone – the first pilot program in north Viet Nam. They credit donor support for their ability to respond to the multiple health care needs of this complex and vulnerable population. That donor is PEPFAR.
The clinic director identified the need for strong support from local political leaders and the engagement of community members as key ingredients of this successful program.