Refocusing the Vietnam HIV surveillance to the most burden areas for epidemic control

ObjectiveTo describe an exercise to identify priority provinces to be focused in the Vietnam National HIV Sentinel Surveillance (HSS).IntroductionThe Vietnam National HSS was established in 1994. In the late 1990s and early 2000s, when the epidemic was increasing rapidly, the HSS helped with the intensive close monitoring of the HIV epidemic. In its first 10 years, the HSS was rapidly expanded from 6 to 40 provinces and in some years, it was conducted semi-annually. After two decades, the HIV epidemic situation has changed. In most provinces, HIV prevalence has reported to have declined. Compared to the peak period, the HIV prevalence among key populations (KP) in the past decade decreased from 40-60% to 20% or lower. In many provinces, HIV prevalence was less than 10% among people who inject drugs (PWID) and less than 3% among female sex workers (FSW), and among men who have sex with men (MSM) (Table 1). At the same time, the HIV programme has since been scaled up widely with various interventions and expanded to most of the 63 provinces. In 2014, the government of Vietnam and international stakeholders conducted a joint review of the health sector response to the HIV epidemic and concluded that for better monitoring of the epidemic, a more focused and higher quality surveillance system was needed(1). In 2015, surveillance stakeholders conducted a detailed review of the HSS to discuss prioritization of the surveillance activities.MethodsThe prioritization exercise followed a principle that the HSS should be conducted in locations where there is a large population of KP with a high HIV prevalence and it is feasible to implement. Criteria for prioritizing provinces for inclusion were: 1) a high estimated KP size; 2) high HIV prevalence, measured as a 5 year (2011-2015) average prevalence (P); 3) few years with low HIV prevalence, defined as P <5% among PWID, <3% among FSW and MSM; 4) few years with insufficient HSS sample size, defined as n<150 for PWID, n<250 for FSW and MSM. Steps to prioritize provinces were:- Reviewed provincial data on KP estimates; HIV prevalence and achieved HSS sample sizes in 5 years, 2011-2015.- Developed a ranking algorithm taking into account KP size estimates, HIV prevalence and achieved sample sizes.- For each survey on PWID, FSW, MSM, took top ranked provinces for which sum of KP size estimates of these provinces exceeded 50% of the national KP size estimates.- Held a consultation workshop among domestic and international surveillance stakeholders to discuss the prioritization exercise. Issues of regional representation of the HSS in the North, South, Central and Highland regions was added as a criteria to adjust the priority list of HSS provinces. The consensus reached in the workshop was the basis for proceeding a formal approval at Ministry of Health.ResultsThe data review and panel discussion suggested that the number of provinces to implement HSS should be 20 for PWID, 13 for FSW, and 7 for MSM surveys. While total number of provinces reduced from 40 to 20, all 4 geographical regions of the country were covered. Even with the reduction of the geographical coverage of the HSS, large proportions of the KPs (63.9% of PWID, 58.9% of FSWs and 36% of MSM) were covered under the HSS (Table 2). In February 2017, the Ministry of Health officially approved the 20 priority provinces as a part of the new strategic direction of the Vietnam National HSS.ConclusionsThe data review and panel discussion suggested that the number of provinces to implement HSS should be 20 for PWID, 13 for FSW, and 7 for MSM surveys. While total number of provinces reduced from 40 to 20, all 4 geographical regions of the country were covered. Even with the reduction of the geographical coverage of the HSS, large proportions of the KPs (63.9% of PWID, 58.9% of FSWs and 36% of MSM) were covered under the HSS (Table 2). In February 2017, the Ministry of Health officially approved the 20 priority provinces as a part of the new strategic direction of the Vietnam National HSS.References1. World Health Organization. Regional Office for the Western Pacific, 2016, Joint Review of the Health Sector Response to HIV in Viet Nam 2014

Return of test results in Vietnam HIV sentinel surveillance: Implementation and preliminary results

ObjectiveTo describe the implementation and preliminary results of returning HIV test results to participants in Vietnam HIV sentinel surveillance.IntroductionKnowledge of one’s HIV serostatus helps improve quality of life for those who test positive and decreases the risk of HIV transmission. WHO recommends that all participants in HIV prevalence surveys be provided access to their test results, especially those who test HIV positive [1]. Anonymous Vietnam HIV sentinel surveillance (HSS), implemented since 1994, focuses on people who inject drugs (PWID), female sex workers (FSW), and men who have sex with men (MSM) [2]. According to national guidelines, the HIV testing algorithm for surveillance purposes was based on two tests whereas the diagnostic algorithm for individuals was based on three tests. Thus, surveillance test results could not be returned to participants [3] who were instead encouraged to learn their HIV serostatus by testing at public confirmatory testing sites.In 2015, a three-test strategy was applied as part of HSS so that test results could be returned to participants.MethodsIn 2015, return of HIV test results was implemented as a pilot in 16 HSS provinces. HSS participants were asked to identify which of the designated HIV testing and counselling centers (HTC) in the province was most convenient for them. Participants were then given appointment cards with an assigned survey ID to receive their test results at the chosen venue at a specific date and time. Specimens, with assigned survey IDs, were transferred to the respective HIV laboratory at the Province AIDS Center (PAC) for confirmatory testing. The same three-test algorithm was used for surveillance purposes as well as to return confirmatory test results to participants [3]. Final test results were classified as “positive”, “negative” or “indeterminate”. HIV confirmatory test results were made available at all designated HTC in the provinces within 10 days after blood collection; thus, if a participant presented at a location, date or time that differed from the appointment card, s/he could still receive the test result. In some settings in which provinces integrated HSS with either static or mobile HTC, three rapid tests were used at point-of-care so that same-day test results were available. In this case, participants received test results at the end of the specified time regardless of their infection status.At the HTC, individuals showed their appointment cards. The IDs were used to identify the correct test results which were then given verbally to participants by HTC counsellors. Test results were not returned by phone or email. Individuals who tested positive were immediately referred to HIV treatment and other available health/social services in the province.The proportion of participants who received their test results was calculated for each survey group and province.ResultsThe number of provinces that reported returning of HIV test results in 2015 and 2016 were 14 and 15, respectively. Overall, among 15,530 persons tested through HSS in 2015 and 2016, 7,354 persons returned to receive their test results. The proportion of participants who returned for test results varied by province and survey population (table 1). In some provinces where HSS was integrated with HTC, such as Hai Phong and Dong Thap, 100% of participants received their test results within a day [4].ConclusionsReturning HIV test results to HIV surveillance participants is feasible and beneficial in low-income countries like Vietnam. This enhancement facilitates participants learning their serostatus and contributes toward Vietnam’s achievement of HIV control [4]. Based on the pilot experiences, Vietnam Ministry of Health decided to extend test result notifications to all 20 HSS provinces in 2017.Key factors that contributed to the success of the activity were fast turnaround time, roles and level of commitment of PAC, and coordination between the survey and HTC. The returning rate in HSS 2015 and 2016 are promising but these could be improved further. Better coordination and commitment between the survey and HIV testing service are needed to further increase return rates so that HIV-positive individuals can learn their serostatus and be better linked to care and treatment services.References1. WHO, Guidelines for second generation HIV surveillance: An update: Know your epidemic, 2013.2. VAAC, Guidance for epidemiological surveillance of HIV/AIDS & sexually transmitted infections, 2012.3. MOH, National guideline on HIV serology testing, in Decision 1098/QD-BYT, 2013.4. VAAC, Primarily results of HSS, 2016.

Epi Info Cloud Data Analytics to improve quality of HIV Surveillance in Vietnam.

Objective: To use Epi Info Cloud Data Analytics (ECDA) to improve the management, quality and utilization of the Vietnam National HIV Surveillance data.Introduction: HIV surveillance in Vietnam is comprised of different surveillance systems including the HIV sentinel surveillance (HSS). The HSS is an annual, multi-site survey to monitor HIV sero-prevalence and risk behaviors among key populations. In 2015, the Vietnam Administration on HIV/AIDS Control (VAAC) installed the Epi Info Cloud Data Analytics (ECDA), a free web-based analytical and visualization program developed by the Centers for Disease Control and Prevention (CDC)(1) to serve as an information management system for HIV surveillance. Until 2016, provincial surveys, recorded on paper, were computerized and submitted to VAAC, which was responsible for merging individual provincial datasets to form a national HSS dataset. Feedback on HSS issues were provided to provinces 3 to 6 months after survey conclusion. With the use of tablets for field data collection in 2017, provincial survey data were recorded electronically and transferred to VAAC at the end of each survey day, thus enabling instant updating of the national 2017 HSS dataset on daily basis. Upon availability of the national HSS dataset on VAAC’s server, ECDA enhanced wider access and prompt analysis for staff at all levels (figure 1). This abstract describes the use of ECDA, together with tablet-based data collection to improve management, quality and use of surveillance data.Methods: After the installation of the ECDA on VAAC’s server in 2015, investments were made at all levels of the surveillance systems to build the capacity to operate and maintain the ECDA. These included trainings on programming, administration, and utilization of ECDA at the central level; creating a centralized database through abstracting and linking different surveillance datasets; developing analysis templates to assist provincial-specific reports; and trainings on access and use of the ECDA to provincial staff. One hundred and eighty five ECDA analyst accounts, authorized for submission, viewing and analysis of data, were created for surveillance staff in 63 provinces and 7 agencies. Six administrator accounts, created for users at central and regional level, were authorized for editing data and management of user accounts. In 2017, more ECDA activities were conducted to: (i) develop analysis dashboards to track progress and data quality of HSS provincial surveys; (ii) facilitate frequent data reviews at central and regional levels; (iii) provide feedback to provinces on survey issues including sample selection.Results: Since 2015, separate national datasets including the HSS, HIV case reports, HIV routine program reports were systematically cleaned and merged to form a centralized national database, which was then centrally stored and regularly backed up. Access to the national database was granted to surveillance staff in all 63 provinces through 185 designated ECDA accounts. During the 2017 HSS surveys, 70 ECDA users in 20 HSS provinces were active to manage and use the HSS data. Twelve weekly reviews of HSS provincial data were conducted at national level throughout the 2017 HSS survey. Ninety percent of provinces received feedback on their survey data as early as the first week of field data collection. The national 2017 HSS dataset and its analysis were available immediately after the completion of the last provincial survey, which was about 3 to 6 months quicker than reports of previous years. More importantly, the fresh results of the 2017 HSS survey were available and used for the 2018 Vietnam HIV national planning circle (table 1).Conclusions: ECDA is a quick, relevant, free program to improve the management and analysis of HIV surveillance data. Using ECDA, it is easy to generate and modify analysis dashboards that enhances utilization of surveillance data. Successful administration and use of the ECDA during the 2017 HSS survey is positive evidence for Ministry of Health to consider institutionalization of the program in Vietnam surveillance systems

Application of tablet for data collection in HIV sentinel surveillance in Vietnam

ObjectiveTo describe the implementation process, successes, challenges, and lessons learned of the application of tablet for data collection and data system in HIV sentinel surveillance in VietnamIntroductionVietnam has routinely monitored HIV sero-prevalence among key populations through its HIV sentinel surveillance system (HSS). In 2010, this system was updated to include a behavioral component (HSS+) among people who inject drugs, female sex workers, and men who have sex with men. HSS+ has historically used a paper-based questionnaire for data collection(1). At the end of the survey, provincial data were manually entered into computers using EpiData Entry forms (http://www.epidata.dk/) and submitted to the Vietnam Authority of HIV/AIDS Control (VAAC). As a result, feedback to provinces on data issues was not provided until after fieldwork completion. One recent survey used tablets for data collection and found that it saved time, required fewer staff, and reduced costs compared to paper-based data collection(2). In 2017, Vietnam introduced tablet for behavioral data collection in HSS+ to improve data quality, resource saving, and to provide more timely access to data.MethodsDevelopment of data entry forms and data systemSurvey data entry forms were designed using free Epi Info™ software for mobile devices(3) and installed on tablets. A SQL database was established via SFPT data transfer to the current database in VAAC’s server. Field data were instantly synced to the national database when the internet signal was available (Picture 1). Real-time data analysis was granted to surveillance staff at all levels using authorized access to the database via Epi Info™ Cloud Data Analytics (ECDA), dashboards were used to track progress and data quality (Figure 1). HSS+ data were frequently reviewed by the National Surveillance Technical Working Group (NSTWG) and timely feedback was provided.DeploymentManuals and e-leaning materials were developed. The NSTWG conducted a pilot to test the forms and data flow from field to the national database before installed into all tablets. Four to seven tablets were distributed to each province depending on number of HSS+ sites and populations. Surveillance staff at Provincial AIDS Centers (PACs) were trained by the NSTWG on how to use the tablet to interview, check, update, save data, and sync data to cloud and to the national database, and to backup the provincial dataset. They then provided trainings to their local field staff.The NSTWG provided technical assistance and troubleshooting through field visits and online support to help local staff address issues regarding tablet use in addition to other HSS/HSS+ issues.ResultsCurrently, 18 HSS+ provinces have implemented the 2017 HSS+. Of these, nine provinces applied tablets exclusively. Two provinces used tablets, but also used paper-based questionnaires when not enough tablets were available. Seven Global Fund supported provinces used the paper-based questionnaires and entered data into tablets after interview completion due to copies of completed paper-based questionnaires are required by these provincial project management units (PMU) for fund re-imbursement.Additional updates were required after the first few days, which created issues around updating forms once revised forms were sent out by NSTWG. Another challenge was that local staff were not familiar with using tablets at the beginning. Also frequent complaints were mainly on data entry and synchronization regarding participant identity code or a record could not be synced.The NSTWG and PAC staff were able to monitor the HSS+ progress and provided feedback daily. Most commonly, feedbacks were provided on participant codings and site names. Using the tablet did not require staff, time or money for data entry and eliminated data entry errors. In general, staff prefered to use this data collection mode.ConclusionsThis mobile device application for data collection in routine HSS+ in Vietnam is feasible and accepted. However, harmonization and coordination from the central Global Fund PMU and provincial PMU will be required to successfully roll-out this system in all HSS+ provinces. This application in addition to ECDA help to improve data quality, due to timeliness of the data, is cost saving and reduces workload. Most importantly, better quality and timely data will facilitate preparation for timely local planning and response.References1. Thanh DC et al. Brief behavioural surveys in routine HIV sentinel surveillance: a new tool for monitoring the HIV epidemic in Vietnam. Western Pacific Surveillance and Response Journal. Vol 6, No. 1/20152. National Institute of Hygiene and Epidemiology. HIV/STI Integrated Biological and Behavioural Surveillance in Vietnam. Hanoi, 2014.3. https://www.cdc.gov/epiinfo/mobile.htm

Viral load testing to monitor the HIV epidemic among PWID in Vietnam

Objective: To share Vietnam’s experiences piloting the integration of viral load (VL) testing into the national HIV sentinel surveillance (HSS) system to better understand the level of HIV viral transmission among people who inject drugs (PWID).Introduction: Vietnam initiated the HSS system in 1994 in selected provinces with high HIV burden. The surveillance has two components: monitor HIV sero-prevalence and risk behaviors among key population including PWID. However, no VL data were collected among HIV infected people. In 2016, Vietnam piloted an added component of VL testing to the existing HSS system. The purpose was to test the feasibility of adding VL testing to the HSS so that VL data among PWID would be available. The pilot was conducted in two provinces in southern Vietnam-Ho Chi Minh City and Long An. It was expected that adding the VL testing to the existing HSS would also save resources and help monitor HIV viral transmission among PWID in the community regardless if they are currently on anti-retroviral therapy (ART).Methods: Male PWIDs were enrolled into 2016 HSS+ following the standard operating procedure (SOP)[1]. Community-based sampling was based on random selection of wards/communes listed in the sampling frame. In each selected ward/commune, all eligible PWID were invited to voluntarily participate in the survey. Eligibility criteria were males 16 years of age or older, reporting injecting drug in the past month, and residing in the selected area. . The survey included an interview using a standardized questionnaire and 7ml blood drawn for HIV testing. Blood specimens were transferred from districts to provincial labs for plasma separation in the same day. Each plasma specimen was divided into three aliquots of 1ml each. One aliquot was used to test for HIV diagnosis at provincial labs, using the national HIV testing strategy III[2]. The remaining 2 aliquots were stored at provincial labs at 2-80C and within 5 days, were shipped to Pasteur Institute in Ho Chi Minh City (PIHCM) where the plasma specimens were stored at -800C. Processing of samples for VL testing was conducted at the end of the survey where all plasma specimen were transferred to PIHCM lab, which was 2 months since the collection of the first blood specimen. VL was undertaken on COBAS AMPLYPREP/COBAS TAQMAN 48, with identification threshold 20 cps/ml and specificity of 100% using Kit CAP-G/CTM HIV-1 V 2.0. The VL testing results were sent back to relevant Provicial AIDS Centers to return to respective participants, within 3 months.Results: Five hundred male PWID (HCMC: 300; LA: 200) were enrolled into 2016 HSS/HSS+ and agreed to provide blood specimen without any refusal. 84 tested positive for HIV (16.8%. HCMC: 15.0%; LA: 19.5%), 43 (51.2%) specimens had unsuppressed VL (>1000 copies/ml) (HCMC: 66.7%; LA: 33.3%), 35 (41.7%) specimens had undetected level (<50 copies/ml or undetected) (HCMC: 31.1%; LA: 53.9%), and 7.1% had VL that ranged from 50-1000 copies/ml (HCMC: 2.2%; LA: 12.8%). Among those who had VL < 1000 copies/ml, 22 (53.7%) had ever been on ART.Conclusions: The pilot survey has measured VL among male PWID, including those who were aware of their HIV status and those who did not know their status before. Findings indicate that a significant proportion of PWID do not have their VL suppressed leading to high-risk of HIV transmission from PWID to their sexual partners[3] in the community although level of unsuppressed viral load is not a direct measure of HIV viral transmission in itself. This pilot indicated that it was feasible to add VL testing into HSS and Vietnam government can add it as a routine practice in HSS and can be expanded in the coming years

Outbreak of Sexually Transmitted Nongroupable Neisseria meningitidis–Associated Urethritis, Vietnam

We report on an outbreak of nongroupable Neisseria meningitidis–associated urethritis, primarily among men who have sex with men in southern Vietnam. Nearly 50% of N. meningitidis isolates were resistant to ciprofloxacin. This emerging pathogen should be considered in the differential diagnosis and management of urethritis