Person:

Pollack, Todd

Background: The global scale-up of antiretroviral therapy included extensive training and onsite support to build the capacity of HIV health care workers. However, traditional efforts aimed at strengthening knowledge and skills often are not successful at improving gaps in the key health systems required for sustaining high quality care. Methods: We trained and mentored existing staff of the Son La provincial health department and provincial HIV clinic to work as a provincial coaching team (PCT) to provide integrated coaching in clinical HIV skills and quality improvement (QI) to the HIV clinics in the province. Nine core indicators were measured through chart extraction by clinic and provincial staff at baseline and at 6 month intervals thereafter. Coaching from the team to each of the clinics, in both QI and clinical skills, was guided by results of performance measurements, gap analyses, and resulting QI plans. Results: After 18 months, the PCT had successfully spread QI activities, and was independently providing regular coaching to the provincial general hospital clinic and six of the eight district clinics in the province. The frequency and type of coaching was determined by performance measurement results. Clinics completed a mean of five QI projects. Quality of HIV care was improved throughout all clinics with significant increases in seven of the indicators. Overall both the PCT activities and clinic performance were sustained after integration of the model into the Vietnam National QI Program. Conclusions: We successfully built capacity of a team of public sector health care workers to provide integrated coaching in both clinical skills and QI across a province. The PCT is a feasible and effective model to spread and sustain quality activities and improve HIV care services in a decentralized rural setting.

High HIV viral load (VL >100,000 cp/ml) is associated with increased HIV transmission risk, faster progression to AIDS, and reduced response to some antiretroviral regimens. To better understand factors associated with high VL, we examined characteristics of patients presenting for treatment in Hanoi, Vietnam. We examined baseline data from the Viral Load Monitoring in Vietnam Study, a randomized controlled trial of routine VL monitoring in a population starting antiretroviral therapy (ART) at a clinic in Hanoi. Patients with prior treatment failure or ART resistance were excluded. Characteristics examined included demographics, clinical and laboratory data, and substance use. Logistic regression was used to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Out of 636 patients, 62.7% were male, 72.9% were ≥30 years old, and 28.3% had a history of drug injection. Median CD4 was 132 cells/mm3, and 34.9% were clinical stage IV. Active cigarette smoking was reported by 36.3% with 14.0% smoking >10 cigarettes per day. Alcohol consumption was reported by 20.1% with 6.1% having ≥5 drinks per event. Overall 53.0% had a VL >100,000 cp/ml. Male gender, low body weight, low CD4 count, prior TB, and cigarette smoking were associated with high VL. Those who smoked 1–10 cigarettes per day were more likely to have high VL (aOR = 1.99, 95% CI = 1.15–3.45), while the smaller number of patients who smoked >10 cigarettes per day had a non-significant trend toward higher VL (aOR = 1.41, 95% CI = 0.75–2.66). Alcohol consumption was not significantly associated with high VL. Tobacco use is increasingly recognized as a contributor to premature morbidity and mortality among HIV-infected patients. In our study, cigarette smoking in the last 30 days was associated with a 1.5 to 2-fold higher odds of having an HIV VL >100,000 cp/ml among patients presenting for ART. These findings provide further evidence of the negative effects of tobacco use among HIV-infected patients.

Abstract Objectives: We sought to determine the rate of response to hepatitis B (HBV) vaccination among HIV-infected adults in Vietnam. Methods: We retrospectively abstracted data from a cohort of HIV-infected adults who had received HBV vaccine at an HIV clinic in Hanoi. We examined demographic, clinical and laboratory factors for associations with development of a protective antibody (Ab) response following vaccination (defined as ‘responders’ with anti-HBs >10 IU/L). Results: Out of 302 HIV-infected patients who completed the vaccine series and follow-up serology testing, 189 (62.6%) had a positive protective Ab response. Female patients had a higher response rate compared to male patients (71.4% vs 56.8%, P=0.01). Among responders, mean CD4 T cell count was 309 cells/μL as compared to 204 cells/μL in non-responders (P<0.0001). On multivariable analysis, CD4 T cell count prior to vaccination was the only factor independently associated with a positive Ab response. Compared to patients with a count less than 100 cells/μL, those with a CD4 T cell count between 100 and 200 cells/μL were 20% more likely to be responders (relative risk [RR] 1.20, 95% confidence interval [CI] 0.77–1.87), those with a CD4 T cell count between 200 and 300 cells/μL were 61% more likely to be responders (RR 1.61, 95% CI 1.05–2.45), and those with a CD4 T cell count greater than 300 cells/μL were 89% more likely to be responders (RR 1.89, 95% CI 1.26–2.83). Conclusions: We found that the CD4 T cell count at the time of vaccination to be the sole predictor of response to HBV vaccination among HIV-infected Vietnamese adults. Our findings highlight the importance of vaccinating HIV-infected adults prior to advanced immunosuppression.