The cost-effectiveness and budget impact of Vietnam's methadone maintenance treatment programme in HIV prevention and treatment among injection drug users

Cost-Effectiveness of Amphotericin B Deoxycholate Versus Itraconazole for Induction Therapy of Talaromycosis in Human Immunodeficiency Virus-Infected Adults in Vietnam

BACKGROUND

Talaromycosis (penicilliosis) is an invasive fungal infection and a major cause of human immunodeficiency virus (HIV)-related deaths in Southeast Asia. Guidelines recommend induction therapy with amphotericin B deoxycholate; however, treatment with itraconazole has fewer toxic effects, is easier to administer, and is less expensive. Our recent randomized controlled trial in Vietnam found that amphotericin B was superior to itraconazole with respect to 6-month mortality. We undertook an economic evaluation alongside this trial to determine whether the more effective treatment is cost-effective.

METHODS

Resource use, direct and indirect costs, and health and quality-of-life outcomes (measured using quality-adjusted life-years [QALYs]) were evaluated for 405 trial participants from 2012 to 2016. Both a Vietnamese health service and a broader societal costing perspective were considered. Mean costs and QALYs were combined to calculate the within-trial cost-effectiveness of amphotericin vs itraconazole from both perspectives.

RESULTS

From a Vietnamese health service perspective, amphotericin increases costs but improves health outcomes compared to itraconazole, at a cost of $3013/QALY gained. The probability that amphotericin is cost-effective at a conventional (World Health Organization CHOICE) threshold of value for money is 46%. From a societal perspective, amphotericin is cost-reducing and improves outcomes compared to itraconazole, and is likely to be a cost-effective strategy at any value for money threshold greater than $0.

CONCLUSIONS

Our analysis indicates that induction therapy with amphotericin is a cost-effective treatment strategy for HIV-infected adults diagnosed with talaromycosis in Vietnam. These results provide the evidence base for health care providers and policy makers to improve access to and use of amphotericin.

Examining common mental health disorders in people living with HIV on methadone maintenance therapy in Hanoi, Vietnam

BACKGROUND

Injection drug use drives HIV transmission in Southeast Asia, where around a quarter of users are living with HIV. Vietnam developed Methadone Maintenance Therapy (MMT) programs to reduce unsafe drug abuse. Common mental health disorders (CMD), including depression, anxiety and post-traumatic stress disorder (PTSD), can worsen MMT outcomes and are highly prevalent among people living with HIV (PLH). We aimed to characterize HIV and CMD among MMT patients and assess the impact of HIV and CMD on MMT engagement outcomes in Hanoi, Vietnam.

METHODS

This cross-sectional study was conducted at an urban MMT clinic in Hanoi. Participants were screened for CMD with the relevant sections of the Mini International Neuropsychiatric Interview (MINI). Tabular comparisons and regression models were used to understand the association of HIV and CMD with substance use and methadone compliance.

RESULTS

Of the 400 MMT participants, 22% were living with HIV, 11% a CMD, 27% reported injection drug use, and 27% reported methadone noncompliance. Around 17% of those with HIV also had a CMD. Reporting non injection and injection drug use were each higher among those with CMD regardless of HIV status. In addition, reporting any drug use was much higher among those with both HIV and CMD than among those with neither (73% vs 31%, p value 0.001). While methadone noncompliance was lower among PLH than among those without HIV (16.3% vs 30.1%, p value 0.010), noncompliance was higher among those with CMD than among those without (40.5% vs 25.6%, p value 0.045). Among those without HIV, noncompliance was higher among those with CMD than among those without, but among those with HIV, the opposite relationship was observed.

CONCLUSION

There is complex overlap between substance use and methadone noncompliance among MMT patients living with HIV, CMD or both. In this population, we found a high prevalence of CMD and substance use among PLH, and a high prevalence of substance use and methadone noncompliance among those with CMD. Prioritizing provision of mental health care services to MMT patients living with HIV can help improve engagement with substance use disorder treatment and reduce the risk of HIV transmission.

Concurrent drug use among methadone maintenance patients in mountainous areas in northern Vietnam

OBJECTIVES

With the rise in methadone maintenance therapy (MMT) for drug users in Vietnam, there has been growing interest in understanding if and how often MMT patients engage in concurrent illicit drug use while on methadone therapy in various settings. This study examined factors associated with concurrent opioid use among patients on MMT in a mountainous area in Vietnam.

SETTING

One urban and one rural MMT clinics in Tuyen Quang province.

PARTICIPANTS

Survey participants consisted of patients who were taking MMT at the selected study sites. A convenience sampling approach was used to recruit the participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked a series of questions about their socioeconomic status, current alcohol and tobacco use, health problems (measured by the EuroQol-Five Dimension-Five Level instrument), psychological distress (measured by Kessler score), and factors associated with current and/or previous drug use. Regression models were used to determine factors associated with concurrent drug use among MMT patients.

RESULTS

Among the 241 male MMT patients included in the study, 13.4% reported concurrent opioid use. On average, the longer patients had been enrolled in MMT, the less likely they were to concurrently use drugs. Conversely, patients with higher levels of psychological distress were more likely to engage in concurrent drug use while on MMT.

CONCLUSION

Longer duration of MMT was significantly correlated with reduced illicit drug use among participants. Higher levels of psychological distress were associated with increased use of illicit drugs among MMT patients. Regardless of distance, long-term MMT is still effective and should be expanded in mountainous areas.

Social and structural barriers for adherence to methadone maintenance treatment among Vietnamese opioid dependence patients

Introduction

Methadone maintenance treatment (MMT) services may reduce the risk of HIV transmission if patients completely adhere to the treatment. Identifying adherence patterns and potential related factors is vital for the sustainability of MMT program in Vietnam. This study examined social and structural factors associated with adherence to MMT among patients in different service delivery models.

Materials and methods

A total of 510 patients at three MMT clinics in Hanoi were interviewed. Measures of self-reported adherence included the number of missed doses in the past 7 days and the level of adherence in the past 30 days using a visual analog scale (VAS) scoring from 0 (non-adherence) to 100 (perfect adherence). Multivariate regressions were employed to identify factors associated with non-adherence to MMT.

Results

A total of 17.7% of participants reported incomplete MMT adherence in the last 30 days and 8.3% reported missing a dose in the last seven days, respectively. Living with HIV/AIDS, poor self-care and usual activities, and disclosure of health issues to spouses or intimate partners were associated with non-adherence. Those patients with pain or depression were more likely to report better adherence. Disclosing health status to spouse/partner increased the risk of incomplete adherence, while disclosing to friends reduced the number of missed dose in the last seven days. Patients attending clinics with comprehensive services had a lower VAS score of adherence compared to those enrolling in clinics with only MMT and general health care.

Conclusions

Sustaining the compliance of patients to MMT is principal in the rapid expansion of this service in Vietnam. It is necessary to address the complexity of health care demands of drug users, their difficulties to be rehabilitated into workforce and society, and the stigmatization to maximize the outcomes of MMT program.

Expanding co-payment for methadone maintenance services in Vietnam: the importance of addressing health and socioeconomic inequalities

BACKGROUND

Ensuring high enrollment while mobilizing resources through co-payment services is critical to the success of the methadone maintenance treatment (MMT) program in Vietnam. This study assessed the willingness of patients to pay (WTP) for different MMT services delivery models and determined its associated factors.

METHODS

A facility based survey was conducted among 1016 MMT patients (98.7% male, 42% aged 35 or less, and 67% living with spouse) in five MMT clinics in Hanoi and Nam Dinh province in 2013. Socioeconomic, HIV and health status, history of drug use and rehabilitation, and MMT experience were interviewed. WTP was assessed using contingent valuation method, including a set of double-bounded binary questions and a follow-up open-ended question. Point and interval data models were used to estimate maximum willingness to pay.

RESULTS

95.5% patients were willing to pay for MMT at the monthly mean price of US$ 32 (95%CI = 28-35). Higher WTP was associated with higher level of educational attainment, higher income, male sex, and had high expenses on opiates prior to MMT. Patients who reported having any problem in Pain/ Discomfort, and who did not have outpatient care last year were willing to pay less for MMT than others.

CONCLUSION

High level of WTP supports the co-payment policies as a strategy to mobilize resources for the MMT program in Vietnam. However, it is necessary to ensure equalities across patient groups by acknowledging socioeconomic status of different settings and providing financial supports for disadvantaged patients with severe health status.

Adherence to methadone maintenance treatment and associated factors among patients in Vietnamese mountainside areas

BACKGROUND

Medication adherence is essential to achieve successful methadone maintenance treatment (MMT). However, treatment adherence among MMT patients in the mountainous setting in Vietnam has not been yet investigated. This study aimed to explore the medication adherence and associated factors in MMT patients in Tuyen Quang, a mountainous province.

METHODS

A cross-sectional survey was conducted in two MMT clinics namely Tuyen Quang and Son Duong. Convenience sampling method was used to recruit patients. Adherence to MMT was assessed by using three questions: 1) number of days that they missed doses in the last 4 days; 2) whether they missed doses during the last weekend and 3) when they missed a dose within the last 3 months. Adherence was considered optimal if patients reported 'no' to three questions. Socioeconomic status, health status (measured by EuroQol-5 Dimensions - 5 Levels - EQ5D5L and Visual analogue scale - VAS), substance use and abuse and methods to support adherence were also collected.

RESULTS

Among 241 patients, 34.4% reported optimal adherence. Self-help was the most popular (89.2%) method used to support adherence. Risk factors of missing doses and suboptimal adherence included higher education and economic status; being a worker/farmer; longer duration of treatment; and suffering pain/discomfort and anxiety/depression. Protective factors were older age, having problems in usual activities/self-care, higher EQ-VAS and EQ-5D index; and reminded by mobile phone and family members.

CONCLUSIONS

This study found a high sub-optimal adherence rate among MMT patients in a mountainous setting in Vietnam. Measuring adherence by using several simple items could be used periodically to monitor the treatment adherence in the clinical setting. Family and mobile phone support would have a potential role in supporting patients to adhere treatment.

Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs

OBJECTIVE

A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID).

METHODS

We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART.

RESULTS

Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively.

CONCLUSION

OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.

Quality of life and healthcare service utilization among methadone maintenance patients in a mountainous area of Northern Vietnam

Background

The expansion of methadone maintenance treatment in mountainous areas in still limited and little is known about its health impacts on drug users. This study aimed to examine health-related quality of life (HRQOL) and health care access among patients engaging in methadone maintenance treatment (MMT) in Tuyen Quang, a mountainous province in Vietnam.

Methods

We conducted a cross-sectional survey with 241 patients conveniently recruited in two MMT clinics (Son Duong and Tuyen Quang). EuroQol-5 Dimensions – 5 levels (EQ-5D-5 L) and Visual analogue scale (VAS) were employed to measure HRQOL. Multivariate logistic and tobit regressions were used to determine the factors associated with HRQOL and health care utilization.

Results

The overall mean score of the EQ-5D index and EQ-VAS were 0.88 (SD = 0.20) and 81.8% (SD = 15.27%), respectively. Only 8.7% utilized inpatient services, and 14.9% used outpatient services. Being more highly educated, suffering acute diseases, and using health service within the last 12 months were associated with a decreased EQ-5D index. Individuals who were multiple substance abusers and those who recently had inpatient care were more likely to have a lower VAS. Older respondents, those taking their medications at the more impoverished clinic, substance abusers, and individuals who were struggling with anxiety/depression or their usual daily activities were more likely to use both inpatient and outpatient care.

Conclusions

In summary, we observed good HRQOL, but high prevalence of anxiety/depression and low rates of service utilization among MMT patients in Tuyen Quang province. To improve the outcomes of MMT services in mountainous areas, it is necessary to introduce personalized and integrative services models with counseling and interventions on multiple substance use.

A systematic review of health economic models of opioid agonist therapies in maintenance treatment of non-prescription opioid dependence

BACKGROUND

Opioid dependence is a chronic condition with substantial health, economic and social costs. The study objective was to conduct a systematic review of published health-economic models of opioid agonist therapy for non-prescription opioid dependence, to review the different modelling approaches identified, and to inform future modelling studies.

METHODS

Literature searches were conducted in March 2015 in eight electronic databases, supplemented by hand-searching reference lists and searches on six National Health Technology Assessment Agency websites. Studies were included if they: investigated populations that were dependent on non-prescription opioids and were receiving opioid agonist or maintenance therapy; compared any pharmacological maintenance intervention with any other maintenance regimen (including placebo or no treatment); and were health-economic models of any type.

RESULTS

A total of 18 unique models were included. These used a range of modelling approaches, including Markov models (n = 4), decision tree with Monte Carlo simulations (n = 3), decision analysis (n = 3), dynamic transmission models (n = 3), decision tree (n = 1), cohort simulation (n = 1), Bayesian (n = 1), and Monte Carlo simulations (n = 2). Time horizons ranged from 6 months to lifetime. The most common evaluation was cost-utility analysis reporting cost per quality-adjusted life-year (n = 11), followed by cost-effectiveness analysis (n = 4), budget-impact analysis/cost comparison (n = 2) and cost-benefit analysis (n = 1). Most studies took the healthcare provider's perspective. Only a few models included some wider societal costs, such as productivity loss or costs of drug-related crime, disorder and antisocial behaviour. Costs to individuals and impacts on family and social networks were not included in any model.

CONCLUSION

A relatively small number of studies of varying quality were found. Strengths and weaknesses relating to model structure, inputs and approach were identified across all the studies. There was no indication of a single standard emerging as a preferred approach. Most studies omitted societal costs, an important issue since the implications of drug abuse extend widely beyond healthcare services. Nevertheless, elements from previous models could together form a framework for future economic evaluations in opioid agonist therapy including all relevant costs and outcomes. This could more adequately support decision-making and policy development for treatment of non-prescription opioid dependence.

Implementation of methadone therapy for opioid use disorder in Russia - a modeled cost-effectiveness analysis

BACKGROUND

Opioid agonist therapy using methadone, an effective treatment of opioid use disorders (OUD) for people who inject drugs (PWID), is recommended by the World Health Organization as essential to curtail the growing HIV epidemic. Yet, despite increasing prevalence of OUD and HIV, methadone therapy has not yet been implemented in Russia. The aim of this modeling study was to estimate the cost-effectiveness of methadone therapy for Russian adults with a diagnosed OUD.

METHODS/DESIGN

We modeled the projected program implementation costs and estimated disability-adjusted life years (DALYs) averted over a 10-year period, associated with the provision of methadone therapy for a hypothetical, unreplenished cohort of Russian adults with an OUD (n = 249,000), in comparison to the current therapies at existing addiction treatment facilities. Our model compared four distinct scenarios of treatment coverage in the cohort ranging from 3.1 to 55%.

RESULTS

Providing methadone therapy to as few as 3.1% of adults with an OUD amounted to an estimated almost 50,000 DALYs averted over 10 years at a cost of just over USD 17 million. Further expanding service coverage to 55% resulted in an estimated almost 900,000 DALYs averted, at a cost of about USD 308 million.

CONCLUSION

Our study indicated that implementing opioid agonist therapy with methadone to treat OUD at existing facilities in Russia is highly cost-effective.

Cost-effectiveness of center-based compulsory rehabilitation compared to community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam

INTRODUCTION

In Vietnam, two dominant approaches for heroin treatment are center-based compulsory rehabilitation (CCT), funded by the Vietnamese government and community-based voluntary methadone maintenance treatment (MMT), funded primarily by international donors. Recent reduction in international funding requires more efficient allocation of government funding for public health programs. A cost-effectiveness analysis comparing two approaches provides a useful source of evidence to inform the government about funding reallocation.

METHODS

The study was a combined retrospective and prospective, non-randomized cohort comparison over three years of CCT and MMT in Vietnam, conducted between 2012 and 2014, involving 208 CCT participants and 384 MMT participants with heroin dependence. The primary end-point was drug-free days over three years. Total costs, including both program and participant personal costs were measured and cost-effectiveness compared. Mixed effects regression analyses were used to analyze effectiveness data and non-parametric bootstrapping method was used to compare cost-effectiveness.

RESULTS

Over three years, MMT costed on average VND85.73 million (US$4108) less than CCT (95% CI: -VND76.88 million, -VND94.59 million). On average, a MMT participant had 344.20 more drug-free days compared to a CCT participant (p<0.001). The incremental cost-effectiveness ratio for MMT was -VND0.25 million (US$11.99) (95% CI: -VND0.34 million, -VND0.19 million) per drug-free day suggesting MMT is the more cost effective alternative.

CONCLUSIONS

Compared to CCT, MMT is both less expensive and more effective in achieving drug-free days. If the government of Vietnam invests in MMT instead of CCT, it is potentially a cost-saving strategy for reducing illicit drug use among heroin dependent individuals.

Economic Evaluations of Opioid Use Disorder Interventions

BACKGROUND

The economic costs associated with opioid misuse are immense. Effective interventions for opioid use disorders are available; however, given the scarce resources faced by substance use treatment providers and payers of all kinds, evidence of effectiveness is not always sufficient to encourage adoption of a given therapy-nor should it be. Economic evaluations can provide evidence that will help stakeholders efficiently allocate their resources.

OBJECTIVE

The purpose of this study was to review the literature on economic evaluations of opioid use disorder interventions.

METHODS

We performed a systematic review of the major electronic databases from inception until August 2015. A sensitive approach was used to ensure a comprehensive list of relevant articles. Given the quality of the existing reviews, we narrowed our search to studies published since 2007. The Drummond checklist was used to evaluate and categorize economic evaluation studies according to their quality.

RESULTS

A total of 98 articles were identified as potentially relevant to the current study. Of these 98 articles, half (n = 49) were included in this study. Six of the included articles were reviews. The remaining 43 articles reported economic evaluation studies of interventions for opioid use disorders. In general, the evidence on methadone maintenance therapy (MMT) supports previous findings that MMT is an economically advantageous opioid use disorder therapy. The economic literature comparing MMT with other opioid use disorder pharmacotherapies is limited, as is the literature on other forms of therapy.

CONCLUSION

With the possible exception of MMT, additional high-quality economic evaluations are needed in order to assess the relative value of existing opioid use disorder interventions.

A systematic review of modelling approaches in economic evaluations of health interventions for drug and alcohol problems

Background

The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame.

Methods

Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases.

Results

Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector.

Conclusions

This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1368-8) contains supplementary material, which is available to authorized users.

Methadone Maintenance Treatment Promotes Referral and Uptake of HIV Testing and Counselling Services amongst Drug Users and Their Partners

Background

Methadone maintenance treatment (MMT) reduces HIV risk behaviors and improves access to HIV-related services among drug users. In this study, we assessed the uptake and willingness of MMT patients to refer HIV testing and counseling (HTC) service to their sexual partners and relatives.

Methods

Health status, HIV-related risk behaviors, and HTC uptake and referrals of 1,016 MMT patients in Hanoi and Nam Dinh were investigated. Willingness to pay (WTP) for HTC was elicited using a contingent valuation technique. Interval and logistic regression models were employed to determine associated factors.

Results

Most of the patients (94.2%) had received HTC, 6.6 times on average. The proportion of respondents willing to refer their partners, their relatives and to be voluntary peer educators was 45.7%, 35.3%, and 33.3%, respectively. Attending MMT integrated with HTC was a facilitative factor for HTC uptake, greater WTP, and volunteering as peer educators. Older age, higher education and income, and HIV positive status were positively related to willingness to refer partners or relatives, while having health problems (mobility, usual care, pain/discomfort) was associated with lower likelihood of referring others or being a volunteer. Over 90% patients were willing to pay an average of US $17.9 for HTC service.

Conclusion

The results highlighted the potential role of MMT patients as referrers to HTC and voluntary peer educators. Integrating HIV testing with MMT services and applying users’ fee are potential strategies to mobilize resources and encourage HIV testing among MMT patients and their partners.

Budget impact analysis of medicines: updated systematic review and implications

This evaluation determines whether published studies to date meet the key characteristics identified for budget impact analyses (BIA) for medicines, accomplished through a systematic review and assessment against identified key characteristics. Studies from 2001-2015 on 'budget impact analysis' with 'drug' interventions were assessed, selected based on their titles/abstracts and full texts, and their characteristics checked according to key criteria. Out of 1,984 studies, 92 were subsequently identified for review. Of these, 95% were published in Europe and the USA. 2012 saw the largest number of publications (16%) with a decline thereafter. 48% met up to 7 out of the 9 key characteristics. Only 22% stated no conflict of interest. The results indicate low adherence to the key characteristics that should be considered for BIAs and strong conflict of interest. This is an issue since BIAs can be of fundamental importance in managing the entry of new medicines including reimbursement decisions.

Drug addiction stigma in relation to methadone maintenance treatment by different service delivery models in Vietnam

Background

The rapid expansion of methadone maintenance treatment (MMT) services has significantly improved health status and quality of life of patients. However, little is known about its impacts on addiction-related stigma and associated factors.

Methods

A cross-sectional survey was conducted in 2013 in Vietnam’s capital, Hanoi, and Nam Dinh province among 1016 methadone maintenance patients; 26.6 % at provincial AIDS centers (PAC) and 73.4 % at district health centers (DHC), respectively. Drug addiction history and related stigma, health status, MMT-related covariates, and sociodemographic characteristics were interviewed.

Results

More than one-sixth of the sample reported experiencing felt or enacted stigma, including Blame or Judgement (17.2 %), Shame (19.9 %), or Others’ fear of HIV transmission (17.1 %). These proportions were higher in PACs than in DHCs, which are integrated with other HIV or general health care services. Very few patients reported being discriminated at the workplace (2.5 %) or at health care services (1.7 %); however, 15.6 % of patients at PACs and 10.6 % of patients at DHCs reported discrimination in their communities. Drug users taking MMT for longer periods were less likely to report felt stigma. Other factors associated with stigma against MMT patients included the lack of comprehensive services, higher education, presence of pain/discomfort, and anxiety/depression, self-reported HIV positive, and number of previous drug rehabilitation episodes.

Conclusion

The study shows a high level of stigma against MMT patients and emphasizes the necessity to integrate MMT with comprehensive health and support services. Mass communication campaigns to reduce stigma against people with drug addiction and HIV/AIDS, as well as vocational trainings and jobs referrals for MMT patients, are needed to maximize the benefits of MMT programs in Vietnam.

Economic vulnerability of methadone maintenance patients: Implications for policies on co-payment services

BACKGROUND

Co-payment for methadone maintenance treatment (MMT) services is a strategy to ensure the financial sustainability of the HIV/AIDS programs in Vietnam. In this study, we examined health services utilization and expenditure among MMT patients, and further explored factors associated with catastrophic health expenditure among affected households.

METHODS

A multi-site cross-sectional study was conducted among 1016 patients in two epicentres: Hanoi and Nam Dinh province in 2013.

RESULTS

Overall, 8.2% and 28.7% respondents used inpatient and outpatient health care services in the past 12 months apart from receiving MMT. There were 12.8% respondents experiencing catastrophic health expenditure given MMT is provided free-of-charge, otherwise 63.5% patients would suffer from health care costs. MMT integrated with general health or HIV services may encourage health care services utilization of patients. Patients, who were single, lived in the rural, had inpatient care and reported problems in Mobility were more likely to experience catastrophic health expenditure than other patient groups.

CONCLUSIONS

The health care costs are still financially burden to many drug users and remained over the course of MMT that implies the necessity of continuous supports from the program. Scaling-up and decentralizing integrated MMT clinics together with economic empowerments for treated drug users and their families should be prioritized in Vietnam.

Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam

BACKGROUND

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate).

RESULTS

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

Patient Satisfaction with Methadone Maintenance Treatment in Vietnam: A Comparison of Different Integrative-Service Delivery Models

BACKGROUND

Patient satisfaction is an important component of quality in healthcare delivery. To inform the expansion of Methadone Maintenance Treatment (MMT) services in Vietnam, we examined the satisfaction of patients with regards to different services delivery models and identified its associated factors.

METHODS

We interviewed 1,016 MMT patients at 5 clinics in Hanoi and Nam Dinh province. The modified SATIS instrument, a 10-item scale, was used to measure three dimensions: "Services quality and convenience", "Health workers' capacity and responsiveness" and "Inter-professional care".

RESULTS

The average score was high across three SATIS dimensions. However, only one third of patients completely satisfied with general health services and treatment outcomes. Older age, higher education, having any problem in self-care and anxiety/depression were negatively associated with patient's satisfaction. Meanwhile, patients receiving MMT at clinics, where more comprehensive HIV and general health care services were available, were more likely to report a complete satisfaction.

CONCLUSION

Patients were highly satisfied with MMT services in Vietnam. However, treatment for drug users should go beyond methadone maintenance to address complicated health demands of drug users. Integrating MMT with comprehensive HIV and general health services together with improving the capacity of health workers and efficiency of services organisation to provide interconnected health care for drug users are critical for improving the outcomes of the MMT program.

Motivation for smoking cessation among drug-using smokers under methadone maintenance treatment in Vietnam

Background

Smoking cessation treatment service is concerned to be a critical element in methadone maintenance treatment (MMT) in order to diminish the effect of smoke on health outcomes. To implement the smoking cessation services in Vietnam, we examined the stages of change to quit and determined associated factors among MMT patients.

Methods

We conducted a cross-sectional survey with 1016 MMT patients in five clinics in Hanoi and Nam Dinh province, of those, 932 (91.7 %) were ever-smokers. Patients were classified into four groups: “pre-contemplation,” “contemplation,” “preparation,” and “action and maintenance” by using the transtheoretical model. Multivariate logistic regression was applied to determine the associated factor for intention and action to quit smoking.

Results

Overall, 96 % were not actively trying to quit or maintain abstinence. Age older than 45, HIV-positive status, and residence in Hanoi were negatively associated with intention to quit. Meanwhile, higher levels of nicotine dependence and number of years of smoking negatively associated with quitting and abstinence.

Conclusions

The study indicated the high rate of MMT smokers being in pre-contemplation stage but low proportion of quitting and maintaining abstinence. It emphasizes the importance of availability and accessibility of information about smoking cessation therapies and services. Integrating cessation programs into health-care services should be considered to provide tailored interventions for different patient groups.

Preference of methadone maintenance patients for the integrative and decentralized service delivery models in Vietnam

BACKGROUND

Integrating and decentralizing services are essential to increase the accessibility and provide comprehensive care for methadone patients. Moreover, they assure the sustainability of a HIV/AIDS prevention program by reducing the implementation cost. This study aimed to measure the preference of patients enrolling in a MMT program for integrated and decentralized MMT clinics and then further examine related factors.

METHODS

A cross-sectional study was conducted among 510 patients receiving methadone at 3 clinics in Hanoi. Structured questionnaires were used to collect data about the preference for integrated and decentralized MMT services. Covariates including socio-economic status; health-related quality of life (using EQ-5D-5 L instrument) and HIV status; history of drug use along with MMT treatment; and exposure to the discrimination within family and community were also investigated. Multivariate logistic regression with polynomial fractions was used to identify the determinants of preference for integrative and decentralized models.

RESULTS

Of 510 patients enrolled, 66.7 and 60.8 % preferred integrated and decentralized models, respectively. The main reason for preferring the integrative model was the convenience of use of various services (53.2 %), while more privacy (43.5 %) was the primary reason to select stand-alone model. People preferred the decentralized model primarily because of travel cost reduction (95.0 %), while the main reason for not selecting the model was increased privacy (7.7 %). After adjusting for covariates, factors influencing the preference for integrative model were poor socioeconomic status, anxiety/depression, history of drug rehabilitation, and ever disclosed health status; while exposure to community discrimination inversely associated with this preference. In addition, people who were self-employed, had a longer duration of MMT, and use current MMT with comprehensive HIV services were less likely to select decentralized model.

CONCLUSION

In conclusion, the study confirmed the high preference of MMT patients for the integrative and decentralized MMT service delivery models. The convenience of healthcare services utilization and reduction of geographical barriers were the main reasons to use those models within drug use populations in Vietnam. Countering community stigma and encouraging communication between patients and their societies needed to be considered when implementing those models.

Estimating the Cost-Effectiveness of HIV Prevention Programmes in Vietnam, 2006-2010: A Modelling Study

Introduction

Vietnam has been largely reliant on international support in its HIV response. Over 2006-2010, a total of US$480 million was invested in its HIV programmes, more than 70% of which came from international sources. This study investigates the potential epidemiological impacts of these programmes and their cost-effectiveness.

Methods

We conducted a data synthesis of HIV programming, spending, epidemiological, and clinical outcomes. Counterfactual scenarios were defined based on assumed programme coverage and behaviours had the programmes not been implemented. An epidemiological model, calibrated to reflect the actual epidemiological trends, was used to estimate plausible ranges of programme impacts. The model was then used to estimate the costs per averted infection, death, and disability adjusted life-year (DALY).

Results

Based on observed prevalence reductions amongst most population groups, and plausible counterfactuals, modelling suggested that antiretroviral therapy (ART) and prevention programmes over 2006-2010 have averted an estimated 50,600 [95% uncertainty bound: 36,300–68,900] new infections and 42,600 [36,100–54,100] deaths, resulting in 401,600 [312,200–496,300] fewer DALYs across all population groups. HIV programmes in Vietnam have cost an estimated US$1,972 [1,447–2,747], US$2,344 [1,843–2,765], and US$248 [201–319] for each averted infection, death, and DALY, respectively.

Conclusions

Our evaluation suggests that HIV programmes in Vietnam have most likely had benefits that are cost-effective. ART and direct HIV prevention were the most cost-effective interventions in reducing HIV disease burden.

The cost-effectiveness of harm reduction

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Comparing the cost effectiveness of harm reduction strategies: a case study of the Ukraine

Background

Harm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study.

Methods

A Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars.

Results

The Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55].

The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies.

Conclusions

Despite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.

A systematic review of scope and quality of health economic evaluation studies in Vietnam

INTRODUCTION

The application of health economic evaluation (HEE) evidence can play an important role in strategic planning and policy making. This study aimed to assess the scope and quality of existing research, with the goal of elucidating implications for improving the use of HEE evidence in Vietnam.

METHODS

A comprehensive search strategy was developed to search medical online databases (Medline, Google Scholar, and Vietnam Medical Databases) to select all types of HEE studies except cost-only analyses. Two researchers assessed the quality of selected studies using the Quality of Health Economic Studies (QHES) instrument.

RESULTS

We selected 26 studies, including 6 published in Vietnam. The majority of these studies focused on infectious diseases (14 studies), with HIV being the most common topic (5 studies). Most papers were cost-effectiveness studies that measured health outcomes using DALY units. Using QHES, we found that the overall quality of HEE studies published internationally was much higher (mean score 88.7+13.3) than that of those published in Vietnam (mean score 67.3+22.9). Lack of costing perspectives, reliable data sources and sensitivity analysis were the main shortcomings of the reviewed studies.

CONCLUSION

This review indicates that HEE studies published in Vietnam are limited in scope and number, as well as by several important technical errors or omissions. It is necessary to formalize the process of health economic research in Vietnam and to institutionalize the links between researchers and policy-makers. Additionally, the quality of HEE should be enhanced through education about research techniques, and the implementation of standard HEE guidelines.

Spending of HIV resources in Asia and Eastern Europe: systematic review reveals the need to shift funding allocations towards priority populations

INTRODUCTION

It is increasingly important to prioritize the most cost-effective HIV interventions. We sought to summarize the evidence on which types of interventions provide the best value for money in regions with concentrated HIV epidemics.

METHODS

We conducted a systematic review of peer-reviewed and grey literature reporting measurements of cost-effectiveness or cost-benefit for HIV/AIDS interventions in Asia and Eastern Europe. We also collated HIV/AIDS spending assessment data from case-study countries in the region.

RESULTS

We identified 91 studies for inclusion, 47 of which were from peer-reviewed journals. Generally, in concentrated settings, prevention of mother-to-child transmission programmes and prevention programmes targeting people who inject drugs and sex workers had lower incremental cost-effectiveness ratios than programmes aimed at the general population. The few studies evaluating programmes targeting men who have sex with men indicate moderate cost-effectiveness. Collation of prevention programme spending data from 12 countries in the region (none of which had generalized epidemics) indicated that resources for the general population/non-targeted was greater than 30% for eight countries and greater than 50% for five countries.

CONCLUSIONS

There is a misalignment between national spending on HIV/AIDS responses and the most affected populations across the region. In concentrated epidemics, scarce funding should be directed more towards most-at-risk populations. Reaching consensus on general principles of cost-effectiveness of programmes by epidemic settings is difficult due to inconsistent evaluation approaches. Adopting a standard costing, impact evaluation, benefits calculation, analysis and reporting framework would enable cross comparisons and improve HIV resource prioritization and allocation.

Associations between alcohol use disorders and adherence to antiretroviral treatment and quality of life amongst people living with HIV/AIDS

Background

We examined the association of alcohol use disorders (AUD) with adherence to and health-related quality of life (HRQOL) outcomes of antiretroviral treatment (ART) for HIV/AIDS patients.

Methods

A cross-sectional multi-site survey was conducted in 468 drug users and 648 non-drug users (age: 35.4 ± 7.0 years; 63.8% male) in 3 epicentres of Vietnam. AUD, ART adherence, and HRQOL were measured using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C), the self-reported Visual Analogue Scale (VAS), and the World Health Organization Quality of Life instrument (WHOQOL-HIV BREF).

Results

35.0% of drug users were hazardous drinkers, compared to 25.9% of non-drug users. 22.3% of drug users engaged in binge drinking, and 25.9% reported suboptimal ART adherence. Adjusting for propensity scores of AUD, patients who had either at-risk or binge drinking behaviour were about twice as likely to be treatment non-adherent as those who did not have AUD. Hazardous drinkers reported small to medium decrements in the Performance, Physical, Social, Spirituality, and Environment quality of life domains. Binge drinkers had a slightly higher score in Social dimension.

Conclusion

AUD is prevalent and negatively affecting adherence to and HRQOL outcomes of ART services in injection-driven HIV epidemics. Screening and intervention are recommended for AUD, especially during the stable periods of ART. Other social and psychological interventions might also enhance patients’ responses to and outcomes of ART in Vietnam.

Impact of methadone maintenance on health utility, health care utilization and expenditure in drug users with HIV/AIDS

BACKGROUND

This study assessed the impact of methadone maintenance treatment (MMT) on health utility, health care service utilization, and out-of-pocket (OOP) health expenditure in drug users with HIV/AIDS in Vietnam.

METHODS

Using the 2012 Vietnam HIV Service Users Survey data, a post-evaluation was designed to compare 121 MMT patients with 347 non-MMT patients who were matched using propensity scores of MMT covariates. Health utility was measured using the EuroQOL - five dimensions - five levels (EQ-5D-5L) and a visual analogue scale (EQ-VAS).

RESULTS

The mean EQ-5D-5L single index and EQ-VAS score of MMT patients were 0.68 (95% CI=0.64-0.73) and 71.5% (95% CI=68.2-74.9). Compared with the control group, the adjusted differences in health utility were 0.08 and 4.43% (p=0.07), equivalent to 12.1% and 6.5% increases during MMT. There was a 45.9% decrease in the frequency of health care service utilization that was attributable to MMT. Although, antiretroviral treatment and MMT services were free-of-charge, MMT and non-MMT patients still paid their OOP for health care for averagely US$ 16.3/month and US$ 28.9/month. The adjusted difference between the two groups was US$ 19.3/month ($ 231.6/year) that equivalents to a reduction of 66.7% in OOP health expenditure related to MMT.

CONCLUSION

MMT was associated with a clinically important difference in health utility, large reductions in health care service utilization and OOP health expenditure in HIV-positive drug users. Scaling up MMT in large drug-using population could help improve the outcomes of HIV/AIDS interventions and reduce economic vulnerability of affected households.

Willingness to pay for methadone maintenance treatment in Vietnamese epicentres of injection-drug-driven HIV infection

OBJECTIVE

Willingness to pay for methadone maintenance treatment (MMT) in three Vietnamese epicentres of injection-drug-driven human immunodeficiency virus (HIV) infection was assessed.

METHODS

A convenience sample of 1016 patients receiving HIV treatment in seven clinics was enrolled during 2012. Contingent valuation was used to assess willingness to pay. Interviewers reviewed adverse consequences of injection drug use and the benefits of MMT. Interviewers then described the government's plan to scale up MMT and the financial barriers to scale-up. Willingness to pay was assessed using double-bounded binary questions and a follow-up open-ended question. Point and interval data models were used to estimate maximum willingness to pay.

FINDINGS

A total of 548 non-drug-users and 468 injection drug users were enrolled; 988 were willing to pay for MMT. Monthly mean willingness to pay among non-drug-users, 347 drug users not receiving MMT and 121 drug users receiving MMT was 10.7 United States dollars [US$] (35.7% of treatment costs), US$ 21.1 (70.3%) and US$ 26.2 (87.3%), respectively (mean: US$ 15.9; 95% confidence interval, CI: 13.6-18.1). Fifty per cent of drug users were willing to pay 50% of MMT costs. Residence in households with low monthly per capita income and poor health status predicted willingness to pay less among drug users; educational level, employment status, health status and current antiretroviral therapy receipt predicted willingness to pay less among non-drug-users.

CONCLUSION

Willingness to pay for MMT was very high, supporting implementation of a co-payment programme.

Multilevel predictors of concurrent opioid use during methadone maintenance treatment among drug users with HIV/AIDS

Background

Ongoing drug use during methadone maintenance treatment (MMT) negatively affects outcomes of HIV/AIDS care and treatment for drug users. This study assessed changes in opioid use, and longitudinal predictors of continued opioid use during MMT among HIV-positive drug users in Vietnam, with the aim of identifying changes that might enhance program efficacy.

Methods

We analyze data of 370 HIV-positive drug users (mean age 29.5; 95.7% male) taking MMT at multi-sites. Opioid use was assessed at baseline, 3, 6, and 9 months using interviews and heroin confirmatory urine tests. A social ecological model was applied to explore multilevel predictors of continued opioid use, including individual, interpersonal, community and service influences. Generalized estimating equations (GEE) statistical models were constructed to adjust for intra-individual correlations.

Results

Over 9 month follow-up, self-reported opioid use and positive heroin urine test substantially decreased to 14.6% and 14.4%. MMT helped improve referrals and access to health care and social services. However, utilization of social integration services was small. GEE models determined that participants who were older (Adjusted Odd Ratio - AOR = 0.97 for 1 year increase), had economic dependents (AOR = 0.33), or were referred to TB treatment (AOR = 0.53) were less likely to continue opioid use. Significant positive predictors of ongoing opioid use included frequency of opioid use prior to MMT, peer pressure, living with sexual partners, taking antiretroviral treatment, other health concerns and TB treatment.

Conclusion

These findings show that MMT in the Vietnamese context can dramatically reduce opioid use, which is known to be associated with reduced antiretroviral (ART) adherence. Disease stage and drug interactions between antiretrovirals or TB drugs and MMT could explain some of the observed predictors of ongoing drug use; these findings could inform changes in MMT program design and implementation.