HIV Home Visits

Today we set out early in the morning for the countryside of Quang Tri province to call upon 3 of the HIV patients under Di Dien's watch. On the way there we learned that she has 95 HIV/AIDS patients assigned to her and that about 1/3 are on anti-retroviral treatment (ARVs). As a primary care provider of sorts she does not dispense ARVs; the patients must make the trek into Hue once a month to the dispensary at the main hospital. Rather she serves more as a case manager for the patients and their families, periodically checking in on them to ensure that they have the food and water and shelter necessary to comply with their ARV regimen. The standard ARV regimen in Vietnam consists of three medications which must be taken twice a day with food and water; if a patient misses doses the virus can rapidly develop resistance to the medications, rendering them useless. The same is true of anti-tuberculosis regimens (a four drug combination), and about 10% of patients with tuberculosis in Vietnam also have HIV.

Patients are referred to her from the Infectious Disease Unit of Hue Central Hospital after they have been diagnosed with HIV. She and her staff of volunteers conduct an initial home visit to assess the living situation upon discharge. They look for things such as whether there is running water, a clean cooking area, and a separate latrine from the house, or whether the patient even has a house at all. If the living situation is deemed unsafe or unsanitary they argue the case before their board of donors and try to relocate the patient. They also assess the health of the family members, who may or may not have contracted HIV themselves, but are disadvantaged by having a relative with this still stigmitized and often debilitating disease. They check to see whether the children of the family are in school. They provide financial and emotional support for the family, even after the person with HIV dies. All in a day's work for Di Dien.

Of course if she finds a person too sick to stay out in the province, she brings them back with her and admits them to the hospital. Fortunately this did not happen today, although we did visit one young one man with HIV and TB who was recently discharged after she had found him very sick on her last visit. We met him on the side of the road, because his father is currently not allowing him in the house. He showed us his ARV and TB medications, kept in a small baggy in his pocket. Di Dien was very concerned about his situtation and will be working to secure stable housing for him. We also visited a woman widowed after her husband died of AIDS. She and their 3 children (thankfully uninfected) and the grandmother all sleep together on one bed in the simple 2 room structure, although they do have a mosquito net. The cook over an open fire but they do have running water and a proper latrine 20 feet from the house. Much better off than many I met in Tanzania all those years ago. They even have their own local drugstore of sorts - check out this guy on his bike selling an aray of sundries to the tunes of his boombox. He just rolled right on by while we were standing on the path in the middle of the rice fields!

In addition to getting to see the patients in their homes (or lack thereof), today was also an amazing opportunity to see more of the rural countryside. The guidebooks talk about how difficult it can be to get away from the coastline and visit the rural villages nestled in the mountains and foothills of Vietnam. In some cases tourists simply are not allowed by the government. The lack of good roads or anything in the way of a restaurant or hotel is also prohibitive. Standing in the shadows of the rolling green hills which separate Vietnam from Laos today was yet another privledge we were afforded in our roles as part tourist, part family.

Kim Long Charity Clinic

We began work at the Kim Long Charity Clinic this week. Dr Nguyen Thi Dien is the medical director of this clinic which provides free services to over 35,000 people in the Thua Thien and Quang Tri provinces. Despite what you might think, given that Vietnam is a communist country, medical care is not free and patients must pay a fee-for-service for clinic visits, labs, xrays, medicines, etc. The Charity Clinic was started in 1992 to provide free care for those who cannot afford it otherwise, and has grown every year under the careful stewardship of Dr Nguyen and her colleagues. Patients travel for miles from the rural parts of the province and arrive early in the morning to wait to be seen. Each day starts with an education session, this one geared toward reducing the stigma of HIV/AIDS.


Dr Nguyen is a force of nature. Standing at barely 4'10" (making me appear like a giant), she supervises a staff of over 20 volunteers. Her office is full of medical texts and careful records of donations and health statistics from the province. I was thrown right into the fray on Tuesday morning, occupying exam room 14 with my wife Holly and an interpreter, Nguyen. We saw patients with arthritis, heart disease, diabetes, hypertension - the usual for an American clinic, but with a vastly different toolset. We didn't know the function of about 25% of the medications on the limited list that the clinic carries. Lab tests, xrays, and referrals, while available, are understandably reserved for the sickest of patients.



After a siesta during the hottest part of the day, we started all over again in the afternoon. Holly and I have been brainstorming about simple ways to systematize some of the care here and to bring in some new educational tools for the staff and patients. Friday we will do home visits with some of the sicker HIV patients in the province, which should be yet another invaulable learning experience. In two weeks we will move over to the medical university, where I hope to learn about the medical education system in Vietnam. Holly and I will participate in teaching the medical students.

Clinic Time at VCHAP-HCMC

After visiting the VCHAP office and learning about HIV strategy in Vietnam, we also were able to sit in on patient visits to the VCHAP clinic. We shadowed one of the Vietnamese doctors on staff as he saw the many patients who had come to have their HIV monitored and managed.

We sat in with Dr. Khoa, a young physician trained in Vietnam. Patients in Vietnam, like many other developing nations, approaches systematic record keeping by giving all patients a personal medical record that they take with them each time they see their doctor. Mirroring records are also kept on file at the medical institution.


Inside these medical records, physicians note the medications taken, and ostensibly also write in the diagnosis for any medical complaint. In our particular case, however, each patient was there primarily to renew prescriptions for their anti-retroviral regimen, so it the process was much more streamlined for that particular purpose. Dr. Khoa listened to the patients as they described any complaints, how they felt and how the drugs were affecting them. The WHO protocols lay out a particular timetable that describe how a patient should be responding to the medications after beginning the regimen and when the lab tests should be done to determine CD4 count. CD4 white blood cells are the particular cells affected by HIV and their count is used to determine the progression of the disease.


Nine times out of ten, this process resulted in the patient continuing to receive the front-line WHO ARV protocol, a result so common that each of the doctors in the clinic had a small stamp that listed the medications of the therapy. This facility was focused on management of HIV, but was also supposed to be able to hear about and refer patients that were suffering with other medical problems, whether or not those problems had to do with HIV. In practice, however, this clinic dealt almost entirely with the patient's responses to HIV medication.

HIV Care in Ho Chi Minh City

Holly and I spent yesterday getting our bearings and visiting the VCHAP (Vietnam-CDC-Harvard Medical School AIDS Partnership) Clinic in District 5 of Ho Chi Minh City (HCMC). The office is housed at the Infectious Disease Hosptial in HCMC. We met with their staff and saw three HIV case presentations, and in doing so, discovered a gap in our respective strengths. I know more Vietnamese than Holly, and she likewise knows more medicine, but my already tenuous ability to piece together meaning starts to break down when words like "Zidovudine" are thrown in there. The situation was made all the more difficult by the presence of Dr. Donn Colby, Medical Director of VCHAP-HCMC, who speaks Vietnamese as fluently as the guy that sold you pho at the street corner. Only he also knows the medicine.

In addition to the case presentations, we were lucky enough to also get a general overview of VCHAP's role in the national HIV management strategy. The Vietnamese Ministry of Health partners with non-governmental organizations like VCHAP to provide anti-retroviral (ARV) drugs and ARV therapy training to HIV care providers across the country. In the past 5 years, VCHAP has conducted numerous seminars throughout the country, training hundreds of doctors and nurses about HIV management and drug regimines.

HIV mangagement in Vietnam revolves around a set of guidelines set by the World Health Organization (available at this link), and employs a anti-retroviral drug regimine that is no longer used in most developed nations. This particular three-drug combination has quite a few side effects, but is both cheap and effective. A year of medication for a single patient costs $90. The next least expensive option costs $1200, a price that puts nationwide implementation far beyond the resources of a developing nation like Vietnam.

Treatment and management of care occurs at the province level. There are 59 provinces in Vietnam and 5 municipalities that have province-level status. Doctors and nurses at the local level receive training and drugs from the Ministry of Health and NGO's like VCHAP, which are then distributed in the home province or city. If a patient does not respond to the frontline ARV therapy, the case is brought to an advising HIV specialist, who are mostly in the larger cities. Upon consultation with the specialist, the patient can then be prescribed the second-line ARV therapy if the case warrants that treatment. While visiting the VCHAP office, which acts as the consulting body for the southern region of Vietnam, we saw three such case presentations from visiting doctors.

Our overall impression of the VCHAP role in the national HIV management strategy is that it increases efficiency and, most importantly, builds capacity amongst Vietnamese providers to manage HIV at the local level.