Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study.

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Telehealth Interventions for HIV in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: This review summarizes technology-based interventions for HIV in low- and middle-income countries (LMICs). We highlight potential benefits and challenges to using telehealth in LMICs and propose areas for future study. RECENT FINDINGS: We identified several models for using telehealth to expand HIV health care access in LMICs, including telemedicine visits for pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) services, telementoring programs for providers, and virtual peer-support groups. Emerging data support the acceptability and feasibility of these strategies. However, further investigations are needed to determine whether these models are scalable and sustainable in the face of barriers related to cost, infrastructure, and regulatory approval. HIV telehealth interventions may be a valuable approach to addressing gaps along the HIV care cascade in LMICs. Future studies should focus on strategies for expanding existing programs to scale and for assessing long-term clinical outcomes.

Integrated clinical and quality improvement coaching in Son La Province, Vietnam: a model of building public sector capacity for sustainable HIV care delivery.

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.

Embedding viral hepatitis into primary healthcare: results of a strategic landscape analysis in Vietnam and the Philippines.

Chronic viral hepatitis is a significant public health concern in the Western Pacific, including in Vietnam and the Philippines. To accelerate progress toward meeting the 2030 elimination goals, the World Health Organization (WHO) encourages countries to adopt an integrated, people-centered health sector response to hepatitis, grounded in Primary Health Care (PHC). A review of the academic and grey literature, along with policy documents, was conducted to describe the national health system and PHC response to hepatitis B and C in Vietnam and the Philippines. Information was analyzed against the four strategic levers of the WHO Operational Framework for PHC to identify challenges and opportunities. The findings suggest that both countries have relatively robust policy frameworks, with some room for improvement. Vietnam may have stronger political commitment and funding than the Philippines, while the Philippines appears to be stronger in community engagement. Both countries share challenges and opportunities for learning to actualize viral hepatitis elimination utilizing a PHC approach.

Antibiotic prescribing practices of medical doctors in a resource-limited setting and the influence of individual perceptions and stewardship support: a survey in three tertiary hospitals in Vietnam.

Objectives: To understand antibiotic prescribing and influencing factors to inform antimicrobial stewardship (AMS) interventions to reduce unwanted consequences of antibiotic use in hospitals in Vietnam, a lower-middle-income country in Asia. Methods: We conducted a cross-sectional study of doctors at three tertiary hospitals using non-probability convenience sampling, through a paper-based (Hospitals 1 and 2) or electronic (Hospital 3) survey. Questions included items on perceptions regarding antibiotic resistance and AMS, prescribing practices, knowledge, demographics and training. We used principal components analysis and mixed-effects models to examine practices and identify influencing factors. Results: Among 314 surveyed participants, 61%, 57% and 59% in Hospitals 1, 2 and 3, respectively, felt certain about the appropriateness of their antibiotic prescriptions. In total, 9% reported sometimes prescribing antibiotics when not needed to meet patients' expectations, and 13% reported doing so to avoid perceived complications. Higher prescribing confidence was found among those with positive perceptions about AMS (P < 0.0001), whereas negative perceptions about colleagues' practices reduced this confidence (P < 0.0001). Individual preference for branded antibiotics was associated with more unnecessary prescribing whereas having higher prescribing confidence decreased the habits of prescribing when not needed. Conclusions: This study provides important implications for design of hospital interventions to address influencing factors on antibiotic prescribing in Vietnam and similar resource-limited settings. Specific interventions should target improving knowledge through education and training for doctors, enhancing the support from the AMS team, and promoting guidelines and policies for appropriate antibiotic use in hospital.

Undergraduate Medical Education Reform in Viet Nam for a Primary Health Care Workforce.

Strong primary health care (PHC) systems require a robust PHC workforce. Traditionally, medical education takes place in academic medical centres that favour subspecialty care rather than PHC settings. This may undervalue primary care as a career and contribute to a shortage of PHC workers. However, designing undergraduate medical education curricula that incorporate early experiences in clinical care delivery at PHC sites remains a challenge, including in many low- and middle-income countries (LMICs). This paper describes how a collaboration between Harvard Medical School and five medical schools in Vietnam, and in-country collaborations among the Vietnamese medical schools, facilitated curricular innovation and co-creation of coursework relevant to PHC through the development of a Practice of Medicine (POM) course. The collaboration implemented a technical assistance strategy consisting of in-person workshops, focused virtual consultations, on-site 'office hours', site visits and observations to each of the five medical universities, and immersion trips to support the creation and implementation of the POM course. A pilot program was started at a single site and then scaled nationally using local customisation, experience, and expertise utilising a train-the-trainers approach. As a result, five new POM courses have been developed by five Vietnamese institutions. Fifty Vietnamese faculty received training to lead the POM course development, and 228 community-based preceptors have been trained to teach students at PHC sites. A total of 52 new PHC and community-based clinical training sites have been added, and 3,615 students have completed or are currently going through a POM course. This experience can serve as a model for future academic collaborations to support the development of a robust PHC workforce for the 21st century.

A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam.

INTRODUCTION: Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi-pronged facility-level intervention to reduce stigma and discrimination at health facilities across three high-burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities. METHODS: From July 2018 to July 2019, we assessed HIV-related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross-sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi-square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention. RESULTS: Semi-structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self-stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p-values <0.05). Among HCWs, 672 completed the pre- and post-intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p-values <0.05). CONCLUSIONS: A multi-pronged facility-level intervention was successful at reducing healthcare-associated HIV-related stigma in Vietnam. The findings support the scale-up of this intervention in Vietnam and highlight key components potentially applicable in other settings.

A family empowerment strategy is associated with increased healthcare worker hand hygiene in a resource-limited setting.

BACKGROUND: Guidelines recommend empowering patients and families to remind healthcare workers (HCWs) to perform hand hygiene (HH). The effectiveness of empowerment tools for patients and their families in Southeast Asia is unknown. METHODS: We performed a prospective study in a pediatric intensive care unit (PICU) of a Vietnamese pediatric referral hospital. With family and HCW input, we developed a visual tool for families to prompt HCW HH. We used direct observation to collect baseline HH data. We then enrolled families to receive the visual tool and education on its use while continuing prospective collection of HH data. Multivariable logistic regression was used to identify independent predictors of HH in baseline and implementation periods. RESULTS: In total, 2,014 baseline and 2,498 implementation-period HH opportunities were observed. During the implementation period, 73 families were enrolled. Overall, HCW HH was 46% preimplementation, which increased to 73% in the implementation period (P < .001). The lowest HH adherence in both periods occurred after HCW contact with patient surroundings: 16% at baseline increased to 24% after implementation. In multivariable analyses, the odds of HCW HH during the implementation period were significantly higher than baseline (adjusted odds ratio [aOR], 2.94; 95% confidence interval [CI], 2.54-3.41; P < .001) after adjusting for observation room, HCW type, time of observation (weekday business hours vs evening or weekend), and HH moment. CONCLUSIONS: The introduction of a visual empowerment tool was associated with significant improvement in HH adherence among HCWs in a Vietnamese PICU. Future research should explore acceptability and barriers to use of similar tools in low- and middle-income settings.

Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.

Background: The 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of person-centered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data. Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains. Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.

Facilitators and barriers to a family empowerment strategy to improve healthcare worker hand hygiene in a resource-limited setting.

OBJECTIVES: The World Health Organization recommends empowering patients/families to remind healthcare workers (HCWs) to perform hand hygiene (HH). We sought to understand acceptability of a family empowerment strategy in a Vietnamese pediatric intensive care unit (PICU). METHODS: With end-user input, we designed a tool to help families in a PICU in Vietnam to remind HCWs to perform HH. We conducted 3 preliminary focus group discussions (FGDs) with patients' family members (n = 8), physicians (n = 9), and nurses (n = 8) to understand acceptability of preliminary tools, attitudes towards HH and barriers to HH. Tools were then modified and implemented in a 5-week intervention study. We then conducted 3 more FGDs with families (n = 7), physicians (n = 7), and nurses (n = 8). Discussions were analyzed using qualitative directed content analysis. Families who used the tool were asked to complete written surveys. FINDINGS: Both family members and HCWs felt that HCWs had a responsibility to perform HH. Barriers to performing HH were identified, including forgetfulness and time constraints. Family members felt shy reminding HCWs to perform HH. However, the HH reminder tool was acceptable, and some felt it could overcome barriers to reminding HCWs to perform HH. HCWs felt embarrassed when reminded to perform HH, but felt that the reminder was useful. Nearly all (99%) survey respondents felt that family members should speak up if they noticed HCWs omitting HH. CONCLUSIONS: A tool given to families to remind HCWs to perform HH was largely acceptable in a pediatric ICU in Vietnam. Perceived benefits of improving HH were felt to surmount barriers to tool use.

Building HIV healthcare worker capacity through telehealth in Vietnam.

Development of a robust technical assistance system is an essential component of a sustainable HIV response. Vietnam's National HIV Program is transitioning from a largely donor-funded programme to one primarily supported by domestic resources. Telehealth interventions are increasingly being used for training, mentoring and expert consultation in high-resource settings and hold significant potential for use as a tool to build HIV health worker capacity in low and middle-income countries. We designed, implemented and scaled up a novel HIV telehealth programme for Vietnam, with the goal of building a sustainable training model to support the country's HIV workforce needs. Over a 4-year period, HIV telehealth programmes were initiated in 17 public institutions with participation of nearly 700 clinical sites across 62 of the 63 provinces in the country. The telehealth programme was used to deliver certificate training courses, provide clinical mentoring and case-based learning, support programme implementation, provide coaching in quality improvement and disseminate new guidelines and policies. Programme evaluation demonstrated improved health worker self-reported competence in HIV care and treatment and high satisfaction among the programme participants. Lessons learnt from Vietnam's experience with telehealth can inform country programmes looking to develop a sustainable approach to HIV technical assistance and health worker capacity building.

Routine versus Targeted Viral Load Strategy among Patients Starting Antiretroviral in Hanoi, Vietnam.

INTRODUCTION: HIV viral load (VL) testing is recommended by the WHO as the preferred method for monitoring patients on antiretroviral therapy (ART). However, evidence that routine VL (RVL) monitoring improves clinical outcomes is lacking. METHODS: We conducted a prospective, randomized controlled trial of RVL monitoring every six months versus a targeted VL (TVL) strategy (routine CD4 plus VL testing if clinical or immunological failure) in patients starting ART between April 2011 and April 2014 at Bach Mai Hospital in Hanoi. Six hundred and forty-seven subjects were randomized to RVL (n = 305) or TVL monitoring (n = 342) and followed up for three years. Primary endpoints were death or WHO clinical Stage 4 events between six and thirty-six months of ART and rate of virological suppression at three years. RESULTS: Overall, 37.1% of subjects were female, median age was 33.4 years (IQR: 29.5 to 38.6), and 47% had a CD4 count ≤100 cells/mm3 at time of ART initiation. Approximately 44% of study events (death, LTFU, withdrawal, or Stage 4 event) and 68% of deaths occurred within the first six months of ART. Among patients on ART at six months, death or Stage 4 event occurred in 3.6% of RVL and 3.9% of TVL (p = 0.823). Survival analysis showed no significant difference between the groups (p = 0.825). Viral suppression at 36 months of ART was 97.2% in RVL and 98.9% in TVL (p = 0.206) at a threshold of 400 copies/mL and was 98.0% in RVL and 98.9% in TVL (p = 0.488) at 1000 copies/mL. In ITT analysis, 20.7% in RVL and 21.9% in TVL (p = 0.693) were unsuppressed at 1000 copies/mL. CONCLUSIONS: We found no significant difference in rates of death or Stage 4 events and virological failure in patients with RVL monitoring compared to those monitored with a TVL strategy after three years of follow-up. Viral suppression rates were high overall and there were few study events among patients alive and on ART after six months, limiting the study's power to detect a difference among study arms. Nonetheless, these data suggest that the choice of VL monitoring strategy may have less impact on patient outcomes compared to efforts to reduce early mortality and improve ART retention.

Sensitivity and specificity of two dried blood spot methods for HIV-1 viral load monitoring among patients in Hanoi, Vietnam.

The use of dried blood spot (DBS) specimens for HIV viral load (VL) monitoring is recommended to support the roll-out of routine VL monitoring in low and middle income countries (LMICs). To better understand the use of DBS for VL monitoring, we evaluated two DBS testing methods, Roche TaqMan® Free Virus Evolution protocol (DBS-FVE) and Roche TaqMan® SPEX protocol (DBS-SPEX)) in patients receiving ART at an HIV clinic in Hanoi, Vietnam. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each DBS testing method at the thresholds of 1000 and 5000 copies/ml compared to plasma VL. At a threshold of 1000 copies/ml, sensitivity, specificity, PPV and NPV of the DBS-SPEX method were 98.8% (95% CI: 93.3%-100%), 74.3% (95% CI: 70.8%-77.5%), 31.5% (95% CI: 25.8%-37.6%), and 99.8% (95% CI: 98.9%-100%), respectively. Increasing the VL threshold value to 5000 copies/ml improved specificity (97.9% CI: 96.6%-98.9%) and PPV (83.9% CI: 74.5%-90.9%). Using the DBS-FVE method, at the threshold of 1000 copies/ml and with a correction factor of +0.3 log copies/ml, sensitivity was 95.1% (87.8%-98.6%) and specificity was 98.8% (97.7%-99.5%). Sensitivity decreased at the threshold of 5000 copies/ml (65.8%, 95% CI: 54.3%-76.1%). With a correction factor of +0.7 log copies/ml, the sensitivity was 96.3% (89.6%-99.2%) and specificity was 98.2% (96.9%-99.1%) at the threshold of 1000 copies/ml. We found that the Roche DBS-FVE method, with a +0.7 log copies/ml correction factor, performed well with sensitivity and specificity greater than 96% at a VL threshold of 1000 copies/m. These findings add to the growing body of evidence supporting the use of DBS VL testing for ART monitoring. Future research should evaluate the association between VL results by DBS and clinical outcome measures such as HIV drug resistance, morbidity, and mortality.

Cigarette smoking is associated with high HIV viral load among adults presenting for antiretroviral therapy in Vietnam.

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.

Response to hepatitis B vaccination among HIV-infected adults in Vietnam.

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.

Effectiveness of train-the-trainer HIV education: a model from Vietnam.

As HIV prevention and treatment efforts expand around the globe, local capacity-building to update and maintain nurses' HIV competence is essential. The purpose of this project was to develop and sustain a national network of nurse-trainers who could provide ongoing HIV continuing education and training experiences to Vietnamese nurses. Over the course of 6 years, 87 nurses received training to become HIV trainers; their HIV knowledge increased significantly (p = .001), as did teaching self-confidence (p = .001 to .007). The 87 nurses subsequently reported training more than 67,000 health care workers. Recipients of train-the-trainer-led workshops demonstrated increased HIV knowledge (p = .001) and increased willingness to provide nursing care for HIV-infected patients (p = .001). The program demonstrated that including a substantial amount of instruction in pedagogical strategies and experiential learning could enhance knowledge transfer, expand education outreach, and contribute to sustainable HIV competence among nurses.

Prevalence and predictors of cytomegalovirus retinitis in HIV-infected patients with low CD4 lymphocyte counts in Vietnam.

We describe the results of a study to determine the prevalence and characteristics of cytomegalovirus (CMV) retinitis among HIV-infected patients in Vietnam. We conducted a cross-sectional prospective study of patients with CD4 lymphocyte count ≤100 cells/mm(3)recruited from public HIV clinics. The diagnosis was made by a trained ophthalmologist using slit lamp biomicroscopy and corroborated on fundus photography. A total of 201 patients were screened. The median age was 32 years, 77% were men, median CD4 count was 47 cells/mm(3), and 62% were on antiretroviral treatment. Prevalence of CMV retinitis was 7% (14/201, 95% CI 4-11%). CMV retinitis was not associated with age, gender, injection drug use, CD4 count, WHO clinical stage, or antiretroviral treatment status. Blurring of vision and reduced visual acuity <20/40 were associated with CMV retinitis, but only 29% of patients with the diagnosis reported blurry vision and only 64% had abnormal vision. On multivariate analysis, the sole predictor for CMV retinitis was decreased visual acuity (OR 22.8,p < 0.001). In Ho Chi Minh City, CMV retinitis was found in 7% of HIV-infected patients with low CD4. HIV-infected patients with a CD4 count <100/mm(3)or who develop blurring of vision in Vietnam should be screened for CMV retinitis.

Clinically significant adverse events from a drug interaction between quetiapine and atazanavir-ritonavir in two patients.

Clinicians caring for patients infected with the human immunodeficiency virus (HIV) and diagnosed with psychiatric comorbidities must be aware of potential drug-drug interactions, particularly with protease inhibitor-based antiretroviral therapy. Although possible interactions can be predicted based on a drug's pharmacokinetic parameters, the clinical significance is often unknown. We describe two patients who experienced serious quetiapine adverse effects potentially mediated through an interaction with ritonavir-boosted atazanavir. The first patient was a 57-year-old man with HIV and bipolar disease who developed rapid and severe weight gain when quetiapine was added to a stable atazanavir-ritonavir-based antiretroviral regimen. After the patient discontinued both quetiapine and ritonavir, his weight returned to its baseline value. The second patient was a 32-year-old woman with HIV, anxiety disorder, and a history of intravenous drug abuse who developed increased sedation and mental confusion when an atazanavir-ritonavir-based antiretroviral regimen was added to her stable antianxiety drug regimen, which included quetiapine. Her symptoms resolved promptly after discontinuation of the quetiapine. Use of the Naranjo adverse drug reaction probability scale indicated that the adverse effects experienced by the two patients were possibly related and probably related, respectively, to an interaction between quetiapine and atazanavir-ritonavir. Quetiapine is primarily metabolized by cytochrome P450 (CYP) 3A4, and ritonavir is a potent inhibitor of CYP3A4. Thus, it is reasonable to theorize that quetiapine concentrations will increase when these drugs are used concurrently, which would be the likely cause of the toxicities in these two patients. To our knowledge, these are the first published reports of a clinically significant interaction between atazanavir-ritonavir and quetiapine. Clinicians should be aware of the potential for this interaction, and extreme caution should be used when prescribing quetiapine and other atypical antipsychotic agents in HIV-positive patients who are receiving antiretroviral therapy.