Hanoi summit on pharmacists and AIDS

UCSF leaders in pharmacy, international health, and AIDS met with their Vietnamese peers in Hanoi this October to plan how Vietnam's pharmacy workforce can curtail the spread of HIV in Vietnam.

HIV was first detected in Vietnam in 1990. By the decade's end, HIV infection had spread to all 64 provinces and major cities in the country. Estimates now range from 80,000 to more than 100,000 people infected—still well under 1% of the population, but growing. Commercial sex workers and drug users remain the most commonly affected, with infection rates approaching 25%. Sexually transmitted cases continue to rise, according to the United States Agency for International Development (USAID), in what is considered a “concentrated” epidemic.

National strategy and US funding

This year the Vietnamese government approved the National Strategy on HIV/AIDS Prevention and Control to slow the spread of HIV and spare the country the personal tragedy and economic loss an AIDS epidemic would surely bring. The strategy aims to:

• increase awareness of HIV transmission
• promote education programs in schools
• control transmission in groups with high-risk behaviors
• improve care and treatment for people living with HIV and
• provide antiretroviral therapy to eligible people, with a goal of treating 70% of AIDS patients by 2010.

The new effort should soon get a boost, as Vietnam is slated to receive US funds for new antiretroviral drugs, treatment, and education under The President's Emergency Plan for AIDS Relief (PEPFAR). This is particularly good news in a country where less than 1,000 HIV-positive Vietnamese, and possibly only about 100, currently receive AIDS medications.

Not enough doctors

But between the surging needs of HIV-infected people and the promise of new treatments lies a startling shortage of professionals trained to screen, educate, and treat those with HIV. Case in point: Only one doctor in Vietnam is trained in HIV care for every 10,000 currently infected. This workforce gap threatens to sabotage the government's plans and prevent new drugs from reaching those who need them.

The potential of 16,000 pharmacies

This year, in an ambitious effort to forge a response to the workforce crisis, leaders from the UCSF School of Pharmacy and UCSF Global Health Sciences met with colleagues from Vietnam's leading pharmacy and medical schools, hospitals, and pharmacy association to develop an innovative plan. Co-hosted by Hanoi University of Pharmacy and supported by Vietnam's Ministry of Health, the summit aimed to tap the country's most promising line of defense—the well-established network of 16,000 community pharmacies that reach every province of Vietnam.

Because the vast majority of Vietnamese have neither health insurance nor the out-of-pocket income to pay for doctors' visits, pharmacists and pharmacy workers are the primary source of medicine and medical advice for most Vietnamese. The October 2004 conference in Hanoi sought to flesh out a practical approach to improving HIV screening and patient management, drug quality and access, and comprehensive drug information by focusing resources on this pharmacy network.

Summit participants

The summit, “Expanding the Role of Pharmacists in the Management and Prevention of AIDS in Vietnam,” included leaders and representatives from:

• UCSF AIDS Research Institute and UCSF School of Nursing
• the United States Pharmacopeia, the non-government organization that establishes standards to ensure the quality of medicines
• USAID
• Vietnam's 5 pharmacy schools
• Vietnam's Ministry of Health
• Vietnam's hospitals and health institutes
• Vietnamese pharmacy association
• humanitarian organizations such as CARE, Family Health International, and the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Opening remarks

As Vietnam's Minister of Health Tran Thi Trung Chien said at the opening ceremony, “In the battle against this century's disease…pharmacists have great opportunities (to reach)…patients and populations at risk…We should mobilize this source…of HIV/AIDS prevention.”

In her opening address, Mary Anne Koda-Kimble, PharmD, dean of the UCSF School of Pharmacy, stressed the urgency of having a well-trained workforce in place even before Vietnam receives a fresh supply of potent antiretroviral drugs through PEPFAR and other international programs. “We have learned from other countries the dire consequences of inappropriate use of antiretrovirals and inadequate numbers of health workers well trained in HIV screening, prevention, and treatment,” she said. “The result in Vietnam could be resistance to antiretrovirals, an accelerating spread of HIV, inattention to drug quality, and poor adherence in following drug regimens.

“Many countries must turn to local people who have no healthcare training at all to take on this role,” Koda-Kimble added. “Vietnam, by contrast, is fortunate because it has a large cadre of pharmacists who can take on this vital responsibility and a government that recognizes the potential of pharmacists to this looming epidemic.”

Haile T. Debas, MD, executive director of UCSF Global Health Sciences and a US host of the conference, observed, “UCSF Global Health Sciences chose to begin a relationship in Vietnam through the country's pharmacy workforce because pharmacists are widely sought for care, and because the Vietnamese government understands the potential of these professionals to arrest AIDS and prevent a national disaster.”

Summit workshops

The conference included 3 workshops:

1. Screening and Managing Patients
2. Drug Information
3. Drug Quality Assessment and Access.

In addition, a Deans' Meeting brought together Vietnam's pharmacy and medical school leaders with UCSF's Koda-Kimble, Debas, and UCSF delegates to address issues of academic importance, such as pharmacy school curriculum needs.

Training pharmacists

Despite cultural differences and vastly different access to resources, participants from the two countries readily agreed that the first priority is to train Vietnam's pharmacists in HIV prevention, screening, and education, as well as in the proper use and effectiveness of new antiretroviral drugs and the basics of drug quality assessment. This goal of “capacity building,” they agreed, is both urgent and of paramount importance.

Yet while the network of pharmacies extends throughout the country and into small villages, Vietnam has no retraining program—no established practice of continually upgrading and updating the skills and information available to trained pharmacists.

The leaders of the Vietnamese schools of pharmacy recognized this during the course of the 3-day summit and asserted that they must establish programs to provide HIV and AIDS education to practicing pharmacists throughout the country. The type of education will evolve as the pattern and pace of HIV infection changes and as drug regimen recommendations are modified.

The Vietnamese pharmacy participants stressed that this continuing education should include screening, prevention, and patient education, as well as coursework on drug quality assessment and storage. They envisioned the potential of regional workforce training sites where pharmacists could learn the new skills and information needed to prevent and treat HIV.

“One of the wonderful things about the conferences was the flexibility and openness of our Vietnamese partners,” said John Inciardi, PharmD, a UCSF School of Pharmacy faculty member who played a major role in planning the conference along with Sacramento clinical pharmacist Kate Nguyen, PharmD. “We already knew they were capable and committed professionals, and we were pleased to see how quickly they applied new ideas, such as retraining, that are not part of their tradition. It was exciting, and gives me hope that Vietnam will be able to avert a tragedy.”

Developing clinical curricula

Vietnam's pharmacy schools teach their students about drug composition, kinetics, modes of action, and related technical knowledge, but not how to diagnose, treat, and cure disease through the use of medicines. This lack of clinical focus resembles the curricula of US pharmacy schools before the mid-1960s. By the end of the conference, Tu Minh Koong, PhD, rector of Hanoi University of Pharmacy, and his colleagues at other Vietnamese pharmacy schools asserted the need to integrate into their curricula information about HIV/AIDS and increasingly common diseases. The final recommendation urges using HIV/AIDS as the model for clinical pharmacy practice and later applying clinical pharmacy skills to the management of other ailments such as heart disease and cancer.

"In many ways, Vietnam is way ahead of where we in the US were 30 years ago in terms of clinical pharmacy," said Koda-Kimble. "The Vietnamese government and academic leaders recognize the potential of a clinically trained pharmacy workforce, and they will be quick to ensure that the pharmacist comes to be an equal member of the health care team. Vietnam does not have the luxury of waiting 30 or 40 years for this change in attitude."

Developing faculty expertise

Stepping back from the current, urgent needs, Koong and the other Vietnamese pharmacy school leaders recognized, too, the need to increase HIV/AIDS expertise within the teaching staffs of the country's pharmacy schools—the ultimate source of training students as well as pharmacists already in the field. Vietnamese and US conference participants agreed that this would require that select Vietnamese faculty members train at UCSF while also acquiring broad skills and knowledge to teach HIV/AIDS courses as well as other disease-based courses.

Creating a drug information network

Conferees also recognized that Vietnam needs an effective system to provide current information about medications to health care professionals throughout the country. Pending the identification of funding, UCSF School of Pharmacy leaders agreed to establish a drug information service for Vietnam pharmacists, selecting key papers from the HIV/AIDS literature and current treatment guidelines. These would be translated into Vietnamese by the large corps of Vietnamese-American pharmacy graduate students at UCSF.

A goal is to create a drug information repository at Hanoi University of Pharmacy, drawing on expertise of the UCSF Drug Information Analysis Service. Information would be distributed throughout Vietnam, initially in the form of a clinical pharmacy bulletin distributed to all provinces and all 16,000 pharmacies free of charge. Ultimately, Vietnam's health care providers would have fast, electronic access to the data.

Assuring drug quality

Information and clinical training about AIDS drugs is of modest value if the quality of such drugs is not good. Vietnamese planners stressed the need for the conference to include a pointed discussion on the topic of drug quality assurance. Leaders from the United States Pharmacopeia led this discussion with Vietnam's director of drug quality control. Their recommendations were to include drug quality evaluation in the pharmacy curricula, teach pharmacists and others the simple tasks of visually inspecting drugs and labels, and improve communication among government agencies in order to control the spread of substandard and counterfeit drugs.

Talks end, work begins

“The collegiality among all who participated was wonderful,” said Koda-Kimble. “The appreciation we developed for each other's challenges and expertise will surely carry us forward as we work together to implement conference goals.”

Debas found that the summit was on target to avert grave health and social problems. “The Hanoi conference,” he said, “set priorities within the healthcare workforce where they should be, for without the right people in the right numbers with the right skills to deliver prevention and treatment in the right ways, no amount of antiretroviral therapy will halt the spread of AIDS in Vietnam.”

The 3-day summit included about 200 participants and ended with agreement for both countries to set up working groups to address the goals they had identified. Going forward, US delegates stressed the need to continually assess projects. Koong noted the need for Vietnamese academic leaders to develop the effective grant writing skills required to secure the international funding needed to implement conference recommendations.

UCSF School of Pharmacy, UCSF Global Health Sciences, UCSF AIDS Research Institute, United States Pharmacopeia through its Global Assistance Initiatives program, and USAID sponsored the summit in partnership with Hanoi University of Pharmacy.

More

• Haile Debas, MD
• USAID, Asia, Countries, Vietnam
• [USAID, Regional Overview, Vietnam][link defunct as of Wednesday, January 18, 2012]
• WHO, Viet Nam
• Scaling Up Treatment for the Global AIDS Pandemic: Challenges and Opportunities
• TREAT Asia Special Report: Expanded Availability of HIV/AIDS Drugs in Asia Creates Urgent Need for Trained Doctors
• Pharmacist Combats AIDS in Malawi
• Clinical Pharmacists Specialize in AIDS