To the Editors:
“Scientific understanding proceeds by the way of constructing and analyzing “models” of the segments or aspects of reality under study. The purpose of these models is not to give a mirror image of reality, not to include all its elements in their exact sizes and proportions, but rather to single out and make available for intensive investigation those elements, which are decisive. We abstract from nonessentials, we blot out the unimportant to get an unobstructed view of the important, we magnify to improve the range and accuracy of our observation. A model is, and must be, unrealistic in the sense in which the word is most commonly used. Nevertheless, and in a sense paradoxically, if it is a good model, it provides the key to understanding reality.”1
We appreciate the interest and debate by Dimitrov et al2 in responding to our article.3 Dimitrov et al call for enhanced attention to population demographics, particularly population recruitment and departures, and other parameters when modeling the effectiveness of HIV prevention interventions. If our study objective were to provide the exact estimates of HIV transmission, adding a wide range of demographic, programmatic, socioeconomic, and biologic parameters would have been helpful. However, our objective was to evaluate potential policy options to minimize new HIV infections and AIDS deaths in Vietnam. For this query, we were guided by the philosophy of Baran and Sweezy, “to single out and make available for intensive investigation those elements which are decisive,” in constructing the simplest model possible to answer our study question.1
Early initiation of antiretroviral therapy (ART) is associated with a substantial reduction in HIV-related mortality, morbidity, and transmission4,5 and is a key component of national HIV responses. We considered the current epidemic dynamics in Vietnam and modeled various policy scenarios of expanding HIV testing and treatment in combination with other prevention interventions. The key messages from our model are: (1) earlier and expanded access to HIV testing and ART will likely lead to a substantial reduction in AIDS deaths and new HIV infections in Vietnam; (2) prioritizing key populations with a high HIV incidence such as people who inject drugs, sex workers, and men who have sex with men, will improve cost-effectiveness; (3) combining ART with other prevention interventions will accelerate the impact; and (4) investing in earlier and expanded access to HIV testing and ART will lead to relative cost savings in the future.
Demographic parameters play a relatively important role in certain HIV epidemic phases and geographical areas. For example, migration of Vietnamese sex workers from Cambodia back into Southern Vietnam probably contributed to increased HIV transmission in the early 2000s.6 However, Vietnam's National Estimation and Projection Working Group agrees that migration among populations in Vietnam is low and its impact on the epidemic is negligible. We agree with Dimitrov et al that changes in demographics can influence the modeling outputs in the long term; however, for the concentrated epidemic in Vietnam, the size of key populations, rather than the size of the general population, will likely be more important when modeling the epidemic and intervention impact. Given the difficulties of accurately projecting the size of key populations over decades, a more meaningful approach would be to update the projections as new population and behavioral data become available.
From a national programming perspective, it is important to understand how behavioral and programmatic parameters influence the impact of public health interventions. Our model assumed (1) high uptake of HIV testing and treatment and (2) high retention and adherence to ART as part of a well-functioning programme. In the next phase of the model, we are planning to develop programme targets for testing and treatment for minimizing annual AIDS deaths and HIV infections. Moreover, to understand the operational feasibility of expanded testing and treatment, the Vietnam Authority on HIV/AIDS Control is working with partners on pilot studies to evaluate three key issues:
1. Knowledge of HIV status in key populations: we made various assumptions regarding the uptake and coverage of testing in key populations, linkage to care, and prevention. Although these assumptions were based on the available data, their validation in programme settings is important.
2. Uptake of immediate ART: after linkage to care, immediate ART uptake was an important component of successful HIV outcomes in our study. However, limited data are available on ART uptake at high CD4 counts in resource-limited settings.
3. Degree of viral suppression over time: sustained viral suppression requires retention in care and high levels of ART adherence. Vietnam Authority on HIV/AIDS Control is expanding access to viral load testing and will be evaluating the levels of viral suppression when ART is initiated at high CD4 counts.
Despite the perceived simplicity of our model structure, we believe that the direction of our findings is unlikely to be substantially changed with additional compartments and parameters.
1. Baran PA, Sweezy PM. Monopoly Capital: An essay on the American Economic Order. Harmondsworth, England: Penguin Books; 1970.
2. Dimitrov D, Kuang Y, Masse BR. Assessing the public health impact of HIV interventions: the critical role of demographics. J Acquir Immune Defic Syndr. 2013.
3. Kato M, Granich R, Duc Bui D, et al.. The potential impact of expanding antiretroviral therapy and combination prevention in Vietnam: towards elimination of HIV transmission. J Acquir Immune Defic Syndr. 2013;63:e142–e149.
4. Cohen MS, Chen YQ, McCauley M, et al.. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.
5. Anglemyer A, Rutherford GW, Easterbrook PJ, et al.. Early initiation of antiretroviral therapy in HIV-infected adults and adolescents: a systematic review. AIDS. 2014;28:S105–S118.
6. Rekart ML. Sex in the city: sexual behaviour, societal change, and STDs in Saigon. Sex Transm Infect. 2002;78(suppl 1):i47–i54.