Tropical Medicine and International Health

doi:10.1111/tmi.12032

volume 18 no 2 pp 212218 february 2013

Financial burden of health care for HIV/AIDS patients in

Vietnam
Bach X. Tran1,2, Anh T. Duong3, Long T. Nguyen3, Jongnam Hwang1, Binh T. Nguyen3, Quynh T. Nguyen4,
Vuong M. Nong2, Phu X. Vu6 and Arto Ohinmaa1,5
1
2
3
4
5
6

School of Public Health, University of Alberta, Edmonton, Alberta, Canada

Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
University of Nantes at Foreign Trade University, Hanoi, Vietnam
Institute of Health Economics, Alberta, Edmonton, Canada
Department of Health Economics, Hanoi School of Public Health, Hanoi, Vietnam

Abstract

objective To assess the out-of-pocket (OOP) payments for health-care services of HIV/AIDS
patients, and identify associated factors in Vietnam.
methods Cross-sectional multisite survey of 1016 HIV/AIDS patients attending 7 hospitals and
health centres in Ha Noi, Hai Phong and Ho Chi Minh City in 2012.
results HIV/AIDS patients used inpatient and outpatient care on average 5.1 times (95%
CI = 4.75.4) besides ART services. Inpatient care cost US$ 461 on average and outpatient care US$
50. Mean annual health-care expenditure for HIV/AIDS patients was US$ 188 (95% CI = 148229).
35.1% of households (95% CI = 32.238.1) experienced catastrophic health expenditure; 73.3%
(95% CI = 70.676.1) of households would be affected if ART were not subsidised. Being a patient at
a provincial clinic, male sex, unstable employment, being in the poorest income quintile, a CD4 count
of <200 cells/mL and not yet receiving ART increased the likelihood of catastrophic medical expense.
conclusions HIV/AIDS patients in Vietnam frequently use medical services and incur OOP
payments for health care. Scaling up free-of-charge ART services, earlier access to and initiation of
ART, and decentralisation and integration of HIV/AIDS-related services could reduce their financial
burden.
keywords HIV/AIDS, antiretroviral treatment, cost, out-of-pocket expenditure, financial burden,
Vietnam

Introduction
Over the past decade, antiretroviral treatment (ART) has
been rapidly scaled-up in developing countries with substantial supports from global health initiatives (Vella
et al. 2012). With ART patients can achieve suppression
of HIV replication, improve their health and quality of
life and continue to be productive (Gardner et al. 2010;
Tran 2012). Although ART has been subsidised, out-ofpocket (OOP) payments for HIV/AIDS care remain high
and could affect treatment compliance and outcomes
(Duraisamy et al. 2006; Moon et al. 2008; Riyarto et al.
2010). Therefore, understanding the financial burden of
HIV/AIDS is necessary to develop protective mechanisms,
and improve efficiency of the health-care system.
In Vietnam, an estimated 320,000 people have HIV/
AIDS, and 30% require ART at the treatment eligibility
criterion of a CD4 count of <250 cells/ml (Ministry of
212

Health 2008). Patients with HIV/AIDS are provided freeof-charge antiretroviral drugs, CD4 cell count tests and
medications for opportunistic infections. However, some
HIV/AIDS-related services are not covered, such as viral
load tests, hospital admission fee or diagnosis and treatment of comorbid diseases. Patients also bear the costs of
other health-care services, which are high and can push
these economically vulnerable people into poverty. The
economic impact of the ART programme is still modest:
firstly, because of its moderate coverage, which was 50%
by 2010. Secondly, patients usually seek health care and
initiate ART very late, when their immune system has
deteriorated with severe comorbid diseases (Do et al.
2012). Thirdly, as the majority of HIV/AIDS patients
engaged in high-risk behaviours such as drug injection
and sex work, they often lack stable jobs and steady
incomes, and are less capable to pay for health-care services (Tran et al. 2011, 2012a,b). Although OOP health

2012 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 18 no 2 pp 212218 february 2013

B. X. Tran et al. Financial burden of HIV in Vietnam

payments prevail among patients with HIV/AIDS, there is

little evidence on the economic impact of HIV/AIDS in
Vietnam. In this study, we sought to evaluate the financial burden of health care for HIV/AIDS patients in a
multisite survey. Specifically, we assessed the rate of
health service use and OOP health payments of HIV/
AIDS patients, and identified associated factors.

Methods
Study settings and participants
We conducted a cross-sectional multisite survey in Ha
Noi, Hai Phong and Ho Chi Minh City from January to
February, 2012. These cities were selected because they
experienced the countrys largest HIV epidemics, and they
have been implementing comprehensive HIV/AIDS interventions. The present study is a part of a greater effort,
namely the 2012 HIV Service Users Survey, to assess the
effectiveness and performance of HIV/AIDS services to
inform policy development in Vietnam (Tran 2012). In
each city, we selected study sites based on the following
criteria: (i) Central, provincial and district clinics were
involved; (ii) hospitals/health centres have been providing
ART services; and (iii) there was a sufficient number of
HIV/AIDS patients in each clinic. There were seven sites
purposively selected, including one central hospital
(National Hospital of Tropical Diseases), three provincial
hospitals (Dong Da, Viet Tiep and Ho Chi Minh Hospital
for Tropical Diseases) and three district health centres
(Tu Liem, Binh Tan and Le Chan District Health Centres).
As constructing a sample frame was not possible due to
confidentiality; we selected patients on a convenient basis.
Subjects were HIV-positive inpatients and outpatients
who were registering for care or taking ART at selected
sites. All patients present at the clinics during the study
period were invited to participate in the survey, and gave
written consent if they agreed. We recruited patients until
a sufficient sample size of at least 100 was reached per site.
Measures
Socio-economic background and HIV-related characteristics of patients were collected using face-to-face interviews
with structured questionnaires. Monthly household
income was self-reported including all sources of each
household members income in 2011, such as salary,
wages, pensions, relatives supports, interests and revenues. Households expenditure was estimated including
recurring expenses in the last month (e.g. food, utility,
rent, education and others), and non-recurring expenses in
the last 12 months (e.g. construction, health care,

2012 Blackwell Publishing Ltd

furniture, travels, community events and others). Seven

hundred and ninety (77.8%) patients responded to the
questions regarding household expenditure. The OOP
health expenditure of household included the total
expenses for health-care services of all family members
including HIV-positive individuals. Healthcare service
utilisation of HIV-positive individuals included any inpatient and outpatient care received during the past
3 months, excluding regular HIV outpatient clinic visits
for ARV medications. The 3-month recall of health service
use was commonly applied in previous national surveys
(Chaudhuri & Roy 2008). For the convenience of reporting, we converted the frequency of health service use for
1 year. Although patients at different disease stages or
periods of ART could use healthcare services differently,
this conversion did not distort the mean rate of use. Unit
costs were estimated for the last inpatient- and outpatient
care. Patients were asked about any expenses incurring
during their last use of healthcare services. It included
(i) medical expenditures (non-ARV medications, lab tests,
hospital fees and others) and (ii) non-medical expenditures
(transportations, accommodation and special meals if
any). OOP health payments for HIV/AIDS patients were
estimated by multiplying the rate of health service use by
the mean costs of each visit. All expenditures and incomes
were converted from Vietnam Dong to US$ using the
exchange rate in 2011 (1 US$ = 20,500 Vietnam Dong).
Data analysis
Analysis of variance test was used to examine the differences between means. Household expenditure categories
were presented in both means (95% CI) and medians (interquartile ranges). Catastrophic health expenditure was
defined at the threshold of 40% total households
monthly non-subsistence expenditure (Xu et al. 2003).
Multivariable logistic was used to determine correlates of
experiencing catastrophic OOP health expenditure. Zeroinflated Poisson models were constructed to examine the
correlates of the rate of health service use. Candidate
independent variables included socio-economic and HIVrelated characteristics of respondents at the time of the
interview. Collinearity was examined using the variance
inflation factors. We applied a stepwise forward model
building strategy that selected variables based on the loglikelihood ratio test at a P-value <0.1, and excluded variables at P-values >0.2 (Hosmer & Lemeshow 2000).
Ethics
This is a part of the research project on Cost and costeffectiveness of HIV/AIDS care and treatment policy
213

Tropical Medicine and International Health

volume 18 no 2 pp 212218 february 2013

B. X. Tran et al. Financial burden of HIV in Vietnam

options in Vietnam. The use of data was approved by

the Authority of HIV/AIDS Control, Ministry of Health
of Vietnam. Ethical approval was granted by the University of Albertas Health Research Ethics Board.
Results
The response rate was 85-90% in different clinics. We
interviewed 1016 patients, accounting for 17% of total
HIV patients in selected sites. Mean age was 35.4
(SD = 7.0) years, 36.2% were female, 45.0% had completed high school, 64.0% were living with spouses or
partners and more than 70% were freelancers or had stable jobs. The mean monthly household income was US$
346.5 (SD = 293.1) or US$ 99.6 (SD = 79.6) per capita
(household size was 3.8 people). Besides ART, HIV/AIDS
patients reported an average number of inpatient and

outpatient care of 0.3 and 4.8 times in the past

12 months, respectively. As shown in Table 1, patients at
central clinics reported a significantly lower rate of health
service use (1.8 times) than those at provincial (5.8 times)
and district (5.9 times) clinics (P < 0.01). Patients who
were on the 1st year ART and who had not yet received
ART also had a higher rate of health service use.
In Table 2, the monthly household expenditure was US$
289 (95% CI = 262; 317), of which 47% was food, 5%
was health care for HIV/AIDS individuals and 6% was
health care for other members. There were 33.8% HIV/
AIDS patients reported having inpatients care, and 32.0%
having outpatient care over the past 3 months besides
monthly visits to HIV/AIDS outpatient clinics to receive
ARV medications (Table 3). The cost of inpatient and outpatient care was US$ 461 and US$ 50 on average. Direct
medical costs accounted for about 60% of the total, half of

Table 1 Characteristics of respondents and frequency of healthcare service utilisation

Heath service utilisation rate per year
Outpatient
N

Level of health service administration

Central
201
19.8
Provincial
406
40.0
District
409
40.3
IDU
No
548
53.9
Yes
468
46.1
HIV/AIDS stages
Asymptomatic
126
12.4
Symptomatic
508
50.0
AIDS
382
37.6
CD4 cell count
 200
249
24.5
200 < cd4  350
249
24.5
350 < cd4  500
194
19.1
>500
109
10.7
Not reported
215
21.2
Length of ART
None
114
11.2
 1 year
196
19.3
1;  2
144
14.2
2;  4
270
26.6
4;  7
292
28.7
Household expenditure quintiles
Poorest
158
15.6
Poor
158
15.6
Middle
158
15.6
Rich
158
15.6
Richest
158
15.6
Not reported
226
22.2

214

Inpatient

All

Mean

95% CI

Mean

95% CI

Mean

95% CI

P-value

1.4
5.4
5.8

0.92.0
4.85.9
5.26.3

0.3
0.4
0.2

0.20.5
0.30.5
0.10.2

1.8
5.8
5.9

1.22.4
5.26.4
5.46.5

0.00

4.9
4.6

4.45.4
4.15.1

0.3
0.4

0.20.3
0.30.4

5.1
5.0

4.75.6
4.45.5

0.42

4.8
4.8
4.7

3.85.7
4.35.3
4.15.3

0.2
0.3
0.3

0.10.3
0.20.4
0.30.4

4.9
5.1
5.0

4.05.8
4.65.6
4.45.6

0.14

4.8
5.6
4.5
4.3
4.2

4.15.5
4.86.3
3.75.3
3.35.3
3.55.0

0.5
0.2
0.2
0.2
0.3

0.40.7
0.10.3
0.10.2
0.10.3
0.20.4

5.4
5.8
4.7
4.6
4.5

4.76.1
5.06.5
3.85.5
3.55.6
3.85.3

0.54

5.2
4.8
4.4
4.8
4.7

4.36.1
4.05.6
3.55.3
4.15.5
4.05.4

0.2
0.6
0.2
0.2
0.2

0.10.4
0.40.7
0.10.3
0.20.3
0.20.3

5.4
5.4
4.6
5.1
4.9

4.56.4
4.66.2
3.85.5
4.35.8
4.25.6

0.08

5.2
4.1
4.9
4.0
3.6
6.2

4.26.1
3.24.9
3.95.8
3.24.9
2.84.4
5.47.0

0.3
0.3
0.3
0.4
0.3
0.3

0.20.4
0.20.4
0.20.4
0.30.6
0.20.4
0.20.3

5.5
4.4
5.1
4.4
3.9
6.4

4.56.4
3.65.2
4.26.1
3.65.3
3.14.7
5.67.2

0.04

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B. X. Tran et al. Financial burden of HIV in Vietnam

Table 2 Household monthly expenditures (US$)

Food
Household utility
Rent
Education
Other
Health care
For others
For HIV/AIDS patients
Non-recurring expenses
Construction
Furniture
Travel
Community events
Total expenditure
Expenditure per capita

Median

790
790
790
790
790

p25

p75

Mean

95% CI

122
15
0
8
0

73
7
0
0
0

146
24
0
39
24

135
21
8
25
24

128143
1923
610
2328
2028

47
7
3
9
8

790
790

2
0

0
0

12
6

17
16

1419
1220

6
5

790
790
790
790
790
790

0
0
0
2
218
62

0
0
0
0
141
42

0
0
0
8
320
94

31
4
1
7
289
84

1052
26
02
68
262317
7790

11
1
0
2
100

Table 3 Average costs per an inpatient and an outpatient care

(US$)
Inpatient care
(n = 343,
33.8%)

Outpatient care
(n = 325,
32.0%)

Mean

Mean

95% CI

95% CI

Costs for an inpatient and an outpatient care

Total
461
419502
Direct non-medical costs
Boarding and lodging
105
90120
Transportation
67
5777

50

4061

9
14

612
1019

Direct medical costs

Medication (excl. ARV)
Lab tests
User fee
Others

29
14
11
1
4

2235
624
715
02
26

289
159
31
64
34

262315
119204
2341
4387
2149

Average annual costs for health care for an HIV/AIDS patient

Times of service used
0.3 0.30.3
4.8
4.45.1
Total direct medical cost
54
4166
57
3479
Total direct cost
90
69111 98
65131
Total annual costs
188
148229

which was medications (excluding ARV) as the greatest

proportion of the total costs. The mean total expenditure
for healthcare services for HIV/AIDS individuals was US$
188 (95% CI = 148229) per annum or US$16 per month
(Table 3). There were 35.1% (95% CI = 32.238.1)
households with catastrophic OOP payments for health
care. In a scenario of non-ART subsidy where patients bear
ART costs, the proportion of household experiencing catastrophic health expenditure would be 73.3% (95%

2012 Blackwell Publishing Ltd

% of
total
expenses

CI = 70.676.1). In other words, the free-of-charge ART

programme had prevented 52.1% HIV-affected households from catastrophic OOP health expenditure.
Table 4 presents the correlates of catastrophic OOP
health expenditure and the expected differences in the
rate of health service use in various patient groups.
Increased likelihood of incurring catastrophic health
expenditures was observed in patients at provincial
clinics, males, those with unstable jobs, those in the poorest income quintile, people with CD4 counts less than
200 cells/mL, and those not yet receiving ART. In the
post-estimation of Zero-inflated Poisson model, patients
who were at provincial and district clinics, female, with
unstable jobs, with CD4 counts less than 350 cells/mL,
or who had taken ART for more than 2 years had significantly higher expected rates of health service use than
their counterparts.
Discussion
This study examined OOP expenditure and healthcare
service utilisation of HIV/AIDS patients in Vietnam.
Although ART services are offered free-of-charge, HIV/
AIDS patients had to pay US$ 188 a year for their health
care. This OOP health payment was catastrophic for
more than one-third of HIV-affected households. The
rate of health service use and its associated financial burden were heterogeneous across central, provincial and
district clinics, and significantly associated with disease
severity and the duration of ART.
The mean income per capita of this patient sample (US
$99/month) was close to the national mean income
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B. X. Tran et al. Financial burden of HIV in Vietnam

Table 4 Correlates of catastrophic out-of-pocket (OOP) and healthcare service use

Expected differences in health service use, times/year (Coef., 95% CI)
Catastrophic OOP
AOR, (95% CI)
Level of clinics (central)
Provincial
District
Female vs. male
Education: High school vs. below
Marital status (single)
Live with spouse/partner
Separated, divorced, widow(er)
Employment (unemployed)
Stable jobs
Unstable jobs
Income per capita (poorest)
Poor
Middle
Rich
Richest
HIV stages (asymptomatic)
Symptomatic
AIDS
IDU vs. Non-IDU
CD4 (a  200)
200 < cd4  350
350 < cd4  500
>500
ART (not-yet)
 1 year
1;  2
2;  4
4;  7
Constant

Inpatient care

0.7 (0.5; 1.0)

0.4* (0.3; 0.6)

0.8 (0.6; 1.1)

1.7 (1.0; 2.9)

0.4*
0.6*
0.3*
0.4*

(0.3;
(0.3;
(0.2;
(0.2;

0.8)
0.9)
0.5)
0.7)

1.3 (0.9; 1.8)

0.0
0.2
0.0
0.3*

(
(
(
(

Outpatient care

0.2; 0.3)
0.4; 0.0)
0.2; 0.3)
0.5; 0.1)

2.6*
2.0*
0.7*
0.2

(1.4; 3.7)
(0.8; 3.3)
(0.1; 1.4)
( 0.8; 0.4)

0.1 ( 0.7; 1.0)

0.8 ( 1.8; 0.1)

0.2 ( 0.7; 1.1)

0.8 ( 1.8; 0.2)

0.0 ( 0.2; 0.3)

0.1 ( 0.1; 0.3)

0.2 ( 1.1; 0.6)

0.0 ( 0.9; 1.0)

0.5 ( 1.4; 0.4)

0.2 ( 1.3; 0.8)

0.0
0.0
0.0
0.2

(
(
(
(

0.2;
0.3;
0.3;
0.4;

0.3)
0.2)
0.3)
0.1)

0.3* (0.1; 0.6)

0.0 ( 0.1; 0.2)
0.3* (0.1; 0.6)
0.5* ( 0.7; 0.2)
0.3* ( 0.6; 0.1)
0.2 ( 0.5; 0.1)

0.4*
0.4*
0.3*
0.3*
6.4*

0.4
0.6*
0.5
0.5*

0.7)
0.7)
0.5)
0.6)
13.8)

( 0.2; 2.5)
( 0.7; 2.0)
(0.0; 1.2)
( 0.9; 0.3)

0.2 ( 0.5; 0.0)

0.0 ( 0.6; 0.6)

0.6* (0.4; 0.9)

0.4* (0.3; 0.7)
0.5* (0.3; 1.0)
(0.2;
(0.2;
(0.2;
(0.2;
(2.9;

1.2
0.6
0.6
0.3

Total

(
(
(
(

0.9; 0.1)
1.1; 0.2)
0.9; 0.0
1.0; 0.0)

1.5*
1.2*
0.5
0.1

(
(
(
(

2.4; 0.5)
2.2; 0.3)
1.4; 0.4)
1.1; 0.8)

1.3*
0.8
0.1
0.5

(
(
(
(

2.3; 0.4)
1.8; 0.2)
1.1; 0.8)
0.5; 1.5)

1.3* ( 2.5; 0.0)

1.1 ( 2.3; 0.1)
0.3 ( 1.1; 0.5)

0.6 ( 1.8; 0.6)

0.3 ( 1.5; 0.9)
0.2 ( 1.0; 0.5)

0.7 ( 0.4; 1.7)

0.6 ( 1.7; 0.4)
0.9 ( 2.1; 0.3)

0.0 ( 1.1; 1.0)

1.2* ( 2.3; 0.2)
1.4* ( 2.6; 0.3)

0.6
0.2
1.8*
2.5*

( 0.3; 1.5)
( 0.6; 1.1)
(0.9; 2.7)
(1.6; 3.5)

0.1
0.0
1.4*
2.2*

( 0.9; 1.0)
( 1.0; 0.9)
(0.4; 2.4)
(1.1; 3.3)

Reference group.
Adjusted odd ratio.
*P < 0.05.

per capita in 2011 (US$ 108/month). The OOP health payment for HIV/AIDS patients in this study was higher than
that of the general population, which was about US$ 10
per household in the 2008 Vietnam Living Standards Survey, or about US$ 40 per household in another estimate
(Van Minh 2011; Nguyen et al. 2012). The percentage of
households that experienced catastrophic health expenditure due to HIV/AIDS care (35.1%) was substantially
higher than that of the general Vietnamese population
(5.7%) (Van Minh 2011). In fact, the OOP health payment
for an HIV/AIDS patient was as high as the total health
expenses of all other family members, and approximated
40% of the average costs for ART services (US$ 452, Tran
BX, 2012b).
As for health service use, we observed a smaller rate of
outpatient care, but higher rate of inpatient care and
216

OOP health payments in this study than in another

household survey in 2010 (US$ 131.9/year) (Glandon
2011). The difference may be explained by the fact that
we selected patients based on their clinic attendance.
High OOP payments for HIV/AIDS care, excluding ART,
were also found in other settings. In China, they ranged
from US$ 13 to 3939 in 2006 depending on disease
stages (Moon et al. 2008). In India, OOP direct costs for
HIV/AIDS care were US$ 244 in 2002. In terms of health
service utilisation, our findings were in line with previous
studies which found that the rates of health services use
decreased significantly in patients with better
immunological status (Luseno et al. 2010; Yehia et al.
2010). Moreover, women had a higher rate of outpatient
care than men. Drug users also used healthcare service
more often than non-drug users because they can have

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B. X. Tran et al. Financial burden of HIV in Vietnam

more severe comorbidities and poorer treatment outcomes (Tran et al. 2012c,d).
Several policy implications arise from these results. First
of all, although ART is provided free-of-charge, a large
proportion of HIV/AIDS patients had high demand for
health care, and still faced catastrophic healthcare costs.
This emphasises the importance of a wide-scale expansion
of ART services along with impact mitigation programmes to improve health status and reduce economic
vulnerability of HIV/AIDS patients. Also, other protective
financial mechanisms, for instance, health insurance or
community-based funding sources, should be in place.
Secondly, patients who had better immunological status,
beyond the threshold of CD4 = 350 cells/mL, also used
and paid less for healthcare services than other patient
groups, suggesting an earlier initiation of ART. Besides, in
the breakdown of unit costs, transportation accounted for
15% and 28% of an inpatient and outpatient care, respectively. This cost could be reduced by decentralising HIV/
AIDS-related services are to district level and putting more
integrative and comprehensive service delivery for HIV/
AIDS care, support and treatment in place.
The strengths of this study included the involvement of
multiple sites with a relatively large number of respondents. Although these sites were not selected by a statistically derived algorithm and not nationally representative,
they are in different geographical regions and levels of
health service administration. However, the study was
subject to several limitations. First, we approached
patients during their visits to clinics; thus, the sample
might exclude patient groups who did not access to
healthcare services, for example, those who were not yettested, or who did not yet know their HIV diagnosis, and
who were severely ill and stayed at home. Second, estimates of spending for the last inpatient and outpatient
care were self-reported by patients that could be biased
and unverifiable without patients medical records. Similarly, the household income and expenditure, which was
based on respondents recalls, could be under-reported
(Riyarto et al. 2010). Finally, the scope of this cost analysis included only direct costs incurred by HIV/AIDS
patients, excluding ART and other indirect costs. Notwithstanding, the study contributes to the understanding
of the economic impact of HIV/AIDS, and supports the
development of HIV/AIDS policies in Vietnam.
In conclusion, use and OOP payment for healthcare
services of HIV/AIDS patients were high and even
catastrophic to more than one-third of affected households. Scaling up free-of-charge ART services, earlier
access to and initiation of ART, and decentralisation and
integration of HIV/AIDS-related services could reduce the
financial burden of HIV care and treatment in Vietnam.

2012 Blackwell Publishing Ltd

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Corresponding Author Bach Tran, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Vietnam.
Tel.: + 84 98 222 8662; E-mail: bach@hmu.edu.vn or bach.tran@ualberta.ca

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