SUBSTANCE ABUSE TREATMENT, HIV/AIDS AND HCMC'S DRUG

UNCLAS SECTION 01 OF 03 HO CHI MINH CITY 000398

SIPDIS

SENSITIVE

DURBAN FOR A. PATEL

E.O. 12958: N/A
TAGS: PGOV PREL SOCI KHIV SNAR PHUM VM CNARC HIV AIDS
SUBJECT: SUBSTANCE ABUSE TREATMENT, HIV/AIDS AND HCMC'S DRUG
REHABILITATION CENTERS

REF: A) HCMC 132; B) HCMC 160


1. (SBU) Summary. HCMC is struggling to provide effective
substance abuse and medical treatment for injecting drug users,
one of the principal vectors of the HIV/AIDS epidemic in Vietnam.
HCMC maintains 21 rehabilitation centers for roughly 30,000 drug
addicts, who are administratively -- and often involuntarily --
assigned to the centers for detoxification, follow-up treatment
and vocational training. Of these 30,000, at least 50 percent are
HIV positive. Personal drug use and commercial sex work in
Vietnam are administrative rather than criminal offenses; control
of these cases falls to local governments, not the criminal
courts. Officials responsible for managing the program privately
tell us that their model for substance abuse treatment is not
working, with recidivism rates approaching 95 percent within 18
months, posing a real public health risk from both drug abuse and
HIV/AIDS transmission perspectives. They say they are ready to
try new approaches, including substitution therapy for drug
addicts, so long as foreign and domestic partners -- including
religious organizations -- can provide needed technical, personnel
and financial assistance. End Summary.

DRUG ABUSE, HIV/AIDS AND REHABILITATION CENTERS
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2. (U) With 20,000 reported HIV infections, 10,000 persons
diagnosed with AIDS and another possible 45-50,000 HIV infections
unreported, Ho Chi Minh City has the highest prevalence of
HIV/AIDS of all provinces and provincial-level cities in Vietnam,
according to Dr. Tran Thinh, Vice-Director of the HCMC HIV/AIDS
Committee. On March 30, Thinh told the Ambassador that, according
to the results of the HIV sentinel surveillance system in HCMC,
intravenous drug use is the most common method of HIV transmission
and as many as 80 percent of injecting drug users in HCMC may be
HIV positive.


3. (SBU) The high prevalence of HIV among injecting drug users
presents a distinct challenge for preventing the spread of
HIV/AIDS and treating victims of drug abuse. The largest
accessible pool of HIV-infected victims is in the city's 21 drug
and prostitution rehabilitation centers, which house approximately
30,000 residents. According to HCMC administrators of the
centers, between 85 and 90 percent of the residents are injecting
drug users. Case workers report that at least 50 percent, and
perhaps up to 70 percent, of injecting drug users in the
rehabilitation centers are HIV positive.


4. (SBU) Placing addicts in rehabilitation centers is the
established method for managing drug abuse in Vietnam. In
Vietnam, there are 84 rehabilitation centers for over 62,000 drug
users and commercial sex workers. Mr. Nguyen Van Minh, Vice-
Director of HCMC's Department of Labor, Invalids and Social
Affairs (DOLISA),which administers HCMC's rehabilitation centers,
told us that the majority of the centers' residents are
administratively ordered to enter the rehabilitation program. He
explained that after village or commune-level authorities become
aware that a member of their community is using drugs, they will
notify the individual's family and encourage the victim to seek
treatment. If the individual continues to use drugs after several
months of local intervention, the case is referred to a
consultative committee of the local People's Committee. (Our
DOLISA contacts added that families often petition local
authorities to assign their addicted relatives to the
rehabilitation centers.) If the village-level committee
recommends admittance to a rehabilitation center, the case is
referred to the district level People's Committee, which will make
the final decision. There is no appeals procedure nor does the
detainee have right to legal counsel as the process is an
administrative, and not criminal, in nature. (Under Vietnamese
law, commercial sex work and intravenous drug use normally are not
considered criminal offenses, but are "social evils" that
government must combat. Repeat drug offenders who have been
through the rehabilitation program could be criminally prosecuted
and imprisoned for two to five years.) Minh added that police are
not involved in the administration of the rehabilitation centers.


5. (SBU) Our contacts maintain that the administrative process
that assigns addicts to rehabilitation centers has adequate checks
and balances. They say that if Vietnam had no administrative
process, most addicts eventually would be prosecuted under the
criminal system. They argue that injecting drug users require
addiction and HIV/AIDS therapy irrespective of whether they are in
a rehabilitation center, prison or another treatment facility.


6. (U) Upon entering a rehabilitation center, residents receive a
medical examination and treatment for existing medical conditions.
Managers of the centers told us that HIV testing is voluntary and
not part of the overall medical exam. The patient usually spends
the first ten days of treatment in a hospital or clinic while
going through detoxification. Traditionally, drug users are
detained for up to two years while commercial sex workers are
detained for three to eighteen months. Residents spend their time
working, receiving vocational training, and attending primary
school classes, if needed. Vocational training programs include
welding, sewing, farming, and engine and automotive repair. Our
visits to a number of rehabilitation centers showed the facilities
to be generally well-managed, not oppressive but spartan.

REHAB PROGRAM NOT SUCCESSFUL
--------------


7. (SBU) DOLISA representatives in HCMC and in the neighboring
province of Binh Duong tell us that they estimate the recidivism
rate is between 85 and 95 percent for IDUs released from the
centers. They say the high recidivism rate is due to the lack of
reintegration programs to support residents returning to the
community. They add that local governments cannot afford
substitution maintenance therapy -- methadone -- for addicts; this
also hinders the success rate for rehabilitation.


8. (SBU) In response to the high recidivism rate and what HCMC
officials believe is the prohibitive cost of substitution
maintenance therapy, HCMC extended the rehabilitation period for
injecting drug users from two to four years. HCMC officials tell
us that during the first two years of the program, residents stay
in a traditional rehabilitation center. During the third and
fourth years of detention, residents transfer to a "Stage Two
Center," where they receive paid employment, vocational training,
and further education. Both state-owned enterprises (SOEs) and
private companies, including cashew processing and garment
companies, have set up factories within the Stage Two centers.
Employed residents are paid monthly or weekly, depending on the
terms of their labor contract, and officials say that wages are
commensurate with similar jobs outside the centers. Residents may
place their earnings in savings accounts or purchase goods and
services at stores within the centers. The residents of the
rehabilitation centers did not have the right to appeal the two-
year extension of their detention period.


9. (SBU) HCMC officials explained to us that the goal of the new
initiative is to isolate injecting drug users from access to drugs
for a longer period of time in hopes of giving them time to break
their addiction as well as to give residents the time to acquire
more marketable skills, which would ease their reintegration into
the community. HCMC authorities are awaiting the results of the
release of the first group of residents in late 2005. Prime
Minister Phan Van Khai has praised the HCMC initiative and has
indicated that, if successful, the GVN would encourage other
provinces to follow suit.

HIV/AIDS WITHIN REHABILITATION CENTERS
--------------


10. (SBU) Our contacts readily acknowledge that most
rehabilitation centers are not equipped to treat AIDS or the
serious opportunistic infections AIDS causes. Anti-retroviral
(ARV) treatment and veritable voluntary counseling and testing
(VCT) are not currently available at any centers, though some
centers have residents who have been tested prior to entry based
on their ability to afford the test. (Some centers in the north
test all of their residents, but disclosure is not the norm.) In
Ho Chi Minh City, most residents are not tested for HIV/AIDS until
they show symptoms of the disease and are transferred to a
hospital or clinic for treatment. As a result, many individuals
in the centers are unaware of their HIV status and are often
released without receiving any counseling or testing.
Additionally, our contacts in DOLISA say that the city has been
hard-pressed to recruit qualified health care providers to work at
the city's rehabilitation centers. Most centers are located in
the countryside in neighboring provinces, where doctors and nurses
are unwilling to relocate. Additionally, the centers offer lower
salaries and fewer opportunities for career advancement than
private practice.


11. (U) To begin addressing this need, in December 2004, DOLISA
opened an HIV/AIDS clinic at HCMC's Trong Diem Rehabilitation
Center -- the first clinic of its kind within a rehabilitation
center in Vietnam. The city has invested over $650,000 in the 300-
bed clinic and plans to expand the clinic within two years into a
1,000-bed hospital capable of treating AIDS patients from all 21
of the city's rehabilitation centers. DOLISA had been unable to
find qualified doctors and nurses to work at the Trong Diem
clinic. In response, the city administration broke new ground by
inviting the Catholic Church to provide doctors and nurses for the
clinic. According to its HCMC Vice-Director, DOLISA would like to
expand its cooperation with the Catholic Church; the Vice-Director
of the HCMC HIV/AIDS Committee similarly told the Ambassador that
Trong Diem exemplified the future of public-private partnership in
HCMC.

COMMENT
--------------


12. (SBU) Government officials in HCMC and in neighboring
provinces privately admit that their rehabilitation centers have
not been successful in treating substance abuse and preventing
HIV. Some have expressed skepticism that extending the length of
stay in rehabilitation centers from two to four years will make a
meaningful reduction in recidivism. However, they argue that cash-
strapped local governments cannot afford substitution therapies
and that addicts, if released after two years, would pose a clear
public risk from drug abuse, crime and HIV/AIDS transmission
perspectives. HCMC authorities are eager to find ways to improve
testing, care, treatment, and prevention activities within the
city's rehabilitation centers. They tell us that they are ready
to cooperate with foreign and domestic groups to improve substance
abuse and HIV/AIDS treatment. This includes the use of
substitution maintenance therapy for drug addicts if funding is
provided for such programs. They also seek partnerships to deal
with follow-up HIV treatment and community reintegration of
rehabilitation center graduates.

WINNICK