HHS SECRETARY LEAVITT, VIETNAM SCENESETTER, PART III

UNCLAS SECTION 01 OF 03 HANOI 000406 SIPDIS SENSITIVE SIPDIS FOR THE SECRETARY OF HEALTH FROM THE AMBASSADOR STATE FOR AMBASSADOR MARK DYBUL STATE FOR EAP/MLS, EAP/EP, INR, OES/STC, OES/IHA, OGAC STATE PASS TO USAID FOR ANE AND GH HHS/OSSI/DSI PASS TO OGHA (WSTIEGER/LVALDEZ/ CHICKEY/KMCLEAN),SAMHSA, FIC/NIH (RGLASS),AND FDA (MLUMPKIN/MPLAISIER) CDC FOR SBLOUNT, JGERBERDING, MCOHEN, DBIRX, RJSIMONDS, KCASTRO BANGKOK FOR REO (JWALLER),USAID (WHELDON/CBOWES) E.O. 12958: N/A TAGS: TBIO KPAO KFLU KHIV VM SUBJECT: HHS SECRETARY LEAVITT, VIETNAM SCENESETTER, PART III (PEPFAR) REF: A) Hanoi 369; B) HANOI 370; C) 07 Hanoi 1082. ¶1. (U) This cable is Sensitive but Unclassified. For official use only, not for dissemination outside USG channels or posting on the Internet. ¶2. (SBU) Secretary Leavitt, this cable highlights the overarching health-related successes and challenges facing our work under the President's Emergency Plan for AIDS Relief (PEPFAR). It is the third and final segment of my message to you in advance of your visit (Ref A and B). While the PEPFAR interagency program in Vietnam faces obstacles, the program continues to build local capacity to prevent the spread of HIV/AIDS and to provide care and treatment for an increasing proportion of the estimated 302,000 Vietnamese currently infected. Unlike many other PEPFAR focus countries, Vietnam faces an epidemic which is still concentrated in high-risk groups, especially injecting drug users (IDUs),commercial sex workers (CSWs),and men who have sex with men (MSM). In addition to treatment, therefore, we focus much more attention and resources than other PEPFAR programs on preventing the spread to the general population. We owe our successful progress over the past four years of field implementation to the diverse talents of the U.S. agencies that make up the PEPFAR team, the dedication and commitment of more than 30 local and international implementing partners, and an increasingly constructive attitude from the Government of Vietnam (GVN). In your discussions next week, we would like you to advocate for GVN approval of use of rapid tests for confirmation of HIV status, and a comprehensive, more community-based approach to addressing the needs of IDUs. TEN YEARS IN THE FIGHT -------------- ¶3. (U) The United States and Vietnam have long collaborated on HIV/AIDS control activities. As early as 1998, CDC and USAID began working together with the Vietnamese Ministry of Health (MOH) to identify needed support for the Vietnamese national HIV/AIDS prevention and care program. Initially, CDC provided training and technical assistance to the MOH on HIV/AIDS issues. By 2000, CDC invited Vietnam to become the 24th partner country in CDC's Global AIDS Program (GAP),and in 2001 CDC and MOH signed a 5-year Cooperative Agreement for developing programs. In 2004, Vietnam became the fifteenth (and the only Asian) focus country under PEPFAR. From a budget of USD 17.3 million in 2004, PEPFAR funding has grown to USD 88.8 million for FY 2008. VIETNAM'S CONCENTRATED EPIDEMIC -------------- ¶4. (U) Although UNAIDS estimates that 0.5 percent of adults are living with HIV in Vietnam, IDUs make up 50 to 60 percent of all reported cases, and suffer from the highest HIV prevalence rates, estimated in 2006 at 23 percent nationwide and up to 55 percent in some provinces. Both the IDU and the HIV epidemics remain concentrated in major urban centers, making these settings priorities for program efforts, despite pressure from the GVN to promote "equitable" distribution of resources throughout the country. Men make up 84 percent of all persons infected with HIV, largely due to their over-representation in the ranks of IDUs. Similarly, HIV largely affects the young, with 83 percent of reported HIV infections among individuals aged 20 to 39 years. Finally, as noted in Part II (Ref B),Vietnamese tuberculosis (TB) rates, an indicator of serious co-infection of HIV-infected patients, remain high. HIV prevalence among TB patients is 4.9 percent nationally and has been rising, offsetting an otherwise expected decline in notified TB cases -- possibly due to limited service uptake among IDUs, CSWs, and other marginalized, high-risk populations. COMPREHENSIVE PROGRAMMATIC SUPPORT -------------- ¶5. (U) After a rapid 4-year scale up, PEPFAR Vietnam, in cooperation with our GVN partners, has designed and implemented a national program to contribute to the GVN's strategy to prevent the spread of HIV/AIDS, with support for localized efforts in more than 30 of 64 HANOI 00000406 002 OF 003 provinces, prioritizing comprehensive support in seven of the most epidemiologically important provinces. Targeted prevention efforts are critically important to curtail the spread of HIV in high-risk groups and thereby further reduce infection rates in the general population. These interventions focus on outreach-based efforts to reduce high-risk behaviors, treat drug abuse, and enhance access to HIV testing, care and treatment services among marginalized and hard to reach populations. As in other focus countries, PEPFAR has rapidly scaled up care for persons living with HIV/AIDS, including support to orphans and vulnerable children. Strengthening of laboratory infrastructure, enhancement of human capacity, and provision of technical assistance to support monitoring and evaluation systems underpin traditional treatment strategies. ¶6. (U) Delivering assistance and training to upgrade GVN strategic information capacity supports the UNAIDS global strategy, and is a fundamental priority in the GVN National HIV/AIDS Strategy. Much of this work includes parallel effort directed at the central level, and additionally focuses on building sustainable programs through technical assistance of national guidelines and policy development. As of September 30, 2007, approximately 12,000 patients receive life-saving antiretroviral therapy, while 43,000 patients receive palliative care and support through PEPFAR assistance. In 2007 alone, PEPFAR-funded counseling and testing services reached 160,000 pregnant women and an additional 156,000 individuals, and provided care to approximately 4,000 orphans and vulnerable children affected by HIV/AIDS. PEPFAR financial support for MOH efforts continues to grow, jumping from USD 4.5 million in FY 2004 to USD 24.3 million in FY 2008 (now 27 percent of the total budget). EXTERNAL CHALLENGES -------------- ¶7. (SBU) The top-down nature of the government structure limits the ability of Vietnam program implementers at the district and community levels to make independent decisions and to find creative venues to reach our target populations with critically needed outreach and prevention services. The GVN organization of HIV policy continues to evolve -- and not always smoothly. The current GVN HIV/AIDS policy coordinating body, the Vietnam Administration of AIDS Control (VAAC) is located within MOH and does not have the institutional position or clout to guide other major stakeholder ministries, including the Ministry of Public Security (MOPS) and the Ministry of Labor, Invalids, and Social Affairs (MOLISA). VAAC also has suffered from a lack of continuity in leadership, with the recent (and unexpected) appointment of its third director in as many years. At the same time, increased MOH staffing and HIV/AIDS programs have created a continued need for additional technical and administrative management support. Overall, this hampers policy development. One of the most current poignant examples concerns rapid testing. Although international health organizations recommend the use of same day rapid tests for confirmatory HIV diagnosis, the GVN has yet to provide approval for this algorithm in Vietnam, preventing critically needed increased access to HIV prevention, care, and treatment services. THE SPECIAL CHALLENGES OF IDUs -------------- ¶8. (SBU) Although injecting drug use continues to be the leading source of HIV infections in Vietnam, many in the GVN continue to treat injecting drug use solely as a social problem and not as a health issue, hampering PEPFAR efforts to support essential evidence-based approaches to the treatment and rehabilitation of drug users. Some GVN authorities and opinion leaders wish to revise the Law on Drug Control and Prevention (LDCP) to expand the use of "06" centers (government-run IDU rehabilitation centers),which currently house nearly 100,000 people, while increasing the period of confinement to an automatic 5-year sentence. Confinement does not follow due process and is for the most part involuntarily. USG estimates that 50 percent or more of the detainees are HIV-infected. Overall, the current approach has proven costly and ineffective with a 70 percent relapse rate and little HIV/AIDS care for patients during confinement. ¶9. (SBU) Curbing the transmission of HIV/AIDS in Vietnam will require a comprehensive package of care (Ref C),including the use HANOI 00000406 003 OF 003 of medication-assisted treatment (i.e., methadone),to reduce injecting drug use. The first methadone shipment is expected to arrive over the next several weeks. The pilot program, run by the GVN and implemented with intensive technical assistance and financial support from PEPFAR, will begin in two provinces determined to be centers of IDU transmission. In the meantime, we have been working hard to assist with renovating clinics, training providers and preparing communities. Current Office of the AIDS Coordinator (OGAC) guidance on methadone use allows the support of only HIV-infected persons. Vietnam has a special dispensation from OGAC for the pilot program, where clients can receive services regardless of their HIV status, consistent with current evidence-based best practices, and GVN policy. Although these clinics will not be operational by the time of your visit, we hope that you have the opportunity to meet with staff and other stakeholders. INTERNAL CHALLENGES -------------- ¶10. (SBU) PEPFAR's documentation, reporting and approval requirements create an extraordinarily time-consuming, resource-intense process (ref C). For example, many members of Vietnam PEPFAR Team staff spend up to 60 percent of their time assisting with Country Operational Plan (COP) preparation and approval. This obviously detracts significantly from their ability to effectively implement and monitor programs, an issue which must be addressed to ensure we are not squandering public funds. We need improved coordination between OGAC and our PEPFAR team to better allow our staff to do the mission for which it is deployed -- fight the spread of HIV/AIDS. In addition, I would also recommend that PEPFAR shift its primary focus from providing emergency relief to building Vietnam's capacity to sustain the fight against HIV/AIDS over future decades (Ref C). We need to help buttress the institutional and human capacity of core GVN public health agencies to respond to all infectious diseases and to ensure the sustainability of PEPFAR achievements. At the same time, we need to build more effective partnerships and strategic coordination with major groups, such as the Global Fund to Fight AIDS, Malaria and TB, UNAIDS, World Bank and the Asian Development Bank, at the working level in Washington, as well as in the field. LAST WORD -------------- ¶11. (SBU) I hope that your visit helps to continue our ongoing efforts to refine and improve our HIV/AIDS prevention strategies for Vietnam. We have a unique opportunity to contribute to the GVN-led response to HIV and substantially upgrade the public health capacity of an increasingly close and valuable partner. MICHALAK