PEPFAR VIETNAM, SUCCESSES AND CHALLENGES

UNCLAS SECTION 01 OF 05 HANOI 000578

C O R R E C T E D C O P Y (AMEMBASSY BANGKOK ADDED TO ADDRESSES)

SENSITIVE
SIPDIS

STATE/OGAC: FROM AMBASSADOR MICHALAK FOR AMBASSADOR ERIC GOOSBY
STATE PASS TO OGAC MMALONEY-KITTS AND JHOLLOWAY
AMEMBASSIES PASS TO PEPFAR COORDINATORS, ESTH, AND HEALTH ATTACHES
HHS/OSSI/DSI PASS TO HHS/OGHA JKULIKOWSKI, MABDOO, ACUMMINGS,
CMCCLEAN); NIH/FIC RGLASS; SAMHSA WCLARK, RLUBRAN; AND FDA LVALDEZ,
BCOREY)
USAID FOR ANE CJENNINGS; AND GH GSTEELE, RCLAY
BANGKOK FOR USAID/RDM/A OCARDUNER, MSATIN
CDC FOR COGH SBLOUT; CCID MCOHEN; AND GAP DBIRX, RJSIMONDS, JTAPERO

E.O. 12958: N/A
TAGS: TBIO PGOV PROP SOCI EAID SNAR KHIV VM
SUBJECT: PEPFAR VIETNAM, SUCCESSES AND CHALLENGES

REF: A. 2007 Hanoi 1082; B. Hanoi 278; C. 2008 Hanoi 406; D. 2008
Hanoi 370

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SENSITIVE BUT UNCLASSIFIED. NOT FOR INTERNET POSTING


1. (SBU) Summary: Warm congratulations on your appointment from me
and the entire PEPFAR team here at Mission Vietnam. I wanted to
personally congratulate you and spend a little time giving you my
perspective on what I believe is a somewhat unique component of your
PEPFAR community. Before you become embroiled in the African side
of the issue, I hope you will take a few minutes to look at the
Vietnam program to think a bit about some of the unique dimensions,
both political and programmatic, that we face here. I hope to be
able to meet you personally in the not too distant future.

In Vietnam, health diplomacy -- our work on HIV/AIDS, pandemic
influenza, and dioxin remediation -- is fundamental to trust
building and improved relations with our former foe. Our highest
priorities are to

a) improve both the quality and coverage of the current PEPFAR
supported programs;

b) improve development of and access to effective drug addiction
prevention and treatment services given that the epidemic is driven
by drug use in Vietnam;

c) better support generalized health systems strengthening critical
to sustainability; and

d) expand USG assistance for tuberculosis programs.

Serious challenges remain, primarily: low health sector capacity and
GVN allocation of resources based on geography rather than
epidemiology; rigid governmental controls; insufficient donor
coordination (and poor GVN coordination of the Global Fund process);
and a Country Operating Plan (COP) process which has become so
cumbersome that it undermines our ability to plan strategically or
provide on-site technical assistance. To achieve our goals, OGAC
needs to work in close collaboration with experienced field staff to
drastically ease COP burden, reduce indicators to a limited number
of required core elements, diminish reporting frequency, and allow
field programs to establish a workable timetable for the partnership
frameworks based on in-country circumstances.

The Epidemic and PEPFAR in Vietnam
--------------

2. (U) In Vietnam, we have the opportunity to implement and test a
national prevention strategy. The HIV/AIDS epidemic here remains
concentrated among injecting drug users (IDU),commercial sex
workers, and men who have sex with men. UNAIDS estimates there are
302,000 persons living with AIDS (PLWA) in Vietnam. Continued
stigma and discrimination make it difficult to provide services to
these populations. PEPFAR is working closely with the GVN to find
ways to provide essential HIV prevention services to the
approximately 326,000 IDUs and 144,000 female sex workers. These
figures include the approximately 60,000 persons in GVN drug
rehabilitation (detention) centers, who suffer from very high HIV

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prevalence (60 percent or higher). Our program uniquely focuses on
the drivers of the epidemic, including the use of innovative IDU
approaches, such as Medication-assisted Therapy (MAT); distinctive
health systems strengthening activities, including improving public
health management capacity, improving disease surveillance,
providing technical assistance to health sector reform, and
improving overall program quality through guidelines, protocols, and
program management; behavioral change communications; and capacity
building for civil society and community organizations, of
particular importance in this single party Communist state with
virtually no independent community-based organizations.


3. (SBU) There are an estimated 243,000 PLWA in Vietnam, 28 percent
(about 67,000 people) of whom need ART. As of March, 2009, the USG
supports the GVN's provision of antiretroviral therapy (ART) to
about 28,000 persons. Of these, over 19,000 receive direct,
comprehensive support through PEPFAR implementing partners.
Combined, donors currently cover about 42 percent of PLWA in need of
ART, leaving an estimated 39,000 persons still in need of ART. We
are working closely with the government in developing or operating
PEPFAR-sponsored activities in 32 of Vietnam's 63 provinces.

MAT and Prevention Strategies
--------------


4. (SBU) Drug abuse and addiction prevention and treatment provide a
real opportunity to help Vietnam stop the spread of HIV/AIDS into
the general population. One fundamental risk reduction strategy is
the expansion of MAT using methadone. PEPFAR continues to urge the
GVN to change its current "rehabilitation" program based on
incarceration, rapid detoxification and vocational training to one
using internationally recognized drug rehabilitation and prevention
strategies. After several years of substantial effort, the USG, in
collaboration with UNAIDS, the World Health Organization (WHO),and
other partners, developed and implemented the MAT approach for
treatment of heroin addicts. PEPFAR currently supports the GVN's
pilot MAT program at five sites in two provinces. We hope to expand
to additional provinces during FY 2009. Challenges for MAT
expansion include: the requirement that clients pass through the GVN
system of compulsory drug rehabilitation centers prior to accessing
MAT services; GVN concerns about negative public reaction to the
program; very poor staff training, and GVN unwillingness to expand
the program without a full assessment of the pilot and methadone
procurement procedures.


5. (SBU) In addition to MAT, we continue to provide and strengthen
peer outreach programs to address high risk behaviors, including
communications campaigns for IDUs and condom access for commercial
sex workers and men who have sex with men. We coordinate closely
with other donors particularly where we face competing reporting
requirements or where USG restrictions on needle and syringe funding
require close cooperation with other donors to provide a
comprehensive set of services.

Health Systems Strengthening and Sustainability
-------------- --


6. (SBU) Fundamental problems in Vietnam's health system stem from

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vertically-aligned health services (for example, AIDS, tuberculosis,
maternal and child health, and reproductive health all have separate
operating units and do not collaborate effectively); highly
centralized government control; insufficient donor coordination; and
the GVN's allocation of resources based on equity and geography
rather than epidemiology. PEPFAR is working with GVN to develop a
cadre of highly skilled clinicians; however, these skill sets are
not considered to be highly desirable due to continuing stigma of
HIV/AIDS, low public sector pay, and lack of opportunities for
advancement. To ensure long term sustainability of both Vietnam's
health system and HIV/AIDS programs, we must work to improve
Vietnam's legal and regulatory environment, local public health
management systems, and linkages between the public sector and
grassroots organizations. Increasing human capacity (particularly
for clinicians and public health managers) is absolutely essential.
One immediate and straightforward direction is to expand areas such
as tuberculosis, a substantial public health problem in Vietnam.
PEPFAR efforts in these areas will leverage our successes with
HIV/AIDS-specific policies to strengthen general public health
capacity that will benefit PLWA as well as the general populace.


7. (SBU) In 2006, the National Assembly passed a National HIV/AIDS
Law which explicitly allowed for harm reduction programs and paved
the way for MAT. We are working now to assist GVN implementation
efforts (including drafting of necessary regulations). Amendments
to the Law on Drug Prevention and Control in 2008 do not appear to
reflect substantial donor input and contain unhelpful provisions
including requirements to report drug use, which undermine peer
education programs. Additionally, the law continues to require
two-year terms in rehabilitation centers followed by two years of
community monitoring with the potential to return to the
rehabilitation center (without due process) for a total period of
four years. We continue to urge the GVN to move away from the Drug
Law's focus on coercive treatment towards voluntary or drug court
mandated services.

Civil Society
--------------

8. (U) A sustainable response to HIV/AIDS requires the broad
participation of Vietnamese citizens. We are encouraging this
through strengthening civil society and increasing GVN acceptance of
a greater role for local non-governmental and private sector
organizations. Faith-based organizations with an interest in
providing HIV/AIDS-care and support services have faced particular
challenges receiving permission to organize and implement
activities.

Securing the Future of the DOD PEPFAR Program
--------------


9. (SBU) PEPFAR's work with the Ministry of Defense (MOD) is key as
MOD covers health care for about 10 percent of the total population.
Work with MOD also helps address war legacy issues which continue
to serve as a brake on the overall bilateral relationship. Since
the inception of our program, the DOD component of the program has
faced a number of difficulties (primarily related to internal DOD
organizational complexities) which resulted in the "red lighting" of
all DOD-related plans for the 2009 COP. To address these problems,

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DOD determined that the program will no longer be managed from the
Center of Excellence in Hawaii. Instead, the in-country Defense
Attache has realigned the management of the DOD PEPFAR component to
work more closely with the PEPFAR team and hired a well respected
in-country Program Manager. The DATT also instituted new local
procurement and accounting procedures to ensure proper oversight of
DOD funds and programs. DOD is partnering with USAID to develop
prevention materials for the Vietnam People's Army and teaming with
CDC on laboratory training and laboratory quality assurance. The
DOD component to the PEPFAR team is currently evaluating proposals
from local NGOs it will use to build indigenous health care capacity
(both in the military and civilian sectors). I hope that these
actions are sufficient for OGAC to lift the restriction now so that
we can move forward with this important PEPFAR element.

Coordination in Vietnam
--------------


10. (SBU) Coordinating with the GVN and other in-country donors and
organizations has been challenging, particularly with efforts funded
by the Global Fund. While coordination has improved at the
programmatic level, we still face serious challenges at the Country
Coordinating Mechanism (CCM) level, where basic issues of
Secretariat function and governance are causes for continued concern
and monitoring (Ref A). Despite some recent progress (Ref B),the
international community needs to be more organized and assertive to
overcome GVN tendencies to avoid collaborative planning. On the
positive side, the GVN now allows PEPFAR to report national ART
numbers, which include those of the GF activities and has permitted
PEPFAR-funded technical assistance and second line drugs at GF
sites.

How OGAC Can Help
--------------


11. (U) We have an excellent relationship with your dedicated OGAC
staff. To improve our collaboration, we hope you will consider: 1)
reducing the Washington-driven burden of planning (Ref A and C); 2)
promoting capacity-building in the broader health sector beyond
HIV-specific activities (Ref C and D); 3) re-evaluating the legal
restrictions on needle exchange to prevent the creation of separate
cadres of case workers indoctrinated in different approaches to
prevention; 4) eliminating caps on budgetary expenditures and
allowing country/field based programs to set ceilings for budgetary
line-items; and 5) enhancing donor coordination and budgeting at a
global level to optimize resource allocation and staffing (Ref A).


12. (SBU) While we understand the need for strategic planning and
strict oversight of a program this large, the burden of the annual
COP unduly stresses our resources and compromises program efficiency
and quality by focusing months of staff time each year on COP
drafting, which has become an end to itself, instead of a means to
improve program delivery. Compounded by the number of timelines and
indicators, many of which do not align with national programs and or
relate to local conditions, the COP creates a major burden on
partners, the GVN, and PEPFAR. Frankly, from a practical
perspective, our team needs to spend less time struggling to jam the
proverbial square target peg into the round OGAC indicator hole, and

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more time providing in-country support in their areas of substantive
expertise. A substantial reduction in the number of required
indicators, with more flexibility in data reporting would result in
higher quality data for PEPFAR. OGAC should consider ways to
increase field input -- perhaps by formalizing the existing Field
Contact group, which has improved communication and reprogramming
procedures, and resulted in more feasible deadlines. Biannual
budgeting and annual reporting, for example, instead of the current
annual budget and semi-annual reporting, would free hundreds of
thousands of staff hours annually to concentrate on program quality,
service delivery, cost effectiveness, efficiency and financial
accountability.


13. (SBU) Although we believe strongly in the utility of a
Partnership Framework (PF) with the GVN to make the fight against
HIV/AIDS a truly cross-sectoral effort with input beyond the Vietnam
AIDS Administration Control (Ministry of Health),like many OGAC
staff and PEPFAR teams worldwide, we believe the requirement to
develop a framework within the short time frame established by OGAC
significantly increases the burden on my already stretched PEPFAR
team and will likely raise tensions with Vietnamese officials. A
meaningful framework will take more time, particularly in Vietnam
where virtually all decisions are run through the Prime Minister's
office and where consensus building is critical even at very senior
levels.


14. (U) Again, the team and I look forward to working with you to
strengthen our program here and PEPFAR worldwide. I hope we will be
able soon to welcome you to Vietnam and show you the impact the
PEPFAR program has on the health of some of Vietnam's most
vulnerable citizens and its population at large and on the
development of our bilateral relationship.

PALMER