VZCZCXRO7306
OO RUEHHM
DE RUEHHI #0406/01 1001028
ZNR UUUUU ZZH
O 091028Z APR 08
FM AMEMBASSY HANOI
TO RUEAUSA/DEPT OF HHS WASHINGTON DC IMMEDIATE
RUEHC/SECSTATE WASHDC 7568
INFO RUEHPH/CDC ATLANTA GA PRIORITY
RUEHHM/AMCONSUL HO CHI MINH 4548
RUEHJA/AMEMBASSY JAKARTA 0707
RUEHGP/AMEMBASSY SINGAPORE 2597

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