VZCZCXRO6416
RR RUEHHM
DE RUEHHI #0578/01 1731128
ZNR UUUUU ZZH
R 221128Z JUN 09 ZDS
FM AMEMBASSY HANOI
TO RUEHC/SECSTATE WASHDC 9794
INFO RUEHHM/AMCONSUL HO CHI MINH 5952
RUEHAB/AMEMBASSY ABIDJAN 0030
RUEHUJA/AMEMBASSY ABUJA 0047
RUEHDS/AMEMBASSY ADDIS ABABA 0043
RUEHDR/AMEMBASSY DAR ES SALAAM 0033
RUEHNE/AMEMBASSY NEW DELHI 0417
RUEHOR/AMEMBASSY GABORONE 0032
RUEHGE/AMEMBASSY GEORGETOWN 0019
RUEHSB/AMEMBASSY HARARE 0019
RUEHKM/AMEMBASSY KAMPALA 0030
RUEHLGB/AMEMBASSY KIGALI 0043
RUEHLG/AMEMBASSY LILONGWE 0007
RUEHLS/AMEMBASSY LUSAKA 0025
RUEHNR/AMEMBASSY NAIROBI 0043
RUEHTO/AMEMBASSY MAPUTO 0025
RUEHPF/AMEMBASSY PHNOM PENH 3764
RUEHPU/AMEMBASSY PORT AU PRINCE 0026
RUEHSA/AMEMBASSY PRETORIA 0069
RUEHWD/AMEMBASSY WINDHOEK 0025
REUHBK/AMEMBASSY BANGKOK 6803
RUEHPH/CDC ATLANTA GA
RUEAUSA/DEPT OF HHS WASHINGTON DC
RUEKJCS/SECDEF WASHINGTON DC

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 
 
HANOI 00000578  001.2 OF 005 
 
 
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 
 
HANOI 00000578  002.2 OF 005 
 
 
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 
 
HANOI 00000578  003.2 OF 005 
 
 
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, 
 
HANOI 00000578  004.2 OF 005 
 
 
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 
 
HANOI 00000578  005.2 OF 005 
 
 
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