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Cablegate: Hhs Secretary Leavitt, Vietnam Scenesetter, Part Iii

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

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