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Bordered by China to the north, Laos and Cambodia to the west and the South China Sea to the east, Vietnam lies in a culturally diverse and politically volatile region of the world. After being ruled by Chinese dynasties, Vietnam achieved independence in the 10th century. In the mid-19th century France colonized Vietnam and remained in power until World War II, when Japan occupied Vietnam. After that war, France unsuccessfully attempted to regain control during an eight-year war that ended in 1954 when Vietnam was temporarily split in two by the Geneva Accords, which called for national elections in 1956 to unify the country.

But the elections didn’t happen, and instead, Vietnam was entrenched for two decades in a civil war, with the U.S. sending combat support for South Vietnam. Millions of Vietnamese died in the conflict which ended in 1973 when U.S. troops withdrew. In 1975, the North captured Saigon — renaming it Ho Chi Minh City — and extended the communist regime to the South. In the mid-1980s the Communist Party started to ease its control over the economic market and slowly adopted capitalist practices. Since then, the Vietnamese economy has grown robustly, and political repression has declined.

Vietnam had no formal diplomatic ties with the United States until 1995, when it opened an embassy in Washington. Over the past decade, diplomatic relations between the two nations have developed rapidly.

The country is one of the few remaining with a Communist government and despite its political gains over the past decades, maintains a highly centralized one-party system.

That political system may have its benefits when fighting disease. “In Vietnam, when the government — and especially the Party — decides something is a priority, it gets done,” says Lisa J. Messersmith, director of Harvard University’s Vietnam AIDS Public Policy Training Program, which receives about half of its funding through the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion U.S. initiative to fight AIDS abroad.

Fortunately, says Messersmith, the Vietnamese government has decided that fighting HIV/AIDS is a priority.

The face of HIV

In a country of 84 million people, fewer than 300,000 infected people may not seem like an epidemic. Indeed, as Daniel Levitt, the HIV/AIDS and health programs manager for the U.S. Agency for International Development in Vietnam, points out, “unlike Botswana or Swaziland, where you’re very likely to come across someone with HIV in a community, it’s less visible.” According to Levitt, current estimates are that one in every 75 households in Vietnam, or 600,000 people, are affected by HIV in some way. And the numbers are increasing. “We certainly are seeing many, many more people coming into outpatient centers and hospitals with symptoms,” he says.

Some provinces have very high infection rates. Ho Chi Minh City, for instance, is home to about one-quarter of the entire infected population of Vietnam.

Nationwide, injection drug users comprise 53 percent of the infected population. Female sex workers account for 3 percent, but 6.5 percent of all those women are infected and the percentage is higher in some areas. According to the Center for Strategic and International Studies (CSIS), a Washington, D.C.-based think tank with a focus on global security and prosperity, many female sex workers are also injection drug users, which complicates determining infection rates.

While the disease still mostly affects intravenous drug users — where infection rates can be as high as 70 percent — and commercial sex workers, transmission through heterosexual sex continues to rise nationwide. Climbing infection rates among pregnant women and military recruits also are of concern, Messersmith says.

Challenges to fighting the HIV epidemic

Drug use, prostitution and sex between men are considered “social evils” in Vietnam, and all are illegal. Fear of public rebuke can block those seeking help. The Vietnamese government is actively working to combat social stigma and provide a more positive and supportive approach, says Messersmith, but enforcing destigmatization laws remains a challenge.

High-risk groups in Vietnam “tend to be hidden populations” that are difficult to reach, Levitt says. Police raid brothels sporadically and round up sex workers. Some are detained in rehabilitation centers for prostitutes, called 05 Centers; others pay a fine and return to sex work. Levitt says such raids can hinder reaching out to sex workers because brothel owners avoid admitting aid workers, who they feel call attention to their illegal operations.

Heroin addicts, another high-risk population, are the driving force behind the HIV epidemic in Vietnam, Levitt says. Injection drug users are also rounded up and sent to rehabilitation or reeducation centers, in these cases called 06 Centers, where they receive vocational training. Generally, patients stay in 06 Centers one to two years, but in some areas of the country, such as Ho Chi Minh City in the South where the epidemic is wider spread, they can stay as long as five years. The relapse rate of patients in drug rehabilitation centers — which can be as high as 85 to 95 percent — raises questions about the effectiveness of the centers.

There are also concerns about new data showing the infection rate is growing among women who are not part of any of the high-risk groups and about the increasing mother-to-child transmission rate. According to Messersmith, there is no clear government policy on the prevention of mother-to-child transmission and babies who are born HIV positive. As a result, “some families are abandoning babies born to HIV positive women because they assume [the baby] will also have HIV” even though that is not necessarily the case.

Vietnamese government response

Unlike many of the countries plagued by the epidemic, Vietnam has an adequate number of health workers, with those working on HIV/AIDS programs more than doubling in the last five years, according to a CSIS report. The report goes on to say that workers also are better trained and have more experience with implementing HIV/AIDS prevention, care and treatment programs than five years ago.

The government has worked to keep the epidemic from spiraling out of control by targeting high-risk groups for treatment as well as providing preventative education for transients and youths, according to Deputy Prime Minster Pham Gia Khiem in an address on HIV/AIDS to the U.N. General Assembly in June 2006. He also noted that Vietnam has been responding to the HIV epidemic with national programs since 1995.

In November 2005, the Communist Party issued Party Directive 54, which sets up a legal framework to fight the epidemic, including regulations to facilitate HIV prevention and control, improving the dissemination of information and enhancing the government’s relations with its people and the international community in combating the disease.

Vietnam has also recently enacted a law that allowing needle and syringe exchanges — programs that the U.S. government will not fund — as well as condom promotion. Messersmith expects that this law will greatly reduce infection rates among high-risk groups.

U.S. government response

The U.S. chose Vietnam in 2004 to be PEPFAR’s 15th “focus country,” the only one located in Asia, for a couple of reasons. According to Levitt, Vietnam exhibits strong political support for fighting the epidemic, which is essential in the fight against HIV. Additionally, choosing Vietnam to be a focus country is another step in the process of reconciliation between the two nations, whose formal relationship is only a little more than a decade old.

Since the designation, the U.S. has developed a number of programs within Vietnam.

PEPFAR’s involvement in Vietnam is balanced among prevention, care and treatment programs compared with the other participating countries, where funding is often focused on one aspect above the others, according to Levitt.

Prevention programs offer interventions for the most at-risk populations, which include intravenous drug users, commercial sex workers, men who have sex with men, male clients of sex workers and partners of intravenous drug users, Levitt says.

The programs also target lower-risk youths by encouraging abstinence and faithfulness and delayed first sexual encounters. To discourage visits to sex workers, Levitt says young men who are potential clients are encouraged to use the “B,” or “Be Faithful,” component of the Abstinence, Be Faithful, and correct and consistent Condom use, or so-called ABC, approach to fight HIV. “This has been shown to be very effective in Thailand,” he said.

According the 2005 Country Operational Plan for Vietnam, 22,000 HIV-infected and -affected people are expected to receive treatment by 2008. According to UNAIDS, the Joint United Nations Program on HIV/AIDS, 12 percent of people living with HIV/AIDS in Vietnam are receiving ARV, or antiretroviral, drug treatment, which has largely transformed HIV/AIDS from a fatal condition to a manageable illness.

In fiscal 2005, Vietnam received $6.3 million for prevention activities, or 30.4 percent of the country’s total PEFPAR funding for prevention, care and treatment. Another $7.7 million — or 37.1 percent — went to care, while treatment activities were allocated $6.7 million — or 32.5 percent, including $3.2 million for antiretroviral drugs.

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