Meeting the needs of Vietnam's most-at-risk populations

AIDS Support and Technical Assistance Resources

MEETING THE NEEDS OF VIETNAM’S MOST-AT-RISK POPULATIONS: Using a causal pathway analysis to determine funding priorities to address HIV/AIDS

Submitted to USAID by Management Sciences for Health

DATE: July 12, 2011 This document is made possible by the generous support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID) under contract No. GHH-I-000700068-00. The contents are the responsibility of the AIDSTAR-Two Project and do not necessarily reflect the views of USAID or the US Government.

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Contents ACKNOWLEDGEMENTS .................................................................................................................................... 4 ACRONYM LIST ................................................................................................................................................. 5 EXECUTIVE SUMMARY ..................................................................................................................................... 6 1. INTRODUCTION ...........................................................................................................................................10 1.1 Most-at Risk populations (MARPs) ............................................................................................. 12 1.2 Redefining the approach to health system strengthening for HIV/AIDS .................................... 13 1.3 Linkages between Community and Health Systems ................................................................... 15 2. METHODOLOGY...........................................................................................................................................16 2.1 The control knob framework ...................................................................................................... 19 2.2 The analytic methodology utilized: Causal pathway analysis ..................................................... 19 2.3 Nine Steps for Conducting a Causal Pathway Analysis ............................................................... 19 3. COUNTRY ANALYSIS: SUPPORTING VIETNAM’S MOST-AT-RISK POPULATIONS THROUGH A HEALTH SYSTEM STRENGTHENING APPROACH ............................................................................................................20 3.1 General Background/Overview of Vietnam’s Health System ..................................................... 20 3.2 Epidemiology............................................................................................................................... 28 3.3 Characteristics of MARPs ............................................................................................................ 43 3.4 Evidence Based Prevention Interventions .................................................................................. 63 3.5 System Bottlenecks and Required Health System Strengthening Actions ................................. 74 4. RECOMMENDATIONS ..................................................................................................................................85 5. SUMMARY GUIDANCE .................................................................................................................................89 1. Recommendations on methodology............................................................................................. 89 2. Recommendations on the availability and use of evidence ......................................................... 89 3. Recommendation on gender issues.............................................................................................. 90 4. Recommendation on legal and regulatory issues and private sector engagement ..................... 90 5. Recommendation on financing ..................................................................................................... 90 6. Recommendation on demand issues ............................................................................................ 91 7. Recommendation on scaling up what works ................................................................................ 91 APPENDIX I DEEP DIVE EXAMPLE: CONDOMS .................................................................................................92 APPENDIX II CAUSAL PATHWAY ANALYSIS GUIDELINES ................................................................................111 INTRODUCTION .............................................................................................................................................112 PRINCIPLES ....................................................................................................................................................112 CONDUCTING A CAUSAL PATHWAY ANALYSIS ..............................................................................................113 Step 1: Identify the problems to be overcome and the causes of those problems ....................... 113 Step 2: Determining the characteristics of the population(s) at risk .............................................. 114 Step 3: Selecting the vital few evidence based interventions ........................................................ 115 Step 4: Health system requirements and system bottlenecks ....................................................... 116 Step 5: Health system strengthening actions ................................................................................. 117

Acknowledgements This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group, the USAID Mission in Vietnam, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV/ AIDS. The AIDSTAR-Two Project, led by Management Sciences for Health (MSH) in partnership with the International HIV/AIDS Alliance, would like to express its gratitude to the many people who provided input and guidance for this report. Dan Kraushaar and Khuat Thi Hai Oanh are the co-authors of this report. We would particularly like to thank the USAID Mission in Vietnam, led by Xerses Sidhwa and Nguyen Thi Minh Ngoc, as well as Asia Nguyen from the CDC and Vivian Chao, PEPFAR Coordinator.

We are indebted to the following people from various organizations in Vietnam who graciously agreed to be interviewed by the authors: David Jacka and Masaya Kato from the World Health Organization; Rachel Burdon and Kim Green from Family Health International; Sarah Bale at the Ministry of Health; Le Ngoc Bao at Pathfinder; Ted Hammet and Nguyen Duy Tung at HPI Vietnam; and Tran Tien Duc, an independent public health consultant. Their input based on real experience on the ground was invaluable and greatly sharpened the content of this report.

We would also like to thank Elden Chamberlain, HIV/AIDS and MARPS Specialist with AIDSTAR Two/Alliance for his guidance and support. Alyson Clark, Ummuro Adano and Sarah Johnson, the AIDSTAR-Two team in the USA, provided much needed ongoing administrative and technical support, and reviewed the final report. Elizabeth Walsh provided skillful editorial, formatting and production assistance.

Finally, we thank Pamela Rao, Senior Health Systems Advisor, Office of HIV/AIDS, USAID Washington, for her insightful technical feedback, commitment to, and encouragement and support of this initiative.

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Acronym List AIDSTAR ART ARV ATS BCC CSO CSS CSW DALYs FHI FSW HCMC HSS IBBS IEC MARP MMT MOET MOH MOLISA MOPS MOU MSM NGO PEPFAR PLHIV PMTCT PWD PWID SOW STI SSW SW TB UNAIDS UNODC USAID VAAC VCSPA VCT VSW WHO

AIDS Support and Technical Assistance Resources Antiretroviral therapy Antiretroviral Amphetamine-type stimulants Behavior change communications Civil society organization Community system strengthening Commercial sex worker Disability Adjusted Life Years Family Health International Female sex worker Ho Chi Minh City Health system strengthening HIV/STI Integrated Biological and Behavioral Surveillance Information, Education and Communication Most-at-risk population Methadone Maintenance Therapy Ministry of Education and Training Ministry of Health Ministry of Labor, War Invalids and Social Affairs Ministry of Public Security Memorandum of understanding Men who have sex with men Nongovernmental organization President’s Emergency Plan for AIDS Relief People Living with HIV Prevention of mother-to-child transmission People with disabilities People who Inject Drugs Scope of work Sexually transmitted infection Street-based sex worker Sex worker Tuberculosis Joint United Nations Programme on HIV/AIDS United Nations Office on Drugs and Crime United States Agency for International Development Vietnam Administration of AIDS Control Vietnam Civil Society Partnership Platform Voluntary counseling and testing Venue-based sex worker World Health Organization

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Executive Summary Recognizing there is no single prescription for a multitude of diverse HIV epidemics around the world, UNAIDS led a rally “Know your epidemic, Know your response” in 2009 to build awareness on the importance of designing evidence-driven strategies based on the analysis of transmission sources in a given setting. This rally was initiated after the sobering realization that for every person that is put on treatment, there are four to five people that are newly infected. This pattern is particularly pronounced in countries with concentrated epidemics driven by people who inject drugs, men who have sex with men, sex workers and other Most-at-Risk Populations. This lays bare the fact that there are many barriers to reach universal coverage of key prevention, treatment and care interventions for these groups.

Health systems strengthening is a process of improving policies and health sector management to meet the needs of all populations. Given that health systems operate as open systems, it is important to understand their context, using an analytical approach to manage the dynamic relationships between all the various components of the health system. To plan, monitor and evaluate health system functioning, the World Health Organization (WHO) developed a framework to define health systems by six core building blocks: finances, health workforce, information, governance, medical products and technologies, and service delivery. The health systems building blocks are complex, adaptive systems as opposed to stand alone mechanical systems which draw resources from each other and must be responsive to their users in order to deliver health results, especially for hard to reach or vulnerable subgroups like the most-at-risk populations described above. By analyzing a health system across the six building blocks, governments can get a better idea of gaps in health interventions, particularly as they pertain to Most-at-Risk Populations. HSS interventions to reach these groups will likely result in higher demand and access to health services to improve overall health outcomes.

This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group, the USAID mission in Vietnam, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV AIDS. The Technical Working Group, working in close coordination with the USAID mission in Vietnam, asked the AIDSTAR-Two Project to conduct an in-country assessment in Vietnam, supplemented by a literature review, to answer the question: How should program managers in USG country teams worldwide invest their HSS funds to maximize the impact on Most At-Risk Populations?

To respond to this question, AIDSTAR-Two applied a causal analytical framework (also known as the “causal pathway”) to determine how to make health systems more responsive to the needs of Most-atRisk Populations (MARPs); this report presents the key findings and recommendations for Vietnam based upon the application of this causal framework.

Causal pathway analysis is an analytic approach which focuses on designing projects to achieve maximum attributable health outcome. Its application in project design maximizes the probability that projects and programs will achieve desired health outcomes, helps managers make appropriate choices among competing technical interventions, programmatic approaches, inputs, processes and outputs. It also helps managers focus on the most important health system strengthening efforts and identify the most appropriate indicators for monitoring progress. Tracing the causal pathway to health impact requires a nine-step process which includes:

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1.

2.

3.

4.

5.

6.

7.

8.

9.

Identifying the health impact goal (in this case, reduce AIDS related deaths) Identifying and quantifying health problems to be overcome (reduce HIV transmission) Identifying and quantifying direct and indirect causes and risk factors Determining the characteristic of the populations that are most at-risk (time, place, geographic distribution, socioeconomic status and who have most of the problems) Identifying the full range of cost effective evidence-based clinical and programmatic interventions and then identifying the vital few health interventions, their current coverage levels and coverage levels required to achieve the goal Determining health system requirements to achieve the needed coverage levels Identifying the few critical health systems bottlenecks to achieving required coverage levels Identifying critical health system strengthening Interventions that improve the functioning and integration of the six building blocks necessary and sufficient to improve coverage levels Identifying the most appropriate and key M&E indicators along the causal pathway that need to be monitored over time.

The AIDSTAR-Two assessment team was comprised of a health system strengthening expert from Management Sciences for Health and a Most-at-Risk Populations/HIV/AIDS expert from the International HIV AIDS Alliance. An experienced local consultant was engaged in Vietnam to assist in the analysis and support was provided by the U.S. Government. The analysis was conducted between September 2010 and January 2011, with two visits made to Vietnam during this time. Over 300 reports and assessments were analyzed and interviews and discussions held with key stakeholders in Vietnam, including UN agencies, international development organizations, local HIV implementing organizations, MARPs groups and government agencies.

The country analysis covered here presents the background and the epidemiology of Vietnam’s HIV/AIDS situation. The adult prevalence rate for HIV/AIDS is 0.5%, and MARPs are disproportionately impacted by the epidemic. With a population of around half a million in a total population of 86 million people, it is estimated that MARPs account for nearly 30% of Vietnam’s current infections, and 45% of new infections. Depending upon the source, HIV prevalence among people who use injecting drugs ranges from 18.6% to 31.5%; prevalence among female sex workers ranges from 3.2% to 9.1%; and prevalence among men who have sex with men (MSM) can be as high as 14.2%. MARPs are also likely to be the source of transmission to the general population.

One of the key recommendations of this report is that Vietnam set as its goal the rapid achievement of the AIDS transition, the point at which new HIV infections equal the number of AIDS deaths. Achieving this transition point is accomplished through a strategy of holding AIDS mortality down while at the same time lowering the number of new infections until the total number of people living with HIV begins to decline. While the good news is that Vietnam is effectively addressing AIDS mortality, there is a massive effort needed to reduce HIV transmission particularly in the population groups most at risk of being infected and of infecting others and in geographic areas where high risk practices take place.

Vietnam’s epidemic cannot be controlled without a tight focus on most-at-risk and vulnerable populations in a few high priority geographic areas where most HIV infections originate and where prevalence is high. Available data suggests that as many as 70% of the 111,000 registered people who inject drugs (PWID) in the country are concentrated in five provinces/ regions: Hanoi, Ho Chi Minh City, Hai Phong, North West Region and Red River Delta. MSM tend to congregate in big cities such as Ho Chi Minh City, Hanoi, and Hai Phong. Rates for condom use among MSM vary, and between 9% and 27% of MSM are married to a female spouse, thus increasing the risk of transmission to the general population.

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There are an estimated 58,000 sex workers living in Hanoi, Hai Phong, South East region, Mekong Delta, Red River Delta and Northwest region; approximately one-third of this group lives in Ho Chi Minh City.

For sex workers, consistent condom use with clients ranged from fairly high (86%) to low (21%).

As a result of this analysis, this report recommends a focus on the following geographic areas in priority ranking (in order below, from 1 to 5): Ranking #1: Ranking #2: Ranking #3:

Ranking #4:

Ranking #5:

Ho Chi Minh City, Hanoi, Hai Phong (high concentration of all MARPs and high number of people living with HIV (PLHIV)) An Giang, Son La, Thai Nguyen, Nghe An (high concentration of at least 1 MARP and high number of PLHIV) Quang Ninh, Da Nang, Thanh Hoa, Can Tho, Dong Nai, Ba ria – Vung tau, Dien Bien, Tay Ninh, Kien Giang, Hau Giang, Lam Dong in that order (high concentration [top 5] of at least one MARP or moderate concentration [top 10] of at least considered populations and mild concentration [top 15] of one considered population) Hoa Binh, Thai Binh, Hai Duong, Lai Chau, Binh Thuan, Yen Bai (moderate concentration of at least one considered population or mild concentration of at least 2 considered populations) Lao Cai, Ha Tinh, Khanh Hoa, Ca Mau, Phu Tho, Phu Yen, Dong Thap, Binh Duong, Dac Lac, Vinh Phuc (mild concentration of at least one considered population)

MARP interventions should include both technical and structural interventions, and address all underlying, proximal and biomedical determinants of infection and transmission. Structural interventions should address the policy environment for engaging MARPs as well as ensure financial sustainability of the response. Technical interventions should focus on the most cost-effective interventions that prevent HIV-negative MARPs from becoming infected and provide PLHIV with services to know their status and protect their health. Critical interventions include: needle and syringe distribution for drug users, methadone maintenance therapy (MMT) for people with heroin dependence, lubricant distribution for MSM, and for all MARPs: condom use promotion, HIV testing and counseling, STI screening and treatment, ARV treatment for HIV-positive MARPs, and peer education and interpersonal communication.

In terms of financing, the report outlines a number of important options for consideration. First, much of the focus should shift to financing a joint prevention and treatment approach with the goal of achieving the AIDS transition as quickly as possible. Such a shift is critical given the fact that much of the funding for the National Target Program comes from donors and PEPFAR in particular and these funding sources are declining.

Second, funding from the national level and funding within the provinces/municipalities should have the right mix of incentives to assure that the right amount of money is spent on HIV/AIDS, that the funds flow to the right services, service providers and geographic areas and finally that different incentive mechanisms be tried in order to address both supply and demand side constraints are overcome. A long term commitment that involves a significantly greater municipal and even private sector response is needed, both financially and programmatically.

Third, it is important that given the limited resources available, the lowest cost, most effective methods of services delivery be identified and implemented at scale. Based on the evidence we have at hand,

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this may require a much more aggressive community level response than is in place today. Making all these fiscal changes and adjustments will require a mix of provincial and national action.

This report concludes with five appendices that provide substantial analysis of several key issues and important pointers that are worth considering, in order to strengthen overall HIV/AIDS programming for MARPs in Vietnam. Appendix I outlines the theoretical system requirements, system bottlenecks and system strengthening actions needed to implement a successful 100% condom campaign in Vietnam.

This is simply an example of using the data which resulted from the authors’ analysis of the problems, causes and risk factors which cause HIV transmission as well as the examination of the characteristics of populations most at risk of being infected or infecting others and, our examination of cost effective interventions.

Condoms have been chosen as the priority intervention because male condoms are 80-95% effective in reducing the risk of HIV infection when used correctly and consistently. In Vietnam, condoms are cheap, available throughout the country, they are acceptable to the Vietnamese people and they are widely used in Vietnam as a method of contraception as part of the national family planning program.

Condoms also address the major problems, causes and risk factors associated with HIV transmission in Vietnam. Finally, condoms are commercially available in all pharmacies and other commercial outlets in both urban and rural areas of Vietnam and through the public health system they are publicly available at low prices. In other words, the platform for scaling up condoms as the major mechanism for reducing HIV transmission exists.

Appendix II provides an overview of the causal pathway analysis.

Appendix III provides an overview of factors which affect current and future financing for HIV/AIDS, and discusses in some detail the fiscal environment within which the HIV/AIDS program must fit and how that environment will influence the amount and distribution of HIV/AIDS related resources in the future.

Appendix IV contains a summary of system bottlenecks faced by Vietnam’s HIV/AIDS program, defines the range of PBF options and then recommends how PBF could be applied in Vietnam to overcome some of the most important health system bottlenecks.

Appendix V provides an analysis of how to achieve the AIDS transition in Vietnam and outlines some of the implications of that process.

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Introduction PEPFAR’s current five-year strategy outlines several principles that will drive US government funding for HIV/AIDS.1 The first principle is to expand the emphasis on HIV prevention, and match interventions and investments with epidemiological trends and needs in order to improve impact.

This principle points to the need for a combination of interventions that are tailored to the needs and risks of different target populations. Given that the epidemic is not static, changes within countries and regions – including the beneficial impact of prevention efforts – require a prevention response that identifies and deploys interventions to meet these new conditions.

“The best measure of a health system’s performance is its impact on health outcomes.”

This principle also calls for support to countries in Margaret Chan WHO reassessing prevention portfolios in order to ensure Everybody’s Business 2007 that they are targeting for maximum impact, assuring intervention strategies are aligned to existing and emerging situations. By working with countries to identify current drivers, including epidemics among subpopulations that may not be reached by general behavioral prevention messages, PEPFAR can target investments to greatest needs.

Finally, this principle calls for implementing, evaluating and expanding innovative, analytic programmatic approaches and interventions which will advance the science around HIV prevention.

A second principle of PEPFAR’s five-year strategy calls for expanding access to high quality prevention, care and treatment services as well as immediate health needs, tailored to conditions in host countries, while laying the groundwork for future sustainability. Among other implications of this principle is that prevention and treatment efforts are focused on the specific drivers of the epidemic and lead to identification and testing of new methods and approaches.

Finally, this principle calls for PEPFAR’s programs – prevention, care, treatment, and linkages to larger health care services – to be evidence based and driven by the needs of the people impacted by this epidemic.

The greatest challenge we face is to address the following question: How can we maximize the impact on the HIV/AIDS epidemic within the context of rising demands for health care, limited system capacity, the push for greater country ownership, and potentially declining donor resources?

1

The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Plan for AIDS

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Paraphrasing the principles outlined in the five-year strategy, we must build a “fit for purpose” health system, specifically targeted at the problems, causes, interventions and approaches required by specific population groups that are driving the epidemic. It is important that health system strengthening include both supply and demand side approaches, as well as focus on government, NGO and private sector actions and recognize the contributions that community systems strengthening makes to ensuring that a sustainable response can be delivered at scale.

The above principles and approaches are also reflected in the Global Health Initiative. The U.S. Government’s 2010 Global Health Initiative Consultation Document states that “Building functioning systems will, in some cases, require a new way of thinking about health investments, with increased attention to the appropriate deployment of health professionals, improved distribution of medical supplies and improved functioning of information and logistics systems – all while maintaining a focus on delivering results. In the end, success will be measured not by the robustness of the health system itself, but by a country’s ability to meet the needs of key populations and improve health conditions.”

In Vietnam, the adult prevalence rate for HIV/AIDS is 0.5%, and Most at-Risk Populations (MARPs) are disproportionately impacted by the epidemic. With a population of around half a million in a total population of 86 million people, it is estimated that MARPs account for nearly 30% of Vietnam’s current infections, and 45% of new infections. Depending upon the source, HIV prevalence among people who use injecting drugs ranges from 18.6% to 31.5%; prevalence among female sex workers ranges from 3.2% to 9.1%; and prevalence among MSM can be as high as 14.2%.2 MARPs are also likely to be the source of transmission to the general population.

This report is the result of a joint effort undertaken by the PEPFAR Health Systems Strengthening Technical Working Group (TWG), the USAID mission in Vietnam, and the AIDSTAR-Two Project, a HIV/AIDS organizational capacity building project that is funded by the USAID Global Health Bureau/Office of HIV AIDS. The TWG, working in close coordination with the USAID mission in Vietnam, asked the AIDSTAR-Two Project to conduct an in-country assessment, supplemented by a literature review, to answer the question: How should program managers in USG country teams worldwide invest their HSS funds to maximize the impact on Most At-Risk Populations?

To respond to this question, AIDSTAR-Two applied a causal analytical framework (also known as the “causal pathway”) to determine how to make health systems more responsive to the needs of MARPs; this report presents the key findings and recommendations for Vietnam based upon the application of this causal framework. The report builds on the desire to develop a “fit for purpose” health system by: 1. Making a case for the importance of understanding the health system to design sustainable responses for MARPs 2. Applying a framework in Vietnam that can provide a health system lens to program managers to prioritize health system strengthening interventions 3. Highlighting the need for creative health system strengthening strategies to attain HIV/AIDS program goals in MARP settings.

The report consists of five parts: an introduction that looks at the general context of MARPs, the health systems strengthening approach to HIV/AIDS and the linkages between the community and health systems. The second part looks at the methodology of this assessment, including a more detailed look at 2

Government of Vietnam. 2010. The Fourth Country UNGASS report.

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the causal pathway analysis. Section three, provides the in-depth analysis and findings of the Vietnam country assessment. The report concludes with recommendations for meeting the needs of Vietnam’s Most-at-Risk Populations in section four and summary guidance in section five.

1.1 Most-at Risk populations (MARPs) According to UNAIDS, Most-at-Risk Populations include people who inject drugs (PWID), men who have sex with men (MSMs), persons engaged in sex work (CSWs), and clients of persons engaged in sex work, and are the main drivers of the epidemic(s) in countries with concentrated epidemics. These populations are the ones most likely to be exposed to HIV and most likely to be affected.

Risk is defined as the probability or likelihood that a person may become infected with HIV. Certain behaviors create, increase, and perpetuate risk. Examples include unprotected sex with a partner whose HIV status is unknown, multiple sexual partnerships involving unprotected sex, and injecting drug use with contaminated needles and syringes.

Most-at-risk populations are most often also vulnerable due to social and institutional rejection and discrimination. Depending on the context, in addition to the examples cited above, these populations might also include transgender people, prisoners, and other groups.

To look at one most-at-risk group: Millions of people worldwide are injecting drugs, and blood transfer through the sharing of non-sterile injecting equipment is an extremely effective way of transmitting HIV. Around 30% of global HIV infections outside of sub-Saharan Africa are caused by risk behavior related to the use of injecting drugs, and it accounts for an increasing proportion of those living with the HIV virus.

Harm reduction programs such as clean needle exchange programs and opioid substitution therapy (e.g., methadone) were introduced some 25 years ago in European cities like Rotterdam and Liverpool and in countries such as Australia and the United States. These programs were among the first successful measures to prevent HIV infection through injecting drug use. Harm reduction practices were widely adopted as public health policy in many countries and, along with safe sex campaigns, are considered a major factor in the relatively low HIV infection rates in those countries.

Nearly three decades later, injecting drug use is now driving the fast growing HIV/AIDS epidemic in Eastern Europe. Some 65% of HIV infections in Russia, for instance, are through injecting drug use. In Vietnam, 70% of PWID are living with HIV. But the universal adoption of harm reduction strategies has not happened resulting in expanding epidemics among PWID around the globe. It is estimated that the global average is fewer than two clean needles a month per injector and only four percent of PWID living with HIV are on antiretroviral therapy (ART).

The factors that put sex workers at risk also vary between contexts. Evidence shows, for instance, that risk factors can include sexual violence on the part of clients or sex workers accepting higher payments for engaging in unprotected sex. In some places, sex workers commonly use drugs and share needles.

The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries, such as China, Indonesia, Kazakhstan, Ukraine, Uzbekistan and Vietnam.

Gay men and other men who have sex with men (MSM) bear a disproportionately heavy burden of the HIV pandemic. In low- and middle-income countries, MSM are 19 times more likely to be infected with HIV than the general population. Despite elevated HIV prevalence rates and heightened vulnerability to

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factors that drive HIV transmission, MSM have been under-recognized, under-studied, under-funded, and under-served historically in the global response to HIV/AIDS. It is estimated that HIV prevention services reach only 9% of MSM worldwide. Additionally, the detrimental effects of stigma and discrimination on sexual health have been well documented in the global north, where HIV infection rates among MSM in large urban centers are unacceptably high and in some places steadily increasing. Furthermore, as of May 2009, criminal penalties for same-sex acts between consenting adults were executed in at least 80 countries, driving the epidemic underground.

There is, therefore, an urgent need to prioritize outreach to MSM with HIV-related services and information that effectively meet their needs in the context of global public health and human rights.

Most-at-Risk Populations are often among those who are most affected by poverty, gender inequity, stigma and discrimination in law and practice, harmful cultural and religious practices, lack of access to credit, property or inheritance rights and other factors that contribute to HIV risk and vulnerability.

Sex workers, transgender people, drug users and men who have sex with men are especially vulnerable to social and State discrimination. Criminalizing these groups’ activities erects major barriers to accessing HIV and other health and support services and programs. Laws and social customs in many countries condone discrimination against the populations who are most at risk of HIV, complicating efforts to deliver lifesaving services to engage affected populations as essential partners in the HIV response.3

1.2 Redefining the approach to health system strengthening for HIV/AIDS Recognizing there is no single prescription for a multitude of diverse HIV epidemics around the world, UNAIDS led a rally “Know your epidemic, Know your response” in 2009 to build awareness on the importance of designing evidence-driven strategies based on the analysis of transmission sources in a given setting. This rally was initiated after the sobering realization that for every case that is put on treatment, there are four to five cases that are newly infected. This pattern is particularly pronounced in countries with concentrated epidemics driven by PWIDs, MSMs, Sex Workers and other MARPs. This lays bare the fact that there are many barriers to reach universal coverage of key prevention, treatment and care interventions for MARPs.4 Health systems strengthening (HSS) is a process of improving policies and health sector management to meet the needs of all populations. Given that health systems operate as open systems, it is important to understand their context, using an analytical approach to manage the dynamic relationships between all the various components of the health system. To plan, monitor and evaluate health system functioning, the World Health Organization (WHO) developed a framework to define health systems by six core building blocks: finances, health workforce, information, governance, medical products and technologies, and service delivery. Weaknesses at one level may be the consequence of a root cause at another level. These are complex, adaptive systems as opposed to stand alone mechanical systems and they all need to draw resources from each other and be responsive to their users in order to deliver health results, especially for hard to reach or vulnerable sub-groups like MARPs. As such, even the best thought-out service delivery system cannot operate independent of the other components of the health system. By analyzing a health system across the six building blocks, governments can get a better idea of 3 4

Enabling Legal Environments, International HIV AIDS Alliance 2011 Rao, Concept Note, Health System Strengthening for MARPs Programs

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gaps in health interventions, particularly as they pertain to MARPs. HSS interventions to reach these groups will likely result in higher demand and access to health services to improve overall health outcomes.

The need to meet Millennium Development Goals targets for health, including HIV/AIDS, has brought “Universal Coverage” and “Health Systems Strengthening” to center stage. Increased attention to HSS has brought many health system specialists to program HIV/AIDS funds for HSS. While this move is timely, there is a tremendous need to orient and sensitize HSS experts and program managers to program interventions to address systems barriers to reach MARPs. With increased attention to HSS, both in the context of the epidemic and in general, many health system specialists and donors are programming HIV/AIDS funds in this area. While these funding decisions are timely and desirable, there is a tremendous need to orient and sensitize HSS experts and program managers to program interventions that will actually strengthen systems to increase the access to and quality of services to reach MARPs, to learn from successful HSS and community strengthening system (CSS) methodologies, and to identify key service delivery areas where the linkages between HSS and CSS interventions need to be strengthened. As program managers start to apply guidance on universal coverage, there is a need to provide appropriate technical guidance on health system strengthening and community system strengthening to countries tackling MARPs in concentrated epidemics.

Current approaches to HSS tend to focus on achieving normative standards for inputs and processes and focus on broad indicators of system performance. These efforts may place more emphasis on inputs, outputs and processes rather than outcomes and impact. For example, some country standards call for achieving a ratio of one doctor per 10,000 people or an investment of a certain percent of GDP in health.

This focus on inputs (doctors/population, money), outputs (enhanced production of doctors, spending) and processes (improved pre-service and in-service training), if uniformly applied, frequently exceeds available resources and furthermore, the degree to which these inputs, outputs and processes contribute to goal attainment is most often unclear.

Current HSS efforts are often vertical and focused on individual health system building blocks.5 Such a vertical focus may lead to well functioning system components (e.g., a well functioning supply chain or a robust health information system or a stronger workforce) but the combined functioning of the entire health system may, in fact, remain sub optimal. Optimizing individual sub systems may not increase effectiveness of the system as a whole.

Given resource constraints, input, output and process oriented HSS efforts focusing on optimizing individual sub systems are less likely to achieve HIV/ AIDS service delivery and health goals. A focus on “good enough” vs. “ideal” system components working together and “tuned” to a common goal is what will maximize the return on HIV investments and will facilitate a sharper focus on prevention as well as attaining the objective of putting more people on treatment.

5

WHO’s “Everybody’s Business” defined six building blocks that define a health system: health workforce; health information; service delivery; health financing; leadership & governance; medical products, vaccines and technologies.

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1.3 Linkages between Community and Health Systems The WHO defines health systems as “all organizations, people and actions whose primary intent is to promote, restore or maintain health.”6 The WHO’s Building Blocks Framework identifies six building blocks that form the basis of a well-functioning health system: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance. Health systems strengthening is defined by WHO as improving these six building blocks and managing the way they interact with each other to achieve more equitable and sustained improvements across health systems and health outcomes.

The WHO’s definition of a health system and health system strengthening relates primarily to the development of national public health systems. However, health care is not exclusively the domain of organizations whose primary intent is to promote, restore or maintain health. Other key sectors of society are also involved. In the final report of the WHO’s Commission on Social Determinants of Health (2008), the Commission points out that “the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age…Policies and programs must embrace all key sectors of society not just the health sector.”

The WHO Health System framework does not make explicit the role of communities in supporting the delivery of health services and ensuring equitable access to these services for all who need them. It does not take into account the critical challenges of stigma and discrimination within health systems and communities, a key barrier to accessing health services, especially for MARPs. The critical role that communities play in providing health services in the absence of, or in partnership with, government services, as well as providing care and support to community members, has been increasingly recognized by key agencies supporting health systems strengthening, such as the Global Fund to Fight AIDS, TB and Malaria, UNAIDS, WHO, UNICEF, USAID, UNDP, and the World Bank as well as by developing country governments. As a result, the Global Fund, in collaboration with other stakeholders, developed the “Community Systems Strengthening Framework” (2010) which highlights six key elements that need to be in place for health and community systems to function well: 1. Preparing community-based organizations to contribute to national responses on HIV, tuberculosis & malaria 2. Building the organizational capacity of community organizations 3. Building human and technical capacity for community-based service delivery 4. Establishing and strengthening networks and partnerships 5. Establishing sustainable financing 6. Creating and maintaining an enabling environment There is no inherent conflict between a health care systems approach and a community health systems approach. Community organizations and networks have a unique ability to interact with affected communities, react quickly to community needs and issues and advocate for improved programming and policy environments. This enables them to build a community’s contribution to health and health systems strengthening, and to influence the development, reach, implementation and oversight of public systems and policies. Community systems strengthening is an integral component of HSS and should not be seen as a separate stand alone activity or system.

6

WHO Framework for Action for Strengthening Health Systems 2007

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Methodology Three core principles guided the methodology used by the AIDSTAR-Two Project in conducting this assessment. First, health system strengthening efforts should be directed at health goal attainment as defined by the individual countries. Second, in the face of severe resource constraints, countries must make rational and hard choices about how their scarce resources should be allocated among competing investment options. Third, countries should focus their system strengthening efforts not only on improving the volume of inputs, outputs and processes, but by the manipulation of those variables which most directly affect health system performance.

Goal oriented health system strengthening Health systems exist and function in order to achieve a country’s health goals. In that light, health systems strengthening should have three objectives: achieve desired health goals more quickly, achieve them more effectively and achieve them more efficiently. Framing health system strengthening actions in this light means that we must first understand the health goals, the problems that must be overcome to achieve these goals, and the system constraints to scaling up the delivery of the most effective interventions to address those problems. In other words, we must start with the goal and work backward to identify constraints that must be overcome through health system strengthening for improved delivery of interventions addressing major health problems. A more traditional focus on inputs, outputs and processes may expand the health system’s capabilities but may not improve effectiveness, efficiencies or goal attainment.

Making rational and hard choices – the 80/20 Rule According to the official report from the MOH, by September 2010, there were 180,312 registered people living with HIV (PLHIV) in Vietnam, among them 42,339 people had developed AIDS. By the end of 2012 the Ministry of Health projects that 254,387 people will be HIV positive.7 The number of new cases is trending downward. The picture seems promising although this can be misleading.

Vietnam is still far from achieving an AIDS Transition, the point at which new HIV infections equal the number of AIDS deaths. Achieving this transition point is accomplished through a strategy of holding AIDS mortality down while at the same time lowering the number of new infections until the total number of people living with HIV begins to decline.8 According to both detection and projections, the number of new infections is still much higher than the number of AIDS deaths (around 6-8 times greater, according to detection, and approximately 3 times according to projections). While the good news is that Vietnam is effectively addressing AIDS mortality, there is a massive effort needed to reduce HIV transmission particularly in the population groups most at risk of being infected and of infecting others and in geographic areas where high risk practices take place.

The methodology used in this assessment is guided by the “principle of the vital few” otherwise known as the 80/20 principle or the “Pareto Principle.” Based on the observations of Italian Vilfredo Pareto, this principle was first stated by Joseph M. Juran (1904-2008), an early quality improvement expert.

7 8

Ministry of Health Vietnam HIV/AIDS Estimates and Projections 2007 – 2012 Over, Mead The Global AIDS Transition Center for Global Development, May 2010

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The 80/20 principle means that in any situation, a few (20 percent) are vital and many (80 percent) are trivial. In Pareto's case, it meant 20 percent of the people owned 80 percent of the wealth. In Juran's initial work, he determined that 20 percent of the defects caused 80 percent of the problems. Project managers know that 20 percent of the work (the first 10 percent and the last 10 percent) consume 80 percent of your time and resources. It is possible to apply the 80/20 Rule to almost anything, from the science of management to the physical world. In the methodology for this assessment, we use this principle to identify the “vital few” problems, causes, population groups, interventions, health system constraints and health system strengthening interventions. By focusing on the “vital few,” it is not only possible to define a critical path to reducing HIV transmission in Vietnam – as well as in other countries for that matter – but it also provides a justification for making hard investment choices in the face of competing demands and declining inflows of external resources.

For HIV prevention, the value of the Pareto Principle for country policy makers and managers is that it reminds them to focus on the 20 percent that matters most since that 20 percent produces 80 percent of the results.

2.1 Improving health system performance: the “Control knob” framework A 2008 review of health systems proposed three types of health system frameworks: descriptive, analytical, and explanatory/predictive.9,10 Descriptive models provide a basic description of the health system and commonly are organized around the six health system building blocks described by WHO. Each system element is examined independently without examination of how these parts interact, contribute to system outcomes, or why one particular system may perform better than another. In the AIDSTAR-Two methodology we found the six building block framework appropriate for describing the health system but not for understanding how it functions. AIDSTAR-Two did not use the six building block framework as the basis for making recommendations since that generally leads to applying normative standards and a focus on improving inputs and processes, e.g., 1 physician/10,000 population.

Analytical models explicitly examine how the different parts of the health system interact and produce outcomes. Systems analysis using these analytic models can be quite comprehensive or it can be used to examining the functioning of specific parts of the system. In either case the attempt is to understand how the system functions as opposed to merely describing its contents.

A third category, explanatory/predictive models are ones which, according to Hsiao and Siadat, try to answer more fundamental questions such as how policy makers can make a national health system perform better. Answering these questions could help us predict what would happen if you strengthened some system elements.

The health system strengthening framework used in this study was a combination of analytic and explanatory and sought to understand not just the causes of HIV transmission but also the causes and determinants of health system performance which are amenable to policy change. Once we understood 9

Hsiao, W. and B. Siadat (2008) “Health Systems: Concepts and Deterministic Models of Performance”, Unpublished manuscript. Harvard School of Public Health.

10 Berman, P and R. Bitran (2011) “Health Systems Analysis for Better Health System Strengthening” Unpublished manuscript.

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the causes, risk factors and populations driving HIV transmission and the system bottlenecks for high coverage of a critical few interventions we could then determine which system changes could bring about rapid improvements in system performance. This process is based on considerable analytic work which suggests that there are five factors that affect system performance. The Harvard School of Public Health describes these five factors as “policy control knobs”.11 This assessment used this control knob framework to bundle recommendations. These “control knobs” are delivery, financing, incentives, regulation, and the influencing of beliefs, preferences, and demand. Figure 1 demonstrates how the control knobs cut across each of the building blocks. Each control knob is defined below.

Figure 1: “Control Knob Framework” applied to reduction of HIV incidence in MARPS

Delivery: Interventions which affect the structure and functioning of the health system, organization, efficiency, quality and the availability of services.

Financing: Interventions which determine amount of funds available for services, the agency(ies) that controls those resources, the mechanism of resource allocation to various governmental and nongovernmental agencies, groups which have access to health care and means by which risks are pooled through insurance and other means.

Incentives and payment: Interventions which alter the incentive structure on both the supply and demand side including interventions that influence rewards and risks for 11

Inside the Black Box of Health Systems: What Are the Policy Control Knobs? William C. Hsiao K.T. Li Professor of Economics and Health Policy Harvard University School of Public Health

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providers, managers and consumers. This may also include the use of financial and other incentives to encourage proper behavior, alter demand and improve care seeking behavior in high risk populations.

Regulation: The creation, amendment or deletion of laws, policies, rules and regulations that correct market failures, improve provider performance or reduce inappropriate practices. This includes laws, rules and regulations governing the private and NGO sectors, whether and how they can exist, the range of services they can provide and the method of payment for services rendered.

Influencing beliefs, preferences and demand: The use of multiple methods, e.g., media, peer counseling, internet that influence people’s beliefs and preferences, expectations, lifestyles and behavior and the behavior of providers.

2.2 The analytic methodology utilized: Causal pathway analysis Causal pathway analysis (see diagram at right) is an analytic approach which focuses on designing projects to achieve maximum attributable health outcome. Its application in project design maximizes the probability that projects and programs will achieve desired health outcomes, helps managers make appropriate choices among competing technical interventions, programmatic approaches, inputs, processes and outputs. It also helps managers focus on the most important health system strengthening efforts and identify the most appropriate indicators for monitoring progress.

Box 1. Causal Pathway Analysis By allowing the desired health goal to dictate system requirements…

System requirements and system bottlenecks

Evidence based interventions & coverage levels

Problems, causes, populations, places, times

Measurable health goal

…we can optimize health systems to reduce HIV transmission Right inputs & processes

More outputs through improve system performance

Higher coverage

Outcomes, impact achieved

This analysis will result in a defined causal pathway linking measurable health impact to key programmatic inputs. Developing this causal chain requires users to deconstruct their project, working “backward,” starting by defining a measurable health goal and prompting a critical thought process about the linkages between the causes of poor health, populations affected, effective interventions, and systems strengthening actions.

Tracing the causal pathway to health impact requires a nine-step process as follows. Working through the analysis, assumptions are challenged and local data collected if it is available.

2.3 Nine Steps for Conducting a Causal Pathway Analysis 1.

2.

3.

4.

Identify the health impact goal: reduce AIDS related deaths.

Identify and quantify health problems to be overcome: Reduce HIV transmission.

Identify and quantify direct and indirect causes and risk factors.

Determine the characteristic of the populations that are most at-risk (time, place, geographic distribution, socioeconomic status and who have most of the problems).

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5. Identify the full range of cost effective evidence-based clinical and programmatic interventions and then identify the vital few health interventions, their current coverage levels and coverage levels required to achieve the goal.

6. Determine health system requirements to achieve the needed coverage levels.

7. Identify the few critical health systems bottlenecks to achieving required coverage levels.

8. Identify critical health system strengthening Interventions that improve the functioning and integration of the six building blocks necessary and sufficient to improve coverage levels.

9. Identify the most appropriate and key M&E indicators along the causal pathway that need to be monitored over time.

This methodology is outlined in more detail in Appendix II. The AIDSTAR-Two assessment team was comprised of a HSS expert from Management Sciences for Health and a MARPs/HIV/AIDS expert from the International HIV AIDS Alliance. An experienced local consultant was engaged in Vietnam to assist in the analysis and support was provided by the USG. The analysis was conducted during the period between September 2010 and January 2011, with two visits made to Vietnam during this time. Over 300 reports and assessments were analyzed and interviews and discussions held with key stakeholders in Vietnam, including UN agencies, international development organizations, local HIV implementing organizations, MARPs groups and government agencies.

To finalize the analysis, a review of the report was undertaken by the US Government (USG), specifically the HSS PEPFAR Technical Working Group and the USAID mission in Vietnam.

3. Country Analysis: Supporting Vietnam’s Most-at-Risk Populations through a Health System Strengthening Approach 3.1 General Background/Overview of Vietnam’s Health System The population of Vietnam is over 86 million people.12 Its economy continues to grow with GDP per capita steadily increasing from less than USD 200 in 1989 to USD 1,200 by 2010.13 Vietnam will soon progress to the lower ranks of middle income country status.

The total health budget has increased remarkably in the recent years – from 5,098 billion in 2000 to 43,048 billion dongs in 2008. This increase has far offset inflation over the same period. Such increases are due to rising government investment as well as health insurance and user fees. To secure the share of health budget, the National Assembly passed Resolution 18 in 2008, which requires the government to increase the annual budget for health care, to “ensure that health expenditure is increased at a higher rate than the state expenditure in general.”

12

General Statistics Office. Population and labourers. http://www.gso.gov.vn/default.aspx?tabid=387&idmid=3&ItemID=9865 Access January 20, 2011.

13 Ministry of Planning and Investment. 2010. Vietnam, the result of two-thirds of the road to achieving the millennium goals, toward 2015.

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For the last two decades or so, the health system has successfully mobilized financial contributions from the population through out-of-pocket payments. Other examples of success could be seen in the participation of PLHIV in the HIV response – from policy development, service provision, to monitoring implementation. People with disabilities (PWD) have also put their landmark in policy development.

However, there has been little to no organization to mobilize the participation of other populations in other health-related issues (for instance, the participation of young people, migrants, ethnic minorities and sex workers in relevant sexual and reproductive health and HIV programs). The success of the PLHIV and PWD communities has only happened with strong support from donors and international organizations to build capacity of civil society and provide leverage.

Equality and equity are a critical health sector issue. The need to institutionalize policies and practices that reduce inequalities and inequities of access to timely and appropriate health interventions remains one the greatest challenges Vietnam will face over the coming decade.

In any society, there are always populations who are hard-to-reach by the mainstream services, either due to social marginalization or their limitation in accessing services – due to geographical terrain, physical ability or financial capacity. In Vietnam, some of these populations include PLHIV, drug users, sex workers, MSM, ethnic minorities, young people, people with disabilities, as well as migrant and mobile people. These populations usually have lower access to health services, are affected more severely by some health problems, and have less desired health outcomes. In addition, they usually have special needs that are not seen in the general population. Drug users, whose HIV prevalence is more than 40 times higher than that of the general adult population, need clean needles and syringes as well as substitution therapy to curb HIV infection; these needs are not relevant to the general population.

Young unmarried women, whose abortion cases account for about one-third of the nation’s total, need contraceptive services – readily available to married couples – to be accessible and non-judgmental.

Although the Law on Protection of People’s Health stipulates people’s right to health protection, there has been almost no discussion on exercising this right. For the vast majority of the people, the notion that they are rights-holders and government institutions are duty-bearers almost doesn’t exist. Most of the popular newspapers have a feature asking for donations to help people in extremely disadvantaged situations – and the majority of these cases are people who need money to undergo certain kinds of treatment. Quite often, those who read Vietnamese newspapers come across stories about children who have to stop their schooling in order to work since their parents have a costly treatment which has put them in debt, or are unable to work due to some health conditions that they cannot afford to treat.

Strengthening awareness among the population, the government and policy makers, about people’s right to health and the government’s duty to protect people’s health, building the capacity of the rightsholder to demand their rights and of the duty-bearers to fulfill their duties, will require strong support from international partners, broad participation of civil society and the engagement of policy makers.

National AIDS response and policy framework Policy The first national body to respond to AIDS was created in 1990 even before the first HIV infection case was detected in the country. However, a comprehensive national response to HIV was not developed until 2004 with the approval of the “National Strategy on HIV/AIDS Prevention and Control till 2010 with a vision to 2020.” The goals of the strategy were “to control the HIV prevalence rate among the general

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population to 0.3% by 2010 and with no further increase after 2010,” and “to reduce the adverse impacts of HIV/AIDS on social-economic development.”14 The strategy clearly identified four priority areas for the national response by 2010: (1) behavior change communication; (2) harm reduction; (3) counseling, care and treatment for PLHIV; and (4) strengthening the M&E system. This is the first time that harm reduction was addressed in concrete language with specific targets in a document at such a level. One of the strategy’s specific objectives is to “control HIV/AIDS transmission from high-risk groups to the community through implementing comprehensive harm reduction intervention measures: all people with high-risk behaviors at risk of HIV/AIDS infection shall be covered by intervention measurers; 100% safe injection and condom use when having risky sex.”15 To achieve these goals and objectives the strategy outlined eight programs of action: (1) behavior change communication; (2) harm reduction; (3) care and treatment; (4) prevention of mother-to-child transmission (PMTCT); (5) sexually transmitted infections (STI); (6) blood safety; (7) M&E; and (8) international cooperation.

However, most of those national programs of action were not approved or implemented at a scale until after the Law on HIV/AIDS Prevention and Control was authorized by the National Assembly in 2006 and came into effect in January 2007, three years after the strategy was signed by the Prime Minister. This law, centered on the human rights of PLHIV, prohibits stigma and discrimination, safeguards all human rights of adults and children living with HIV, guarantees free ARV treatment for pregnant women among others, encourages mainstreaming HIV into social economic development, and – as an important breakthrough – permits distribution of needles and syringes for injecting drug users, condoms for sex workers, and substitution therapy for drug users.

The Action Plan on Harm Reduction 2007–2010, however, was not a direct result of the AIDS Law. It was only approved in September 2009 after a government decree issued in June 2007 provided concrete regulations for the implementation of the law, in particular the harm reduction interventions. The road toward scaling up harm reduction interventions in Vietnam as described above reflects the complexity of the policy making process in Vietnam, especially when it involves a controversial issue such as providing needles for drug users and condom to sex workers.

The government’s response to HIV has always been coupled with its response to so-called “social evils,” such as drug use and sex work. To this day, the official governing body of the national HIV response is the National Committee for Prevention and Control of AIDS, Drugs and Prostitution. This committee is probably the most important symbol of the government’s understanding of HIV and its approach to control it. Although efforts to counter stigma against PLHIV have shown some success in separating HIV from the concept of “social evils,” the perceptions that HIV is the inevitable result of drug use and sex work, that only “evil” people get the disease, or that those who have the disease must have done something “evil,” are still very common among policy makers as well as the population.

The Action Plan on Harm Reduction set the goal of reducing HIV prevalence among PWID to under 20% and under 3% for sex workers. The action plan also aims to build a cadre of government staff to work on 14

National Committee for AIDS, Drug and Prostitution Prevention and Control. 2004. The National Strategy on HIV/AIDS Prevention and Control in Vietnam till 2010 with a vision to 2020. Medicine Publishing House.

15 Ibid.

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harm reduction in all provinces. It sets out to achieve 90% condom use among sex workers, and 80% of sex workers receiving STI examination and treatment. For people who use drugs, the action plan is set to achieve 90% clean injections, reduce needle sharing to 10% among PWIDs and 5% among infected PWIDs. The plan also aims to have substitution therapy provided in at least 10 provinces by 2010.

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Table 1. Targets for the national program by 2010 Source

Indicators

Targets

National Strategy

HIV prevalence among general population

0.3%

National Harm Reduction Action Plan

HIV prevalence among drug user

<20%

HIV prevalence among sex workers

<3%

% of sex workers using condoms

90%

% of sex workers receiving standardized STI services

80%

% of drug users using clean needles

90%

% of drug users sharing needles

10%

% of HIV positive PWID sharing needles

5%

Implementation of substitution therapy % of AIDS patients receiving ARV treatment

At least 10 provinces 100% children 70% adults 90% TB patients

% of ARV needs covered by locally produced ARV

50%

% of districts capable of providing HIV treatment

70%

National Care and Treatment Action Plan

Structure of HIV response The HIV response in Vietnam is governed and implemented by the government system, and financed by international donors. It is only with extraordinary effort that the non-governmental sector can find any space in the response. Both the strategy and the law relating to the organization of the AIDS response refer only to governmental systems. PLHIV, community and other non-governmental institutions are not key stakeholders and are barely mentioned as participants.

At the level of policy setting, the National Committee for Prevention and Control of AIDS, Drugs and Prostitution is chaired by a Deputy Prime Minister, and its members are representatives from different ministries, and government-funded and staffed organizations. This model is replicated across lower levels of the administration at the provincial and district levels. No space has been created for the participation of community and other civil society representatives within such institutions and structures.

For implementation, the Ministry of Health has gradually created a vertical and almost uniform system for HIV/AIDS interventions from the central level with the Vietnam Administration of AIDS Control (VAAC) to the provincial level with Provincial AIDS Center. There is a HIV team in each district preventive medicine center, and a staff person in charge of HIV across each commune health station. This system, rather than focusing on coordination, is now preoccupied with implementing various HIV projects, such as those from the Global Fund, bilateral and multilateral funded projects, and government-funded programs.

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Funding VAAC controls the majority of AIDS related funding. Other departments at the MOH or other governmental bodies have no share of this funding. This has the tendency of making the governmental vertical AIDS system the sole implementer of the national AIDS program.

State funding for HIV and funding that is managed by VAAC has never been shared with a truly nongovernmental institution. This issue was raised during the third UNGASS Report with a recommendation that part of government funding for HIV should be allocated to the civil society sector. There has been no response to this recommendation. Keeping funding for themselves, being a vertical system under the portfolio of preventive medicine, the VAAC system has little influence over non-governmental and governmental non-AIDS institutions.

Most of the major donors for AIDS in Vietnam reinforce this situation by directing their funding through this system. PEPFAR is probably the first major donor to distribute funding between different stakeholders, thus mobilizing a large number of institutions, including international organizations, academia, community-based organizations and NGOs, as well as AIDS and non-AIDS, health and nonhealth governmental agencies to engage in the response. This avoids putting the burden of implementation on the VAAC system, drawing them back to their position of coordination, and at the same time increasing the efficiency of the funding. Other smaller funding mechanisms such as the Collaborative Fund or Irish Aidâ&#x20AC;&#x2122;s Civil Society Facility, which provide small grants to a number of NGOs and CBOs, have also helped those organizations to grow.

Without PEPFAR and such funding mechanisms, it is likely that few non-VAAC institutions would be working on HIV or advocating for issues that concern PLHIV and most-at-risk populations. With the Global Fund (round 9) now providing resources to the Ministry of Labor, War Invalids and Social Affairs (MOLISA), the Ministry of Public Security (MOPS) as well as civil society, one can expect to see more and stronger non-AIDS, non-governmental institutions working on HIV-related issues.

Civil Society Despite a range of significant barriers, it must be recognized that civil society participation in the response is growing rapidly. The fourth UNGASS Report acknowledges that civil society participates in providing all essential HIV services, and had provided 51-75% of home-based care services, 25-50% of prevention for youth, prevention for MSM, care and support for OVC, and some prevention services for PWID, SWs, as well as testing and counseling, and HIV treatment.

Civil society not only provides services but is also active in advocacy around key issues, such as legalizing harm reduction, fulfilling the education rights of children living with HIV, or tackling stigma against PLHIV. It is largely or partly because of civil society that these issues were raised, debated and resulted in appropriate policy.

However, civil society in Vietnam is still at a nascent stage. Most NGOs are small and do not have an accountable governing mechanism or an efficient management system. With some exceptions, CSOs are loosely organized, and heavily dependent on donor funding. This situation is partly due to lack of recognition from the government, and lack of financial and political support from donors. Funding for CSOs is mostly for service delivery. It is very rare that substantial funding is provided for organizational capacity strengthening or for network building. The effort to network CSOs into the Vietnam Civil Society Partnership Platform on AIDS has yielded an unexpected result of having around 200 members from almost 40 provinces, and reflects the readiness of CSOs to network and to participate in the response.

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However, initiatives such as VCSPA will need continuous support to bring about the result of having a united civil society platform that will have impacts in advocacy or in service delivery.

Achievements Among the most recognizable achievements of the response to HIV in Vietnam is the rapid scale up of ARV treatment, the positive change in environment for harm reduction activities, and the scaling up of harm reduction interventions.

According to MOH’s report to the Deputy Prime Minister,16 by the end of September 2010 there were 315 ARV treatment sites delivering treatment to almost 45,000 adults and children. On the prevention side, in the first six months of 2010, nearly 8.4 million condoms had been distributed in 5,388 communes of 494 districts (out of a total of approximately 700 districts) of 60 provinces (of 63 provinces). According to the same report, for the first six months of 2010, nearly 11.9 million needles and syringes were distributed in 2,900 communes of 298 districts of 60 provinces. It also reported that needles and syringes had been distributed through 2,159,565 contacts with people who use drugs. MMT has been more welcomed and is being scaled up as well. By early October 2010, there were 12 MMT sites in five provinces. Three more provinces were ready to start MMT. MOH also reported a large number of personnel involved in HIV activities, with more than 3,500 peer educators for drug users, more than 2,300 peer educators for sex workers, 152 peer educators for MSM and more than 9,700 outreach workers.

These numbers, regardless of accuracy, clearly indicate a relatively favorable environment for HIV prevention and treatment.

Gaps and Weaknesses The majority of the targets in the Harm Reduction Action Plan have not been met. The 2009 HIV/STI Integrated Biological and Behavioral Surveillance (IBBS) indicated that prevalence among PWIDs was over 31% (although data from sentinel surveillance gave the result of 18.6% for the same year).

Prevalence among SWs was 4.5% in 2010 according to sentinel surveillance and more than 9% in 2009 according to IBBS 200917. The 2009 IBBS found needle sharing in the preceding six months to range from 17 to 54% in 9 out of 10 surveyed provinces. Consistent condom use among SWs with clients in the preceding month did not reach 90% in any province as set in the action plan, and was found to be as low as 21% in some provinces. MMT was implemented in five provinces, not the target of 10. More importantly, in comparison with the previous IBBS, reported needle sharing increased and consistent condom use with clients decreased in some provinces.18

Challenges for prevention A significant challenge for the HIV response in Vietnam is the reliability of data. The picture presented by data collected by the routine government system is often “more encouraging” than that presented by data collected through special surveys. Also the number of new infections, and HIV prevalence 16

MOH. 887/BC-BYT. Report on HIV/AIDS Prevention and Control during the 9 months of 2010 and direction in 2011. October 29, 2010.

17 th Government of Vietnam. The 4 UNGASS Report.

18 NIHE-VAAC-USAID-CDC-FHI. Second generation integrated behavioral and sero surveillance survey. Round 2, 2009. Presented at the Plenary 1, the third National Scientific Conference on HIV. Hanoi, December 2010.

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among PWIDs and SWs, differ between regular reporting systems and sentinel surveys, and the national estimates/projections and the IBBS. An additional, striking example of varying and unreliable data is the information available on needle and syringe distribution. The MOH reports almost 24 million clean needles are distributed per year. Based on these figures, 120,000 PWIDs could have received 200 free needles per year – the definition of very good coverage by WHO/UNODC/UNAIDS. This number would constitute almost all, if not all, PWIDs living in the community. However, the IBBS 2009 revealed that in 10 surveyed provinces (most of which are focus provinces for PEPFAR as well as the Global Fund and national program), only 17% of PWIDs surveyed reported ever getting a free clean needle within the six months prior to the survey. In a survey among female PWIDs in Hanoi and Ho Chi Minh City, as many as 99% of respondents in Hanoi and 95% in Ho Chi Minh City reported that their regular source of needles are pharmacies, not peer educators or fixed site services.19 The other important challenge is the quality and effectiveness of the harm reduction program. With reportedly thousands of peer educators and outreach workers, and an extensive coverage of harm reduction interventions across thousands of communes, and tens of millions of condoms and needles distributed, one might expect better outcomes and impacts. During the discussion with the team writing this report, peer educators described inappropriate needles (auto-disposable syringes while PWID use front-loading, needles are too big and not sharp enough for women or for those who have weak veins or want to hide the injection mark). More importantly peer educators are paid a monthly incentive to meet a certain quota of reach and needle distribution; they thus opt to report a good number in order to get their money. Meanwhile, needles are only distributed through the government system, and not through self-help groups of drug users.

Prevention among MSM is another challenge. MSM were included in the sentinel surveillance system only in 2010 and few provinces are implementing MSM interventions. Prevalence among MSM in four provinces surveyed in IBBS 2009 ranged from 5% among MSM who did not report transactional sex in Can Tho to almost 20% in Hanoi, as illustrated in Figure 2 on the following page. It is not only that the prevalence was high, but IBBS 2009 reflected an increase in prevalence in Hanoi and Ho Chi Minh City which were included as focus sites for the 2006 IBBS. The four surveyed provinces of the 2009 IBBS are the sites for long running MSM interventions implemented by Family Health International (FHI). The fact that HIV prevalence among those who reported selling or buying sex in Hanoi and Hai Phong were lower than among those who did not may indicate that the intervention had reached men who sell sex to men but not those who were not involved in transactional sex.

19

Nossal Institute. Harm reductions needs among female PWIDs in Hanoi and Ho Chi Minh City (preliminary results – unpublished).

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Figure 2. Prevalence among MSM in Four Provinces

IBBS 2009 100 % 81

80 60

MSM reported transactional sex

40 20

14.3

19.9

14.8

16.6

16.4

14.4

8.9

MSM who did not

5

0 Hanoi

Hai Phong

HCMC

Can Tho

The increase in share of sexual transmission emphasizes the importance of prevention of intimate partner transmission. A survey in Hanoi in 2008 discovered prevalence of 14% among female sexual partners of male drug users.20 Another survey of 2,600 people living with HIV found that around onethird of men living with HIV were in a sero-discordant or sero-unknown relationship.21 However, prevention intervention among sexual partners of drug users has only been in a piloted project, and interventions among negative partners of PLHIV has only recently started on a small scale by an NGO.

3.2 Epidemiology According to the official report from the MOH, by September 2010, there were 180,312 registered people living with HIV (PLHIV) in Vietnam, among them 42,339 people had developed AIDS. By the end of 2012 the Ministry of Health projects that 254,387 people will be HIV positive.22 The number of new cases is trending downward. The same holds true for death rates from AIDS, although the total number of deaths is projected to fluctuate through 2012. The picture seems promising although this can be misleading.

Vietnam is still far from achieving an AIDS Transition, the point at which new HIV infections equal the number of AIDS deaths. Achieving this transition point is accomplished through a strategy of holding 20

Ted Hammet et al. 2010. Female sexual partners of injection drug users in Vietnam: an at-risk population in urgent need of HIV prevention services. AIDS Care. 2010 Dec;22(12):1466-72 21

ISDS and VCSPA. Sexual and Reproductive Health Needs of PLHIV. Presented at the workshop “Linkage SRH and HIV” organized by MOH, UNFPA and WHO. Hoa Binh, November 2009.

22

Ministry of Health Vietnam HIV/AIDS Estimates and Projections 2007 – 2012

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AIDS mortality down while at the same time lowering the number of new infections until the total number of people living with HIV begins to decline.23 According to both detection and projections, the number of new infections is still much higher than the number of AIDS deaths (around 6-8 times greater, according to detection, and approximately 3 times according to projections). While the good news is that Vietnam is effectively addressing AIDS mortality, there is a massive effort needed to reduce HIV transmission particularly in the population groups most at risk of being infected and of infecting others and in geographic areas where high risk practices take place.

Rates The first case of HIV was detected in 1990. By September 2010, more than 180,000 people were registered as living with HIV, with more than 42,000 people considered to have progressed to AIDS. More than 48,000 people have died of AIDS related illness. 24 The actual number of PLHIV was estimated to be more than 254,000 in 2010 and will continue to rise to over 280,000 in 2012.25 Different data sources provide different pictures of the epidemic. According to the MOH’s official report to the Deputy Prime Minister referring to newly detected cases, after the peak of around 29,000 cases in 2006 and 2007, the number of cases of HIV reduced to an estimated 18,000 in 2008 and 15,700 in 2009.26 For the first nine months of 2010, newly detected cases of HIV were over 9,000, indicating a reduction of around 26% in comparison to the same period of 2009.27 For the same period, data extrapolated from MOH’s HIV/AIDS Estimate and Projection shows no sign of reduction regarding new infections (from 18,774 in 2008 to 19,030 in 2009 and 19,482 in 2010). The rapid increase in 2006 and 2007 may be due to the increasingly available testing services and ARV treatment while the seeming reduction in recent years could be an indication of increasing transmissions among the general population; a population which is much less tested than the most-at-risk populations.

The HIV epidemic in Vietnam is still in a concentrated phase although different data sources produce different numbers. HIV prevalence among people who inject drugs ranges from 18.6% (according to the sentinel surveillance) to 31.5% (according to IBBS 2009); prevalence among female sex workers can be 3.2% (sentinel surveillance) or 9.1% (IBBS 2009); and prevalence among MSM can be as high as 14.2%.28 In the meantime, prevalence among the general population remains well below 1%.

In terms of transmission mode, among the cases detected in the first nine months of 2010, approximately half (49%) were due to unsafe injecting, 38% through unsafe sexual contact, 3% mother to child, and 10% unknown.29 The proportion of newly detected cases of HIV acquired through unsafe 23 24

Over, Mead The Global AIDS Transition Center for Global Development, May 2010

MOH. 887/BC-BYT. Report on HIV/AIDS Prevention and Control during the 9 months of 2010 and direction in 2011. October 29, 2010.

25

MOH. 2009. Estimate and Projection of HIV/AIDS in Vietnam 2007 - 2012.

26

MOH. 199/BYT-AIDS. Report HIV/AIDS situation in 2009. Hanoi, April 6, 2010.

27

MOH. 887/BC-BYT. Report on HIV/AIDS Prevention and Control. October 29, 2010.

28

Government of Vietnam. 2010. The Fourth Country UNGASS report.

29

MOH. 887/BC-BYT. Report on HIV/AIDS Prevention and Control during the 9 months of 2010 and direction in 2011. October 29, 2010.

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sexual encounters increased significantly – from 12% in 2004, to 27% in 2008, and 29% in 2009.

Meanwhile, the share of infections through unsafe injection has decreased from 55% in 2009. The share of women among the infections was more than 29% in this period, an increase from 27% in 2009 and 19% in 2007.30 Age group Approximately 85% of people living with HIV in Vietnam are between the ages of 20 to 39. The “aging” of the PLHIV community is evident over the last two years, as the proportion of PLHIV in the age group 20-29 has gradually reduced from 52.7% in 2006 to 45.4% in 2009, as illustrated in Figure 3, below.

PLHIV in the age group 30-39 increased from 30 to 39.7% over the same period.

Figure 3. Distribution of age-group of reported cases of by year

Source: MOH’s report to Deputy Prime Minister, #1991/BYT-AIDS. 2010.

30

MOH. 199/BYT-AIDS. Report HIV/AIDS situation in 2009. Hanoi, April 6, 2010.

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Gender Men still make up the majority of PLHIV in Vietnam, accounting for more than 70% in 2010. However, the increase the share of women in the number of PLHIV has increased notably – from just 18% in 2008 to 29.3% in 2010. Figure 4, below, demonstrates the trend.

Figure 4. Distribution of gender among HIV cases – 1994 to September 201031.

 Female  Male Geographical distribution Figure 5 presents the significant regional differences evident in transmission routes and thus risk behaviors over time. While in the Northern regions, unsafe injecting drug use has remained the major cause of infections, the opposite is true for the Mekong River Delta, where only a relatively small proportion of infections have been attributed to injections. In the region where Ho Chi Minh City is located (South East), an increase in the share of injection as the route of transmission can be seen, to as much as half of the infections. This region is also the only one of the seven regions where the proportion of infections through injection has increased.

31

Nguyen Tran Hien. HIV infection in Vietnam. Presented at the opening session of the National AIDS Conference.

Hanoi, Nov 2010.

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Figure 5: Distribution of route of transmission among PLHIV by region, from 1990 to 200932

Choice of the priority geographic areas of focus Based on the epidemiologic analysis, the current AIDS response and the different categories of risk, this section provides an overview of what the priority geographies are and the priority with which targeted interventions for prevention and treatment should be directed. There were three criteria used to select these geographic areas: (1) congregation of MARPs; (2) congregation of PLHIV; and (3) frequency of sexual interaction between HIV- MARPs and MARPs with PLHIV. Using these three criteria, five high priority geographic areas in Vietnam for targeting interventions have been identified: Ranking #1: Ranking #2: Ranking #3:

Ranking #4:

Ho Chi Minh City, Hanoi, Hai Phong (high concentration of all MARPs and high number of PLHIV) An Giang, Son La, Thai Nguyen, Nghe An (high concentration of at least 1 MARP and high number of PLHIV) Quang Ninh, Da Nang, Thanh Hoa, Can Tho, Dong Nai, Ba ria â&#x20AC;&#x201C; Vung tau, Dien Bien, Tay Ninh, Kien Giang, Hau Giang, Lam Dong in that order (high concentration [top 5] of at least one MARP or moderate concentration [top 10] of at least considered populations and mild concentration [top 15] of one considered population) Hoa Binh, Thai Binh, Hai Duong, Lai Chau, Binh Thuan, Yen Bai (moderate concentration of at least one considered population or mild concentration of at least 2

32

Nguyen Tran Hien. HIV infection in Vietnam. Presented at the opening session of the National AIDS Conference.

Hanoi, Nov 2010.

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Ranking #5:

considered populations) Lao Cai, Ha Tinh, Khanh Hoa, Ca Mau, Phu Tho, Phu Yen, Dong Thap, Binh Duong, Dac Lac, Vinh Phuc (mild concentration of at least one considered population)

Table 2. Distribution of MARPs and PLHIV in ranked province groups Rank #1 #2 #3 #4 #5 Total in 5 ranks

PWID 39% 18% 12% 12% 7% 89%

SW Urban male 37% 37% 5% 6% 19% 20% 6% 6% 15% 11% 82%

PLHIV 40% 11% 16% 8% 8%

79%

83%

No. of provinces 3 provinces 4 provinces 11 provinces 7 provinces 10 provinces 34 provinces

Behaviors Unsafe injection appears to be the most common route of transmission, accounting for at least half of transmissions. This is followed by unsafe sex. In addition to unsafe injections among PWIDs and unsafe sex between sex workers and their clients, the interaction between drug use and sex work, and sexual transmission between drug users, sex workers, people living with HIV and their intimate partners make the behavior picture more complicated.

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Injection risks Data from different sources suggests that while PWIDs do not share needles very frequently, it is difficult for them to achieve consistent safe injection. While IBBS 2009 indicates that as many as 93% of surveyed PWIDs reported using a clean needle in their last injection, a survey conducted in a World Bank-funded project sites in Son La and Vinh Long provinces found only 74.5% and 87% of surveyed PWIDs reported consistent use of clean needles in the last six months.33.

With the exception of Hai Phong, sharing needles in the previous six months was reported by between 16.7% and 54% of PWIDs in nine other provinces. More notably, among seven provinces surveyed by both IBBS 2006 and IBBS 2009, reported needle sharing increased in four provinces â&#x20AC;&#x201C; from 12% to 19% in Hanoi, 14% to 24% in Quang Ninh, 29% to 39% in Da nang and 33% to 54% in An Giang.

33

Figure 6. Reported needle sharing among PWIDs

100 % 80

% IDUs reported needle sharing in the last 6 months Hai Phong

60

HCMC

40 20

Can Tho

0

2006

2009

th

4 UNGASS Report.

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Sexual risks Multiple sexual partners are common among MARPs. In nine out of 10 IBBS 2009 provinces, between 23% and 62% of participating PWIDs reported having two or more sexual partners in the last 12 months.

Among MSM, it is more common to have multiple partners, with 35% to 62% of surveyed MSMs reporting having two or more partners in the past month.

Sexual mixing – having both MARP and non-MARP partners – is also reported by fairly high percentages of MARPs. In Hanoi, for example, among 300 PWIDs interviewed in the IBBS 2009, 70% reported having had sex in last 12 months, 60% reported having sex with regular partner(s), 48% reported having sex with sex worker(s), and 19% reported having casual partner(s).

Figure 7. Interactions among MARPs and with non-MARPs

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MSM reported a complicated mix of sexual partners, including male sex workers, consensual male sex partners, female sex workers, female clients, and female regular sexual partners (see Figures 8 and 9, below). Sex workers reported having regular partners, regular clients and one-time clients.

Figure 8. Type of sexual partners reported by MSM who reported selling sex 100 %

84

80 74

80

Male sex workers

60

51 40

40 20

33

29 10

9

FSW

23 7

4

4

9

4

0

11 4

3

Female client

1

0 Hanoi

Hai Phong

Consensual partners

HCMC

Female regular partners

Can Tho

Figure 9: Types of sexual partners reported by MSM who reported not selling sex 100 %

85

80 60

56

51

47

38

40

Consensual partners

35 25

20

20

46

Male sex workers

FSW

18 Female client

6

0

4

0

5

5

Female regular partners

0 Hanoi

Hai Phong

HCMC

Can Tho

Inconsistent condom use Inconsistent condom use among female sex workers is common in a number of provinces. As shown in Figure 10, below, reported consistent condom use with clients could be as high as 85%-86%. In some provinces, it can be as low as 21% (among venue-based SWs in Dong nai and 23% among street-based SWs in Ho Chi Minh City). More importantly, among the seven provinces participating in both IBBS rounds, the reported consistent condom use among SWs was seen to decrease in four provinces â&#x20AC;&#x201C; most seriously in Ho Chi Minh City â&#x20AC;&#x201C; from 61 to 23% among venue-based SWs and from 72 to 32% among street-based SWs.

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The more intimate the relationship is, the less likely that condom is used. Figure 9 below shows that across IBBS 2009 provinces, condom use – either at last sex or consistent use in the last month – is reportedly highest with sexual encounters with one-time clients, lower for regular clients, and very low with regular partners. It is also notable that while the vast majority of sex workers use condoms, in some provinces, levels of consistent condom use are low even with one-time and regular clients. In Ho Chi Minh City, for example, while 80% of street-based sex workers (SSWs) reported using a condom during the last sexual encounter with a one-time client, only 31% reported consistent use in the last month with this type of client. Condom use during last sex and during the last month is reported less for regular clients – 64% and 26.6% respectively. With regular partners, condom use is reportedly even less – at 16.8% and 5.5%. A similar trend is observed among venue-based sex workers (VSWs).

Figure 10. Condom use during last sex and consistent condom use in the last month with different types of partners, reported by street-based sex workers* 100 90 80 70 60 50 40 30 20 10 0 Hanoi

Hai Phong

HCMC

An Giang

Nghe An

Dong Nai

Yen Bai

Last time wt 1-time client

Consistent wt 1-time client

Last time wt reg client

Consistent wt reg client

Last time wt reg partner

Consistent wt reg partner

*Constructed from IBBS 2009 data

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Similar to female sex workers, PWIDs reported significantly less condom use with regular partners than with casual partners. Condom use with sex workers was less again. Consistent condom use is low across all partner types (37% to 74% with sex workers, 18% to 71% with casual partners) with the lowest levels evident with regular partners (16% to 53%).

Figure 11: Condom use during last sex and consistent condom use in last 12 months with different types of sexual partner, reported by PWIDs* 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi

Hai Phong

HCMC

SW - last time Casual - last time Reg partner - last time

An Giang

Nghe An

Dong Nai

Yen Bai

SW - consistent Casual - consistent Reg partner - consistent

*Constructed from IBBS 2009 data

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As illustrated in Figure 12, below, data on condom use among MSM who reported selling sex shows a similar trend to that of FSWs and PWIDs â&#x20AC;&#x201C; with the majority of MSM using condoms but only a small proportion doing so consistently. Condoms were more likely to be used in transactional sex, and less so with consensual partners, either male or female (19% to 34%).

Figure 12: Condom use during last sex and consistent condom use in last 12 months with different types of sexual partner, reported by MSM who also reported selling sex* 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi Last sold sex Last MSW Last consensual male Last FSW Last female client Last consensual female

HCMC Consistent male client Consistent MSW Consistent consensual male Consistent FSW Consistent female client Consistent consensual female

Multiple risks A significant proportion of MARPs surveyed in IBBS 2009 reported multiple risk behaviors. Between 11% and 32% of MSM reported ever using drugs, with 2% to 8% reporting injecting drugs. Among those who ever injected, with the exception of those surveyed in Hai Phong, between one-fifth and half of the injectors reported having ever injected with a needle used by someone else. In addition to that, 7% to 30% of MSM reported that their sexual partner injected drugs. It is apparent that some male injectors are included in the MSM groups for selling sex to men although they do not identify as gay.

FSW injectors or female PWIDs selling sex are no longer rare case in cities like Hanoi, Hai Phong, Ho Chi Minh City or Can Tho where 1% to 8% of venue-based SW and 5% to 18% of street-based sex workers reported injecting drugs.

Among female PWIDs, a recent study found 67% of female PWIDs in Hanoi and 34% in Ho Chi Minh City reported selling sex as their main source of income.34

34

Nossal Institute and SCDI. Harm Reduction needs of female PWID in Hanoi and Ho Chi Minh City (report in progress)

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Distribution of infections Using data from MOH’s Estimation and Projection 2007 – 2012, the team came up with the estimation that around 30% of people who are currently living with HIV are among the MARPs, leaving the majority of HIV cases (around 70%) among the general population and bridging populations such as primary partners of drug users and male clients of SW. Figure 13. Distribution of Current HIV Infections

While MARPs account for about 30% of current infections, their share of new infections is even greater – 45% of total new infections. This estimation is made using population size estimation as in MOH’s Estimate and Projection 2007-2012, using incidence of 5.2% for PWID as shown in research by Vu Minh Quan et al; of 1% for sex workers as a rough estimation based on sentinel surveillance and IBBS, and 4% for MSM based on IBBS. MARPs are disproportionately affected by HIV and play a very important role in driving the epidemic in Vietnam. For a total of just above half a million people or around 6% of the country’s total population, MARPs account for 30% of current infections and 45% of new infections. There is not enough data to estimate the transmissions occurring among general population responsible by MARPs, but it is most likely that a significant proportion of new infections among non-MARPs are the results of transmission from MARPs.

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Figure 14: Distribution of new infections among different populations

Recommended MARP groups for interventions People who inject drugs: male, female Sex workers: female, male Men who have sex with men: gay, bi-sexual, straight men selling sex

As illustrated in Figure 14, above, the most vulnerable groups apart from MARPs are male clients of sex workers and the primary sexual partners of PWIDs. However, these groups usually do not have risky interactions and thus are less likely to transmit the infection. As such, the MARP populations are those with the most epidemiological importance; these include male and female drug users, female and male sex workers, and men who have sex with men.

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There are four population groups in Vietnam at risk of being infected or transmitting the infection.

Those with the highest risk are (1) PWIDs, CSWs and MSM who are categorized as most at risk (MARPs).

They are followed by: (2) non-MARP vulnerable populations who are at a higher risk of being infected due to sexual interaction with a MARP or PLHIV (this group includes regular sexual partners of PWID, SW, MSM, PLHIV and clients of SWs); (3) non-MARP PLHIV who are HIV+; and( 4) the general population.

While distinctly different, these groups are connected in a transmission network as shown in Figure 15, below. In this illustration, the blue boxes signify groups falling into category 1, MARPs; the green boxes, category 2; the orange boxes, category 3; and the purple boxes, category 4. All these groups are linked through a network of sexual activity with the exception of PWID, in which the transmission of HIV occurs through unclean needles and syringes. In terms of infections averted, a focus on categories 1 and 2 would result in the greatest impact.

Figure 15: HIV transmission network and populations at risk of being infected or infecting others

MARPs are the most critical chain link in the transmission network due to their high prevalence of HIV coupled with multiple unsafe sexual and/or injection interactions – most importantly during the highly infectious acute undiagnosed period – within and beyond their own population. The general route of transmission is more likely to go from MARPs to vulnerable people and from there to the general population.

Among non-MARP vulnerable people, regular partners of MARPs and of PLHIV are at a moderate to high risk of being infected from their intimate sexual partners but in turn, much less likely than MARPs to transmit the virus to others. Clients of SWs are at a moderate risk of being infected and likely to

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transmit only to their one intimate partner. Non-MARPs who are diagnosed HIV+ are most likely in the asymptomatic phase of HIV infection or on ARV and likely to have sexual interaction with a limited number of sexual partners – many of whom are already infected, thus at a moderate risk of transmitting HIV further. The non-MARP, non-vulnerable populations are at very low risk of being infected or transmitting HIV to others.

3.3 Characteristics of MARPs As mentioned above, MARPs are the critical population driving the HIV epidemic in Vietnam and are therefore the key to addressing the epidemic. MARPs account for a very small proportion of the population and they are clustered in specific geographies in Vietnam. At risk behaviors of MARPs, in fact, are few, and thus require a limited set of interventions. Population sizes used for the MOH’s estimate and projection shows that, in medium scenario, the total size of MARPs in Vietnam is just above 570,000 people – or around 1.3% of the reproductive-age population. The same data reveal that MARPs make up less than 27% of all PLHIV in Vietnam. Focusing on MARPs (and vulnerable people who are associated with them) means investing in a relative small, concentrated, identifiable segment of the population.

Given that the burden of HIV transmissions and prevalence lies with the MARP groups, from a public health perspective, investing in a few highly cost effective interventions targeting these groups would yield a high return on investment in terms of HIV cases averted.

Strategies for targeting MARPs and vulnerable populations (represented in categories 1 and 2 in Figure 15 on the preceding page) have to take into consideration both their risk level as well as their ability to be reached. Reach is critical for achieving scale. Focusing attention initially on the highest risk but easiest to reach MARPs and vulnerable populations will yield the greatest impact in terms of reduced HIV transmission in the shortest possible time.

Figure 16, below, and Figure 17, on the following page, demonstrate this stratification. The shaded boxes are the populations at highest risk of infection or transmitting the infection, but also the easiest to reach. The populations in these shaded cells could be Vietnam’s primary initial focus for a targeted strategy.

Higher risk Undisclosed gay men MARPs who use ATS Amateur sex workers Long-term detained PWID Unregistered PWID Venue-based F/MSW Call-girl/boy, mobile, internet-based F/MSW Male regular partners of FSW/Female PWID Regular clients of injecting F/MSW Regular clients of F/MSW Spouses of untreated, undisclosed PLHIV Older gay men Lower risk

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Female PWID Injecting FSW Registered PWID Injecting MSM Street-based FSW Street-based MSW Homeless injecting children Young gay men MARPs that have STD Female regular partners of PWID Spouses of treated PLHIV

Easier to reach

Harder to reach

Figure 16. Risk of being infected

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Figure 17. Risk of transmitting HIV

Untreated positive MARPs who use ATS Untreated positive long-term detained PWID Untreated positive MSM Undisclosed untreated PLHIV Untreated positive unregistered PWID Untreated positive undisclosed gay men Untreated positive venue-based F/MSW Untreated positive call-girl/boy, mobile, internet-based F/MSW Newly infected clients of SW Non-MARP spouses of MARPs

Newly infected MARPs Untreated positive injecting FSW Untreated positive FPWID Untreated positive registered PWID Untreated positive injecting MSM Untreated positive street-based FSW Untreated positive street-based MSW Untreated positive homeless injecting children Untreated positive young gay men Positive MARPs that have STD Treated positive MARP/non-MARP

Easier to reach

Harder to reach

Higher risk

Lower risk

Drug users According to official statistics from MOLISA, Vietnam has more than 140,000 registered drug users, with an estimated 111,000 of these being injectors. Consultation with drug users from different provinces suggest that registered drug users may account for only around 65% of all drug users. Using data provided in the MOHâ&#x20AC;&#x2122;s HIV/AIDS Estimate and Projection by region and HIV prevalence in each region, the following table was produced.

Table 3. Estimates and prevalence of HIV in PWID in regions of Vietnam

Region North West North Plateau North East Thai Nguyen Hai Phong Quang Ninh Red River Delta North Central Central coast

Estimated number of PWIDs (medium scenario) 42302 14312 7580 8255 5534 1832 19995 834 1812

PWID HIV prevalence 24.2% 22.5% 24.2% 37.4% 61.9% 55.8% 26.3% 14.5% 12.1%

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Estimated number of PWID+ 10237 3220 1834 3088 3425 1022 5259 121 219

Share of all PWID+ 21.3% 6.7% 3.8% 6.4% 7.1% 2.1% 11.0% 0.3% 0.5%

Estimated number of PWID32065 11092 5746 5168 2108 810 14737 713 1593

Share of all PWID27.0% 9.3% 4.8% 4.3% 1.8% 0.7% 12.4% 0.6% 1.3%

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Region Khanh hoa Central highland South East An Giang Can Tho Mekong delta Hanoi HCMC Total

Estimated number of PWIDs (medium scenario) 772 1960 5720 1677 1440 6600 24272 26229 171126

PWID HIV prevalence 29.3% 22.3% 15.5% 13.6% 45.7% 22.0% 32.9% 45.2%

Estimated number of PWID+ 226 437 887 228 658 1452 7986 11856 52155

Share of all PWID+ 0.5% 0.9% 1.8% 0.5% 1.4% 3.0% 16.6% 24.7% 100%

Estimated number of PWID546 1523 4833 1449 782 5148 16287 14374 118974

Share of all PWID0.5% 1.3% 4.1% 1.2% 0.7% 4.3% 13.7% 12.1% 100%

Age distribution varies across provinces. Provinces with earlier epidemics of drug use, like Hanoi, Hai Phong, Quang Ninh and Yen Bai have more than 50% to 80% of PWIDs in the age-group of 30 or older, while provinces with more recent drug use epidemics such as Dong nai or An Giang have a younger population of PWIDs, with the majority younger than 30 years old.

Figure 18: Age Distribution among People Who Inject Drugs 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi Hai Phong Quang Ninh

Nghe An Yen bai Da Nang Dong Nai

< 20

20- 25

25- 30

HCMC

Can Tho An Giang

>=30

Age distribution of PWIDs indicates an ‘aging’ population. In Ho Chi Minh City, for example, 77% of PWIDs were 25 years old or younger in 2006 compared to 52% in 2009. This is possibly due to the fact

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that young people nowadays start first with oral/inhaling ATS. Also, increased access to an ARV treatment program since 2006 has likely reduced mortality among HIV+ PWIDs. IBBS 2009 data also showed that the vast majority of PWIDs have some education. Over two-thirds of PWIDs in Northern provinces and one third in Southern provinces had finished secondary school.

Between 12% and 44% of PWIDs in IBBS 2009 provinces were married at the time of the survey.

The frequency of injection varies between provinces but in Hanoi, Hai Phong, Ho Chi Minh and Can Tho, at least 60% of PWIDs reported injecting at least two times a day.

Figure 19. Frequency of drug injection in the past month Frequency of drug injection in the past month 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi

Hai Phong

Quang Nghe An Yen Bai Da Nang Dong Nai HCMC Can Tho An Giang Ninh

4 times or more per day

2-3 time per day

Once per day

Less than once per day

Sex workers According to official statistics from MOLISA, there are more than 28,000 SWs in Vietnam. This is considered a low scenario with the high scenario triple that figure. Table 4, on the following page, has been produced by using the medium number of SWs and HIV prevalence rates drawn from the MOHâ&#x20AC;&#x2122;s HIV/AIDS Estimates and Projections Report.

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Table 4. Estimated number of sex workers and HIV prevalence in regions of Vietnam Estimated number of SW (medium Region scenario) North West 3128 North Plateau 2490 North East 1792 Thai Nguyen 600 Hai Phong 2000 Quang Ninh 600 Red River Delta 2882 North Central 758 Central coast 2802 Khanh hoa 1100 Central highland 2682 South East 5320 An Giang 1600 Can Tho 1416 Mekong delta 5748 Hanoi 3200 HCMC 20000 Total 58118

HIV Prevalence of SW 9.8% 8.2% 3.8% 9.7% 22.0% 2.8% 13.8% 2.0% 1.1% 4.1% 2.6% 2.9% 8.8% 19.7% 6.8% 12.3% 3.2%

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Number of HIV+ 307 204 68 58 440 17 398 15 31 45 70 154 141 279 425 394 640 3686

Share of all HIV+ SW 8.3% 5.5% 1.8% 1.6% 11.9% 0.5% 10.8% 0.4% 0.8% 1.2% 1.9% 4.2% 3.8% 7.6% 11.5% 10.7% 17.4% 100%

Number of HIV2821 2286 1724 542 1560 583 2484 743 2771 1055 2612 5166 1459 1137 5323 2806 19360 54432

Share of all HIVSW 5.2% 4.2% 3.2% 1.0% 2.9% 1.1% 4.6% 1.4% 5.1% 1.9% 4.8% 9.5% 2.7% 2.1% 9.8% 5.2% 35.6% 100%

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The majority of street-based and venue-based SWs report having different types of sexual partners, including one-time clients, regular clients and regular partners.

Street-based SW tended to have more one-time clients and venue-based SWs more regular clients.

Street-based SW reported between two to 20 one-time clients, and one to two regular clients in the past week. Venue-based SW reported between one to five one-time clients and one to three regular partners.

Figure 20 presents the STI prevalence among venue-based SW in Hanoi and Ho Chi Minh City in 2006 and 2009. The figure shows Chlamydia as the most common STI among SW with rates reducing between the 2 IBBS rounds. Prevalence in HCMC is higher than in Hanoi.

Figure 20. Percentage of SW with Chlamydia or Gonorrhea in Hanoi and HCMC 30 %

20

10

Chlamydia- 2006 9%

Chlamydia- 2006 14% Chlamydia- 2009 11%

Gonorrhea- 2006 Chlamydia- 2009 1.8% 3% Gonorrhea- 2009 0.7%

Gonorrhea- 2006 2.7% Gonorrhea- 2009 1.2%

0 Hanoi

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Men Who Have Sex with Men Data from IBBS 2009 shows that across three of the provinces where MSM participated in the survey (Hai Phong being the exception), between 75% and 80% are 30 years or younger.

Figure 21. MSM by age group

MSM Age group 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi <20

Haiphong 20- less than 25

HCMC 25- less than 30

Can Tho 30 or more

Between 9% and 27% of MSM are married with a female spouse. Almost all MSM had some education, with majority of those who reported not selling sex finishing secondary school.

Geography While MARP individuals can be found anywhere in the country, there are concentrated MARP populations in certain geographical areas of Vietnam. Table 5 below shows the distribution of MARPs in the most concentrated provinces/regions throughout Vietnam.

Table 5. Geographical allocation of majority of MARPs in Vietnam PWID SW

North West Hai Phong Red River delta South East

Share of PWID 24.7%

Share of PWID+ 21.3%

Share of PWID27%

Share of SW 5.4%

Share of SW+ 8.3%

Share of SW5.2%

Share of MSM 8.6%

Share of MSM+

3.2% 11.7%

7.1% 11%

1.8% 12.4%

3.4% 5.0% 9.2%

11.9% 10.8% 2.9%

2.9% 4.6% 9.5%

2% 12.6% 8.1%

* * *

9.9%

11.5%

9.8%

15.3%

*

5.5% 34.4% 72.8%

10.7% 17.4% 70.6%

5.2% 35.6% 72.6%

7.4% 13.3% 67.3%

*** ***

Mekong delta Hanoi HCMC SUM

MSM

14.2% 15.3% 69.1%

16.6% 24.7% 80.7%

13.7% 12.1% 66.9%

*sum after adding up the % in brackets.

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As seen in the table above, almost 70% of PWIDs are concentrated in five out of 17 geographical areas.

These areas also have more than 80% of HIV-positive PWIDs and two-third of HIV-negative PWIDs. Sex workers are more widely distributed than PWIDs. Nevertheless, seven provinces/regions are home to more than 70% of sex workers, with similar percentages of those HIV+ and HIV-. These same provinces/regions are home to two-third of the MSM population.

Prevention Interventions among MARPs This section will provide a brief overview of the scope and scale of prevention interventions among MSM, PWID and sex workers in the context of Vietnam. A broad overview of the National Monitoring and Evaluation environment will then be presented; focusing specifically on implementation challenges and the adequacy of MARPs related indicators. The chapter will offer a concise summary statement on MARP specific prevention program effectiveness.

Prevention Program Coverage A review of the identification of data and evidence gaps in the context of the Vietnamese HIV response is necessary prior to the presentation of the prevention interventions.

Data Limitation There is limited detailed data on MARPs related prevention program coverage. When such data is available, it remains unverified and considered unreliable. A National AIDS Spending Assessment has not been conducted in the context of Vietnam and disaggregated data estimating funding allocations (as a ratio of total prevention related investment, by province, and strategy) has not been systematically collected and analyzed. Although the 2006 and 2009 IBBS may provide some insight into access to prevention technologies among PWIDs, MSM and SW, this data should not be assumed to be a proxy estimate of program coverage. This caution is emphasized when recognizing that the geographic foci of the IBBS studies were limited to those provinces where significant investment in HIV responses is evident, and that study samples are likely biased towards those individuals with exposure to interventions.

Funding The National AIDS Spending Matrix estimates funding allocations to all HIV prevention programming as a ratio of total AIDS spending at 37% in 2007 and 36% in 2008. Available data for 2009 is considered incomplete. Figure 22 on the following page provides a breakdown of prevention expenditure as relative to other areas 2007 through 2009.

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Figure 22: National spending on HIV by categories, 2007-2009

As noted in the 2010 Vietnam UNGASS report, the national aids spending matrix does not capture MARPs specific prevention expenditure and estimating the adequacy of any investment is not possible.

Program Coverage As already noted, detailed data on MARPs-specific prevention program coverage is limited. In order to provide some insight into the scope and scale of MARPs specific prevention interventions, a range of sources have been drawn on.

Prevention interventions and technologies that are considered necessary across the three MARP populations focused on in this report, which are available more or less in Vietnam, are: Condom distribution Prevention and education information and behavior change communication (BCC) Needle/syringe programs Voluntary Counseling and Testing STI Services and Treatment Lubricant distribution (MSM only) Methadone Maintenance Therapy (PWID only) The following pages provide a summary overview of access to such interventions and technologies by sub-population based on available data. This is only a “snapshot” view, not a comprehensive examination.

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Female Sex Workers â&#x20AC;&#x201C; Venue and Street Based: Condom Distribution Condom distribution to FSW would appear to vary significantly across provinces, and again between venue based (VSW) and street based (SSW) sex workers. Preliminary data from the 2009 IBBS indicates that condom access is highest among SSW in Can Tho and An Giang at 84%, with lowest levels of access among VSW in HCMC at 36%. Figure 23 shows trends 2006-2009, including where access appears decreasing over time.

Figure 23. Trends in condom access among female sex workers, 2006-2009

Information, Education, and Communication (IEC) and BCC According to the 2009 IBBS study, 51.5% of all FSWs across 10 provinces were able to identify the correct means of preventing sexual transmission of HIV and reject misconceptions about HIV transmission. Wide variations are again seen across provinces and ranged from 9.9% - 80.3%.

Voluntary Counseling and Testing The percentage of all FSW who had received a HIV test and knew the results in the 12 months preceding the 2010 IBBS was estimated at 34.8%, with provincial and sub-population variations significant once again (see Figure 24 on the following page).

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Figure 24: Percentage of FSW tested for HIV and who know their status between 2006 and 2009 IBBS

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STI Services and Treatment Detailed data on STI service and treatment coverage was not available when writing this report. A small scale study conducted in Hanoi in 2010 would suggest that FSW prefer private services, but would utilize public services if money is not available or free, project-based services if they are familiar with the service or they donâ&#x20AC;&#x2122;t want to spend money on STI services.

Needle and syringe programs There is no available data on needle and syringe availability specific to FSWs. Injecting drug use (ever) among FSWs varies across provinces and is particularly high in Can-Tho, Hanoi, HCMC and Hai Phong. All drug use (ever) is seen to be escalating rapidly among sex workers, based on 2006 to 2009 trend data.

Men Who Have Sex with Men: Condom Distribution Based on 2009 IBBS data, condom access among MSM varies across provinces. Consistent condom use remains low even in areas where reported access is relatively high (e.g., data suggests that at 76.5%, MSM in Can Tho have had better access to condoms, consistent condom use with male partners over the last month there was lower [39%] than Hanoi [54%] where access to condoms was only 47.8%).

Figure 25. MSM with access to condoms in the last six months in Vietnam

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IEC and BCC The 2009 IBBS indicates that access to IEC and BCC is high among MSM in Hanoi, Hai Phong and HCMC, and relatively low in Can Tho. Figure 26: Percentage of MSM who received information on safe sex in last six months

Needle/syringe programs There is no available data on needle and syringe availability specifically to MSM. However, trend data 2006-2009 indicates a rapid rise in injecting drug use among sexual partners. Injecting drug use appears to be increasing in Ho Chi Minh City and decreasing in Hanoi.

Figure 27: Drug increasing trends in Vietnam

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Voluntary Counseling and Testing (VCT) Access to and uptake of VCT remains low across all IBBS focus sites for MSM. Figure28. Percentage of MSM who had HIV test and know results in last year

STI Services and Treatment There is no available data on uptake of STI Services and Treatment services among MSM.

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People Who Inject Drugs - Male Condom Distribution There are wide variations in reported condom access by province among male PWIDs ranging from 7% in Da Nang to 85 % in Yen Bai. Figure 29. Condom access among PWIDs

PWIDs who obtained cheap/free condoms in the last six months among sexually active PWIDs(n) 100.00 80.00 60.00 40.00 20.00 0.00

Prevention and education information and BCC Access to safe sex education and IEC follows a similar trend with significant variances across provinces.

Figure 30. PWIDs who received safe sex education in the past six months

Figure 31. PWIDs who received IEC materials in the past six months

PWIDs who received safe sex education in the past 6 months (n) 120 100 80 60 40 20 0

PWIDs who received IEC materials in the past 6 months (n) 120 100 80 60 40 20 0

Voluntary Counseling and Testing Assuming a correlation between ‘known status’ and VCT access/uptake among male PWIDs, an upward trend is indicated in all sites except Hanoi. Provincial variations continue to be evident.

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Figure 32: Percent of IDUs who know their status: Comparison between 2006 and 2009 IBBS

STI Services and Treatment No data on STI services and treatment specifically for male PWIDs was available when writing this report.

Needle and Syringe Programs Trend data 2006-2009 shows a significant increase in exposure to needle and syringe distribution in An Giang, with downward trends in Da Nang, Hai Phong and most markedly Ho Chi Minh City.

Figure 33: Exposure to needle/syringe distribution: comparison between 2006 and 2009 IBBS

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Methadone Maintenance Therapy As noted earlier in this report, a pilot MMT program is underway. The Vietnamese Government has committed to significant scale up of MMT therapy, aiming to reach 80,000 PWIDs by 2015.

Prevention Program Effectiveness As the preceding sections imply, verifiable and consistent ‘evidence’ is in short supply in Vietnam.

Beyond the lack of good quality and adequate data on ‘what works and where,’ there is also limited understanding of the social characteristics of MSM, PWIDs and SWs, and thus limited accumulated evidence to complete the puzzle and ensure that interventions are both targeted to those at high risk, but also constructed as appropriate to context.

However, the global public health community offers the accumulated experience developed over 25 years of responding to epidemics across markedly different environments. This experience shows that, to be effective, prevention strategies must include a range of interlinked and combined interventions, designed and implemented by all stakeholders including government, civil society and the communities most at risk. It is important that these prevention interventions occur alongside measures that address the broader social-cultural contexts in which relative risk is determined, and in conjunction with the development of policy and legislative settings that enable and facilitate their effectiveness.

National Monitoring and Evaluation Framework Vietnam’s National Monitoring and Evaluation Framework was developed in 2007 in alignment with the UNAIDS ‘three ones’ (see box at right).

The framework aims to monitoring and evaluate progress in responding to the HIV and AIDS epidemic in Vietnam across three sub-groups.

A number of key indicators and questions are then arranged under each sub-group and aim to align with the earlier noted plans of action: Capacity, resources, monitoring and evaluation: - Leadership and coordination - Financial resources - Human resources - Monitoring and evaluation - The current HIV epidemic in Vietnam

The UNAIDS ‘Three Ones’ One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners.

One National AIDS Coordinating Authority, with a broad-based multi-sector mandate.

One agreed country level Monitoring & Evaluation System.

Prevention: - BCC program - Harm reduction program - STI prevention program - Blood safety transfusion program - VCT program Care, treatment and PMTCT: - PMTCT program - Care and treatment program

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The VAAC acts as the lead agency for implementation of the M&E framework, with a range of other Ministries (MOLISA, MOET, etc.) and international partners engaged in oversight and development of the framework. An M&E Technical Working group has been established which includes representation from the range of key stakeholders in the Vietnam HIV response (INGOs, government, etc.). M&E units operate at the Regional, Provincial and District level35. There is no referenced ‘place’ for local NGOs and/or community organizations within the implementation structure or the framework. Figure 34 below explains the organizational structure of the M&E system.

Figure 34. Vietnam’s National Monitoring and Evaluation Framework

Structural Challenges and Weaknesses The effective implementation of any M and E framework at the national level is contingent on adequate capacity across all sub-levels of the system itself, as well as the strength of the broader Health Information System. Achieving adequate and uniform capacity across all levels is an essential component of a functioning national M&E system, and remains a significant challenge in Vietnam. The

35

International data were used in many cases to determine such things as cost effectiveness and efficacy.

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Vietnam UNGASS report 2010 identifies the key challenges and gaps in the implementation of the framework as: Data quality and accuracy, including sex and age desegregation M&E staff capacity at all levels of the system Staff retention M&E capacity among NGOs Lack of MARPs size estimations Limited understanding of MARPsâ&#x20AC;&#x2122; social and sexual networks Data management and use It should be noted however that significant investment by International Partners in strengthening the M&E system continues and progress has been made in a number of areas. Recent activities have included the standardization of reporting formats; capacity development activities at the district, provincial and national levels, as well as data triangulation and costing exercises.

MARPs Prevention Related Indicators and Data Collection As seen in Figures 35 and 36 (on the next page), a number of MARPs specific indicators at both the output and outcome levels are included within the prevention sub-group of the M&E framework. Some but not all have been developed to align with UNGASS indicators.

Figure 35. MARPs-specific indicators in the M&E Framework

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The primary data sources are IBBS studies (targeted by province) and â&#x20AC;&#x153;routine reporting.â&#x20AC;? The challenges noted previously, with respect to capacity, clearly impact on the veracity and availability of any data generated via the latter.

While a detailed assessment of the M&E system (indicators, data collection at various levels, etc.) is outside of the scope of this report; based on available information however (or indeed the lack thereof) it is clear that the current framework and the M&E system has not resulted in the accumulation of data necessary to understand the MARPs epidemic in Vietnam and to ensure that prevention program coverage and strategies are targeted and effective. For this to be achieved, data collection tools which enable further disaggregation (e.g., by intervention modalities such as peer education, by sex, by location, etc.) are required, and strengthened capacity across all levels of the system is necessary.

Figure 36. MARPs-specific indicators in the M&E Framework

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3.4 Evidence Based Prevention Interventions The format and initial data presented in this section of the report were taken from the following publication: Reviewing the evidence on effectiveness and cost effectiveness of HIV prevention strategies in Thailand.36 As further publications were reviewed, results were incorporated into the table on the following page. Categorization of interventions are modified from Michael Sweat, A Framework for Classifying HIV Prevention Interventions.37 There were a number of conflicting results and often the effectiveness data were derived from developed country (e.g., United States) studies. Nevertheless, an assumption was made that the effectiveness would be similar in Vietnam. More weight was given to meta-analyses, Cochran review and systematic reviews than to individual project or program evaluations. As the implementer was often the evaluator, there was a potential bias in the findings.

The term â&#x20AC;&#x153;effectivenessâ&#x20AC;? differed depending on the study reviewed. In some cases, effectiveness meant the change in an output resulting from implementing an intervention. In other cases, effectiveness meant a change in outcome, such as increased coverage of an intervention or increased use of an evidence-based practice (e.g., improved condom use). A third meaning relates to changes in health outcome or health impact such as HIV cases, AIDS deaths averted or a reduction in Disability Adjusted Life Years (DALYs). This report does not differentiate these effectiveness definitions. This should, however, be done and two tables created. One table should focus on interventions that improve outcomes (e.g., coverage of evidence based interventions) while the second would focus on improvements in inputs and outputs which are associated with those outcomes and impact. The former would most likely be constrained to biomedical interventions such condoms which address direct/ proximal causes of HIV transmission while the latter would cover programmatic interventions which are needed to improve coverage of the former, addressing more distal determinants such as knowledge and attitudes and availability of commodities.

There were few good, independent evaluations upon which to judge effectiveness and few evaluations addressed effectiveness in terms of outcomes (e.g., intervention coverage) and impact (e.g., reduction in incidence of HIV infection).

Interventions incorporating a biomedical component seem to be more effective not only at improving outputs but also outcomes and impact to the extent that data allow us to make such a conclusion.

36 37

Pattanapheaj and Teerwattananon 2010 A report to the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2008

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Table 5. Evidence-based Prevention Interventions* FSW Intervention or combination of interventions

MSW

MSM

FPWID

MPWID

Stable 38 partners

Interventions affecting proximate determinants: Improve knowledge, attitudes, influence psychological and social correlates of risk or that reduce the number of risky contacts which are points of transmission Abstinence only programs Abstinence plus programs Community based education General mass media programs39 Condom social marketing Street outreach, peer education, interpersonal education/persuasion, interactive dialogue, face to face communication, street outreach Routine provider initiated voluntary HIV screening in facilities School based sex education (+ life skills)40 Voluntary counseling and testing without STI clinic and condom distribution41 Voluntary counseling and testing (VCT) (+STI clinic and condom distribution)42 Risk reduction counseling with promotion of condoms Interventions affecting biological determinants: Harm reduction interventions which lower the risk of transmission but not eliminate risky behavior43

*Legend detailing meaning of colors appears on page 66.

38

“Stable partners” refers to long-term partners of MARPs. This is important since risky practices are highly dependent on the kind of relationship within MARP groups and between MARPs and other populations as well as the duration of that relationship.

39 There is disagreement about the effectiveness of mass media depending on the study reviewed. Some studies declare this method effective although costs are of some concern. Other studies suggest that mass media is neither effective nor cost effective.

40 School based programs were reported as cost ineffective. One article stated that they were effective at reducing the number of sex partners but said nothing about other risk factors or outcomes. Another reference calculated a cost per HIV case averted at between US $6,704 - $9,448 or $376 - $530 per DALY averted) 41 The evidence of effectiveness of VCT on HIV incidence is ambivalent. In general the impact seems only moderate in terms of reducing unprotected sex and number of sex partners. For this reason VTC along without other interventions has been marked not cost effective. VTC with other services, such as STI treatment and condom distribution seem to be more cost effective.

42

Three studies reported CE results. One study in Cape Town estimated the cost/HIV infection averted to be US $67 where VTC included STI clinics. A study in Kenya calculated an HIV case averted at US $483. (ref BMC Public Health 2009, 9(Suppl 1): S5) 43

Various harm reduction programs include more than one intervention. These have been separated for this analysis. A study in Ukraine calculated that a package of harm reduction interventions results in a cost per HIV case averted of US $97.

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Intervention or combination of interventions

FSW

MSW

MSM

FPWID

MPWID

Stable 38 partners

100% male condom44 Female condom Needle and syringe programs allowing for penetration of at risk groups and volume Needle social marketing Street outreach focusing on PWIDs and PWID networks Livelihood alternatives to transactional sex Proving safe spaces for vulnerable populations to use preventive services, inject safely.

Drug substitution treatment (methadone) with counseling and professional services in clinics Interventions that affect biological determinants: Biological/biomedical interventions that reduce HIV infection, transmission efficiency, duration of infectivity, exposure to HIV HIV vaccine STI diagnosis and treatment in clinics45 Mass or community treatment of STI Male circumcision46 Microbicides ART treatment of sexually active HIV+ populations to reduce onward HIV transmission47 Post exposure prophylaxis Lubricants for reducing HIV infections during sex between MSM Interventions that affect underlying determinants: Altering underlying system factors, socio cultural factors including beliefs, traditions, practices and national/local leadership, governance and policies (sometimes referred to as “structural” interventions) 44

Both the Dominican Republic and Thailand have instituted 100% condom campaigns. In the DR they found a cost per HIV case averted to be US $10,856. The 100% condom campaign resulted in much better CE results. We have left this intervention in this table as very cost effective primarily due to Thailand’s experience.

45

There seems to be some debate about the effectiveness of treating STIs as a way to prevent incident cases of HIV. A study to reduce STIs in female sex workers in hotels in South Africa calculated a cost per HIV case averted from $1,385 - $3,365. This program included condom distribution, treatment of symptomatic STIs and periodic presumptive treatment. A modeling study in Malawi calculated a cost per HIV case averted in men to b e $15.42. An epidemiological model simulating and HIV epidemic suggested that a cost per HIC averted in the range of US $321- $1,665 was cost effective compared to lifetime HIV treatment costs in generalized epidemics of US $3,500.

46

Multiple studies have found male circumcision to be cost effective at reducing HIV transmission. It is a one-time procedure which provides some degree of life time protection and is a simple and relatively low cost procedure.

47

ART for prevention has been in the news lately and evidence suggests that it reduces viral load and therefore a person on ART is less likely to infect others. ART also makes a person feel better and therefore more likely to engage in risky practices.

The interaction between ART and other preventive interventions needs to be explored. The CE of ART also is sensitive to market prices for ARVs.

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Intervention or combination of interventions

FSW

MSW

MSM

FPWID

MPWID

Stable 38 partners

Conditional cash transfers or financial incentives on the demand side48 Conditional cash transfers or financial incentives on the supply side Changes in laws, rules and regulations, e.g., governing detention of PWIDs in Asia Mitigation of barriers to prevention and negative social outcomes of HIV infection Training of service providers and law enforcement officers Separate accommodation to protect at-risk populations Self help and solidarity groups Financial and in-kind support Medical and legal assistance Counseling Legal, policy and institutional reform to protect human rights of vulnerable groups and PLHIV Categories of interventions that improve overall performance of the health system (“policy control knob”) Improving financing, risk pooling, source of TBD money, resource allocation Improve organization of services, the roles of public and private providers and ownership Alter the regulatory environment Change the incentive structure on supply and demand side Alter the mechanisms, scale and scope of the delivery of preventive, promotive and curative interventions Legend color Dark green Light green Orange Red White Grey

Effectiveness Yes Yes Yes No No data NA

Cost effective Yes No data No No, no data No data NA

Description The intervention is both effective and cost effective The intervention is effective but no data on cost The intervention is effective but not cost effective The intervention is not effective and no data on cost There is no evidence on effectiveness or cost The intervention is not relevant for target or too distal a risk factor to link to HIV transmission

48

Evidence is building that even small financial incentives can have a dramatic effect on both the supply and demand for services. Because of the magnitude of effect and the fact that CCTs and other demand side interventions have been used for achieving other outcomes, e.g., maternal and child health, we’ve indicated that this is a cost effective approach. More research, however, is needed to confirm this conclusion in multiple settings.

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Intervention approach along the causal pathway The key to any new program is to break transmission by strategically focusing different CE interventions along the causal pathway, as illustrated in the Figure 37 below for FSW and Figure 38 on the following page for MSM. For FSW interventions include expanded use of condoms (100% condom campaign) and STI prescriptions for CSW and clients of sex workers.

Figure 37: Interventions along the causal pathway for FSW

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Figure 38: Interventions along the causal pathway for MSM

Figure 39: Interventions along causal pathway for PWID

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In Vietnam, HIV transmission for both SWs and MSMs is directly linked to multiple sex partners and inconsistent or no condom use. For PWID, transmission is directly linked to sharing of injecting equipment. However socio-economic and psychosocial issues, such as poverty, lack of education and drug use also fuel the epidemic. A successful impactful prevention will have to be holistic and address not only direct contributors but also indirect ones.

Holistic prevention intervention programs have been implemented in several parts of the world including India49 and Eastern Europe and Central Asia.50 This encompassing or empowerment approach has several facets. It includes various methods to assist the sex worker, MSM and PWID.

49 50

Laga 2010 UNAIDS 2006

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Recommended intervention packages for Vietnam51 Table 6. Recommended Interventions Technical interventions MSM Information, education, and behavior change communication targeted various sub-groups of MSM Promotion and provision of commodities such as condom, lubricant, clean needles and syringes HIV testing and counseling STI prevention, screening and treatment Effective linkage to health care services, including ART Psycho-social support PWID Information, education, and behavior change communication targeted at various sub-groups Distribution of needles and syringes MMT treatment Drug dependence treatment (for heroin injectors and ATS users) Condom distribution ART treatment HTC STI prevention, screening and treatment Effective linkage to health care services, including ART Psycho-social support Sex workers Information, education, and behavior change communication targeted various sub-groups Condom promotion STI prevention, screening and treatment HTC Effective linkage to health care services, including ART Psycho-social support Structural interventions Improving policy environment, including promoting social inclusion of MARPs and tackling stigma and discrimination against MARPs and recognition of MARP-based organizations.

Financial sustainability, including mobilization of community-based response, advocating for government funding for MARP interventions, promoting philanthropy/donation for MARP interventions.

51

Guidelines and tools drawn on for this section include: Vietnam National Guidelines on MSM Interventions (The Socialist Republic of Vietnam); Guidelines on comprehensive interventions for PWIDs (UNODC/WHO/UNAIDS); A strategy to halt and reverse HIV epidemic among people who inject drug in Asia and the Pacific 2010-2015 (WHO/UNODC/ UNAIDS/GF/ANPUD); Toolkit for monitoring and evaluation of interventions for sex workers (WHO - SEARO, WPRO).

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Considerations for interventions In order to be better able to target interventions it is important to determine how easy it is to reach the groups most at risk of infecting others with HIV or being infected by others. Figure 40 shows the different risk levels of MARPs and how easy or difficult they are to reach.

Higher risk Undisclosed gay men MARPs who use ATS Amateur sex workers Long-term detained PWID Unregistered PWID Venue-based F/MSW Call-girl/boy, mobile, internet-based F/MSW Male regular partners of FSW/Female PWID Regular clients of injecting F/MSW Regular clients of F/MSW Spouses of untreated, undisclosed PLHIV Older gay men Lower risk

Female PWID Injecting FSW Registered PWID Injecting MSM Street-based FSW Street-based MSW Homeless injecting children Young gay men MARPs that have STD Female regular partners of PWID Spouses of treated PLHIV

Easier to reach

Harder to reach

Figure 40. Risk of being infected vs. reach

Figure 41 shows the risk of different groups to infect others. Positive MSM and SW, regardless of whether or not they know their status, informal sex workers and their partners, and substance using MSM and SWs, are those most at risk of transmitting the infection, and are also the most difficult to reach.

Figure 41. Risk of transmitting HIV

Untreated positive MARPs who use ATS Untreated positive long-term detained PWID Untreated positive MSM Undisclosed untreated PLHIV Untreated positive unregistered PWID Untreated positive undisclosed gay men Untreated positive venue-based F/MSW Untreated positive call-girl/boy, mobile, internet-based F/MSW Newly infected clients of SW Non-MARP spouses of MARPs

Newly infected MARPs Untreated positive injecting FSW Untreated positive FPWID Untreated positive registered PWID Untreated positive injecting MSM Untreated positive street-based FSW Untreated positive street-based MSW Untreated positive homeless injecting children Untreated positive young gay men Positive MARPs that have STD Treated positive MARP/non-MARP

Easier to reach

Harder to reach

Higher risk

Lower risk

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Choice of intervention package The analysis of the risk factors driving the epidemic and of the cost effectiveness of prevention interventions has led to the identification of a sub set of cost effective interventions (“the vital few”) which have the greatest probability of halting or reducing transmission among MARPs groups with the highest risk of transmitting HIV or of being infected. These vital few interventions should be delivered and demanded at scale by all MARP groups (where appropriate) in the previously specified geographic areas.

Four criteria were applied as a means of selecting these vital few interventions.52 The first criterion was the cost per HIV case averted (cost/effectiveness) based on local or global experience. The second was the efficacy of the intervention at reducing transmission followed by the effectiveness of programmatic approaches to deliver these interventions at scale. The fifth and final criterion was the ability of the intervention to avert the maximum number of new infections if implemented at high coverage. Table 7 gives a summary of the interventions for each MARPs group.

Table 7: Comprehensive package for continuum of prevention to care Services

MSM

SW

PWID

Condoms and lubricants STD services Needles & syringes MMT VCT ART

X X

X X

X X

X X

X X X X X X

X indicates the core services

VCT is the entry point to HIV care and treatment and also can support direct personal motivation to either staying negative, or avoiding infecting others. ART is increasingly known as packing a “dual punch” – it is saving the lives of PLHIV and reducing the risk of HIV transmission. The latter benefit is due to significantly lowering viral load, thus dramatically reducing infectivity. Adding ARVs also demonstrates the necessity of a dual strategy which places priority on prevention (reducing new infections) but at the same time reducing mortality from AIDS. Given the overlap between different MARPs as well as the interaction between MARPs and vulnerable groups, this report recommends that a comprehensive package of continuum of prevention to care is made available to all MARPs, in particular in priority geographic areas – starting with the priority ranking #1 and, as time, money and resources allow, working down the list through ranking #5.

Needle and syringe programs and opiod substitution programs prevent new infections among PWIDs (including female PWIDs, FSW-PWID, and MSM-PWID), which also results in reducing sexual transmission from these sub-groups to their sexual partners – the vulnerable population.

Condom, lubricant and STI services are all effective in preventing sexual transmission of both STIs – a risk factor in transmitting HIV – and HIV, among MARPs, from MARPs to vulnerable populations, and from 52

International data were used in many cases to determine such things as cost effectiveness and efficacy.

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there to the general population. STI diagnosis is a proxy to assess personal sexual-related risk; STI prevention benefits HIV prevention; and STD treatment significantly reduces both HIV infectivity and susceptibility – thus reducing infection and transmission.

Prioritizing interventions Vietnam can’t do everything, all the time, everywhere even within the tight priorities described above.

For that reason prioritization even within the above priority populations, geographic areas and interventions is needed. Table 7 below, and Table 8 on the following page, suggest the further prioritization within prioritized provinces, and prioritized interventions.

Three criteria were used to establish priorities within the defined populations and geographies. Priority one is to focus on where Vietnam can achieve the greatest reduction in new infections within limited available resources. This is a focus on volume of new infections, not reducing in infection rates. The second priority was to focus on reducing volume of new infections (not rates of infection) among MARPs. The third criterion was where to reduce the greatest volume of new infections (not rates) into the general population from MARPs. The shading connotes priority; the heavier the shading the higher the priority.

The reason for the focus on number of new infections as opposed to rates of infections is that it is volume of HIV cases that is driving the epidemic. Areas with high incidence rates are not necessarily areas with the highest number of new infections.

Table 7: Priority for intervention to achieve the AIDS transition.

HIV status HIV+

HIV-

Population category MARP Non-MARP vulnerable Non-MARP not vulnerable MARP Non-MARP vulnerable Non-MARP non vulnerable

1 Priority 1 Priority 3

Level of geographical priority 2 3 4 Priority 1 Priority 1 Priority 2 Priority 3 Priority 4 Priority 4

5 Priority 3 Priority 4

Priority 4

Priority 4

Priority 4

Priority 4

Priority 4

Priority 1 Priority 2

Priority 1 Priority 2

Priority 1 Priority 2

Priority 2 Priority 3

Priority 3 Priority 4

No priority

No priority

No priority

No priority

No priority

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Table 8. Sharpening the intervention HIV status

HIV+

HIV- or unknown

Population category MARP Non-MARP vulnerable Non-MARP not vulnerable MARP Non-MARP vulnerable Non-MARP non vulnerable

1 Full package except VCT ART + condom + STD ART + condom Full package except ART VCT + condom + STD Condom promotion

Level of geographical priority 2 3 4 Full package Full package Full package except VCT except VCT except VCT ART + ART + ART + condom + condom condom STD ART + ART + ART + condom condom condom Full package Full package Full package except ART except ART except ART VCT + VCT + VCT + condom + condom + condom + STD STD STD Condom Condom Condom promotion promotion promotion

5 Full package except VCT ART + condom ART + condom Full package except ART VCT + condom + STD Condom promotion

3.5 System Bottlenecks and Required Health System Strengthening Actions The above section outlined the epidemiology of the epidemic, the specific target populations which are driving the epidemic and, within those target populations, the sub groups that are at the highest risk of infecting others or of being infected. These are the populations that must be targeted with selected interventions, and they include HIV+ and HIV- MARP and non-MARP vulnerable populations. Also identified are the target geographic areas (three major cities and small cities in three geographic areas of the country and three towns in Northwest Province) and the vital few interventions that must be delivered at scale and demanded by those high risk populations groups to reduce or halt transmission.

The comprehensive package consists of six interventions (condoms and lubricant, needles and syringes, STD management, MMT, VCT and ART for HIV+ MARPs). This section of the report examines how to achieve high coverage. This entails identifying the health system requirements for the delivery of these vital few interventions, the health system bottlenecks that hider their delivery and demand and the health system strengthening (HSS) actions needed to overcome those bottlenecks.

Critical health system bottlenecks Given the nature of the epidemic and Vietnamâ&#x20AC;&#x2122;s response there are far more health system requirements that would be helpful in improving the response than Vietnam is capable of addressing.

For that reason this report focuses on a few, specific bottlenecks that are highest priority and suggests a phased approach: Phase one would be focused on addressing bottlenecks to achieving high coverage of the critical few interventions in high priority geographies as outlined in Table 7 above. Phase two would focus on the bottlenecks which hamper a sustainable, long term system response to the epidemic including placing PLHIV on ARVs and sustaining compliance in a cost effective way over time. Since the focus is on short to medium term reduction in HIV transmission this report focuses primarily on phase one efforts.

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The top bottlenecks to phase one include: 1. Scaled up technical focus on prevention in addition to the continued focus on treatment.

2. Need for systems to enhance ability to track HIV transmission.

3. Need for systems to enhance tracking of coverage of chosen interventions in MARPs and priority geographies.

4. Need to scale up MARP engagement in all aspects of program design and implementation which is currently constrained by policy and legislative environment and limited funding for development of MARP organizations.

5. Current regulations make it difficult for alternatives to governmental facilities to provide comprehensive intervention package including the private sector and community level organizations including MARPs groups themselves.

6. Weak demand for prevention and treatment services among MARPs and vulnerable populations.

7. Need for financial resources to be distributed more evenly particularly to provincial/municipal levels.

The criteria for selecting the top priority bottlenecks for short/medium term phase one attention are: 1. Inability to identify, locate and target high risk MARPs groups in high risk geographic areas.

2. Inability to document incidence of new cases which is required not only to identify high risk populations and geographic areas but also to monitor the effectiveness of the response.

3. Factors that negatively affect the delivery of the comprehensive package to MARPs and vulnerable populations in high priority geographic areas including weak engagement of alternatives to public sector delivery (e.g., private sector, community and MARPs engagement in delivering key interventions) 4. Weak demand side response as a result of low awareness or inappropriate perception of risk, stigma and discrimination, high cost and lack of access to services.

As time goes by and as the number of new infections declines, more attention can be focused on phase two bottlenecks. This would include tackling laws, rules and regulations reinforcing stigma and discrimination, addressing sub-culture of MARPs and vulnerable populations affecting demand for services, long term sustainable financing of HIV+ positive populations and changing the national response deal with HIV as a chronic disease.

Table 9, on the following pages, includes some of the more important issues in terms of system requirements, bottlenecks and system strengthening recommendations that should dictate the content of an effective response. This table would ideally be tailored for each intervention and for each target geographic area since each health system is slightly different and thus require a slightly different response. Appendix I provides a â&#x20AC;&#x153;deep dive exampleâ&#x20AC;? of one intervention (condoms).

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Table 9: Summary of health system requirements, bottlenecks and recommended health system strengthening actions for Vietnam System requirements by System bottlenecks System strengthening building block plus demand recommendations

DELIVERY To reach the hard to reach and increase coverage, multiple provider types (public, private, NGO, community level organizations) are needed in the high priority geographic locations to enhance government services.

The entire comprehensive package must be delivered at scale, e.g., 80% coverage to the high priority population groups in priority geographic areas. For target populations with good current behavior (e.g., already on sustained ARV use) they can be left to market forces. For those with poor behavior, active outreach, improved delivery methods other than government and demand side subsidies will be needed.

To lessen the long term demand on the public sector, the private sector â&#x20AC;&#x201C;which is already delivering a number of these interventions â&#x20AC;&#x201C; needs to be expanded and, if necessary, provided with subsidies for expanded effort.

Supervisory methods are needed to assure compliance with protocols and policies and reduce fraud and abuse.

The NGO sector is needed for delivery to some sub populations, e.g., those who are stigmatized such as PWIDs, SW, and MSM. NGOs have an advantage in

Coverage of the interventions that make up the comprehensive package is low in MARPs and vulnerable populations in high priority geographic areas.

Current public sector oriented delivery strategies are not able to achieve high coverage of chosen interventions in MARPs and vulnerable populations in priority geographic areas.

Private for-profit providers and some NGOs are providing quality services but are not an official part of the delivery strategy for key interventions in priority; resultant coverage is low and cost is high.

High user fees and prices for some interventions are high both in public sector and private sector.

The highest risk of transmission exists in a few geographic areas, mostly urban. These areas are currently not capable of mounting a scaled up response from their current base with their current delivery strategies.

Prevention and treatment services are not available in all prisons and majority of drug detention centers.

Unavailability of services appropriate to life-style of MARPs reduces demand for services.

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

Develop delivery strategies for the comprehensive package for MARPs and vulnerable populations in high priority geographic areas.

For MARP groups who have achieved and maintained desired behaviors, and who are on ARVs and stable, allow market forces to dictate the delivery approach.

For underserved MARPs and vulnerable populations, increase the number of NGOs and CSOs operating in priority geographic areas thereby increasing access and demand.

Allow the for profit private sector to distribute key commodities at subsidized prices to MARPs in specific geographies.

Treat stable HIV+ MARPs on ARVs as a chronic disease and develop delivery strategies to maintain them sustainably on ARVs for the long term at low cost.

Develop new, community based prevention strategies using MARP groups, civil society and local CSOs to be active in service delivery, monitoring the HIV response and holding government and private sector accountable.

Diversify service delivery models to include mobile services for HIV testing, STI treatment, as well as condom and needle voucher through pharmacies.

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System requirements by building block plus demand assessing and serving the most stigmatized and marginalized people in the most hard to reach areas.

As AIDS becomes a chronic problem, lowest cost methods of maintaining HIV+ populations on ARVs will become essential. Delivery closest to the community will be needed.

System bottlenecks

System strengthening recommendations

GOVERNANCE/POLICY/ENABLING ENVIRONMENT Policies and regulations governing the private and NGO sectors allowing them to prevent, diagnose and treat HIV/AIDS including VCT. Policies with allocated budget to support MARPs groups, NGOs and private sector players to actively participate in the development of regulation and policy.

Policies that provide incentives for government providers or, alternatively NGOs and the private sector, to operate in underserved geographic areas or during times when the public sector is not operational, e.g., NW, urban slums evenings and weekends.

Policies which allow for subsidies to NGOs and the private sector for critical inputs and commodities, e.g., needles and syringes, methadone, condoms, medicines.

Treatment protocols and guidelines that can be used as well for NGO, MARP groups,

Private and NGO providers are not allowed by policy, law and/or regulation to deliver the comprehensive package.

Current policy does not allow private sector to provide MMT. Supervision of private providers is weak.

Government does not encourage private sector in hard to reach areas. There are no incentives to do so.

National policy on financing encourages high user fees in government facilities even for most elements of the comprehensive package.

While some interventions are subsidized, they are subsidized by donors. The incentives to collect revenue and the incentives to increase demand for HIV services are not aligned.

Current implementation guidelines do not allow/encourage prevention commodities to be distributed to MARP groups.

Government regulations on

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

Create policies, rules and regulations allowing and even encouraging public/private collaboration and more extensive delivery of the comprehensive package of interventions to MARPs; start in target geographic areas.

Reduce or eliminate policies, laws, rules and regulations that discriminate or make illegal MARPs or their behavior.

Create policies and penalties that prohibit discrimination in government and private/NGO clinics.

Allow NGO or private sector clinics to be subsidized using government resources if they deliver key interventions to MARPs in priority geographic areas.

Create supervisory and audit guidelines for private providers, NGO clinics and service providers and penalties for non compliance or bad practices.

Modify policies on user fees and financial autonomy for government facilities which call for high fees and other practices

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System requirements by building block plus demand private providers as well as methods for monitoring and supervision of the services provided by them.

Policies allowing for demand side incentives to be provided to the most difficult to reach populations to increase demand for key interventions, e.g., MSM and VCT. Changes to policies and laws to decriminalize SW, protect rights of MARPs and to reduce stigma and discrimination against them.

Policies that give priorities for diagnosis, ARV treatment to MARPs and vulnerable populations in community as well as in closed settings.

System bottlenecks peer outreach activities and counseling prevent motivated providers who are not associated with government program to provide services.

Social evils control policies leading to arrest, harassment or compulsory detention of MARPs, prevent them from accessing services, or interrupting treatment.

Detentions of large number of drug users prevent many of them from accessing ARV treatment.

System strengthening recommendations which discourage use by MARPs. Program managers should promote and support the development of incentives and rules to regulate performance and to assure accountability and transparency.

Align policies on social evils control with HIV policies.

Encourage the scaling down of drug detention centers and support community-based drug treatment.

FINANCING The HIV/AIDS national target program should be funded at levels necessary to scale up delivery of both preventive and curative interventions for MARPs and vulnerable populations in priority geographic areas.

Municipalities should allocate funding for their local HIV program.

Adequate funding for an increased volume of key commodities (ARV, MMT, condoms, VCT test kits) at lowest possible prices.

Increased allocation and spending on HIV/AIDS in high risk geographic areas particularly for services for MARPs and vulnerable populations

Government funding for the HIV/AIDS National Target program is underfunded.

Current funding is inadequate and there are inadequate resources planned for a more aggressive scale up of activities.

Donor funding will soon be declining.

Most HIV funding and almost all ARVs are funded by donors with no national long term financing strategy in spite of knowing the donor funding will soon decline.

Existing resources are not effectively targeted to the highest risk geographic areas and target groups.

Funding for an effective response in key geographies,

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

Develop a long term financing strategy for the HIV response focusing on the comprehensive package, MARPs, vulnerable populations and high priority geographic areas.

Create a system of incentives (e.g., CCT, performance contracts, subsidized inputs) which reduce the out of pocket costs to MARPs for key interventions and which encourage scaled up delivery of the comprehensive package for MARPs. Improve the targeting of National HIV/AIDS Target Program funding focused on high risk municipalities and geographic areas.

Work with municipalities to modify or refine fiscal

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System requirements by building block plus demand Appropriately apply financial incentives to increase demand and adherence to treatment and preventive practices.

Appropriate financial incentives for delivery of interventions to high risk populations in hard to reach areas.

Consider coverage of HIV treatment, diagnosis, and MMT under insurance schemes and having a wide range of allowable providers eligible for reimbursement, e.g., NGOs and private sector providers as appropriate.

System bottlenecks particularly target municipalities, is too small, poorly targeted and too reliant on donor funding through the National Target Program.

Access to free prevention and STI services is limited due to the unavailability in the place, at the time MARPs need them, and also due to fear of being arrested or stigmatized while price for private-sector services is high, leading MARPs to not seeking services.

Critical commodities and medicines are funded nationally at a level inadequate to achieve high coverage.

Public funding is not being channeled to civil society groups, NGOs and private sector.

Financial incentives in the private sector and in government are aligned to increase demand and effectiveness of service delivery There is no mechanism for implementing conditional cash transfers, performance contracting or other financing mechanisms which would align incentives to improve delivery and as the same time enhance demand.

Many HIV+ people are being impoverished as a result of having AIDS.

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

System strengthening recommendations decentralization policies which hamper the financing of key programs for MARPs. Adequately fund key medicines and commodities.

Price interventions and commodities in a way that encourages consumption (e.g., free condoms, needles and syringes, HIV testing, STI treatment or reduced prices in private sector).

For private providers, NGO and CSOs funded under an expanded prevention effort, funding should be contingent on good performance.

There should be policies from central government to encourage local government to allocate funding for local HIV program.

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System requirements by building block plus demand

System bottlenecks

System strengthening recommendations

INFORMATION Need to be able to measure HIV incidence rate among MARPs and vulnerable populations in high priority areas.

Expanded evidence on effectiveness of risk reduction materials and effectiveness of prevention interventions and program strategies and approaches.

Ability to measure and track over time changes in coverage of the comprehensive package in high risk populations in priority geographic areas.

Ability to track high risk practices, identify and understand emerging highrisk behaviors and high-risk groups, such as MARP ATS users.

Increased ability to track compliance with treatment protocols and quality of care for services delivered by public, private, NGO and CBO providers.

Lack of a system that monitor incidence among MARPs and vulnerable populations. No surveillance system.

Little information exists on the extent of demand for and resulting coverage of key interventions delivered to MARPs and vulnerable populations in high priority geographic areas.

Lack of reliable data on coverage of key interventions in MARPs and vulnerable populations in high priority geographic areas.

Most prevention programs lack data to inform results based management, to interpret data and to develop management structures.

MARP representatives are not parts of efforts to collect and use data.

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

The expanded prevention program in Vietnam should be grounded in strategic analysis of the epidemicâ&#x20AC;&#x2122;s dynamics in local contexts across Vietnam.

Effectiveness of the prevention effort should be based on the extent to which the critical interventions achieve high coverage of MARPs and vulnerable populations.

Identify coverage levels of current interventions for MARPs and vulnerable populations in priority geographic areas.

Collect trends in HIV incidence in different populations so as to better understand the epidemic and assess effectiveness of prevention programs.

Map and estimate the size of MARPs and vulnerable populations in target geographies and measure trends in prevalence and incidence overtime.

Monitor contextual factors, determinants of risk behavior and barriers to prevention over time in key geographies.

Develop an evidence base on effectiveness of interventions, combinations of interventions, program strategies and approaches and cost of delivery of key interventions.

Mobilizing the participation of MARPs in designing data collection and other M&E tools, as well as verifying results of programmatic as well as research data.

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System requirements by building block plus demand

System bottlenecks

System strengthening recommendations

MEDICINES/LOGISTICS Adequate supply of condoms, needles and syringes, Methadone, HIV testing kits and other related laboratory tests.

Improved forecasting, procurement, distribution and tracking of commodities (including subsidized commodities) to approved private sector, NGO and CBO service providers.

MARPs as users are engaged in selecting commodities and, to some extent, medicines.

Funding is made available together with mechanisms that allow MARPs to monitor, and give feedback on quality, supply and distribution of services.

MARPs experience frequent stock outs of condoms, lab tests and needles.

MARPs are not allowed to participate in selecting commodities.

Lack of mechanism to get feedback from MARPs on product quality, supply and distribution.

Prices of ARV and treatment monitoring tests in the market are too high leading to the dependency on programs that provide free treatment.

Commodities needed for prevention and treatment are not available in all prisons and majority of drug detention centers.

Cost of commodities in private sector is high and an impediment to demand.

Adequate medicines and commodities in priority geographic areas to satisfy needs of MARPs and vulnerable populations.

Improve forecasting, procurement and supply.

Develop mechanisms for pooled procurement, negotiation/sanction/regulation to pharmaceutical industry, reducing/exempting taxes and other means of reducing unit costs for essential commodities and medical products.

Develop a strategy for publicly financing what now is financed by donors, including ARVs and other inputs.

HUMAN RESOURCES Adequate number of trained peer educators and outreach workers in high risk areas.

Organized civil society including MARP organizations who can dialogue with and influence policy.

Adequately motivate providers.

Greater numbers of private, NGO, and CBO providers operating in high priority geographic areas.

Trained eligible workers motivated to deliver key intervention to MARPs groups

Training programs that make providers eligible to provide services according to the government regulation usually only target public providers, and not private or NGO/CBO providers.

Inadequate numbers of trained and motivated health workers willing to work with MARPs and vulnerable populations in high priority geographic areas.

Inadequate recognition of services already provided by non government providers.

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

Adequately numbers of trained, eligible and motivated public, private, NGO and CSO workers need to be in place to deliver the comprehensive package in high priority geographic areas.

Private sector providers need to be engaged in the prevention and treatment response.

Adequate supervision by government workers is needed.

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System requirements by building block plus demand in high priority geographic areas.

System bottlenecks

System strengthening recommendations

In adequate supervision of non government providers.

There is no more CE alternative to government tracking and service provision at community level where considerable work could be done by community level providers more cost effectively.

DEMAND

MARP organizations â&#x20AC;&#x201C; who provide peer education and support - play a key role in behavior change interventions.

Increased demand for testing, treatment, condoms through behavior change interventions.

Services are available and accessible to MARPs. Services at a price that does not reduce demand Use of cash incentives (demand side financial incentives) for those with no demand or no established behavior.

Encourage people to try and then adopt the new behavior and gradually reduce incentives.

Lower cost and subsidized services in the private sector

Prevention for commodities and treatment services are not available in all prisons and majority of drug detention centers.

Unavailability of services appropriate to life-style of MARPs reduces demand for services.

Stigma and discrimination reduce demand for medical services.

Low awareness of risk and poor knowledge of ways to prevent being infected or infecting others, especially among MSM and sexual partners of PWIDs. Effects of drugs â&#x20AC;&#x201C; especially stimulants lead to judgment impairment and risk behaviors.

Meeting the Needs of Vietnamâ&#x20AC;&#x2122;s Most-at-Risk Populations

Support MARP organizations to expand their reach for peer education and support.

Providing MARPs organizations with prevention commodities to support behavior change.

Test conditional cash transfers and other financing mechanisms to increase demand and overcome obstacles to demand for the essential package.

Reduce the unit cost of key commodities, e.g., condoms, needles and syringes, STD treatment in private pharmacies and clinics.

Develop demand creating social marketing and communication programs, including MARPs groups and peer counseling, to increase demand.

Increase mobile services to reach MARPs in locations where they feel comfortable.

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Potential for high coverage There is great potential for scaling up the interventions on the direction of achieving AIDS transition but effective scaling up will only be possible if the most critical bottlenecks are addressed adequately.

Congregation of MARPs – and thus PLHIV and vulnerable populations – is an advantage to scale up quickly. As shown earlier, 37% to 40% of MARPs are congregating in three big cities: Ho Chi Minh City, Hanoi, and Hai Phong). Adding the four (4) second-ranked provinces – An Giang, Son La, Thai Nguyen, Nghe An – results in a concentration of 57% of PWIDs, 51% of PLHIV and more than 40% of SWs and MSM from the whole country. Among these seven provinces, except for Son La, the six other provinces are geographic areas that have significant human resource and service delivery capacity.

However, as proven by the recent IBBS, even in places with relatively heavy investment such as in HCMC, achieving high coverage is not easy because of both supply and demand side constraints. Fear of being arrested, services not tailored to their needs, lack of MARP organizations that have trust and intimate connection with target populations, and having the government as the main or the only service provider with an overstretched staff that are not always friendly to and understanding of MARPs, are some of the factors that can negatively affect the program. These issues need to be addressed in order to achieve high coverage.

Financing the HIV/AIDS response Special attention has been paid to the financing of the HIV response in this report and a detailed analysis of the health financing aspects of the AIDS response can be found in Appendix III. Government and donor financial flows are significant and have grown in recent years but prevention is significantly underfunded and based on this analysis, resources could be better targeted to specific populations, geographies and a limited set of cost effective interventions to more rapidly reduce the number of new infections. In addition, priority focus has not been on specific, high risk geographic areas that are the drivers of the epidemic. In particular this relates to specific urban centers which are the centers of HIV transmission. This is partly due to the flow of resources available in these priority geographies which have not been commensurate with need. This is likely to get worse as donor funds decline and as there is more pressure on limited funding through the National Target Program. Without an aggressive response in these urban areas the epidemic will not be curbed.

By policy, responsibility for financing and delivery of HIV services has been delegated to provinces and municipalities. Based on current policy, HIV financing and service delivery is in competition with other health priorities for funding and system capacity at this level. The decision whether to fund and deliver HIV services are made in the context of competing demands. So the real issue is how to provide adequate incentives to local governments to meet national HIV/AIDS policy objectives and to assure that funds and services are targeted to the highest risk populations (MARPs and vulnerable populations) and services as outlined above. The National Target Program provides conditional grants to provinces/ municipalities in order to offset some of the costs associated with the HIV/AIDS program and national block grant allocations and local resource generation provides the rest of the funding provided provincial leadership places HIV/AIDS as a priority.

User fees are high and a major source of national and provincial/municipal resources for health including for funding HIV programs. This source of revenue is encouraged by policy. User fees provide a disincentive to use critical services and also encourage providers to over prescribe medicines, over prescribe diagnostics and in patient services and under prescribe prevention. As a result coverage of prevention interventions is lower than needed and demand for critical services is suppressed.

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What are the implications for the funding and delivering a program targeted at the geographic areas and populations that are driving the epidemic in Vietnam? There are several: First, the provincial HIV/AIDS program is expensive; costs are escalating and financial liabilities will last many years. In the face of limited resources, the provinces must decide whether AIDS funding is higher priority than other programs. They may not choose to spend enough on AIDS. Second, the HIV problem is greater in some provinces/municipalities than others. Current resource allocation formulae may not take HIV incidence or prevalence or the density of high risk populations into account in their allocation formulae. Third, local revenue capacity is limited and so the majority of AIDS funding must come from national conditional transfers under the National Target Program and from user fees. The final issue is that the benefits from a focused HIV program accrue not just to the municipality but to the nation as a whole. As such, some of the burden should be shared with other provinces and the national level.

There are three main conclusions from this assessment. First, much of the financial burden for addressing this HIV epidemic should not be supported through user fees and should not be delegated to the provinces, but rather should remain at national level with funds transferred to the provinces, particularly high priority provinces, on a conditional grant basis with strong requirements for the extent and type of services to be provided. This entire program is at risk because much of the funding for the National Target Program comes from donors and from PEPFAR in particular and these funding sources are declining.

Second, funding from the national level and funding within the provinces/ municipalities should have the right mix of incentives to assure that the right amount of money is spent on HIV/AIDS, that the funds flow to the right services, service providers and geographic areas and finally that different incentive mechanisms be tried in order to address both supply and demand side constraints are overcome. A long term commitment is needed.

Third and finally, it is important that given the limited resources available, the lowest cost, the most effective methods of services delivery be identified and implemented at scale. Based on the evidence at hand, this may require a much more aggressive community level response than is in place today.

There are other finance-related interventions that may be needed and which could overcome some of the system constraints to an effective scaled response. Making these changes will require a mix of provincial and national action. For example, there are several impediments to the demand for services

by MARPs and vulnerable populations as a result of financing policies that exist, such as the widespread use of fees, the unregulated pricing of key commodities in the private sector, stigma and discrimination which exists in the public sector and the unavailability of key interventions (e.g., condoms, needles and syringes) at the times and places where/when they are needed the most. This is partly due to current delivery strategies, but also due to financial and pricing incentives.

Finally, the HIV/AIDS epidemic in Vietnam will be around for years. AIDS cases on ARVs should be considered a chronic problem, and cheaper and more sustainable community based service and private sector delivery strategies need to be established in order for this program to be affordable in a time of declining donor funding.

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Recommendations Following the control knob framework, the recommendations below are based on the causal pathway analysis conducted by AIDSTAR-Two during this assessment.

Mobilize, allocate and manage financial resources (control knob 1) 1. Target funding and cost effective interventions and programs for MARPs and vulnerable populations in the high priority geographic areas outlined in this report.

2. Invest resources in operations research and evaluation so that the cost and cost effectiveness of different interventions and approaches for delivery services, for improving demand and for reaching hard to read MARPs can be determined. Once CE has been established, a strategy for scaling them up should be developed. In the meantime, rely on the best available regional and global evidence.

3. The capacity of provinces/municipalities to deal with increased responsibility and autonomy for fiscal and revenue management (revenue administration, expenditure planning, budgeting, execution, reporting and monitoring), determine whether or not results from fiscal decentralization will be optimal or suboptimal. And the capacity of the national level to monitor and supervise local governments need to be increased.

4. Develop an explicit strategy for the transition away from heavy donor support to the national AIDS program. This strategy should explicitly focus on local revenue generation and allocation to address immediate financial needs but also long term, sustainable financing treating HIV as a chronic disease.

5. Reduce reliance on user fee revenue particularly in high priority geographies and for high priority interventions.

6. Better target NTP resources to MARPs, high priority geographies and cost effective interventions.

Organization of service delivery and role of public and private/NGO sectors (control knob 2) 1. Organizations of community groups including MARPs should be engaged in the response at both policy and service delivery levels. Engagement actions should include: a mechanism to register, funding and technical support for MARP organizational development, representatives to have membership in or be in regular consultation to policy-making bodies and program management at all levels, funding allocated to MARP organizations to deliver services. Actions may include: disseminate policies and provide training to those sectors, remove discriminatory policies and strengthen accreditation and monitoring so that those organizations can provide all services including ART and MMT with controlled quality and sufficient security, allocate resources â&#x20AC;&#x201C; funding and commodities â&#x20AC;&#x201C; for service provision, have special policies that encourage private sector to provide condoms and needles at low price, in odd hours, at odd places, etc.

2. Improving the forecasting, procurement, supply and distribution of key commodities to community level for private, NGO and community level delivery of prevention interventions, VCT and ARVs for HIV+ people in high priority geographic areas. This may entail a more active role for NGOs and the private sector which may, in turn, require changes in rules and regulations.

3. Set up a system to monitor incidence among MARPs and, if possible, vulnerable populations, that is capable of providing valid and reliable data. Focus on high priority geographies.

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4. Voluntary treatment for drug users and job change for sex workers as replacement of detention centers should be adopted by the government to avoid them having to hide from social interaction and services for fear of being detained.

Change payment methods and incentives (control knob 3) Consider testing different performance based financing options that could address some of the health system bottlenecks. Detailed information on PBF as a financing option can be found in Appendix IV. 1. Experiment with and apply performance based methods of finance and delivery to improve resource allocation at all levels, better program performance and, on the demand side, enhanced demand by MARPs and vulnerable populations for the cost effective package of interventions in priority geographic areas. A summary of the options to be considered are: a. Vouchers for key commodities and conditional cash transfers for certain behavior changes and to facilitate access to privately provided HIV/AIDS services b. Performance contracting with private providers, NGOs and CBOs c. Conditional grants/budget transfers to municipalities through the NTP d. Cash on delivery aid for agreed upon policy change 2. On the demand side, reduce or eliminate user charges for critical interventions, services and commodities even in the private sector (condoms, needles and syringes, lubricant, testing). This could be done by offsetting revenue through conditional grants, use of vouchers for MARPs to pay for the services or other mechanisms and potentially by allowing high priority geographies and MARPs to receive waivers from fees. This will entail working with the private commercial sector in fee regulation Policy and regulation (control knob 4) 1. Adopt achieving the AIDS transition as the national goal which will require an expanded prevention effort with continued funding for testing, care and treatment.

2. Allow greater private commercial and NGO/CBO participation in the AIDS response particularly in the delivery of key interventions and sustaining a community level response over time. This may require policy changes including the ability for these groups to obtain state funding and a review of regulations to allow and encourage private sector, NGO and MARP organizations to provide comprehensive services to MARPs and vulnerable populations, at least in high priority provinces.

3. Change policies on user fees to discourage high charges for critical commodities and interventions in both the public and the private sector.

Influence beliefs, preferences and demand (control knob 5) 1. More aggressively employ community based groups, peer educators and MARPs groups themselves in targeted efforts to reach and motivate MARPs to be tested, treated, adopt safe practices and sustained on appropriate treatment regimes.

Where to spend the next HIV/AIDS dollar?

Incidence of new infections is not known but inferred. Priority should be placed on developing a system for measuring incidence among MARPs and between MARPs and vulnerable populations in the above high priority geographic areas. Without this information, Vietnam will not know the effectiveness of its prevention response.

A specific few bottlenecks are constraints on effective system response to the epidemic and

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should be tackled: a. Sharpen the geographic program focus to high risk geographic areas and within those areas to places where particularly vulnerable MARPs groups practice high risk sex and where PWIDs congregate. b. Invest more in just a vital few interventions. Investments in condoms and lubricant, needles and syringes and getting them in the hands of those that need them at the right times and places should be priority. High coverage is needed. c. Change policies allowing for community-based voluntary treatment for drug users and voluntary job alternative support for sex workers as an alternative to detention centers. d. Change policies that currently result in discrimination into ones that encourage MARPs, NGO and private sector to participate in the response in all aspects, at all levels. e. Provide financing and fund organizational development for community based organizations of MARPs and vulnerable populations and encourage them to expand their reach and create sub-cultures that support safe behaviors. f. More effectively engage the private sector’s involvement (including NGO, FBO and CBO) in ways that improve access to critical services and interventions in hard to reach geographic areas (e.g., slums, parks) when the need for services is greatest (e.g., nights, weekends) g. Test performance based approaches to financing both public and private sector provision of preventive and curative services. This could include better ways to leverage donor funding for policy and program change, enhancing competition between providers, making grants conditional on achieving a certain level of performance.

Aligning financial incentives at all levels of the system will be required. a. The National Target Program must first and foremost be adequately funded. The transition from a primarily donor supported program to a nationally financed program will be important. b. Target Program resources should be allocated through conditional block grants with preference given to high priority provinces and municipalities. In addition, these conditional grants should specify the target populations and priority geographic areas within these provinces/municipalities that should receive high priority funding. c. Incentives should be put in place on both the supply and demand side adequate to motivate providers to deliver the right services to the right people at the right times and places, but also to increase demand for those services by MARPs and vulnerable populations. Test performance based approaches to increasing demand for key interventions and services such as vouchers for condoms, needles and syringes and cash transfers to MARPs for testing.

Generating demand for services a. Reduce or eliminate formal and “under the table” user fees and prices for all services, commodities and medicines related to HIV prevention and treatment in priority geographic areas. b. Improve access to services and to sustainably long term provision of ARVs to HIV+ people using community based approaches.

Providing comprehensive service package to priority groups in priority provinces a. Diversify service providers in coordinated ways to reach a greater number of MARPs. Reliance on the government system will not achieve the level of coverage needed. b. Encourage private sector, NGO, MARPs to deliver services through policy, financial, technical support c. Involve MARPs and vulnerable populations in surveillance, service provision and in the

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monitoring of quality of services. d. Change policies and/or use legislative tools – when needed – to reduce price of ARV and other essential commodities and medicines.

Who should pay for what?

Vietnam can’t afford to do everything nor can it afford everything. In addition, some actors are best placed to spend on certain things as opposed to others. Going forward, what should government spend money on and what should donors, in particular PEPFAR, spend money on?

1. Responsibility for development of methods and a system for monitoring incidence in MARPs and financing that system should rest with the government. Implementation of that system should be the responsibilities of municipalities and other high risk geographies.

2. Policy change and development: donors and government.

3. Development of MARP organizations and sub-cultures: donors with participation of government.

4. Behavior change interventions: Should jointly be funded by government and donors and executed by the private sector.

5. Essential services: o Reducing price of medicines and commodity: government and donors o ART: donors, government, segments of PLHIV population. o Condoms/lubricants and needles and syringes: government and donors (for behavior change interventions and the poorest users), and users whose condom use behaviors have been established and who can afford them. o STI treatment: government and donors for the poorest, and users who can afford.

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6. Summary Guidance 1. Recommendations on methodology Issue: Not all country programs are designed with a thorough understanding of the epidemiology, characteristics of the at risk populations, knowledge of the risk factors driving HIV transmission or the effectiveness of interventions but rather are designed on accepted best practice. Health system strengthening actions are not driven by an understanding of specific health system requirements or specific health system bottlenecks impeding delivery of the most effective combination of evidence based interventions.

Recommendation: Much greater rigor and specific attention to epidemiological detail would allow a more finely tuned response to the epidemic. This will take time and energy and a specific focus placed on including more emphasis on research and data in program design and implementation.

Issue: Interventions are addressing risk factors which are on different places on the causal pathway to transmission. Some interventions address indirect risk factors while most address direct risk factors.

Some are systems focused while others are focused on indirect risk factors. In most cases it is unclear where the most important points of intervention might be along that causal chain.

Recommendation: Using the causal pathway analysis approach allows planners to understand what risk factors they are targeting, which specific points in the transmission pathway would disrupt transmission the greatest, and what level of impact you could expect to have.

Issue: Current health system assessment approaches, using normative standards and high level analysis are inadequately precise to identify the very specific health system bottlenecks that need to be addressed to scale up a very specific set of evidence based interventions targeting very specific population groups.

Recommendation: While current health system analysis approaches offer good input into broad health system strengthening needs at a national level, a much more specific, detailed and analytic approach to health system analysis which is focused on identifying specific system bottlenecks for specific interventions targeted at the needs of specific populations is required to scale up evidence based interventions.

2. Recommendations on the availability and use of evidence Issue: The evidence base on incidence of HIV transmission, understanding HIV transmission-related risk factors in high risk sub populations, effectiveness of technical and programmatic interventions and effectiveness of health system strengthening actions at overcoming specific system bottlenecks is limited.

Recommendation: Operations research is needed to define the effectiveness of approaches that need to be developed addressing country-specific issues. The lack of evidence across the board is one of the most formidable obstacles to selecting and implementing the most cost effective approaches to reducing HIV transmission.

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Issue: Those planning and implementing programs need access to and knowledge about what evidence is available to them to tailor their response. Evidence, although limited, does exist. The challenge is to make it accessible to policy makers, planners and implementers. The second challenge is to ensure these people have the capacity and skills to use that evidence to design their programs.

Recommendation: Existing evidence needs to be synthesized and made much more readily accessible to those that need it. Support needs to be provided to policy makers, planners and implementers to apply existing evidence in the design of tailored approaches which address the specific needs of individual countries.

3. Recommendation on gender issues Issue: Universally, women are unable to afford or access preventive and curative interventions. They are also unable to negotiate with their male partners when it comes to use of effective interventions, such as condoms, and they are bound by social and cultural factors that make them susceptible to HIV infection. Finally, data are not disaggregated adequately in health information systems to fully understand the supply and demand for effective interventions by women.

Recommendation: Specifically, it is important to understand more about the risks to women, the factors that influence that risk, the systems response to those risks in women and the uptake of interventions which address those risks. In addition, more effort needs to be made to create information systems which provide disaggregated data on health system performance related to the delivery and uptake of effective interventions. This may require sociological, anthropological analysis to understand some of these issues and how to address them.

4. Recommendation on legal and regulatory issues and private sector engagement Issue: A few specific legal and regulatory issues are system bottlenecks that need to be addressed.

These are indirect risk factors that influence the behavior of specific MARPs populations (e.g., MSM) but also the financing, delivery and update of these interventions. This includes the effective engagement of the private sector in an appropriate HIV response.

Recommendation: A specific focus is needed to understand which legal and regulatory issues are health system bottlenecks constraining a countryâ&#x20AC;&#x2122;s response on both the supply and demand side, in both the government and private/NGO sector. The legal and regulatory constraints will be different depending on the individual country, so a normative approach wonâ&#x20AC;&#x2122;t work. An understanding of the potential for private sector engagement and the legal and regulatory and systems issues that impede this engagement is needed.

5. Recommendation on financing Issue: Significant attention has been paid to how vertical, well-funded HIV programs can affect the performance of the health system to address other issues. Less attention has been paid to what is financed, the role of municipalities, provinces and national governments in financing the response and how resources flow in the system. These are critical issues related to sustainability particularly in countries which have been dependent on high levels of donor funding. A significant issue, however, is

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that data on donor, government, out of pocket spending is not readily available and the effectiveness of the allocation, management and use of resources is limited. As a result of these shortcomings it was not possible to address this in the analysis.

Recommendation: More attention needs to be placed on the current and future trends in the use of resources, the mix of donor, public, private and out of pocket spending, and the management of financial resources. More attention needs to be paid to the transition from USAID/PEPFAR funding to funding from domestic resources and the effect of that transmission on the scale up of effective approaches targeting specific populations, risk factors and interventions.

6. Recommendation on demand issues Issue: Significant attention has been paid to the supply side of the response but very little focus has been paid to the issues that affect the demand for evidence based interventions and approaches. Poor coverage is the result of both supply and demand side constraints and scaled up delivery requires both a supply and demand side strategy.

Recommendation: More attention needs to be paid to factors that affect the demand for effective interventions by specific high risk populations. Effective programmatic strategies need to address both supply and demand issues and building the evidence base on how to influence demand is greatly needed.

7. Recommendation on scaling up what works Issue: There are a number of technical and programmatic interventions that are being implemented and the selection of many of these interventions and approaches is made without fully considering the evidence base that exists.

Recommendation: There are many technical interventions whose efficacy and effectiveness is known, such as the effectiveness of male condoms in reducing HIV infections. The current evidence base on effectiveness of technical and programmatic interventions needs to be more widely disseminated and that evidence base is used to determine the most effective combination of interventions.

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APPENDIX I Deep Dive Example: Condoms

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Deep dive example of health system requirements, bottlenecks and system strengthening recommendations for a 100% condom program to reduce HIV transmission in MARPs and vulnerable populations in high risk geographies and sub geographies in Vietnam Introduction to the deep dive example Table 10, starting on page 101, outlines the theoretical system requirements, system bottlenecks and system strengthening actions needed to implement a successful 100% condom campaign in Vietnam.

This is simply an example of using the data which resulted from our analysis of the problems, causes and risk factors which cause HIV transmission as well as the examination of the characteristics of populations most at risk of being infected or infecting others and, our examination of cost effective interventions.

This deep dive example will not repeat the epidemiologic analysis that has led us to focus on specific MARPs and vulnerable groups and specific geographic areas. It will start from the point of choosing the most cost effective intervention that needs to be scaled up to reduce HIV transmission and then reexamine current condom program implementation status. This material has been taken directly from the main report.

Choosing condoms as the priority intervention Why are we focusing on condoms as our deep dive example? The best prevention approaches meet four criteria: effectiveness, relevance, efficiency and sustainability. For preventing HIV transmission, effectiveness refers to the underlying ability of the technical interventions and program approaches to reduce HIV transmission. Relevance refers to the appropriateness of the intervention/approach given the specific epidemiological, cultural and social context of the setting. Efficiency refers to the interventionâ&#x20AC;&#x2122;s ability to leverage existing social, technical, political and public health structures that already exist. Finally, sustainability refers to the ability of the intervention to achieve long term behavior and system change for the least amount of money. Using these four criteria we have chosen condoms as our deep dive example. Condoms are highly effective at reducing HIV transmission and are relevant to the current situation in Vietnam. There are policies, programs and systems in place that already promote condom use and condoms use is high and steady. Scalability perhaps should be the fifth criteria. Very cost effective interventions may, in fact, be difficult to scale up thus lowering their effectiveness when considered as a nationwide program. The fact that condoms are highly effective but also widely used around the world, and in particular in Vietnam, low cost and procurement and logistic systems are in place suggests condom programs and different integrated approaches are not only cost effective but scalable. In spite of this few CE studies exist on how to scale up these integrated programs.

Male condoms are 80-95% effective in reducing the risk of HIV infection when used correctly and consistently. In Vietnam, condoms are cheap, available throughout the country, they are acceptable to the Vietnamese people and they are widely used in Vietnam as a method of contraception as part of the national family planning program. Condoms also address the major problems, causes and risk factors associated with HIV transmission in Vietnam. Finally, condoms are commercially available in all pharmacies and other commercial outlets in both urban and rural areas of Vietnam and through the public health system they are publicly available at low prices. In other words, the platform for scaling up condoms as the major mechanism for reducing HIV transmission exists.

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The extent of the literature on effectiveness of condoms to reduce HIV transmission is extensive. We’ve briefly reviewed that literature below. There are several publications extolling the cost benefit of condoms, highlighting the effectiveness of condoms as a way of reducing HIV transmission and the sustainability of the results. The 100% Thailand condom promotion campaign is one of the best examples. In its 100% Condom Program, the Thai government mandated condom use for female sex workers and their clients. As a result, condom use increased and the number of new HIV infections in Thailand is estimated to have decreased by more than 80% by the end of 2000. A systematic review conducted by Omar Galarraga and others53 reviews the effectiveness of a number of condom programs.

As part of a biomedical intervention, the report notes that if antiretroviral treatment could be delivered in a way that also scaled up condom use, cost per life saved would be between US $10-$30 in one study.

Another study assessed the cost effectiveness of condoms as part of an STI control program modeled the cost effectiveness and found that the cost per HIV case averted was US $2,093 or cost per DALY averted was US$ 78. As a structural intervention, a 100% condom program supported with appropriate laws and strong consequences for non compliance coupled with positive rewards for the user in Dominican Republic, resulted in a cost per HIV case averted of US $28,208. In India, four strategies, all including peer education and condom promotion, were evaluated to determine the effectiveness of preventing HIV transmission in commercial sex workers in an urban center of Ahmadabad City. The authors found that the cost per HIV case averted ranged from US $33.70 to US $133.40 when peer educators were valued as financial costs, and from US $55.60 to US $128.50 when considered as economic costs. Cost per DALY averted was as low as US$ 43.10.

There are multiple examples of combined interventions that are cost effective, all including condom promotion. Small financial incentives provided to MARPs in Malawi to increase demand for HIV testing also increased the purchase of condoms lead to greater demand for condoms for those testing positive.

This suggests that effectiveness of condoms is not only based on desirability, knowledge and improved attitudes about use of condoms but also related to the other services bundled as part of an integrated program. The authors state that Only when information is available about the likely synergies between different prevention interventions will CEA realize its potential in helping to identify the optimal package or the "right mix" for a given country or situation.

Mass media is very popular and millions of dollars around the world have been spent on mass media campaigns and social marketing. Yet mass media campaigns have not been found to be CE or have had mixed results for reducing HIV transmission. VCT without STI detection and treatment and condom distribution has not been found to be CE at reducing transmission. While many people believe mass media and public information/education is essential, there is little evidence supporting this.

Cost effectiveness of any project is highly dependent on the design of the program and that is highly dependent on the data used to determine who is at risk of HIV transmission. Cambodia, for example, attempted to replicate Thailand’s 100% condom campaign but has had some difficulties. While the 100% condom campaign in Thailand achieved significant and rapid reduction of HIV transmission, a similar program in Cambodia was less successful. The Cambodia example aimed at achieving 100% condom use during commercial sex work but targeted brothel based female sex workers (FSW) instead of the higher risk “informal” FSWs who work out of massage parlors, karaoke clubs and other establishments. The design also did not target users of amphetamine-type stimulants (ATS) which is a major risk factor in unsafe sex.

53

Galarraga, Omar; Colchero, M. Arantxa; Wamai, Richard G.; and Bertozzi, Stefano M., "HIV prevention costeffectiveness: a systematic review" (2009). African American Studies Faculty Publications. Paper 1.

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Current statues of condom use in Vietnam among MARPs Inconsistent condom use among female sex workers is common in a number of provinces. As shown in Figure 10, reported consistent condom use with clients could be as high as 85%- 86%, in some provinces, it can be as low as 21% (among venue-based SWs in Dong nai and 23% among street-based SWs in Ho Chi Minh City). More importantly, among the seven provinces that participated in both IBBS rounds, consistent condom use among SWs was reported to decrease in four provinces – most seriously in Ho Chi Minh City – from 61% to 23% among venue-based SWs and from 72% to 32% among street-based sex workers.

The more intimate the relationship is, the less likely that condom is used. Figure 10 shows that across IBBS2009 provinces, condom use – either at last sex or consistent use in the last month – is reportedly highest with sexual encounters with one-time clients, lower for regular clients, and very low with regular partners. It is also notable that while the vast majority of sex workers use condoms, in some provinces, levels of consistent condom use are low even with one-time and regular clients. In Ho Chi Minh City, for example, while 80% of street-based sex workers reported using a condom during the last sexual encounter with a one-time client, only 31% reported consistent use in the last month with this type of client. Condom use during last sex and during the last month is reported less for regular clients – 64% and 26.6% respectively. With regular partners, condom use is reportedly even less – at 16.8% and 5.5%.

A similar trend is observed among venue-based SWs. Figure 10: Condom use during last sex and consistent condom use in the last month with different types of partners, reported by street-based sex workers*

100 90 80 70 60 50 40 30 20 10 0 Hanoi

Hai Phong

HCMC

An Giang

Nghe An

Dong Nai

Yen Bai

Last time wt 1-time client

Consistent wt 1-time client

Last time wt reg client

Consistent wt reg client

Last time wt reg partner

Consistent wt reg partner

*Constructed from IBBS2009 data

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Similar to female sex workers, PWIDs reported significantly less condom use with regular partners than that with casual partners (see Figure 11 below). Condom use with sex workers was less again. Consistent condom use is low across all partner types (37% to 74% with sex workers, 18 to 71% with casual partners) with the lowest levels evident with regular partners (16% to 53%).

Figure 11: Condom use during last sex and consistent condom use in last 12 months with different types of sexual partner, reported by PWIDs* 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi

Hai Phong

HCMC

SW - last time Casual - last time Reg partner - last time

An Giang

Nghe An

Dong Nai

Yen Bai

SW - consistent Casual - consistent Reg partner - consistent

*Constructed from IBBS 2009 data

Data on condom use among MSM who reported selling sex (Figure 12) shows a similar trend to that of FSWs and PWIDs, with the majority of MSM using condoms but only a small proportion doing so consistently. Condoms were more likely to be used in transactional sex, and less so with consensual partners â&#x20AC;&#x201C; either male or female (19 â&#x20AC;&#x201C; 34%).

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Figure 12: Condom use during last sex and consistent condom use in last 12 months with different types of sexual partner, reported by MSM who also reported selling sex* 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Hanoi Last sold sex Last MSW Last consensual male Last FSW Last female client Last consensual female

HCMC Consistent male client Consistent MSW Consistent consensual male Consistent FSW Consistent female client Consistent consensual female

Sex workers According to official statistics from MOLISA, there are over 28,000 sex workers in Vietnam. This is considered a low scenario with the high scenario triple that figure. Using the medium number of SWs and HIV prevalence rates drawn from the MOH’s HIV/AIDS Estimates and Projections Report, the following table is produced.

The majority of street-based and venue-based SW report having different types of sexual partners, onetime clients, regular clients and regular partners. Street-based SW tended to have more one-time clients and venue-based SWs more regular clients. Street-based SW reported between two to 20 one-time clients and one to two regular clients in the past week. Venue-based SW reported between one to five one-time clients and one to three regular partners.

Among sex workers, Chlamydia as the most common STI among sex workers, with rates reducing between the 2 IBBS rounds. Prevalence in Ho Chi Minh City is higher than in Hanoi. Detailed data on STI service and treatment coverage was not available when writing this report. A small scale study conducted in Hanoi in 2010 would suggest that FSW prefer private services for their privacy but would utilize public service if money is not available or free-project-based services if they are familiar with the service or they don’t want to spend money on STI services.

According to the 2009 IBBS study 51.5% of all FSWs across 10 provinces where able to identify the correct means of preventing sexual transmission of HIV and reject misconceptions about HIV transmission. Wide variations are again seen across provinces and ranged from 9.9% - 80.3%.

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Condom Distribution among CSW Condom distribution to FSW would appear to vary significantly across provinces, and again between venue based and street based workers. Preliminary data from the 2009 IBBS indicates that condom access is highest among SSW in Can Tho and An Giang at 84%, with lowest levels of access apparent among VSW in HCMC at 36%. Figure 23 shows trends 2006-2009, including where access appears decreasing over time.

Figure 23. Trends in condom access among female sex workers, 2006-2009

MSM Condom Distribution Figure 24. MSM with access to condoms in the last six months in Vietnam Based on 2009 IBBS data, condom access among MSM varies across provinces and between non MSW and MSW. Consistent condom use remains low even in areas where reported access is relatively high (e.g., data suggests that at 76.5%, MSM in Can Tho have had better access to condoms, consistent condom use with male partners over the last month there was lower [39%] than Hanoi [54%] where access to condoms was only 47.8%).

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STI Services and Treatment There are no available data on uptake of STI services and treatment among MSM. Male PWID There are wide variations in reported condom access by province among male PWIDs ranging from 7% in Da Nang to 85 % in Yen Bai. Figure 29. Condom access among PWIDs PWIDs who obtained cheap/free condoms in the last 6 months among sexually active PWIDs (n) 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Ha Hai Quang Nghe Yen Bai Da Dong HCMC* Can An Noi* Phong Ninh An Nang* Nai Tho* Giang

STI Services and Treatment No data on STI services and treatment specifically for male PWIDs were available when writing this report.

Program design and strategy Accepting the above information, the epidemiology of HIV transmission in Vietnam suggests that a 100% condom program could potentially be an effective strategy for preventing HIV transmission for a number of reasons.

Our strategy for implementing a 100% condom campaign is to quickly obtain 100% use of condoms in the highest risk, easiest to reach MARPs and vulnerable populations followed by efforts to reach the most at risk but hard to reach at risk populations. How to reach those hard to reach populations is central to our learning agenda.

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The learning agenda We donâ&#x20AC;&#x2122;t know everything there is to know about condoms in Vietnam. A number of questions remain unanswered: 1. What are the effects of adding small supply side and demand side financial incentives to the uptake of condoms and to their sustained use over time by MARPs and vulnerable populations?

2. Evidence suggests that different packages, all including condom promotion, can be effective.

What are the costs and effectiveness of these different models? Which are more scalable and sustainable?

3. What are the best methods of reaching the most at risk populations who are difficult to reach with condoms and once they do begin to use condoms, how to sustain that behavior over time?

4. What is the best means of improving access to condoms in hard to reach geographic areas (e.g., slums)?

5. What is the best method for supplying condoms to these areas and populations and at what price? Should condoms be free or subsidized or can we rely on the market?

6. What should the role of the private commercial sector (e.g., pharmacies and private clinics) in the supply, distribution, treatment and provision of HIV prevention services, including condoms?

How should they be regulated? Incentivized? Supported by government? To what extent could private sector involvement expand coverage, improve cost effectiveness and reduce costs when compared to a purely public sector program?

Joint effects For the purpose of this paper it is assumed that Vietnam wishes to implement a 100% condom program and that it has learned lessons from neighboring Thailand which has implemented a successful program.

What are the system requirements, system bottlenecks and system strengthening actions needed to implement a successful program? The following table attempts to answer these questions and serves as an example of the kinds of analysis needed for a range of interventions need to reduce HIV transmission.

Please note that many of the system requirements, bottlenecks and HSS recommendations are the same for a 100% condom program as they would be for scaling up methadone or needles and syringes for PWID. Thus by addressing these issues for condoms, the health system will be building the foundation for scaling up other cost effective interventions which are in the proposed comprehensive package for MARPs in high priority geographic areas of Vietnam.

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Table 10: Requirements for a scaled up 100% condom campaign to reduce HIV transmission in Vietnam System requirements by System bottlenecks System strengthening building block plus demand recommendations DELIVERY Condoms need to be universally available at times and places where sex will occur even in hard to reach areas. Every CSW, PWID, MSM, both HIV+ and HIVmust use a condom for every sexual act. Since the location and time of day of need for condoms is unpredictable, access to condoms must be high.

Condom distribution should be linked with programs for the control of STIs and to VCT programs which are frequented by high risk populations.

Condoms need to be made available in every hotel room, sex establishments, parks and other locations here unsafe sex occurs.

STI and VCT clinics must be made available. Weekly physical exams for sex workers should be required and enforced.

A monitoring and feedback system needs to be put in place to encourage feedback on program performance and design including feedback on the condoms used in the program and their acceptability to the target population.

Initial efforts should be aimed at 100% condom use by those most at risk of infecting others of being infected. As coverage

Coverage of condoms in MARPs is low and inconsistent across priority geographic areas.

Reasons vary from poor geographic and financial access to lack of demand and stigma.

The current public sector oriented delivery strategies are not able to achieve high coverage of condoms in MARP populations particularly in hard to reach areas.

Private for profit and some NGOs are providing quality services but are not an official part of the delivery strategy for key interventions in priority and resultant coverage is low and cost is high.

Access to condoms at the right times and places is poor, condoms are costly, demand is irregular and there are few incentives to purchase and use condoms.

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To extend coverage and improve access to condoms, four actions will be needed.

First, municipal heath authorities should encourage the development of CBOs and civil society groups to advocate for resources and to track local implementation and hold local authorities accountable for proper program execution and use of funds.

These groups could also implement peer counseling and education of high risk groups in priority sub geographies. Second, private providers, including pharmacies, should be allowed to delivery services.

Policies as well as financial incentives should be put in place to encourage their active involvement in the purchase and distribution of condoms to MARPs in priority geographies. Third, mobile clinics may be needed in very hard to reach locations or where high risk populations are not mobile or where limited access to VCT and STI clinics is poor or where time costs are an impediment to demand.

Finally, the NGO sector will probably be needed for delivery to some sub populations, e.g., those whose behavior is illegal such as PWIDs. NGOs have

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System requirements by building block plus demand rises in that group, attention should shift to more effectively reach high risk groups who are harder to reach. Innovation in project design and other operations research will be needed and should be encouraged.

To lessen the long term demand on the public sector the private sector should play a larger and larger role and be supported both financially and logistically where needed and appropriate. Greater public sector supervision and oversight will be needed.

System strengthening recommendations an advantage in assessing and serving the most stigmatized and marginalized people in the most hard to reach areas.

Condom programs should be integrated with STI and VCT programs.

Operations research and program evaluation should be used to fine tune the delivery strategy over time.

HIV+ MARPs will be on ARVs for their lifetimes. As such they should be treated as though they have a chronic disease and delivery cost effective delivery approaches developed to sustain them on ARVs, condoms and other service over the long term. These strategies need to be defined and tested.

Community based delivery approaches using CBOs should be encouraged.

GOVERNANCE/POLICY/ENABLING ENVIRONMENT

The current vertical, centrally designed and orchestrated needs to be replaced with a decentralized design allowing for the selection of a core intervention, e.g., condoms, but also the adaptability of program strategy and approach to local situations recognizing that the epidemic is different in different locations in Vietnam.

Municipal health offices should be responsible for the program including promulgation of appropriate

System bottlenecks

Private and NGO providers are not allowed by policy, law and/or regulation to deliver the comprehensive package.

Policy does not allow for civil society engagement or formalized groups of PWID to engage in policy dialogue No policy on private sector testing, treatment for HIV of STIs or for the same of other critical medicines such as methadone. In fact rules and regulations forbid private sector involvement.

Supervision and regulation of

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Create policies, rules and regulations allowing and even encouraging public/private collaboration and more extensive delivery of the comprehensive package of interventions to MARPs in target geographies.

Reduce or eliminate policies, laws, rules and regulations that discriminate or make illegal MARPs or their behavior.

Create policies and penalties that prohibit discrimination

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System requirements by building block plus demand policies, regulations and strategies. They should have strong links to and support from municipal administration, police and HIV offices. A multisectoral team may need to be created.

Several policies need to be promulgated and monitored: preferential financial allocation to condom programs, price controls on condoms in private sector outlets, mandatory STI testing for CSWs and mandatory weekly physical exams.

Policies allowing for distribution of free or heavily subsidized condoms are needed and in some cases policies allowing for health vouchers for MARPs for purchasing condoms from local outlets.

Policies allowing for use of financial incentives, performance contracts and other supply and demand side incentive schemes would be needed.

To assure accountability and oversight, national and provincial level authorities need to be involved in oversight and monitoring functions.

To assure proper treatment of STIs and testing, protocols need to be developed and their use monitored over time to assure good quality.

Policies and regulations governing the private and NGO sectors allowing them to prevent, diagnose and treat

System bottlenecks private providers is weak.

Government does not encourage private sector in hard to reach areas. There are no incentives to do so.

No active supervision of the private and NGO sector although there is a mechanism in place.

Treatment guidelines are not being followed nor is there supervision.

National policy on financing encourages high user fees in government facilities even for most elements of the comprehensive package. While some interventions are subsidized, they are subsidized by donors. The incentives to collect revenue and the incentives to increase demand for HIV services are not aligned.

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System strengthening recommendations in government and private/NGO clinics.

Allow private sector clinics to be subsidized sing government resources if they deliver key interventions to MARPs in priority geographic areas.

Create supervisory and audit guidelines for private providers, NGO and CSO clinics and service providers and penalties for non compliance or bad practices.

Modify policies on user fees and financial autonomy for government facilities which call for high fees and other practices which discourage use by MARPs. Program managers should promote and support the development of incentives and rules to regulate performance and to assure accountability and transparency.

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System requirements by building block plus demand HIV/AIDS including VCT. Policies allowing MARPs groups, NGOs and private sector players to actively participate in the development of regulation and policy.

Treatment protocols and guidelines for lay health workers as well as methods for monitoring and supervision of NGO, private sector and lay health workers.

Policies allowing for community based distribution of ARVs for HIV+ MARPs and vulnerable populations,

System bottlenecks

System strengthening recommendations

FINANCING Condoms must be priced at a level that would not deter demand or use.

For the hardest to reach, and for the poor, prices may need to be negative, i.e., financial incentives may need to be in place to encourage use.

Voucher or other conditional cash transfer programs to encourage demand for condoms may be needed for the hardest to reach.

Performance contracts for local NGOs and CBOs who are program extenders at community level may be required to enhance the supply side response.

At a national level, this 100% condom program should be funded at levels necessary to scale up delivery of condoms until it reaches a sustainable 80% coverage. This includes funding STI kits, testing kits as

Prevention is generally underfunded and the condom component of the national HIV/AIDS National Target program in particular is underfunded and block grants to target municipalities and other high priority geographic areas are inadequate to fund a scaled up delivery of condoms for MARPs and vulnerable populations.

Most of the condoms are donor funded and the programâ&#x20AC;&#x2122;s sustainability is at risk of declining donor funds.

Municipalities do not raise their own revenue nor do they budget adequately for these interventions and the money they have is spread thinly across all interventions and population groups. Not adequately targeted.

Out of pocket spending for condoms by MARPs and

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Develop a long term financing strategy for the HIV response focusing on the comprehensive package, MARPs, vulnerable populations and high priority geographic areas.

Create a system of incentives (e.g., CCT, performance contracts, subsidized inputs) which reduce the out of pocket costs to MARPs for key interventions and which encourage scaled up delivery of the comprehensive package for MARPs. Improve the targeting of National HIV/AIDS Target Program funding focused on high risk municipalities and geographic areas.

Work with municipalities to modify or refine fiscal decentralization policies

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System requirements by System bottlenecks building block plus demand well as condoms and other vulnerable populations is high VCT and STI program costs. and growing. They seek services from the high priced Continued coverage of HIV private sector even when free under government insurance government services are schemes but expanded available. High prices number of allowable providers discourage demand. eligible for reimbursement, e.g., NGOs, CBOs and private There is no mechanism for sector providers as channeling public funding to appropriate. civil society groups, NGOs and private sector to promote condom use or to monitor progress.

System strengthening recommendations which hamper the financing of key programs for MARPs. Adequately fund key medicines and commodities.

Price interventions and commodities in a way that encourages consumption (e.g., free condoms, needles and syringes or reduced prices in private sector shops).

For private, NGO and CSOs funded under an expanded prevention effort, funding should be contingent on good performance.

INFORMATION The current framework and the M & E system has not resulted in the accumulation of data necessary to understand the MARPs epidemic in Vietnam and to ensure that prevention program coverage and strategies are targeted and effective.

There is little evidence in Vietnam on the efficacy or effectiveness of HIV prevention interventions and approaches operating in Vietnam.

We need to estimate the need for condoms, the likely geographic need in high risk sub geographic areas.

There must be a system that

Most models for determining the most appropriate resource allocation strategy are flawed.

The assume linear outcomes, do not consider simultaneous resource allocation to both treatment and prevention programs, they donâ&#x20AC;&#x2122;t consider non-linear interactions among types of programs, do not allow repeated allocation decisions over time and do not incorporate uncertainty in the effect size estimates of different treatment and prevention interventions.54 Lack of specific data on where PWIDs live, work, practice unsafe behavior so it is difficult to target condom program inputs.

Evaluation methods need to be improved. Data collection tools which enable further disaggregation (e.g., by intervention modalities such as peer education, by sex, by location etc) are required, and strengthened capacity across all levels of the system is necessary There is a need to build better models to overcome the shortcomings of existing models allowing policy makers to understand complex interactions, allow adaptations to local circumstance across priority geographies and target populations, and allow for

54

Till Barnighausen and Salal Juair, Concept Note: Optimal resource allocation modeling in the HIV sector.

Unpublished. Harvard School of Public Health, April 2011

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System requirements by System bottlenecks building block plus demand measures who uses condoms, Lack of coverage information how much, when and where for this population group. in order to model the effect of Little understanding of factors condom use on HIV that lead to low demand for transmission. and use of condoms.

We must map hot spots Data are few and weak on use where high risk groups of condoms by MARPs and practice high risk sex in the vulnerable populations in high priority geographic areas. This priority geographic areas. mapping should drive the Most prevention programs lack delivery strategies and the data to inform results based logistics and supply of management, to interpret data condoms. and to develop management We must develop models for structures. optimal allocation of resources across HIV prevention interventions including condoms in order to anticipate the shift from donor to local resources.

We must measure the price elasticity of demand for condoms across different MARPs and vulnerable populations in order to affect proper pricing strategies and to link condoms to other potentially desirable interventions such as STI control.

To advocate for adequate funding for 100% condom campaign, the costs and effects of this campaign would need to be modeled and compared to other prevention strategies demonstrating the effectiveness of investments in condoms. Real time cost and effectiveness data would later result from robust ongoing program evaluations.

System strengthening recommendations easy to manipulate variables for “what if” analysis.55 The expanded prevention program in Vietnam should be grounded in strategic analysis of the epidemic’s dynamics in local contexts across Vietnam.

Effectiveness of the prevention effort should be based on the extent to which the critical interventions achieve high coverage of MARPs and vulnerable populations.

Identify coverage levels of current interventions for MARPs and vulnerable populations in priority geographic areas.

Collect trends in HIV incidence in different populations so as to better understand the epidemic and assess effectiveness of prevention programs.

Map and estimate the size of MARPs and vulnerable populations in target geographies and measure trends in prevalence and incidence overtime.

Monitor contextual factors, determinants of risk behavior and barriers to prevention over time in key geographies.

Develop standardized social science protocols that provide guidance on how to use qualitative and quantitative data collection

55

The Lives Saved Tool developed by the Futures Institute in collaboration with the Bloomberg School of Public Health, the Child Health Epidemiology Reference Group and UNICEF with funding from the Gates Foundation is an example of the kinds of useful models that could be developed

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System requirements by System bottlenecks building block plus demand Information on produce acceptability to the user needs to be collected and used in making purchasing decisions Information systems need to be developed to forecast needed volume, estimate costs, track procurements, monitor distribution and track stock in depots and local distribution locations.

Private and public sector sales and provision of condoms needs to be monitored for volume of distribution, storage, quality control and sales prices.

Information needs to be provided to MARPs and vulnerable populations about the availability, access, quality and cost of condoms An effective monitoring and evaluation effort needs to be put in place. In the absence of a case control or other rigorous evaluation methodology to measure program effectiveness and impact, new evaluation methods measuring effectiveness against the counterfactual would be needed.

Evidence of effectiveness of condom promotion methods and materials is scarce and many methods are not cost effective. OR is needed to test and refine cost effective approaches to increasing coverage and use of condoms

by MARPs in high priority geographic areas.

Need to be able to measure

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System strengthening recommendations methods.

Develop and evidence base on effectiveness of interventions, combinations of interventions, program strategies and approaches and cost of delivery of key interventions.

Determine the cost effectiveness of prevention over treatment and use that as an advocacy tool for greater resources.

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System requirements by building block plus demand HIV incidence rate among MARPs and vulnerable populations in high priority areas.

Expanded evidence on effectiveness of IEC and other risk reduction materials and effectiveness of prevention interventions and program strategies and approaches.

Ability to measure and track over time changes in coverage of the comprehensive package in high risk populations in priority geographic areas.

More specific information on where PWIDs live, work, practice high risk behaviors, who they interact with and how to influence them.

Increased ability to track compliance with treatment protocols and quality of care for services delivered by private, NGO and CBO providers.

System bottlenecks

System strengthening recommendations

MEDICINES/LOGISTICS Condoms need to be universally available at times and places where sex will occur even in hard to reach areas. As such, supply chains must extent to these hard to reach sites. There must be no stock outs, the types of condoms need to be acceptable to the users and the procurement of condoms must take into consideration the need to more condoms in more harder to supply places.

Each MARP and vulnerable group in high priority

The supply chain does not extend to the community or to areas where high risk behavior is practices.

Frequent stock outs.

Low cost commodities (e.g., condoms) not sold in private pharmacies and informal outlets so prices are too high.

The types of condoms currently being purchased and supplied do not always meet the needs of MARPs.

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Adequate medicines and commodities in priority geographic areas to satisfy needs of MARPs and vulnerable populations.

Improve forecasting and procurement.

Develop mechanisms for pooled procurement and other means of reducing unit costs.

Develop a strategy for publicly financing what now is financed by donors, including ARVs and other inputs.

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System requirements by building block plus demand geographic areas and sub areas should be given free of charge as many condoms as they demand. This can be done using a voucher program or free distribution at point and time of need.

A series of depots in high priority geographic areas and sub areas would be needed where adequate stocks of condoms would need to be maintained. They would need to meet certain standards to keep condoms safe, e.g., not too hot.

System bottlenecks

System strengthening recommendations

HUMAN RESOURCES Adequate personnel would need to be recruited and assigned to run this program.

CBOs and NGOs and civil society groups could be trained and funded to be community level extenders of this publicly management and financed program.

Recruitment of private commercial sector, CBO, NGO and community based providers would be needed and they would need to be trained, monitored and supervised and supported over time.

Staff need adequate skills in monitoring and evaluation including data collection or the resources needed to contract monitoring and evaluation activities.

Inadequate numbers of trained and motivated health workers willing to work with MARPs and vulnerable populations in high priority geographic areas.

Inadequate recognition of services already provided by non government providers.

In adequate supervision of non government providers.

Adequately numbers of trained and motivated public, private, NGO and CSO workers need to be in place to deliver the comprehensive package in high priority geographic areas.

Private sector providers need to be engaged in the prevention and treatment response.

Adequate supervision by government workers is needed

DEMAND Demand

Demand Condoms are purchased mostly

Demand Barriers to access to

Every CSW, PWID, MSM, both

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System requirements by building block plus demand HIV+ and HIV- must want to use a condom for high risk sexual act, must be willing and able to obtain one when the time is right and be motivated to continue using condoms indefinitely.

Price, geographic access and other supply side factors should not be barriers to demand for condoms.

Use of condoms could be enhanced through the integration with other interventions such as STI and VCT programs. Different methods of increasing demand should be tested.

Subsidized low cost or free condoms should be readily available in all locations where unsafe sex is practiced regardless of the location.

System bottlenecks in the private sector where prices are high and access is spotty. Publicly funded condoms are not readily available.

Stigma and discrimination reduce demand for public services including those that provide free or low cost condoms resulting in low demand.

Poor knowledge of ways to prevent being infected or infecting others.

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System strengthening recommendations condoms should be identified and reduced or eliminated. Where demand is elastic to price, different pricing approaches should be tested for different MARPs groups in different settings for different programs to identify the appropriate program.

Testing of demand side incentives should be tried to see if cash incentives are cost effective in the short and long term.

Demand creating social marketing and communication programs, including peer counseling using MARPs groups should be tested for effectiveness and applied if appropriate.

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APPENDIX II Causal Pathway Analysis Guidelines

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INTRODUCTION Many things are needed to address the HIV/AIDS epidemic. First, we need to identify and treat all those who are HIV positive thereby reducing their infectivity and also reducing mortality. This effort is ongoing and has received the greatest attention and resources to date. Second, expanded HIV prevention can only be achieved with a thorough analysis of the epidemic’s dynamics and drivers in the context of each country, identifying the people at risk, where they practice unsafe behavior how many there are. Third, we need to be able to target cost effective intervention interventions and approaches to the people most at risk and in the course of this, engaging many state and non state actors. Finally, the ultimate effectiveness of any prevention program s depends on the degree to which effective interventions reach people at high risk of getting or transmitting HIV.i This requires in almost all circumstances strengthening the health systems of countries in very specific ways.

According to the U.S. Government’s 2010 Global Health Initiative Consultation Document: “Building functioning systems will, in some cases, require a new way of thinking about health investments, with increased attention to the appropriate deployment of health professionals, improved distribution of medical supplies and improved functioning of information and logistics systems – all while maintaining a focus on delivering results. In the end, success will be measured not by the robustness of the health system itself, but by a country’s ability to meet the needs of key populations and improve health conditions.”

The following guidelines are a resource to assist teams to understand how to link health goals with interventions with health system strengthening actions designed to achieve those goals.

Causal pathway analysis is an analytic approach which focuses on designing projects to achieve maximum attributable health outcomes within limited resources. It starts with an understanding of the epidemiology of HIV transmission and then helps planners identify the most effective interventions, the system requirements for scaled up delivery and the health system strengthening actions needed to improve system performance. Its application in project design helps managers make appropriate choices among competing technical interventions, programmatic approaches and inputs. It also helps managers focus on the most important health system bottlenecks that impede success and focus on those system strengthening efforts that will result in the greatest improvement in system performance.

PRINCIPLES Causal pathway analysis is based on the following four principles: 1. Country specific. The choice of interventions, programmatic approaches and health system strengthening actions should be specific to the setting where they will be implemented and driven by an analysis of the epidemiology, specific causes and risk factors and characteristics of the people and systems that exist in that setting.

2. Evidence-based. Within each technical strategy, project or program, the choice of program inputs, processes, outputs, and health system strengthening actions, must be rooted in evidence. Managers should use data and evidence as the basis for decision making. They must be able to clearly articulate why a choice in one direction is better than alternatives and understand how each choice is a move in the right direction.

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3. Causation. Project activities should be logically and systematically constructed along a causal chain of programmatic action so that relative contribution of each intervention and program activity can be located along that causal chain from input, to process, output, outcome and impact.

4. Principle of the “vital few.” Given finite resources, managers need to focus first on the vital few problems and causes, population groups, interventions and program approaches that are most effective at making progress towards the goal. As capacity and resources allow they can extend our efforts to other things. Not all risk factors cause most of the problems. Some problems are worse than others. Not all interventions are equally effective and not all health system bottlenecks are equally important. Not all health system strengthening actions result in equal changes in system performance all other things equal.

CONDUCTING A CAUSAL PATHWAY ANALYSIS The objective is to construct a tailored program, focusing on the most important things and build specifically to address the situation in the location/country of interest. Causal pathway analysis will result in a specific causal pathway linking measurable health impact to key programmatic inputs.

Developing this causal chain requires us to deconstruct our project, working “backward,” starting by defining a measurable health goal and prompting a critical thought process about the linkages between the causes of poor health, populations affected, effective interventions, and systems strengthening actions.

Tracing the causal pathway to health impact requires a 5-step process: 1.

2.

3.

4.

defining the problems, causes and risk factors driving new HIV cases identifying and understanding characteristics of the population(s) most at risk and why identifying the most cost effective, evidence based interventions determining the health system requirements for the scaled up delivery of those vital interventions 5. identifying the health system strengthening actions needed to improve health system performance in specific areas and carrying out health system strengthening actions for system improvement.

Step 1: Identify the problems to be overcome and the causes of those problems The goal of reducing HIV incidence and prevalence and ultimately mortality from AIDS can only be tackled with a thorough understanding of the direct and underlying causes of transmission.

Epidemiological analysis is the key to understanding this epidemic and countries can be quite varied in terms of mode of transmission and populations at risk. Interventions have to be focused on the specific drivers of HIV transmission. Without an understanding of the main drivers it is impossible to make a choice between interventions. Interventions can be focused on either the direct or indirect (underlying) causes of transmission. For example, a direct cause of transmission is unprotected sexual intercourse.

An indirect cause is inaccessibility to condoms.

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Questions to be answered Problems (proximal & distal) What are the epidemiologic problems to be addressed, e.g., what are the major causes of HIV transmission?

What is the relative contribution of each of the causes to the overall problem?

What are the risk factors that impact the problem most?

When does the problem manifest itself?

Who is being affected?

How are the problems distributed in time and place?

Causes What are the major causes of the most important problems?

What are the direct and indirect causes of each of the major problems?

Which direct and indirect causes contribute most to the major problems?

How much of the problem is the result of which cause?

Step 2: Determining the characteristics of the population(s) at risk Not all populations are at equal risk. Those that are at highest risk exhibit particular characteristics, exhibit risky practices in specific times and places, are of certain socioeconomic classes, and so on. In order to have programs focus on the most important target groups, managers need to know who makes up these populations, where they live and what influences their beliefs, preferences and practices.

Questions to be answered In Step 2 we analyze the determinants of health which include: The social and economic environment The physical environment The population groupsâ&#x20AC;&#x2122; individual characteristics and behaviors It is important to consider all determinants of health but determining the population groupsâ&#x20AC;&#x2122; individual characteristics and behaviors is especially important. Identify the population groups that have the problems (step 2) and that are exposed to the direct and indirect causes of those problems (step 3). This includes examining whether these population groups have the risk factors associated with the direct or indirect causes of the problems to be overcome including their socioeconomic status, education, location, health status, and other factors that characterize these high risk groups.

Who is dying and from what and who is getting sick from what?

Who are at greatest risk of the problem and what are their characteristics?

Why is this population at risk?

Who are the people that have the greatest influence on the people who are at greatest risk? Who do they listen to? What shapes their behavior?

How is the population exposed to the risk factors?

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Is geographic location a cause? Gender? Age? Education?

Does socioeconomic status play a role?

What’s the trend in these causes?

What are their perceptions? What are their preferences? Where (geographically) are deaths occurring and where are the risk factors most prevalent? Who are the people who are most exposed to the risk factors (who don’t yet have the problem)?

Is the problem addressed at the facility or home? What percentage of population seeks care in facility vs. home? What is included in facility care that isn’t in home or community care?

What are the risk factors at the community level?

Are those who access health facilities most at risk? What are their characteristics? Are they wealth/poor, uneducated/educated, older/younger?

When is a population at greatest risk? Are there any trends in care seeking behavior?

Step 3: Selecting the vital few evidence based interventions Not all interventions are equal in terms of effectiveness or in their ability to address problems, causes and risk factors that are driving the HIV epidemic. Based on the epidemiologic drivers of the epidemic and the characteristics of the populations at risk which are the most vital interventions? It is critical to identify the range of interventions and select those that can be delivered. Technical as well as programmatic interventions should be examined.

Questions to be answered Technical interventions What are the interventions that focus on the direct and indirect risk factors which must be overcome to address the problems, e.g., inconsistent use of condoms by commercial sex workers?

Which interventions are most cost effective?

Which are acceptable to our target populations?

What are the baseline coverage levels of these evidence based interventions in particular?

What coverage levels are needed for the goal to be achieved with an emphasis on coverage levels in the highest risk population groups?

If more than one intervention is needed what is the best combination?

If only packages of interventions are available which elements of the package are actually the “active ingredient” and the most effective?

Provide the cost and effectiveness for the interventions, where available.

How much of the problem can be solved by each intervention given baseline coverage levels? How much in combination?

Programmatic interventions What is the standard package for the intervention?

How has the intervention been adapted in the country context?

When is the most critical time during the programmatic intervention?

What are the interventions for each problem and what is the known effectiveness of each?

What are the baseline coverage levels? Under what conditions are they most effective?

Why is there a belief that a focus on certain interventions will overcome the problem and achieve the goal?

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Step 4: Health system requirements and system bottlenecks Health systems will have to function in very specific ways to scale up the delivery of chosen interventions if they are to reach target populations at coverage levels that would reduce the problems.

What are those specific health system requirements for the vital few chosen interventions? What would be the ideal state of the health system? While there are requirements for each heath system building block, it is the combined functioning of the building blocks that would allow for scaled up delivery of the interventions. For simplicity and clarity the building blocks have been separated here. This section answers the question â&#x20AC;&#x153;Health system strengthening for what?â&#x20AC;? The answer is to overcome bottlenecks.

Questions to be answered Governance/policy/legal What policies, rules and regulations are needed to address the intervention?

Do policies encourage provision of services where they are needed at the right time through the public or private sectors Stewardship: who are the stakeholders in which part of the public, NGO, and private sectors who need to be champions for this success? What is the best way to align donors with supporting the most critical interventions and more critical system improvements to make the greatest impact?

What are the major policy, legal, regulatory, governance, leadership bottlenecks?

Delivery What are the characteristics of the delivery system needed to deliver those interventions?

What kind of demand needs to be created for these interventions for the high risk population groups?

What is the best combination package of interventions? What is the best service mix?

What kind of service delivery system is needed to get the interventions to the right people and right place?

What would be the demand that needs to be created?

What is the best way to get to the right providers at the right time and right place?

Where is the most effective place to deliver the services?

What are the major delivery bottlenecks?

Financing How much funding is required for the interventions?

How should the funding be allocated?

What are the major financing bottlenecks?

Information What kind of information is needed to be able to track people who are at risk and the services they receive (relevant for the interventions)?

Where does that information need to be collected?

How often does that information need to be collected?

How will the information be used, by whom, for what, and does it align directly with the achievement of the health goal?

What are the greatest information gaps and bottlenecks?

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Human resources How many staff are needed? Or what kind and of what skills? Where would they need to be distributed?

What support do the staff need to succeed?

What are the most important human resource bottlenecks?

Medicines/supplies/logistics What kind of supply system is needed?

What kind of guidelines/protocols are needed?

What kinds of medicines needed to be procured?

Where do they need to be distributed to?

What kind of treatment protocols are necessary?

What does the essential medicine list need to look like?

Who are the users and what do the need to look ensure rational and effective use?

What are the most important bottlenecks in the procurement, distribution and use of medicines, commodities and technology?

Step 5: Health system strengthening actions Overcoming the most critical health system bottlenecks is the objective of health system strengthening.

HSS can focus on one specific bottleneck or combination of bottlenecks. In reality, to have a scaled up response to HIV will require simultaneous work across more than one, and perhaps all, system building blocks plus demand.

This examination will specifically focus on the reason for poor health system performance relative to the system requirements identified in step 3 above. The outcome will be to identify the sequence of actions needed to implement health system strengthening in order to scale up the delivery of the vital few interventions.

Questions to be answered What factors in each of the six building blocks serve as constraints to effective health system performance?

What are causes of these bottlenecks?

What changes are needed so the building block functions well (i.e., what are the causes of underperformance?).

Determine key leverage points for system strengthening across the six health system building blocks.

i

Piot, Peer, et. al., Coming to terms with complexity: a call to action for HIV prevention The Lancet; 372: 845-59; and Bertozzi, Stegan M, et. al., Making HIV prevention programmes work. The Lancet 2008; 372: 831-44

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