Tuoitrenews has a Question and Answer interview via mails with UNAIDS Country Director, Tony E. Lisle on the occasion of the 2012 World Aids Day on December 1.

He sees Vietnam has made progress in the past years and points out some ways the nation should focus on its way ahead.

Can you please tell us the achievements Vietnam has gained in the response to HIV/AIDS?

There has been great progress. According to the latest data from the Ministry of Health, 60,935 adults and children are now on antiretroviral treatment – a 22-fold increase since 2005. Vietnam’s HIV treatment program has prevented an estimated 18,110 AIDS-related deaths between 2000 and 2009. That is a huge achievement.

Vietnam’s efforts to provide sterile injecting equipment to drug users and condoms for sex workers and homosexual people are also having an impact. There is evidence that the number of new HIV infections is decreasing in many provinces. There has been a steady drop in annual reported new cases of HIV, and Ministry of Health surveillance suggests that the national percentage of men who inject drugs and female sex workers who have HIV has declined substantially.

In the first nine months of this year, more than 50 percent of all pregnant women being tested for HIV screening. Vietnam’s strong healthcare system, demonstrated by the provision of at least one antenatal care visit by 95% of pregnant women, provides a solid basis for reaching the global goal to eliminate mother-to-child transmission of HIV by 2015.

What is your overall assessment of the current situation of the epidemic in Vietnam?

Vietnam’s HIV epidemic is highly concentrating among three key groups – people who inject drugs, sex workers and men who have sex work men.

Injecting drug remains the most important mode of transmission in Vietnam, and people who inject drugs are the highest priority population for HIV prevention. Sexual transmission of HIV in Vietnam is primarily among people who inject drugs and their regular sex partners, men who have sex with men, and sex workers and their clients.

Some worry that HIV may quickly spread from these groups to the general population, but when we look at the routine blood tests of pregnant women over the years, we can see that HIV is very low in the general population and shows no sign of increasing. Most of the women who test positive for HIV report that they were infected by stable sexual partners who either inject drugs or visit sex workers. So we need to stay focused on the key populations.

What are your assessment of the effectiveness of the HIV program in Vietnam, and how to maximize the effectiveness in the future?

Vietnam’s HIV treatment program and its HIV prevention efforts to provide sterile needles and syringes to drug users deserve particular praise.

Vietnam is also a regional leader in the scale up of methadone maintenance treatment. Just a few years after launching a pilot program in 2008, there are now 45 methadone clinics in 11 provinces providing methadone to nearly 10,200 patients. Methadone is an extremely effective way to reduce illicit drug use, reduce crime and reduce HIV infections. It is far more effective and cheaper than the compulsory drug treatment.

Epidemiological modeling tells us that if Vietnam continues scale up methadone and reaches 40 percent of the country’s drug users, a tipping point will be reached and that should translate into a significantly lower HIV infections among people who inject drugs.

A Thu Duc player poses for a photograph with his daughter and the trophy. Photo: Ngoc Dong

Sex workers are among people most at risk of HIV. Can you assess the current situation of HIV transmission in sex work?

HIV among female sex workers appears to be slowly declining. According to data collected by the Ministry of Health in 2011, about three percent of sex workers in Vietnam have HIV – the lowest level since 1998. However, in some provinces HIV among sex workers remains very high – for example, one in five sex workers in Hanoi and Hai Phong were living with HIV in 2011. And HIV prevalence is particularly high among street-based sex workers and sex workers who inject drugs.

The data show the importance of ensuring that sex workers have easy access to affordable condoms, and that they must be supported to insist that every client uses a condom every time. Some provinces, such as Can Tho and An Giang, have been leaders in what we call a “100% condom use” approach within sex work. But a few other provinces still want to send sex workers to compulsory treatment centers.

The new Law on Administrative Sanctions passed earlier this year by the National Assembly will make a big difference. It orders all provinces to stop sending sex workers for compulsory treatment and education. The United Nations urges all provinces to follow the examples of Can Tho and An Giang.

About financial issues, donor funding for HIV in Vietnam is decreasing. Where do you think Vietnam should look for the future funding of the HIV response?

The United Nations will work with donors to ensure that their withdrawal from Vietnam’s HIV response is slow and predictable. Future funding must come from within Vietnam to ensure the sustainability of the national response. It will be difficult to replace the donor funds, but not impossible.

Thailand, China and Malaysia all manage to fund nearly 100% of their HIV responses.

Vietnam, with its great economic progress, can do the same in the coming years. Some of the costs for HIV prevention and treatment will need to be covered through traditional means, such as national health insurance. But national insurance cannot bear the full cost of keeping all people living with HIV on antiretroviral treatment. Other innovative approaches will need to be found to raise these funds, including through public-private partnerships. Some countries have managed to do it through progressive taxes such as a small levy on the purchase of airline tickets.

There has also been discussion on the possibility of the Vietnamese people paying some of the difference themselves. This is already happening to some extent. Some people can afford private healthcare and private health insurance. And we can also see that many people are willing to pay for quality condoms and sterile needles and syringes. The government is already moving away from an emphasis on free condom and needle distribution, and towards the sale of subsidized condoms and needles.

But we must be very cautious about asking people living with HIV to pay for their antiretroviral treatment. Most people living with HIV are very poor, and they cannot afford additional healthcare costs. Other countries have tried to put in place “user fees” for HIV treatment, and the results have been bad – people stop taking their medications regularly, resulting in drug resistance and higher AIDS-related deaths. Losing the current momentum on treatment scale up will be very dangerous. Now we know that people on treatment are very unlikely to transmit HIV to others, as the virus has been reduced in their bodies to a very low level. So less treatment also means less prevention.

US Consul An Le with 'special' members of the Can Tho team at the tournament (Photo: Ngoc Dong)

What is your plan to support Vietnam to achieve the Millennium Development Goal on HIV/AIDS, especially in the shortage of financial aid?

It is unclear whether Vietnam will achieve this goal, but the race is not over. Vietnam can achieve it if the HIV response continues to move in the correct direction. Continued scale up of antiretroviral treatment and methadone maintenance treatment is very important. But the secret to success will be to ensure that funds for HIV prevention are well focused. We know who is at risk, and we know where that risk is greatest. We know what works and what doesn’t work.

Ensuring that drug users have access to clean needles and methadone works.

Sending drug users to compulsory detention doesn’t.

Ensuring that sex workers have access to condoms and are empowered to demand their use with every client works.

Arresting sex workers and forcing them to change their jobs doesn’t.

Respecting the lifestyles of men who have sex with men and providing them with condoms and lubricant works.

Insisting that they pretend they are heterosexual men doesn’t.

And as I already mentioned, we now know that early diagnosis and early initiation of antiretroviral treatment can be a big help in the prevention of new HIV infections. I am confident that Vietnam can use the above approach to reach the Millennium Development Goal on HIV and its other international commitments, and to ultimately achieve the UNAIDS goal of Getting to Zero – Zero New Infections, Zero Discrimination, and Zero AIDS-Related Deaths.

A wife of a Thu Duc player is pictured on the stadium stand (Photo: Ngoc Dong)