This activity will utilize $350,000 of COP 2008 Yellow Lighted funds under COP 2009

The new recruit population within MOD has been targeted with abstinence (AB) and other prevention (OP)

activities as they are considered to be at risk due to their younger age, time spent living in remote areas,

and tendency towards risk taking behavior. However, little data collection has taken place alongside AB/OP

programming that would allow one to qualify: the level of risk this population has, how effective the

prevention programs targeting this population have been/are, or how to direct future programming in a

strategic manner. Therefore this narrative is requesting the funds necessary to complete a nationally

representative sero-behavioral survey within the new recruit population to collect sexual risk and drug use

data.

The Bangkok-based Armed Forces Research Institute of Medical Sciences (AFRIMS), a special medical

detachment of the Walter Reed Army Institute of Research (WRAIR), will provide technical assistance with

the execution and implementation of a the Ministry of Defense's bio-behavioral survey. AFRIMS/WRAIR has

extensive experience in conducting surveys in collaboration with the Royal Thai Army as well as other

militaries. The surveys conducted in Thailand have been a key surveillance indicator to inform HIV/AIDS

public health policy.

TECHNICAL ASSISTANCE: $ 300,000

DOD will support AFRIMS involvement to provide the training and technical assistance (TA) needed to

support health care workers located in Military Institute of Hygiene and Epidemiology (MIHE) and Southern

Preventive Medicine Center (SPMC), to complete data collection and data interpretation. More specifically,

this will cover training and TA on development of survey methodology, protocol, and data collection

instruments.

DEVELOPMENT OF SURVEY: $ 50,000

DOD will support AFRIMS to develop a behavioral survey questionnaire with appropriate field testing and

format to survey participants.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Military Populations

Workplace Programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $0

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The introduction of the new "injecting and non-injecting drug users" budget code (IDUP) in FY09 provides an important opportunity

to highlight efforts to scale up programming for this priority population. However, this change has also made it essential for the

Vietnam team to split-fund a large number of continuing activities that were historically supported under the "condoms and other

prevention" budget code (HVOP) into both the IDUP and HVOP categories. To avoid confusion, we have opted to rewrite the

narratives for many of these ongoing activities in FY09 to reflect their relative scope under each of these budget codes. In

addition, although there are no required targets associated with the IDUP budget code in FY09, we have provided illustrative

targets in each of the activity narratives to document the fact that this budgetary shift is not actually resulting in a reduction in

beneficiaries of PEPFAR-supported prevention programming in Vietnam. This effort should also help to establish provisional

benchmarks to facilitate the development of partner work plans and improve program coverage.

INJECTING AND NON-INJECTING DRUG USERS

Addressing the HIV prevention needs of injecting drug users (IDU) remains the foremost priority in Vietnam's efforts to combat

HIV/AIDS. The government of Vietnam (GVN) estimates that more than 60% of all HIV infections in Vietnam are among IDU, and

many additional infections result from transmission to the sexual partners and children of these individuals. PEPFAR-supported

behavioral and biological surveillance (IBBS) has documented HIV prevalence rates as high as 65% among IDU in at least one

PEPFAR priority province (Hai Phong), and has revealed that injecting drug use is likely the most important driver of new

infections among commercial sex workers (CSW) and other high-risk populations. For example, CSW who report injecting are

three to 30 times more likely to be infected with HIV than those who do not, and the prevalence of injecting among sex workers is

a strong predictor of overall HIV prevalence in this population.

The concentration of HIV infection in IDU populations in Vietnam has spurred the PEPFAR team to focus HIV prevention, care,

and treatment efforts in key urban settings and along drug transport corridors to prevent the continued spread of HIV.

Unfortunately, even in these focused settings, stigma and discrimination against IDU in Vietnam - exacerbated by historical

campaigns characterizing drug use as a "social evil" - have made it difficult to obtain accurate IDU population size estimates and

to expand access to needed services. The GVN has officially "registered" more than 180,000 IDU nationally, but the actual size of

this population is many times higher. In addition, using even the most conservative estimates of population size, coverage of basic

prevention services remains low. For example, according to the latest program reports, PEPFAR-supported peer outreach efforts

only provided education to a maximum of 4% of the estimated number of IDU in Hanoi, and a maximum of 40% of the estimated

number of IDU in Ho Chi Minh City. The successful referral of these individuals to HIV counseling and testing (CT) and other care

and treatment services also remains a key priority given the burden of HIV infection among IDU. According to the latest program

reports, a maximum of 5% of the number of IDU in Hanoi, and a maximum of 13% of the number of IDU in Ho Chi Minh City, have

received CT.

The notion that the PEPFAR team should focus its efforts in FY09 on improving access to services in existing catchment areas -

rather than continuing to expand into new geographic locations and provinces - is further amplified by the findings from Boston

University's (BU) recently completed evaluation of PEPFAR-supported peer outreach programs. In interviewing IDU in priority

areas for current PEPFAR programming, the BU team had no difficulty identifying a large number of IDU who reported no

exposure to either PEPFAR- or other donor-supported outreach efforts in the past year.

In the initial "emergency" phase of support to Vietnam, the PEPFAR team has sought to empower peers who are themselves well-

connected to networks of high-risk and often marginalized populations to offer or provide referrals to an expanding set of

prevention, care, and treatment services, as well as to play a greater role in program planning and advocacy. Over time, the

program has put mechanisms in place to supplement peer outreach with: efforts that work with existing drug users to prevent the

initiation of new users to drug use; integration of services for injecting and non-injecting drug use (including methamphetamine

use) into programs targeting CSW and men who have sex with men (MSM); provision of outreach-based CT services;

establishment of community-based drop-in centers offering addiction counseling, CT, sexually transmitted infection (STI)

treatment, and economic rehabilitation services; linkages to outpatient clinics (OPCs) offering a full range of HIV care and

treatment services; linkages to medication-assisted therapy (i.e., methadone) in sites that are often co-located with OPCs;

linkages to community based care and support; and provision of HIV prevention, care, and treatment services to the sexual

partners and family members of current and recovering drug users.

Because building sustainable mechanisms to train individuals in evidence-based approaches to addiction treatment is perhaps the

greatest human capacity development challenge pertaining to HIV in Vietnam, the local team has also prioritized the creation and

institutionalization of training programs for case managers, professional addictions counselors and health personnel placed

considerable resources thorough prior COP development and reprogramming. These efforts will be consolidated under a new

PEPFAR addictions services training mechanism in FY09 to foster coordination and sustainability.

Looking ahead, the Vietnam team is championing resource sharing across PEPFAR-supported partners and other donors to

improve service coverage and quality in the face of rising costs and fewer resources. Using the findings from the BU evaluation as

a springboard for action, PEPFAR continues to support national and provincial workshops focused on improving and harmonizing

approaches to hotspot mapping and size estimation, peer educator training, commodities forecasting, program linkages, quality

improvement, and monitoring and evaluation systems. The initial national workshop was viewed as such a success that the MOH

issued formal guidance to all 64 provinces codifying the workshop findings as recommendations for the conduct of peer outreach

efforts in Vietnam. Furthermore, the GVN has embraced PEPFAR-supported peer outreach coordinators in PEPFAR priority

provinces as focal points for the coordination of all peer outreach programming for most-at-risk populations at the provincial level,

and is encouraging other donors to support these positions in additional provinces. The coordinated implementation of activities

supported by PEPFAR, the World Bank (WB), DfID, AusAID, and other donors, should help ensure that current and recovering

IDU have access to a full range of risk reduction, HIV care and treatment, and drug treatment services.

Other donors and stakeholders in Vietnam have historically questioned the ability of USG to make inroads in reducing HIV risk

among IDU given current USG policy restrictions on funding needle and syringe programming. However, this sentiment is

changing in response to the local team's efforts to coordinate service delivery with other stakeholders, and in light of the leading

role that USG has played in the development and implementation of the methadone pilot program. The FY09 COP includes

support for expansion of the methadone pilot program to eight sites beyond those previously established in Ho Chi Minh City, Hai

Phong, and Hanoi. Although the GVN has not yet approved the scale up of methadone beyond the pilot sites, PEPFAR is

supporting sustainable technical assistance and training platforms to ensure service quality as access to methadone is eventually

expanded further through other donor support.

Beyond improving access to pharmacotherapy, supporting recovering drug users in achieving the social and economic stability

they need to get and stay off of drugs is a key HIV prevention priority in Vietnam. In FY09, Chemonics will play a leading role in

building others' capacity to implement best-practice approaches for economic rehabilitation of IDU, CSW and people living with

HIV/AIDS (PLHIV) in the domains of vocational training, job placement, and microcredit/microfinance programming. Through this

partner, the local team also hopes to foster private investment in improving the quality of private drug treatment services in

Vietnam to meet rising demand.

Addressing the concentration of HIV in the IDU population is further complicated by the GVN's continued practice of placing drug

users and sex workers in custodial rehabilitation centers for periods of 18 months to four or more years. Currently, an estimated

60,000 IDU reside in more than 84 centers nationwide. Reliable data is lacking on HIV prevalence among center residents, but

prevalence has been estimated as high as 70%. The further concentration of high-risk individuals in rehabilitation centers makes

these settings a high priority for service delivery, particularly given that the vast majority of centers only offer detoxification and

labor programs, with no formal drug treatment or HIV programming. However, human rights concerns about the fact that many

residents are placed in centers with no judicial process, concerns about the risks of treatment interruption among individuals who

may be started on antiretroviral medications in centers but who will return to communities all across the country upon release, and

concerns about the sustainability of building infrastructure in centers that should rightly give way to more efficient and evidence-

based drug treatment models, have all presented the team with difficult and important challenges regarding expanded support.

PEPFAR is currently supporting a pilot program that provides HIV-related services to current and former residents of the Nhi Xuan

rehabilitation center. A formal evaluation of the program is underway, but it is clear from review of routine program data that in-

center HIV counseling and testing and OPC services are underutilized, and are not conveniently located to accommodate the

ongoing needs of clients post-release. With this in mind, PEPFAR has put mechanisms in place through prior reprogramming and

through the FY09 COP to support training and in-reach models using existing community-based OPC staff to bring needed pre-

release services to residents of five more centers without building additional center infrastructure, and facilitating the continuity of

care in the community upon release. In FY09, a new cooperative agreement with the ministry that operates the centers will

expedite the adoption of alternative best-practice drug treatment models.

To address a new priority for FY09, PEPFAR will extend its support to UNODC beyond the community-based drug treatment

centers that are now being recognized as a viable alternative to custodial rehabilitation centers in the northwest, to also support

the development of national guidelines, training, and pilot intervention programming for HIV prevention in prisons in Vietnam.

BLOOD SAFETY

The Ministry of Health's (MOH) National Institute of Hematology and Blood Transfusion leads Vietnam's blood safety efforts with

support from WHO, the Luxembourg Agency for Development Cooperation, and the WB. They are stocking three national blood

banks, improving blood screening capabilities, establishing national guidelines to ensure universal testing of donated blood,

promoting appropriate clinical use of blood and blood products, and promoting a voluntary blood donation system.

However, Vietnam's large military health system, which is operated by the Ministry of Defense (MOD) and serves both military and

civilian personnel, has been receiving no such assistance apart from provisional national screening guidance that has been in

place for over a decade.

In 2005, a survey by the U.S. Department of Defense (DOD) and MOD found that funds and TA were not sufficiently addressing

blood safety needs within the MOD health care system. A review of Military Hospital 103 in Hanoi found that 80% of blood units

were obtained from paid donors, and that screening procedures and storage equipment were outdated. The hospital's laboratories

did not have a quality assurance program. It was not clear whether HIV-positive donors were informed of their status, and

counseling, care, and treatment were not offered to those who tested positive.

To address these needs, PEPFAR will support improved blood safety in five military hospital sites to prevent medical transmission

of HIV by: 1) improving storage and screening capacity of blood products; 2) promoting adherence to the national policy on blood

safety, which calls for the screening of all donated blood; 3) promoting appropriate clinical use of blood; 4) strengthening

collaboration with key national partners from MOH and other international donors; 5) expanding CT and referral systems; and 6)

promoting the establishment of a 100% volunteer blood donor system.

INJECTION SAFETY

Poor medical injection practices exist in many of Vietnam's hospitals. Sharps containers and disposable needles are often not

available. Surveys indicate that many nurses in government and private facilities lack knowledge of correct injection safety

techniques and have little information about post-exposure prophylaxis procedures. A 2005 MOH study found that 35.4% of

nurses failed to wash their hands prior to giving injections and 9.5% recapped used needles. MOH reported 515 HIV-related

sharps injuries in 2006 but the actual number is believed to be much higher.

In FY07 and FY08, PEPFAR supported the development of an injection safety curriculum through collaboration with the World

Health Organization (WHO), the Vietnamese Nurses Association (VNA), and Pact. With this curriculum now completed, PEPFAR

will support implementation in FY09 of three injection safety activities in priority PEPFAR provinces through: 1) provision of

training to nurses on injection safety practices; 2) design, printing, and dissemination of job aids on injection safety; and 3)

procurement of equipment and supplies for health services safety at civilian and military sites.

MALE CIRCUMCISION

In light of the fact that Vietnam is facing a concentrated HIV epidemic in which most new infections occur as a result of injecting

drug use, the Vietnam team has not prioritized the implementation of male circumcision activities in COP09.

Table 3.3.04:

SUMMARY and BACKGROUND:

Note this activity will be supported with 2008 carryover funding.

Bangkok based - Armed Forces Research Institute of Medicine Science (AFRIMS) has been partnered with

DOD PEPFAR in the Laboratory Infrastructure program area. Since 2004, AFRIMS has been involved in

providing DOD PEPFAR Viet Nam with technical assistance in HIV laboratory establishment, including

laboratory design, equipment need assessment, installation and training for our 04 (four) HIV referral

laboratories, which provide HIV diagnosis and related follow up treatment tests. AFRIMS will also continue

to collaborate closely with PACOM technical experts, in providing technical assistance to sites where

appropriate.

By the end of COP 2009 the DOD Vietnam PEPFAR program will be supporting 04 (four) referral

laboratories with the capacity to carry out HIV serology, hematology, biochemistry, CD4, and PCR for the

purpose of viral load in the cases of adult treatment failure. These four sites and their locations are as

follows: Military Institute for Health and Epidemiology (MIHE) based in Hanoi, Southern Preventative

Medicine Center (SPMC) based in HCMC, Hospital 121 based in Can Tho, and Hospital 17 based in Da

Nang. The initial laboratories (MIHE and SPMC) are Ministry of Defense (MOD)'s regional referral centers.

They also serve as Center of Excellence for training and research purposes in area of military medicine

science. The remaining two laboratories (Hospital 121 and Hospital 17) are provincial referral laboratories

embedded within the hospital setting.

These four referral laboratories support four out-patient/in-patient clinics and three voluntary counseling and

testing centers (VCT's) that are located in the same city.

Moreover, by the end of COP 2009 the DOD Vietnam PEPFAR program will be supporting five blood safety

laboratories with the capacity to carry out HIV screening. These five sites and their locations are as follows:

Hospital 103 based in Ha Noi City, Hospital 175 based in HCMC, Hospital 121 based in Can Tho City,

Hospital 17 based in Da Nang City, and Hospital 87 in Nha Trang City.

These five blood safety laboratories support a safe blood supply for the hospitals that they are embedded

within as well as neighbor military and civilian hospitals (based on adequate supply). In addition these

laboratories support the four physician-initiated testing and counseling (PITC) centers that are co-located.

It is important to note that although military health care facilities are mandated to care for military personnel

and their family members approximately 90 per cent of the clients who access the facilities are civilian.

DOD in country staff will actively participate in PEPFAR laboratory technical working group to ensure close

interagency coordination and oversight for this activity.

ACTIVITIES and EXPECTED RESULTS:

ACTIVITY 1 (Funding $70,000) - The first activity will support AFRIMS support of Quality Assurance/Quality

Control with an External Quality Assessment (EQA) program. AFRIMS will purchase and ship proficiency

panels as well as perform monitoring, evaluation, and feedback to the sites of the results.

ACTIVITY 2 (Funding $140,000) - The second activity will support AFRIMS to visit each site at least one

time per year in order to monitor and evaluate the implementation and maintenance of the QA/QC program.

This includes providing TA on the development of standard operating procedures (SOP's) and a functioning

post exposure prophylaxis program (PEP).

Activity 3 (Funding $105,000) - The third activity will support AFRIMS to carry out refresher training and as

well as improve OI diagnostic capabilities at MOD sites (where needed) using AFRIMS developed training

packages that utilize both international and national guidelines/principles.

Activity 4 (Funding $35,000) - The fourth activity will support AFRIMS to carry out program oversight and

remote TA where needed, communicating through the DOD in-country team, to assist MOD laboratory staff

with any questions and concerns they may have regarding laboratory testing.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15250

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

15250 5713.08 Department of To Be Determined 8672 8672.08 TBD

Defense

9502 5713.07 Department of Armed Forces 5177 3112.07 AFRIMS $63,500

Defense Research Institute

of Medical

Sciences

5713 5713.06 Department of Armed Forces 3112 3112.06 $335,000

Defense Research Institute

of Medical

Sciences

Emphasis Areas

Military Populations

Workplace Programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.16: