This is a continuing activity from FY08.

The USAID Regional Development Mission-Asia (RDM/A) Continues to provide south to south strategic

information technical assistance and HCD support through regional trainings, workshops, and information

sharing. Following on COP08 activities where PEPFAR Vietnam support was used to organize two

workshops for 1) sharing empirically-based lessons on monitoring & evaluation (M&E) of ART service

delivery and 2) reviewing and standardizing HIV/AIDS service delivery measures and coverage modules for

most-at-risk populations (MARPs) in Southeast Asia, RDMA will continue to facilitate similar activities.

RDM/A manages regional HIV/AIDS programs in close coordination with bilateral programs in China, Laos,

and Vietnam, and is therefore in a unique position to assemble public health practitioners and program

administrators from these and other Southeast Asian countries with similar HIV epidemics to share

knowledge and lessons learned from prevention and care and treatment program M&E.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17651

Continued Associated Activity Information

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

System ID System ID

17651 17651.08 U.S. Agency for Regional 7769 7769.08 $150,000

International Development

Development Mission/Asia

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $4,555,568

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

PROGRAM AREA SETTING

Vietnam's HIV/AIDS epidemic remains concentrated in most-at-risk populations (MARP). Injecting drug users (IDU) and

commercial sex workers (CSW) continue to account for more than 80% of HIV positive people. Advocacy efforts have led to

HIV/AIDS policies including the 2004 National Strategy on HIV/AIDS, the 2007 National HIV/AIDS Law and the completion of the

National Plan of Action for Orphans and Vulnerable (OVC NPA). These policies have helped shift the national response from

stigmatizing HIV/AIDS, to a more comprehensive and rights-based approach of addressing the epidemic as a health issue.

However, putting policy into action remains a challenge as public perception continues to target IDU and CSW as the source of

the epidemic, and enforcement of the HIV/AIDS Law remains weak. These challenges are multiplied by the lack of effective multi-

sectoral coordination of health and social welfare programs, and resource gaps in the national health care system, which continue

to limit the successful implementation of policies and programs at the national, provincial and community levels.

While the Government of Vietnam (GVN) is increasingly addressing the needs of high-risk groups, strategies often lack a strong

evidence base. Additionally, the health-care system continues to struggle with pervasive stigma and discrimination, an under-

trained and under-utilized workforce, and an institutional approach to addressing IDU and CSW that is expensive and ineffective.

The recently passed revised National Drug Law, despite advocacy efforts, has maintained the criminalization of drug behavior and

has continued policies that require IDU to be confined in GVN-run compulsory rehabilitation or "06" centers. Institutionalizing IDU

in the centers promotes continued stigma, social isolation and inadequate HIV and drug treatment. These policies continue to

promote addiction as criminal behavior rather than a medically treatable condition.

Civil society continues to wrestle with legal constraints that inhibit their participation in HIV policy and programming. The GVN

recognizes the role of civil society organizations (CSOs) in a comprehensive national response to expand access to HIV services

to communities. As such, advocacy groups and local NGOs, including groups of people living with HIV (PLHIV) are beginning to

assume a larger role in programming and policy advocacy and have found creative and legal ways to circumvent policy barriers by

registering as businesses or charities within provinces. However, with no national codified legal framework for the establishment

of civil society, they operate with tenuous legal registration and sporadic funding.

KEY ACCOMPLISHMENTS

In spite of these barriers, the HIV policy landscape has changed dramatically during the first five years of PEPFAR. After the

release of the 2004 National Strategy on HIV/AIDS, the GVN called for multi-sectoral mobilization of national, provincial and

community resources to prioritize IDU transmission prevention, and increase efforts to diminish HIV-related stigma. This includes

disassociating HIV from drug use and sex work. Through the development of several key documents, including the National

HIV/AIDS Law, many key policy principles have been codified, including the rights of PLHIV. This, along with the adoption of the

Three Ones principle, is a considerable accomplishment by the GVN and represents new opportunities for expanded and

innovative programming to drive policy change.

Continued policy advocacy holds promise for long-term sustainable change in health and social welfare systems. The Ministry of

Labor, Invalid and Social Affairs (MOLISA), which is mandated to regulate the 06 centers, has begun to discuss alternatives to

drug treatment, and has requested assistance from PEPFAR to develop a pilot program. This represents a significant shift in the

national dialogue on addiction services, and indicates a response to evidence-based policy advocacy efforts from local and

international organizations. Another area of importance that falls under the scope of MOLISA is the implementation of the OVC

NPA. PEPFAR will continue to work with MOLISA, other donors, and implementing partners to integrate the approved NPA into

activities.

Building on the momentum of change during PEPFAR Phase I, future efforts will focus on continued coordination with other

donors such as GFATM, DfID, the World Bank, and AUSAID to strengthen policy, health and social welfare systems, with a goal

to achieving solutions that are sustainable, host country-owned, and technically sound. To that end, PEPFAR will build on recent

successes to identify next steps and key opportunities to improve health systems, introduce alternative programs for at-risk

populations, strengthen the role of PLHIV and civil society, and expand multi-sectoral collaboration.

In PEPFAR Phase I, the USG Team supported a number of activities to build local capacity and to address the needs of PLHIV.

To create an enabling policy environment, PEPFAR supported the drafting of the National HIV/AIDS Law, and the development

and implementation of national guidelines, including the National Palliative Care Guidelines, the National Medical Assisted

Therapy Guidelines, National Plan for Action for OVC, and 100% Condom Use Policies. To strengthen management of the

national HIV response, PEPFAR supported the Vietnam Administration on HIV/AIDS Control (VAAC), the national HIV

coordinating body, at the national and provincial levels to strengthen human capacity and program management. In collaboration

with the Hanoi School of Public Health (HSPH), PEPFAR supported the training of public health managers from across public

sectors, in Total Quality Management (TQM) and project management training. To improve capacity at the national and provincial

level, PEPFAR has supported the Ho Chi Minh National Political Academy (HCM NPA) to train government cadres across sectors

on best practices in HIV programs, and coordination of a rights-based, evidence-based and multi-sectoral response.

Through a partnership between the International Center for Research on Women (ICRW) and the Institute for Social Development

Studies (ISDS), PEPFAR has supported the roll out of a stigma-reduction toolkit to be used at service delivery sites, and a stigma

and discrimination assessment in four PEPFAR provinces. Through this assessment and subsequent dissemination workshops,

PEPFAR is supporting a direct intervention to address stigma and discrimination at the national and provincial levels.

PEPFAR has supported the United Nations, through the UNAIDS secretariat, to coordinate efforts in policy advocacy, the greater

involvement of people living with HIV/AIDS (GIPA), and local organization ownership. UNAIDS continues to coordinate the

Ambassadors and Heads of Agency Coordination Group, which conducts quarterly meetings to identify and address key HIV

policy issues, including strategic planning, program coordination, harmonized cost norms, and health sector development.

Despite the lack of a legal framework, local organizations have made tremendous strides in scaling up activities in policy

advocacy and in community-based service models. Through Pact and the Health Policy Initiative (HPI), PEPFAR continues to

support capacity-building of local organizations and collaboration between local and international organizations. PEPFAR

continues to build the capacity of PLHIV through umbrella grants to CSOs, and financial and capacity-building technical

assistance. Perhaps the most significant accomplishment for GIPA and civil society in FY08 has been the establishment of

Vietnam's first national network of people living with HIV (VNP+) in August 2008. Through long-term advocacy efforts, with

PEPFAR support to UNRC, HPI and others, VNP+ was established with GVN permission. This national network, nascent for

several years, has emerged as a highly organized and nationally owned group to advocate for PLHIV at the national, provincial

and community levels.

In other areas, PEPFAR has provided critically needed support to strengthen legal services for people affected by HIV and to

advocate for increased enforcement of existing laws that support the rights of affected people. Under HPI, PEPFAR has

supported the establishment of legal aid clinics for PLHIV in Hanoi and HCMC. These clinics provide legal counsel for PLHIV, and

are working to address gaps in enforcement of HIV-related laws for women and affected children in the health and education

sector. Additionally, through journalist training on the HIV/AIDS Law and media coverage of legal services for PLHIV, HPI is

expanding public attention to the difficulties faced by affected populations. As private sector health care continues to expand in

Vietnam, PEPFAR has supported advocacy and technical assistance through Pathfinder International, in the development of

national guidelines on the regulation and private healthcare providers.

CHALLENGES

Despite current efforts, stigma and discrimination against PLHIV remains strong, creating difficulties in implementation of

innovative interventions targeting high risk populations. PLHIV continue to report difficulty in accessing basic services, including

education, employment, and quality health care. Additionally, HIV-infected IDU and CSW face double-stigma as they struggle to

access services within a national system that creates strong disincentives for full disclosure of their health status due to fear of

legal and social reprisals.

Despite GVN willingness to engage civil society, PLHIV and CSOs legal status remains limited. VNP+, like most CSOs, has the

ability to organize and advocate. However, without full legal recognition of civil society in Vietnam, VNP+ has difficulty opening

bank accounts, and soliciting or receiving direct funding. The National Law on Associations, which would allow the legal

establishment of not-for-profit organizations in Vietnam, remains under review in the Ministry of Home Affairs, mired in political

sensitivities and bureaucratic process.

Coordination of resources remains difficult as the national health system cannot yet cope with increased need for services and the

number of donor organizations supporting HIV programs. While the GVN has made advancements in harmonizing national and

international resources, effective implementation mechanisms are lacking. Added to this, gaps in human resource capacity

(please see HRH program area narrative) continue to limit efficiency and quality of service provision. Regardless of GVN

commitment to developing the capacity of the health workforce, funding and staffing shortages persist and available health

professionals are challenged to support a wide range of services.

Vietnam continues to struggle in developing a multi-sectoral national response. The VAAC sits within MOH and does not have the

broad-based multi-sectoral mandate required to be a truly effective coordinating body across Ministries. As such, key ministries

such as the Ministry of Public Security (MOPS), MOLISA and the Ministry of Education and Training (MOET) remain only

peripherally engaged in HIV/AIDS.

COP 2009 PRIORITIES

In COP09, PEPFAR in coordination with the GFATM and other donors will continue to strengthen GVN capacity in strategic

planning, management and implementation. PEPFAR will continue to reinforce GVN capacity at the national and provincial levels.

Through funding to VAAC, PEPFAR will support national and provincial management, technical oversight, coordination and

human capacity development. PEPFAR will support VAAC to develop a national capacity building strategy in COP09, and support

the strengthening of the multi-sectoral response at the provincial level. PEPFAR, in collaboration with other donors, will assist the

GVN to meet WTO requirements for health provider certification, and licensure with the creation of a national health provider

registration system. PEPFAR will partner with the MOH to strengthen sector regulation and stewardship capabilities, and continue

to support more effective and strategic engagement of the private health sector and to continue to coordinate the dissemination of

international best practices in private sector responses to HIV.

To work towards creating a sustainable and knowledgeable workforce, HSPH will expand technical assistance and training on

public health program management, with a focus on HIV, to improve provincial and national management capacity. In a new

initiative, HSPH will collaborate with the Vietnam Ministry of Defense (MOD) to provide HIV program management and EQA

training for MOD health-care staff. HIV training will continue to be integrated into MOD academic and training institutes.

To increase direct, multi-sectoral engagement of new ministries in PEPFAR activities, COP09 funds will provide support to build

relationships and expand the capacity of MOPS and MOLISA. These two ministries, which have the most direct contact with high-

risk populations, will provide a more direct opportunity for policy advocacy and improved technical strategy to address gaps in

programming for at-risk populations.

To address stigma and discrimination and GIPA, PEPFAR will continue to support the UN and HPI on policy advocacy, continued

expansion and strengthening of PLHIV organizations, including the further development of VNP+. Activities will support the

implementation of the National HIV/AIDS Law at the provincial level, and provide training to provincial authorities and service

providers on the rights of PLHIV. Support to ISDS/ICRW will follow on the FY08 assessment to support development of a cross-

cutting strategy to combat stigma and discrimination.

To strengthen support for civil society, PEPFAR will partner with UNAIDS and HPI to address the needs of PLHIV and CSOs

through broad policy advocacy. PEPFAR will work with organizations such as Pact to increase coordination and strengthen the

capacity of CSOs. Additionally, COP09 funds will provide expanded support for the US Ambassador's small grants program,

which provides funding opportunities for local organizations working on media-related HIV outreach activities.

In COP09, PEPFAR will continue to support UN in policy advocacy around health system strengthening and improving the

national multi-sectoral response. UNAIDS will work to strengthen coordination mechanisms, particularly through the Office of the

Government and provincial People's Committees. WHO will support the Health Partnership Group (HPG) and the Joint Annual

Health Review, two multi-ministerial forums that provide key opportunities to expand involvement of HIV partners in multi-sectoral

dialogue. Additionally, PEPFAR will continue to support the HCM NPA to develop the skills of national and provincial leaders to

design evidence-based HIV policies and programs.

Table 3.3.18: