Here is an article I wrote in 1996 about Viet Nam and its impending AIDS epidemic. Despite a great opportunity to curb the spread of HIV and AIDS, the Vietnamese government blew it, ignoring the appeals of epidemiologists to undertake much stronger preventive measures.
(This article was originally published in the NIRA Journal, a Japanese publication, in the Summer of 1996)
by Dylan Foley
Vietnam appears to be on the edge of a devastating AIDS epidemic. The official figure for the number of HIV-positive people, 3,706 (with 148 deaths since the first case was recorded in 1990), is almost certainly underestimated by several orders of magnitude. Aid workers from non-governmental organizations say that estimates by the World Health Organization of 100,000 HIV-positive people in Vietnam are much closer to reality. More ominous are WHO reports that estimate 500,000 people in Vietnam will be HIV positive by 1998 unless massive education efforts slow the epidemic.
Vietnam still has time to prevent becoming another Thailand, with its one million HIV-positive citizens. Vietnam's only hope is through decisive and aggressive action: it must not only educate prostitutes and drug users--traditional sources for AIDS infection-- but must also create massive, active education and outreach programs directed at the mainstream population. The Vietnamese government has decided to fight the epidemic through an extensive if passive AIDS prevention campaign using television and billboards that explain HIV transmission, and by urging morality and monogamy.
The government is also setting up small programs for high-risk groups using the "harm-reduction" model of AIDS education, a hands-on method that uses outreach workers. Harm-reduction education teaches sex workers to use condoms and to avoid high-risk sexual activity. Intravenous drug users are also taught to use clean hypodermic needles and not to share injection paraphernalia with other users. Government AIDS policy also focuses on educating government employees like police officers and medical workers about HIV transmission. There is some education in the schools, but it is only on HIV and AIDS transmission; no sex education courses exist. Moreover, there are no special hospitals for AIDS patients. In the destitute Vietnamese medical system, where a patient's family must go to the black market to buy medicine, the AIDS drug AZT is given only to pregnant women.
In Ho Chi Minh City (formerly Saigon), the government and Save the Children both run similar programs using peer outreach workers, employing former sex workers to teach safe sex to prostitutes, and using former intravenous drug users to educate present drug users on how to avoid AIDS. Although the programs have the same goal--to stop the spread of HIV and AIDS--the way that they are run says a lot about the attitudes toward the sex workers and drug users whom they attempt to help.
The Vietnamese government has set up pilot syringe-exchange programs in Hanoi and Ho Chi Minh City. Save the Children has created pilot AIDS education and outreach programs with the hope that locally supported versions will eventually be run in other provinces in Vietnam.The government is now hopeful that more nongovernmental organizations will come into Vietnam to set up more projects.
Ho Chi Minh City is the epicenter of Vietnam's AIDS epidemic, with half the reported HIV cases coming from the city. Police figures estimate 33,000 prostitutes and 150 brothels there, though these figures are at least three years old. An estimated 10,000 IV drug users and 30,000 children live alone or with their families in the streets. In the past five years, more than a million people have come to Ho Chi Minh City to try to escape the crippling poverty of the countryside. Some women from the provinces inevitably wind up working as prostitutes.
Dr. Thue Vinh is a member of the District One AIDS Committee in Ho Chi Minh City. "When we first set the program up, in 1993, we had some resistance from the police officials. They did not understand why we gave condoms to sex workers; they said we were helping them to be prostitutes," Vinh explained. Attitudes are better, according to Vinh, because of the massive government AIDS education campaign. Among the general population, the knowledge about HIV transmission is high.
But the government campaign has some big holes. "We have classes in the schools on how HIV is transmitted," said Vinh, "but no sex education programs." Efforts to reach prostitutes who work in hotels are hampered by the hotels' refusal to accept free government condoms. Accepting the free condoms, the hotel managers reason, is the equivalent of pleading guilty to charges of promoting prostitution. They fear the police will shut them down.
Last February the AIDS committee also restarted their needle exchange, shut down two years ago because of conflicts with the police. The exchange has 87 clients out of the 500 users in the district. Estimates for IV drug users are bleak--the HIV infection rate may be as high as 80 percent. According to Aaron Peak, an American AIDS policy consultant in Vietnam, the addicts of Ho Chi Minh City frequent "shooting galleries," where they buy the opium they shoot and where one person injects all the clients, often with the same needle.
The District One Women's Union runs the government's peer outreach program to sex workers. At a recent meeting, eight former sex workers were gathered around a long table. The meeting was led by Hoa Hong, a Women's Union official who has never worked as a prostitute, and the mood was very serious. Hong asked each woman to make a report. Several women said the new law against social evils, known as Local Law 87, has forced prostitutes off the street because it is easier for the police to arrest them for vagrancy. Many of the sex workers now work inside, and some have resorted to having an accomplice drive them around on a scooter, allowing for quicker propositions with less danger of being arrested. Local Law 87, which cracks down on gambling, prostitution, and drug use, was passed last winter to appease Communist Party hard-liners in preparation for June's Party conference. It has put a damper on safe-sex education and condom distribution.
At Save the Children, the atmosphere was much more relaxed. The offices were in a large house and the sex workers' meeting was held on the floor, with the half-dozen women volunteers, all present and former sex workers, sitting and discussing their work while exchanging lively banter.
Truong is a former sex worker and staff member. Although more than 100,000 Saigon bar girls and prostitutes were sent to communist "reeducation" camps in 1975, that's whenTruong's career as a sex worker started. Her father, who had worked with Americans in Vietnam, was sent to a reeducation camp where he spent 11 years. To support her mother and brother, Truong sold her virginity at the age of 21 and spent 16 years as a prostitute. She stopped after she was recruited to do outreach for Save The Children four years ago.
"I'd say about 70 percent of the commercial sex workers start because of poverty," Truong said. "Most come from the provinces and are very poor; they have a low education level and no stable job. The Women's Union hates commercial sex workers. They don't try to determine the reasons why women sell themselves. They just say it is a social evil without knowing the reasons why."
Harm-reduction education has to be done without moral judgment, to actively address the needs of high-risk groups while appealing to their ability to take care of themselves. This flies in the face of abstinence models of HIV-prevention: don't have sex until you are married, don't have sex outside of marriage, don't do drugs ever.
Harm reduction is still controversial in the United States because it involves teaching members of groups at high risk for HIV infection how to protect themselves from AIDS, and to prevent those who are already infected from spreading the disease. Giving out needles and condoms acknowledges that drug addicts and prostitutes exist and are a part of society in Vietnam (as well as in just about every country); they cannot be simply disposed of by arresting them and sending them off to prison or reeducation camps.
Most AIDS education outreach efforts in Ho Chi Minh City are directed at high-risk populations. Besides drug users and sex workers, Save the Children also has projects doing HIV-prevention work with street children and gay men. In Vietnam, homosexuality is illegal.
Vietnam should be aware that the country has already entered a crisis. To slow the spread of HIV, the Vietnamese government should not merely wait for increased spending on the part of nongovernment organizations; it should itself increase spending on HIV prevention. For example, with new joint ventures between the government and foreign corporations being formed every week, the government could impose a small corporate tax to pay for increased AIDS spending.
The Save the Children program is small, with a staff of just 24 in addition to its 50 outreach workers, but it is vital. By approaching the sex workers with respect, they gain their confidence and give them tools with which to protect themselves. Though some sex workers still have unprotected sex despite knowing about AIDS, the outreach workers have changed attitudes, raised self-esteem, and helped sex workers convince their clients to use condoms.
As a first step, the Vietnamese government should expand the education and outreach toward high-risk populations. For example, the needle-exchange program in Ho Chi Minh City should be expanded to include all addicts interested, not just the five percent now involved. These education and outreach programs should also be set up on a smaller scale in the capital of each province: as affluence spreads through the country, attendant social problems such as prostitution will also become an issue in the smaller cities and town.
The European nongovernmental organization Medicins Du Monde has set up a "Condom Coffee Shop" in the city's youth center to educate young people about HIV and AIDS. "We are targeting the heterosexual population with education, trying to get to them before HIV spreads even further to the general population," said Martine David, the 23-year-old Canadian who runs the program. The coffee shop is staffed with young volunteers trained to discuss HIV and AIDS prevention with their teenage and young adult clientele. They stage puppet shows and dramas that address HIV and AIDS and distribute free condoms with names like Trust and OK. David said they hope to start inviting high school classes to the coffee shop. "There is no condom education in the schools," she said. "Mainly, the teachers are too shy."
"The government does a good job on AIDS education with TV and radio, but the attitudes don't change," said David. "People tell me 'I go out with good girls,' or 'I'm a university student.' They see AIDS as a problem for prostitutes and drug users."
Programs like the Condom Coffee Shop, though minuscule, are effective because they appeal to people's intelligence, as well as to their fear of AIDS. Programs like these need to be expanded and set up in different areas of Vietnamese society, such as bars catering to businessmen or farmers.
Government billboards and television announcements that warn of the risks of HIV and AIDS are necessary, but this passive form of education is not as effective as the more active, individual education that changes attitudes. In Ho Chi Minh City, a married man who has unprotected sex with a prostitute may read a billboard on his way home urging him to be faithful to his wife to avoid AIDS. But it is only by changing sexual practices and ways of drug use that AIDS in Vietnam will be curtailed.
While the first part of Vietnam's AIDS strategy should address high-risk populations, the second phase should deal with mainstream society. A comprehensive sex education program should be set up for high school and university students. If the teachers are too shy to teach it, specially trained instructors should be used. Outreach programs promoting discussions of safe sex should then be developed and used with groups such as labor unions and other professional bodies.
It is essential that the control of these programs not be limited to "official mass organizations" such as the Women's Unions and the Youth Union. There must be mass participation on a local level to promote active education, not just the passive education from billboards and television. It is as necessary to reach the farmer in the countryside with AIDS education as it is to reach the doctor or government clerk in the city.
Although cultural practices that prevent the candid discussion of sex and AIDS remain strong in Vietnam, it is necessary to try to change these traditions; it's also best if these changes are done by the Vietnamese themselves and not by foreign nongovernmental organizations. Unfortunately for Vietnam, HIV and AIDS do not respect cultural traditions.
Dylan Foley is a journalist based in New York City.