2008 PEPFAR Country Profile Update: Viet Nam
Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.
(The following document is a 2008 update to the status of PEPFAR funding and related issues in Vietnem. Click Here to Read Vietnam's 2005 Original Country Profile)
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries. PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action. At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying. Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts. Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs. Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings.
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time.
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds.
In addition to this data, each update also offers further analysis on particular items of note in the country. And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries. While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective.
Vietnam has not historically been considered a country heavily burdened by the HIV/AIDS epidemic, however, in recent years Vietnam has experienced a harrowing rise in HIV infections among populations such as injection drug users (IDU). The first case of HIV in Vietnam was detected in December 1990. Now twenty-eight years later, over 75,000 people have died from AIDS-related illnesses in the country.
The estimated number of people living with HIV in Vietnam more than doubled between 2000 and 2005 (100,000 to 250,000), and in 2007 there were an estimated 280,000 adults and 10,000 children living with HIV. The current national HIV prevalence of 0.5 percent is remarkably low, and has remained stable since 2004.
Unlike other PEPFAR-focus countries, adult men rather than women make up nearly three-fourths of people living with HIV (73 percent). The disproportionate impact of the Vietnamese epidemic on men is attributed to a number of factors, most significantly the fact that Vietnam’s epidemic is driven by the use of contaminated needles among injecting drug users (IDUs), particularly among adult male IDUs, as well as unprotected sex between IDUs and their regular partners.
In addition to increasing HIV prevalence and a larger number of people living with HIV, care and treatment efforts in Vietnam have not resulted in people living longer. In fact, the number of AIDS-related deaths is continuing to increase at exponential rates. Roughly 20,000 adults and children died of AIDS-related illnesses in 2007 alone in Vietnam compared to only 7,000 in 2002.
Additional evidence of Vietnam’s inability to scale-up treatment is found in the nation’s delivery of antiretroviral therapy (ART) to those infected with HIV. The number of sites providing ART has nearly tripled, from 74 ART sites in 2005 to 202 in 2007. This has meant that ART coverage has increased from 14 percent of those in need receiving treatment in 2006 to 26 percent in 2007. Still this is very low. Moreover, other indicators suggest that the country may be going in the wrong direction  For example, unlike most PEPFAR-focus countries where there is generally an increase in the percentage of HIV-positive pregnant women receiving ART to prevent mother-to-child transmission, in Vietnam this has decreased from roughly 40 percent coverage in 2006 to 20 percent coverage in 2007. This is despite the fact that 91 percent of pregnant women in Vietnam do received antenatal care.
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Vietnam. The stories behind these statistics are fleshed out in greater detail following the chart.
PORTRAIT OF VIETNAM IN NUMBERS
The epidemic in Vietnam is still concentrated among certain populations most-at-risk such as IDUs, female sex workers (FSWs), and men who have sex with men (MSM). According to the 2006 Integrated Biological-Behavioral Study (IBBS) conducted in targeted cities such as Hanoi and Ho Chi Minh City, all three groups share one high-risk behavior: low use of condoms. IDUs are the most impacted by the epidemic as the predominant mode of HIV transmission in Vietnam is through the sharing of used syringes and needles.
While the first AIDS case was reported in 1990, Vietnam did not respond to the epidemic until 1995 when the Standing Committee of the National Assembly adopted an ordinance on HIV/AIDS prevention and control. The ordinance was the first legal framework for HIV-prevention efforts in Vietnam. Nearly ten years later in February 2003, Prime Minister Phan Van Khai signed a directive on strengthening HIV/AIDS prevention and control that included prevention, care, and treatment in a multisectoral framework. The directive led to the National Strategy on HIV/AIDS for 2004–2010 with a Vision to 2020. The strategy adopts most international best practices on HIV/AIDS prevention, care, support, and treatment, including harm reduction for IDUs and FSWs.
In addition to launching the National HIV Strategy, the government created the Vietnam Administration for HIV/AIDS Control (VAAC). The VAAC is under the Ministry of Health and reports on national HIV issues and progress to the National Committee for HIV/AIDS, Drugs and Prostitution Prevention and Control, a multi-sectoral committee which is chaired by the Deputy Prime Minister.
The overall objective of the National HIV Strategy is to restrict HIV prevalence among the general population to below 0.3 percent by 2010, with no further increase after 2010. The following specific objectives are laid out below.
While the targets established in Vietnam’s National HIV Strategy are more concrete than other PEPFAR countries and suggest a high level of dedication to addressing the epidemic, its lofty goal of universal coverage is simply unrealistic. It also aims to address risk behaviors while not addressing structural and societal concerns at the core of the country’s epidemic including stigma, discrimination, and homophobia.
The nation is far behind in reaching three of its goals: increasing ART coverage to 60 percent ART coverage, preventing 100 percent of mother-to-child transmission of HIV, and ensuring that 90 percent of people display comprehensive knowledge of HIV/AIDS. In fact, as mentioned earlier there is only 26 percent coverage of ART and 20 percent coverage of PMTCT in Vietnam. This is significantly below global coverage levels of 31 and 33 percent, respectively. Further, less than half of young women (42 percent) and half of young men ages 15–24 display accurate knowledge of HIV transmission and reject common misconceptions of the virus. If current trends proceed, Vietnam will not meet the majority of its universal access 2010 goals.
Vietnam has also shown resistance in decreasing levels of stigma and discrimination against people living with HIV. The most recent and comprehensive survey of beliefs and attitudes about HIV in Vietnam is from the 2005 Vietnam Population and AIDS Indicator Survey (VPAIS). According to VPAIS, less than 30 percent of men and women have accepting attitudes towards persons living with HIV/AIDS. For example, only half of all women and 60 percent of men (ages 15–49) report that they would buy fresh vegetables from a vendor if they knew that the vendor was HIV-positive. And, roughly the same number believe an HIV-positive female school teacher should be allowed to keep teaching. This level of fear and misunderstanding presents significant obstacles to reaching vulnerable populations with messages of prevention, testing, care, and treatment.
To its credit, however, Vietnam has an ongoing condom promotion program that was implemented in one-third of all its districts in 2007 with a targeted focus to reach FSWs and MSM. In addition, with the help of the United States Centers for Disease Control and Prevention (CDC), Global Fund, World Bank, and Family Health International, Vietnam has increased voluntary HIV counseling and testing (VCT) sites from 157 in 2005 to 228 in 2006, helping to increase HIV tests among IDUs and FSWs.
Vietnam became the 15th focus country under PEPFAR in June 2004, and is the only PEPFAR-focus country in Asia. Like most of the PEPFAR-focus countries, Vietnam relies on international governments and agencies for funding of HIV/AIDS expenditures. In 2006, Vietnam only covered 10.5 percent of all HIV/AIDS-related costs while 89.5 percent was covered by international sources. While Vietnam receives funding from the Global Fund, the UK Department for International Development, the World Bank, and many other agencies, the majority of funds dedicated toward HIV/AIDS spending in the country come from PEPFAR.
According to the U.S. Department of State, “As of March 31, 2008, PEPFAR supported life-saving antiretroviral treatment for 11,809 people in Vietnam, and provided care to 3,976 orphans and vulnerable children last year alone. [U.S. funded] programs reach more than 43,000 people affected by the HIV/AIDS virus [in Vietnam].”
President’s Emergency Plan for AIDS Relief (PEPFAR)
PEPFAR began implementing its HIV/AIDS programs in Vietnam in 2004 with an initial grant of nearly $18 million dollars, making Vietnam one of the least-funded PEPFAR-focus countries. As mentioned, Vietnam relies heavily on foreign governments and international agencies for funding and PEPFAR covers the majority of those funds. In 2008, PEPFAR almost quadrupled the initial allocation to nearly $70 million.
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstain, Be-Faithful, and Correct and Consistent Condom Use. Abstain/Be-Faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
Allocated PEPFAR Funds 2004–2008*
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.
** Total funding allocated to Field Programs only, excludes Agency costs.
† Total field and central program funding allocated in 2004
In 2008, $20 million (28.6 percent) of the total budget was allocated for prevention programs, $25 million (36.1 percent) was allocated for care services, and $24 million (35.3 percent) was allocated for treatment services. Like in other PEPFAR-focus countries the prevention budget has the smallest allocation. However, unlike in other PEPFAR-focus countries, OP funding is nearly six times greater than that of AB funding and makes up the majority of the prevention budget (65 percent of the prevention budget compared to 15 percent).
Beginning in Fiscal Year 2006, Vietnam received a waiver from the Office of the Global AIDS Coordinator (OGAC) exempting it from spending two-thirds of its prevention funding on AB programs. OGAC approved the waiver request but recommended that Vietnam allocate one-third of sexual transmission prevention money to AB activities. This means that despite the waiver, OGAC continued to ask Vietnam to focus on abstinence and marriage promotion/faithfulness programming. This, despite the fact that abstinence is the least acknowledged strategy for reducing HIV transmission in Vietnam: only half of women and two-thirds of men (ages 15–49) acknowledged abstinence as a preventative measure in 2005. At the same time, the majority of Vietnamese (69.5 percent) are against teaching school kids between the ages of 12–14 about using condoms to prevent HIV infection and nearly all Vietnamese think young men and women should wait to have sex until marriage.
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding.
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP). The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR's overall impact on prevention programming in the country.
According to the 2007 Country Operation Plan, within the area of prevention PEPFAR funded a total of five organizations to implement both AB and OP programs and six organizations to implement only OP programs. No organizations implemented AB-only programs. Only five organizations promoted the correct and consistent use of a condom.
The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for Vietnam. This list indicates whether grantees received only Abstinence-only/Be-faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.
Organizations that received AB funding only:
Organizations that received AB and OP funding:
Organizations that received OP funding only:
Vietnam received a total of $2,886,871 in funding for AB programs which were estimated to reach over 320,000 people. In contrast, OP programs received $8,456,700 and were expected to reach 360,000 people and target 1,300 condom outlets. No organizations received AB-only funds in 2007.
Pact, Inc. received the most combined AB and OP funding at a total of $4,465,000 (four AB grants at $2,060,000 and ten OP grants at $2,405,000). The organization partnered with many others in delivering Abstinence/Be-Faithful messages and targeted mainly IDUs. Pact also distributed comprehensive HIV-prevention booklets to 15,000 students at seven universities. The booklets provide information on sexual delay, mutual faithfulness, and partner reduction. They use music/knowledge contests and writing competitions to provide and enhance HIV/AIDS knowledge.
Pact also supported a media campaign and associated community outreach in Haiphong, Hanoi, Ho Chi Minh City, and up to four additional provinces, to reduce the “acceptability and practice of sex worker visitation….The initiative is grounded in the PEPFAR Vietnam 5-Year Strategy’s recognition of the growing risks of HIV transmission among younger Vietnamese men—and the potential role of this population in contributing to a generalized epidemic.” Pact trained 4,235 outreach workers to provide “tailored, AB prevention education to 103,020 individuals, including injection drug users (IDU), men who have sex with men (MSM), mobile workers, migrants, male clients of sex workers and youth.”
Within Pact, Inc’s OP activities, the organization mainly worked to provide outreach to people at risk of drug abuse or risky sex behavior and distribute condoms. In addition, Pact provided referrals to substance abuse treatment; resources for FSWs who want to leave sex work; treatment for sexually transmitted infections (STI); access to testing, care, and treatment options; and extensive peer outreach on HIV education and risk reduction among IDUs and FSWs.
The organization that received the most OP-only funding was the country’s Ministry of Health (MOH) at a total of $900,000. The MOH trained outreach workers in behavior change communication for HIV prevention targeting 22,000 IDU; 8,000 commercial sex workers; and 1,500 former residents of government centers for rehabilitating drug users. Individuals who were identified as “at-risk” by the MOH received condoms and were referred to services including “counseling and testing, care and treatment, drug and alcohol abuse treatment options, and STI services.” Another OP-only funded grantee, Population Services International, launched the “Number One” male condom in October 2007 to “improve correct and consistent condom use among the most-at risk population groups.”
Items of Note: A Concentrated Epidemic among Injecting Drug Users
The overall HIV prevalence of 0.5 percent in Vietnam is relatively low when compared to other PEPFAR focus countries, which experience general prevalence upwards of almost 24 percent. However, despite the low HIV prevalence among the general population, Vietnam is experiencing a concentrated HIV/AIDS epidemic among injecting drug users (IDUs) who have an estimated HIV prevalence of 23.1 percent or roughly 46 times the national prevalence.
In fact, the epidemic in Vietnam is fueled primarily by injection drug users and their sexual partners. IDUs report low rates of consistent condom use with sex partners, low access to and use of voluntary counseling and testing services, irregular check-ups for sexually transmitted infections. Perhaps the biggest hurdle to HIV prevention among this population, however, is unsafe injection practices. Efforts to adopt safer injection practices are often impeded by poor availability and prohibitive cost of sterile needles as well as fear of being identified as an IDU.
Despite the central importance of preventing new HIV infections among IDUs as a means of curbing the epidemic in Vietnam, in 2007 less than half of IDUs were reached with HIV-prevention programs and only 38 percent showed comprehensive knowledge of HIV transmission risks. Harm reduction programs including treatment for drug addiction as well as access to sterile needles and syringes are key HIV-prevention tools for IDUs. This approach is supported by the World Health Organization.
In the last few years, the Vietnamese government has stepped up its efforts to support the expansion of evidence-based prevention initiatives for IDUs. For instance, the country distributed 7.5 million clean needles and syringes in 2007. In 2008, the country initiated its first pilot project of methadone substitution therapy. In partnership with the Vietnamese government, Family Health International, a PEPFAR provider, has been administering methadone as part of a “comprehensive set of healthcare services provided by selected providers to reduce injection drug use and criminal activity, prevent the spread of HIV and hepatitis C, and provide treatment to HIV-positive patients.”
When used properly, methadone is a safe and extremely efficacious medication for the treatment of opioid dependence including heroin and morphine. Family Health International works with a number of clinics in Hai Phong and Ho Chi Minh City to dispense methadone seven days a week and provide counseling and other services five days a week. At the end of 2008, Family Health International and other PEPFAR partners including the Ministry of Health will conduct a preliminary evaluation to determine “whether the methadone program should be scaled up throughout the country. The evaluation will provide data on methadone’s impact on patients’ quality of life, relapse to drug use, and other behaviors.”
The U.S. government, however, may stand in the way of the expansion of this program as it bans the use of federal funding for needle exchange programs both domestically and internationally. The ban originated in the Ryan White CARE Act (a funding bill for domestic HIV/AIDS programs) and was further institutionalized by the Substance Abuse and Mental Health Services Administration (SAMHSA) authorization and the Fiscal Year 1997 Labor-Health and Human Services (HHS)-Education appropriations legislation. Many top government officials, including President Bush, do not support needle exchange programs based on the notion that providing sterile syringes would be perceived as condoning, or even promoting, illegal drug use. Numerous studies have not only disproven this fear but have demonstrated the effectiveness of needle exchange programs at preventing the spread of HIV. Furthermore, a majority of Americans are in support of such programs.
Nonetheless the ban remains and impacts PEPFAR funding. Guidance developed by the Office of the Global AIDS Coordinator clearly explains that“[PEPFAR] funding may not be used to support needle or syringe exchange programs.” During the recent reauthorization of PEPFAR in the U.S. Congress, advocates noted that this ban hurts countries like Vietnam that have a growing epidemic among IDUs. Despite their best efforts, however, they were unable to garner authorization to fund needle exchange programs.
While PEPFAR funding cannot be used to support needle exchange programs, it can support substance abuse treatment programs for HIV-positive individuals, which may include medication-assisted treatment with methadone, buprenorphine and naltrexone. However, for HIV-negative individuals, these funds can only support such programs on a pilot basis and require prior OGAC approval. While Family Health International is able to use its PEPFAR funding to treat HIV-positive IDUs using methadone, it can only use it as a pilot program among HIV-negative IDUs and it cannot provide clean needles and syringes to the population.
It is clear that a few key changes in protocol can increase the effectiveness of PEPFAR funding and bolster Vietnam’s commitment to reducing and controlling the HIV/AIDS epidemic among IDUs and achieving its National HIV Strategy targets. The U.S. government should remove the ban on supporting needle exchange programs and instead increase PEPFAR’s commitment to funding harm reduction programs that, among other things, improve availability of and access to clean needles. This would enable organizations in Vietnam to use all known best-practices regarding prevention of HIV-transmission among IDUs. PEPFAR should also show its commitment to harm reduction by helping Vietnam expand the availability of methadone programs to individuals across the country regardless of their HIV status. As PEPFAR is the largest contributor of international funding for HIV/AIDS efforts in Vietnam, it can help stem the spread of HIV among the general population by improving prevention among IDUs.
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
1. Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion. As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
2. Increase Transparency of PEPFAR Prevention Funds
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement, OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession.
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.
4. Rescind the Anti-Prostitution Pledge
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable. The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease. However, such segmentation has also led to too narrow a framework/conceptualization. Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground.
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
6. On-the-Ground Monitoring of Funded Activities
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways. Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming. PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs. We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 2008 Report on the Global AIDS Epidemic Annex 1, 219-220
 Status of the global HIV epidemic, 49
 2008 Report on the Global AIDS Epidemic Annex 1, 222; Vietnam: Epidemiological Country Profile on HIV and AIDS
 Vietnam: Epidemiological Country Profile on HIV and AIDS
 Ibid., 16
 Ibid., 11
† According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
 Ibid., 11
 2008 Report on the Global AIDS Epidemic Annex 1, 219
 Ibid., 220
 Ibid., 222
 Ibid., 309
 Ibid., 315
 Monitoring ICPD Goals – Selected Indicators, 87
† According to UNFPA, “Modern or clinic and supply methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.”
 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY) accessed 9 September 2008,
 Monitoring ICPD Goals – Selected Indicators, 87
 The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 9 September 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 14
 2008 Report on the Global AIDS Epidemic Annex 2, 297
 Ibid., 292
 The Third Country Report on Following Up the Implementation to the Declaration of Commitment on HIV and AIDS, 11
 Ibid., 12
 2005 Vietnam Population and AIDS Indicator Survey (VPAIS), 47
 Ibid., 2; 2005 Vietnam Population and AIDS Indicator Survey (VPAIS), 15
 The Third Country Report on Following Up the Implementation to the Declaration of Commitment on HIV and AIDS, 12
 Decision No. 36/2004/QD-TTg of March 17, 2004 approving the National Strategy on HIV/AIDS Prevention and Control in Vietnam Till 2010 with a vision to 2020, Includes the National Strategy on HIV/AIDS Prevention and Control in Vietnam Till 2010 with a vision to 2020, The Government, Socialist Republic of Vietnam, Hanoi, March 17, 2004 Phan Van Khai (Prime Minister of Vietnam), accessed 14 September 2008, http://www.unaids.org.vn/local/gov/36-2004-qd-ttg.pdf 2
 Progress towards Universal Access Vietnam, UNAIDS, (New York, NY), accessed 9 September 2008, http://data.unaids.org/pub/FactSheet/2008/ua08_vtn_en.pdf
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 2005 Vietnam Population and AIDS Indicator Survey (VPAIS), 12
 Ibid., 55-56
 Ibid., 55-56
 The Third Country Report on Following Up the Implementation to the Declaration of Commitment on HIV and AIDS, 20
 Ibid., 22
 2008 Report on the Global AIDS Epidemic Annex 2, 256
 Ibid., 2
 Total Dollars Planned for FY 2005 by Program Area, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 9 September 2008, http://www.state.gov/s/gac/progress/other/data/program/59808.htm
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 Ibid., 39
 Ibid., 72-73
 Ibid., 48, 52, 56, 62, 85, 88, 90, 94, 98, 101, 103, 106, 108, 166
 Ibid., 56
 Ibid., 63
 Ibid., 49
 Ibid., 98, 101
 Vietnam Country Operational Plan, 114
 Ibid., 114
 Ibid., 114
 2008 Report on the Global AIDS Epidemic Annex 1, 223
 Ibid., 6-7
 2008 Report on the Global AIDS Epidemic Annex 2, 290, 299
 “FHI-supported Clinics Participate in Pilot Methadone Program: Health Services to Help Strengthen HIV Prevention in Vietnam”, May 2008, Family Health International, (Arlington, VA), accessed 15 September 2008, http://www.fhi.org/en/CountryProfiles/Vietnam/res_Methadone.htm
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Injection Heroin Use March 2006, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 23 September 2008, http://www.state.gov/documents/organization/64140.pdf 2
 Ibid., 3