In Vietnam: The Challenges of Addressing Drug Use and HIV
August 27, 2008
I sat cross legged on the floor of a single room house at the end of a bumpy dirt road, drinking bitter green tea and looking at the faces of the men around me as they told us about their lives. The family’s few belongings were neatly stacked under the beds and family photos were pinned to the white walls. We – a group of public health researchers – were sitting alongside a group of young Vietnamese heroin addicts, several of whom were HIV positive, hearing a few of the stories behind the statistics on drug use and HIV here in Vietnam. These young men, mostly under the age of thirty, have watched many of their peers die from drug overdose or from AIDS, and have felt their own lives crumble around them.
Contracting HIV/AIDS from infected needles is an urgent problem facing countries all over the world and, in Vietnam, HIV/AIDS in Vietnam cannot be separated from injection drug use, primarily of heroin. While the overall prevalence of HIV is under 1%, the rate among drug users is estimated to be 32%, with rates as high as 66% in some provinces. Sharing needles and unsafe injecting is the cause of 50 to 60% of HIV cases here.
Drug use in Vietnam is highly stigmatized as it is in many countries around the world, and the approach to combating it has historically had little to do with health. The young men we interviewed described sharing needles rather than going to the pharmacy to buy clean ones because of their fear of being identified as drug users. The fear is warranted: drug use is illegal in Vietnam and carrying needles is sufficient evidence for arrest and urine testing, and can result in incarceration for 2 to 5 years in Treatment and Education Centers. At the same time, there has been a recent increase in something called ‘harm reduction’ programs in Vietnam. These programs aim to provide resources and tools to reduce the consequences of drug use without necessarily stopping it.
And this illuminates the inherent conflict between law enforcement and public health approaches to injection drug use here and in many other societies. This split exists not only in people’s attitudes, but also in the law and between ministries. While the Ministry of Health has taken a progressive public health approach to drug use, including harm reduction programs, condom promotion, clean needle and syringe programs, and HIV testing, these activities are criminal in the eyes of the Ministry of Public Security and the Ministry of Labor, Invalids and Social Affairs (MOLISA). Under the Law on Drug Prevention and Control, issued by MOLISA, it is illegal to shelter or support drug users, and individuals and health staff are required to report any known drug users to the police. This makes it difficult for clinics and programs that provide services and treatment to drug users and other high risk groups to maintain contact with their clients.
When arrested by the police, drug users in Vietnam are first given an opportunity for community-based rehabilitation (although in reality, many say they aren’t always given this chance), but if this fails they are put into mandatory two year detoxification programs in rehabilitation centers. Forced detoxification for heroin, an extremely addictive substance, is, according to experts, both painful and often ineffective. Many programs around the world have shown high success rates using drug replacement therapy programs like methadone. But, I have been told that in rehabilitation centers in Vietnam, heroin addicts receive no support, apart from a few doses of sedatives to calm their initial withdrawal symptoms. Not only is there no drug treatment, but there are very few HIV testing or treatment services available in these centers, where 20 to 40% of residents are thought to be HIV positive. Although accurate data is virtually non-existent in Vietnam, experts report that most drug users relapse after release from these “cold turkey” rehabilitation centers. Even more disheartening, a black market has developed giving center residents continued access to drugs.
But, things are changing. At the national level, the contradiction between the laws on HIV/AIDS and Drug Prevention and Control has been acknowledged and politicians are working with local stakeholders and international experts to reconcile these inconsistencies. It has become clear that this is not just a task of erasing a few lines of policy, but rather a reconfiguration of an entire system and set of attitudes, so this process is taking longer than hoped and deadlines have been missed. But small steps are being made. Clean needle and HIV testing programs continue to expand their reach, and early this year pilot drug replacement methadone programs have been introduced in Ho Chi Minh City and the northern port city of Hai Phong. Cracking down on drug use, prostitution and other “social evils” remains the key government responses, often driving these activities beyond the reach of health services. The government’s commitment to addressing HIV/AIDS is very real. However, HIV brings into the spotlight highly sensitive and controversial social issues in Vietnam: drug use, prostitution, homosexuality, and gender. Given that Vietnam is still a highly traditional society, greater social awareness is needed to shift the discussion beyond a condemnation of social evils.
A few weeks after sitting on the floor of that tidy room, listening to personal stories of drug use, addiction and HIV, and looking at the family wedding albums, we received a phone call informing us that the owner of the house had committed suicide. I realized how closely these people are living to the edge of life and how dire the situation is.
Zarah Rahman was a 2007-2008 Luce Scholar based in The Asia Foundation’s Vietnam office, where she focused on public health issues.
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