Patients risk being left behind as foreign donors pull the plug on HIV/AIDS in Vietnam

Vietnam is racing against the clock to provide free drugs under health insurance but around half of HIV patients are uninsured.

People living with HIV in Ho Chi Minh City have been given all the more reason to be concerned. Their anti-retroviral drug treatment could be interrupted starting from 2018 when the drugs are scheduled to be provided under Vietnam’s health insurance system.

Most HIV clinics in the city have yet to sign a contract with Vietnam Social Security, the agency charged with administering the health insurance fund.

“If patients with HIV/AIDS stop using anti-retroviral (ARV) medicine for one week, they will become resistant to the medicine, leading to the problem of preventing an epidemic in the city,” Vietnam News quoted Dr. Trieu Thi Thu Van as saying at a meeting in early September.

Regular treatment suppresses the development of the virus and its risk of spreading, and actually allows patients to lead a relatively healthy and normal life.

The problem is not just limited to Vietnam’s largest metropolis. Half of the country's HIV outpatient clinics are located in health facilities that come under the “preventive” element of Vietnam's healthcare system. But to provide care and treatment under health insurance, these facilities need to meet “higher” standards to be classified as “curative”.

As an interim solution, experts suggest these clinics should merge with general hospitals.

Transitionary mess

A man presents flowers to U.S. Secretary of State Hillary Clinton (R) after she signed a memorandum of understanding for the U.S. support of HIV/AIDS programs in Vietnam, at Ngoc Lam Pagoda in Hanoi July 22, 2010. Photo by Reuters/Julian Abram Wainwright/Pool

The above is just one example of the administrative nightmare Vietnam is facing as a result of transitioning its HIV/AIDS treatment program to health insurance as foreign funds will come to a full stop in 2020 as Vietnam has reached middle income status.

Thus far, the vast majority of funding for HIV/AIDS treatment and prevention has been coming from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund.

Since 2004, PEPFAR has been the main funder of HIV treatment, care and prevention in Vietnam, channeling a massive $288.7 million between 2004-2008 alone. The state budget paled in comparison, and thus, for over a decade, it wasn’t Vietnam’s state sector that shaped HIV/AIDS intervention, it was PEPFAR.

“PEPFAR had not opted to work through the existing health system but chose to build a ‘parallel’ system, connected to but organized apart from it,” Professor Alfred Montoya, an anthropologist at Trinity University in the U.S., wrote in 2013. “The Ministry of Health operates as a PEPFAR partner/client rather than a significant organizing force.”

Faced with changes ahead, Vietnam is actually one of the fastest in the region to integrate HIV treatment into health insurance and has actually drawn up plans for alternate funding sources until 2020. This reflects Vietnam’s “tremendous political will” to ensure a smooth transition, according to UNAIDS.

Prof. Montoya, who had worked for a year with HIV professionals in Vietnam, thinks “the challenge will be identifying and weighing the myriad ways that HIV/AIDS articulates with questions of inequality, exclusion, place and politics to affect different communities to different degrees at different moments.”

So while Vietnam's prime minister has signed a decision to ensure a co-payment scheme for health insurance premiums from local governments for HIV patients, complicated and conflicting regulations have left them with more questions than answers.

From Ho Chi Minh City, Nguyen Anh Phong who represents VNP+, a national network of people living with HIV, told VnExpress International that patients have been “confused due to ever-changing information […] as policy continues to be revised and improved, so even health officers can’t keep up with the process.”

This is particularly critical given that not everybody can get insurance due to lack of awareness, financial barriers or necessary identifications.  

Currenly, only about 40-50 percent of HIV positive people have health insurance, according to local media reports quoting the Vietnam Administration of HIV/AIDS Control (VAAC). With nearly 116,000 people, or half of the HIV community, on ART, that’s roughly 60,000 patients without health insurance.

“The government is aware that not all have health insurance; indeed we want to make sure it works for everybody,” Marie-Odile Emond, UNAIDS Viet Nam country director, told VnExpress International.

Indeed, as this story was about to be published, the Ministry of Health started to call for comments on a draft circular aiming to resolve existing red tape that prevents people vulnerable to HIV from obtaining health insurance.

The draft attempts to give ARV patients flexibility to choose a clinic; introduces subsidies for health insurance premiums to be paid by local governments; and scraps the ID requirements.

A member of the MSM (Men who have Sex with Men) Club sits near a red ribbon while waiting for his performance during a HIV/AIDS awareness campaign in Hanoi November 27, 2011.

The latter is critical to key populations, a term used for groups most vulnerable to HIV who are often marginalized by policies that criminalize their behavior.

They are injecting drug users, female sex workers and men who have sex with men, with HIV prevalence in Vietnam at 11, 2.7 and 8.2 percent respectively.

It is common for people in these groups not to have any personal identifications. Men who have sex with men, including transgender people, are often rejected by their families and forced to leave without any documentation, according to Duong Tu Anh who leads I-Girl, a support group for transgender women in Hanoi.

Drug users who are released from detention centers, in turn, are required to pay a small amount upon leaving. If they don’t, their ID is withheld.

But when it comes to costs, even with fully subsidized health insurance premiums, while ARV drugs are free, patients still have to pay 20 percent of the costs of tests and check-ups required every three to six months. In some cases, certain tests may not be available at local clinics, which require patients to incur additional travel costs.

On average, HIV/AIDS patients in Vietnam spent $188 on healthcare in 2013 when the drugs were free, and over a third of HIV-affected households couldn’t afford it, according to a 2013 study by Tran BX et al.

For these reasons, experts recommend that subsidies should be available for insurance premiums, drugs and tests and other treatment associated with HIV.

Stigma and trust in health system

As Vietnam’s policies toward people living with HIV have become more inclusive with greater availability of testing and a treat-all policy, half of the people living with the virus in Vietnam were on treatment in 2016, and AIDS related deaths were at their lowest since 2004 with new infections steadily decreasing.

However, as 2018 nears, another issue that has been plaguing Vietnam’s fight against HIV for over a decade is resurfacing again. 

“It’s getting a bit more difficult to involve more people in the treatment. We need to find out why,” said Emond from UNAIDS.

To Phong, the prominent VNP+ activist who lives with HIV, it’s a stigma.

“This is the reason why a sizable number of people within the LGBT community and people living with HIV distance themselves from society, don’t dare to acknowledge their identity, lack opportunities or reject opportunities to receive healthcare services, social and legal support… which we [VNP+] have been providing for many years.”

And it matters now because Vietnam’s health system is tasked with gaining the patients’ trust, just like PEPFAR had to when it brought its HIV program to Vietnam over a decade ago. 

How it all began

A Vietnamese woman walks past posters warning of the dangers of HIV/AIDS in Vietnam's capital Hanoi November 30, 2000. Photo by Reuters

Since the early 1990s, HIV/AIDS has been portrayed in campaigns as a catastrophe that results from the harms of social evils like prostitution and drug use. The disease was being depicted as a threat to the people, and perpetuated the idea that if you were infected with HIV, regardless of how you were infected, you were associated with these social evils and subject to socio-moral disqualification, Professor Montoya argued in a 2012 paper.

This encouraged HIV positive Vietnamese to actually hide their illness for fear of rejection and abandonment, Montoya wrote.

A woman stands in front of a HIV/AIDS prevention billboard displaying a condom image in Vietnam's northern Do Son resort town 120km east of Hanoi on September 18, 2007. Photo by Retuers/Kham

The government changed its approach to HIV in the early 2000s, when “social evils” could no longer fully explain the epidemic. The 2004 National Strategy on HIV/AIDS Prevention and Control for the first time looked at fighting stigma and considered the virus a threat to human health, officially recognizing the epidemic as a health issue, not a moral problem.

“Vietnam’s apparatus for the prevention and control of HIV/AIDS is in the main long past its 'social evils' days," Montoya told VnExpress International in an email. “Which is not to say that authorities no longer have recourse these kinds of campaigns.”

Old habits die hard

A UNAIDS study from 2015 found that while healthcare staff working in HIV clinics are friendly, caring and supportive toward people living with HIV, stigma largely prevailed at general clinics. Numerous studies have reported cases of health facilities exposing HIV patients’ identities to their families or local authorities without their consent - which given ongoing stigma could cost them jobs and even families.

A number of patients were found wearing masks when coming for treatment and they kept them on during interviews for the study for fear of being recognized.

Because I feel so inferior, I am afraid that other people will discriminate against and stigmatize me when they find out my status. So I don't go to the hospital. A while ago I fell sick, but I bought medicines on my own. And if I get really ill, I'll ask a doctor to come to my house.

Woman living with HIV - in-depth interview by UNAIDS - Dak Lak Province, Vietnam

It gets worse if you belong to the LGBT community, especially men who have sex with men - the only key population in which the HIV epidemic will continue to grow in the next decade, according to the Ministry of Health.

Tu Anh, an advocate for transgender rights, said transgender people are often “refused” treatment as doctors, confused by the difference between their registered sex and gender, often put them last on the waiting list. “This is why, many transgender people prefer going to private clinics, even if the costs are higher,” Tu Anh said.

Such stigma is aggravated when considered in light of the general lack of trust in Vietnam’s healthcare system, which is notorious for being corrupt. In its latest report published in March, Berlin-based Transparency International found that Vietnam and India had the highest bribery rates for healthcare (59 percent) among 16 surveyed countries in Asia Pacific.

Lack of trust is further fueled by news of the health insurance fund going into the red, rumors that insurance is costly and its funded drugs are low quality.

It’s not just a medical issue, it’s social

A Vietnamese takes a leaflet and a free condom from anti-AIDS campaigners during a ceremony to mark World AIDS Day in Hanoi, December 1, 2000. Photo by Reuters

A lot of the progress achieved so far, analysts say, couldn’t have been possible without outreach programs run by people infected with HIV like Phong or those belonging to key populations like Tu Anh because they are part of the community.

Health workers with extensive experience of working with HIV communities in Vietnam have confirmed that in areas with strong outreach work, where HIV patients take up ART, there’s a greater acceptance toward them.

This is why UNAIDS in a statement last July called for “integrated and community-based HIV services as well as successful innovative and user friendly approaches.”

Funding for these communities are, however, also depleting as foreign donors are pulling out. Tu Anh’s network of key populations are awaiting funding approval from the Global Fund and other sources for now until 2020, but she’s unsure what will come after that.

“I firmly believe that the true issue lies not with the will, commitment or abilities of these Vietnamese health workers and experts and so forth, but with a lack of commitment on the part of the USG [U.S. government] to sustain these life-saving and life-enriching programs, and their lack of awareness that […] the fight against HIV/AIDS is a necessarily global one,” said Prof. Montoya. “Fighting the virus in Nashville AND Nha Trang works toward securing health for us all.”

“Disease is profoundly social,” Montoya concluded.

Tu Anh and her network have already made up their minds. If foreign funds leave, they’ll find another way to continue their outreach work.

“We could set up a social enterprise,” she said.

Lam Le

Chart by Ha Phuong

Photos by Reuters

By Lam Le