continues to evolve, with rapid increases in infection in the north, a region previously little affected. In this paper, we summarize the recent changes through 1999 and describe the national response to the epidemic. Vietnam is a country of 76.7 million people, according to the Vietnamese Ministry of Health. It is divided into 61 administrative units that comprise 57 provinces and four major cities (Hanoi, Hai Phong, Da Nang, and Ho Chi Minh City HCMC), expanded from a total of 53 such units in 1996. A summary of the country’s demographic characteristics relevant to HIV has been published (1)
Trang 1HIV in Vietnam: The Evolving Epidemic and the Prevention
Response, 1996 Through 1999
*‡Vu Minh Quan, *A Chung, †Hoang Thuy Long, and ‡Timothy J Dondero
*National AIDS Committee of Vietnam, Hanoi; †National Institute of Hygiene and Epidemiology, Hanoi, Vietnam; and ‡Division
of HIV/AIDS Prevention—Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, U.S Centers for
Disease Control and Prevention, Atlanta, Georgia, U.S.A.
Objectives: To describe epidemiologic patterns and trends in HIV infection in
Vietnam from 1996 through 1999, and to summarize the national response to the epidemic
Methods: We reviewed nationwide HIV case reports, and we analyzed annual
seroprevalence among different sentinel populations in 21 provinces, using the2test for linear trend to assess trends in HIV prevalence HIV prevention efforts were also reviewed
Results: Through 1999, 17,046 HIV infections, including 2947 AIDS cases and
1523 deaths had been reported in Vietnam The cumulative incidence rate for the country was 22.5 per 100,000 population Injection drug users (IDUs) represented 89.0% of all those for whom risk was reported before 1997 and 88.0% in the period
1997 to 1999 In 1999, HIV prevalence rates among IDUs ranged by province from 0%
to 89.4% Significantly increasing HIV trends among IDUs (p < 05) were found in 14
of the 21 sentinel provinces during 1996 to 1999 HIV prevalence among commercial sex workers (CSWs) ranged from 0% to 13.2%, increased significantly in 6 of 21 provinces In 1999, prevalence among pregnant women, blood donors, and military recruits were 0.12%, 0.20% and 0.61%, respectively Major prevention activities in-clude mass information; peer education and outreach among groups at increased risk;
availability of low-cost syringes and condoms through pharmacies; needle exchange pilot projects; widely available treatment for sexually transmitted diseases; antibody screening of blood for transfusion; and free medical treatment at government hospitals
Discussion: The HIV epidemic continues to evolve rapidly, intensifying among
IDUs and increasing among CSWs Serosurveillance indicators of HIV in the popu-lation at large continue to indicate the relatively slow extension beyond those at highest risk Immediate, intensive preventions in high-risk groups may decelerate expansion to the broader population
Key Words:
HIV—AIDS—Vietnam—Asia—Prevalence—Surveillance—Epi-demiology—Trend—Prevention
The HIV epidemic has emerged rapidly in Vietnam
since the first infection was detected in 1990 The
epi-demiologic situation through the end of 1996 has been
summarized elsewhere (1) Since that time, the epidemic
continues to evolve, with rapid increases in infection in the north, a region previously little affected In this pa-per, we summarize the recent changes through 1999 and describe the national response to the epidemic
Vietnam is a country of 76.7 million people, according
to the Vietnamese Ministry of Health It is divided into
61 administrative units that comprise 57 provinces and four major cities (Hanoi, Hai Phong, Da Nang, and Ho Chi Minh City [HCMC]), expanded from a total of 53 such units in 1996 A summary of the country’s demo-graphic characteristics relevant to HIV has been pub-lished (1)
Address correspondence and reprint requests to Vu Minh Quan,
Division of HIV/AIDS Prevention—Surveillance and Epidemiology,
National Center for HIV, STD, and TB Prevention, Centers for Disease
Control and Prevention, 1600 Clifton Road, Mailstop E-46, Atlanta,
GA 30333, U.S.A.; e-mail: vaq1@cdc.gov
Vu Minh Quan is currently an officer in the Epidemic Intelligence
Service [EIS] Program and Division of HIV/AIDS Prevention at the
Centers for Disease Control and Prevention.
Manuscript received March 28, 2000; accepted August 2, 2000.
360
Trang 2Social changes in Vietnam continue to occur as the
economy advances Many of these changes have been
beneficial, but there are unwanted consequences as well
Drug use continues to be a concern, as it is throughout
much of Asia During the past decade, heroin has
emerged as one of the drugs most commonly used, and
injection drug use remains the principal mode of HIV
transmission in Vietnam Increases in investment and
business, along with increased numbers of visitors, have
helped the economy but have also encouraged
commer-cial sex
AIDS-related activities, including surveillance,
pre-vention, and treatment, are coordinated and funded
na-tionally by the National AIDS Committee of Vietnam,
which is made up of numerous government ministries
and mass organizations At the provincial and city levels,
AIDS activities are coordinated by the provincial or city
AIDS committee, which includes the local counterparts
of the same groups that comprise the National AIDS
Committee
AIDS cases are reported to the respective provincial
AIDS committee in two ways: hospitals report AIDS
cases to the provincial Department of Health (which
par-ticipates in the provincial AIDS committee); additional
cases are detected by the provincial center for hygiene
and epidemiology in the course of public health
follow-up of persons who have tested HIV positive
HIV infection is detected through several means,
in-cluding serologic surveys, counseling and testing,
diag-nostic procedures, evaluation of partners of HIV-infected
persons, and occasional epidemiologic field
investiga-tions Within a province or city, most of these public
health activities are conducted by the provincial Center
for Hygiene and Epidemiology, which is part of the pro-vincial department of health
Reports of HIV infection as well as reports of AIDS cases and deaths are provided weekly by the provincial center for hygiene and epidemiology to the Pasteur In-stitute serving the region or (for the north) to the Na-tional Institute for Hygiene and Epidemiology (NIHE) Compilation of all data are done at NIHE, and the results are provided to the National AIDS Committee
Cases of sexually transmitted diseases (STD), primar-ily those seen at public-sector provincial STD centers and clinics, are reported to the National Institute for Der-matology and Venereology, which analyzes the data and provides them to the Ministry of Health and the National AIDS Committee
HIV AND AIDS REPORTING
Through 1999, 17,046 HIV infections, including 2947 AIDS cases and 1523 deaths, were reported The number
of reported HIV infections per year continues to increase rapidly, whereas AIDS cases and deaths climb more slowly (Fig 1) The 1999 cumulative incidence rate for the country as a whole was 22.5 per 100,000 population, compared with only 7.0 per 100,000 population in 1996 (1)
Infections have been reported from all of the country’s
61 provinces and major cities Most of the recent in-crease in reported HIV infections has taken place in the north, a region where HIV was very limited even 3 years before Indeed, by the end of 1999, of the 10 areas with the largest cumulative numbers of cases, five were in the
FIG 1. Reported HIV infections, AIDS cases, and AIDS deaths, Viet-nam, by year of report, 1990 through 1999.
Trang 3north; 3 years earlier, no northern province or city was
among the top 10 areas The three areas with the highest
cumulative incidence rates of reported HIV (Fig 2) are
in the north: Quang Ninh (222 per 100,000 population),
Lang Son (81 per 100,000 population) and Hai Phong
(70 per 100,000 population)
The most dramatic recent increase in HIV infections is
associated with injection drug use and has occurred
pri-marily in the northeastern corner of the country In the
area that includes the provinces of Lang Son, Thai
Nguyen, Bac Giang, Quang Ninh, Bac Ninh, Hanoi,
Hung Yen, Hai Duong, and Hai Phong, the number of
newly detected infections has increased from 8 in 1995,
to 126 in 1996, to 969 in 1997, to 2043 in 1998, to 2885
in 1999 During the same 5 years, the proportion of
newly detected infections rose from 1% of the country’s
total in 1995, to 9% in 1996, to 32% in 1997, to 55% in
1998, and leveled to 52% in 1999
The principal risk for HIV in Vietnam remains
injec-tion drug use, which accounts for 88.3% of all cases for
which risk has been reported or can be inferred
Al-though there is some geographic variation in frequency,
infections associated with injection drug use far exceed the infections associated with all other risks except in the southern provinces of An Giang and Can Tho, and this predominance has not changed over time; injection drug users (IDUs) represented 89.0% of all persons for whom risk was reported before 1997 and 88.0% in the period from 1997 to 1999
Although currently much less frequent than drug-related transmission, the second most common risk re-mains sexual transmission, principally heterosexual transmission Of all infections reported through 1999, 5.0% of cases with risk information were in commercial sex workers (CSWs); an additional 3.6% of cases were in patients being seen clinically for an STD (for whom sexual risk is assumed to be the source of transmission), and another 2.3% were in workers in the entertainment industry or others thought to be at increased sexual risk Thus, at least 10.9% of cases with known or reasonably presumed risk seem to have been sexually acquired
No case of HIV has been determined to be associated with sexual transmission between men Although this risk may be underascertained, the frequency of
male-to-FIG 2. Cumulative HIV incidence per 100,000 population by prov-ince, Vietnam, 1996 and 1999 Map does not illustrate small offshore is-lands.
Trang 4male HIV transmission still seems to be very low
Chil-dren thought to have acquired HIV infection from their
mothers (24 cases) remain a small part (0.2%) of the
epidemic thus far HIV infection resulting from
transfu-sion of blood or blood products has not yet been
de-tected
Of those reported with HIV infection, 86.7% have
been men Distribution by sex has not changed
apprecia-bly: 84.4% men during 1990 to 1996 and 87.9% during
1997 to 1999 However, infections are occurring
increas-ingly in younger persons, especially in those 20 to 29
years old (Fig 3)
Although reported HIV infections and AIDS cases
il-lustrate the geographic, demographic, and risk
character-istics of the epidemic, the number of detected, reported
infections and AIDS cases will always be a fraction of
the total in the country The National AIDS Committee
estimates that in reality 120,000 to 140,000 infections
existed in Vietnam by the beginning of 1999
SEROSURVEILLANCE
An important part of monitoring HIV in Vietnam is
the sentinel serosurveillance program (2) As part of this
program, in 1999, 20 provinces and major cities
con-ducted annual or semiannual HIV surveys in sentinel
populations (IDUs, CSWs, STD patients, tuberculosis
[TB] patients, pregnant women, and military recruits)
The annual target sample size (not always reached in
some provinces) is 400 each for IDUs, CSWs, STD
pa-tients, and TB papa-tients, and 800 each for pregnant
women and military recruits, respectively Data from the
screening of blood donors are also available in many
sentinel provinces Serosurveys were begun in some
provinces in 1994; by 1999, they were being conducted
in all 20 sentinel areas In addition, Quang Ninh prov-ince, not a formal part of the sentinel surveillance pro-gram, has also conducted surveys since 1996 Serosur-veillance data are more reliable than case reporting for evaluating trends, because the methods for survey sam-pling remain essentially consistent, whereas the com-pleteness of case reporting, which is affected by factors aside from the epidemiologic situation, can differ from year to year We used the2
test for linear trend to assess trends in HIV prevalence in the 20 sentinel provinces and Quang Ninh province, from 1996 through 1999 Sentinel surveillance among IDUs continues to indi-cate high levels of infection associated with drug injec-tion (Table 1) The epidemic among IDUs has intensified
in 14 of the 21 provinces surveyed (Fig 4) In the central region, where HIV prevalence among IDUs was moder-ately high by 1996, the levels by 1999 had uniformly, and in some places dramatically, increased (e.g., Binh Dinh, from 23.3% to 71.1%; Khanh Hoa, from 50.8% to 89.4%) In the south, the HIV prevalence among the sentinel IDU populations increased significantly in four provinces, An Giang, Can Tho, Kien Giang and Vung Tau-Ba Ria, but stabilized in three areas, of which HCMC and Dong Nai already had high prevalences However, the greatest overall change in HIV prevalence has been the explosive increase from 1996 through 1999
in 7 of 9 provinces surveyed in the north (Table 1) The most dramatic increases have occurred in Quang Ninh and Hai Phong
The two sentinel indicators of sexual transmission risk, surveys among CSWs and surveys among STD clinic patients, continue to indicate that sexual trans-mission is a distant second to transtrans-mission associated
FIG 3. Reported HIV infections
by age group, Vietnam, by year,
1990 through 1999.
Trang 5with injection drug use, again, a pattern that is consistent
with HIV case reports Nonetheless, the prevalence of
HIV among CSWs has increased in several areas (Table
1), although to levels well below those in some other
southeast Asian countries (3–5) The HIV prevalence
among sentinel groups at increased sexual risk has been
highest in the south, where sex-related transmission was
already evident by 1996 In 1999, HIV prevalence
among CSWs reached 5.0% to 13.2% in some areas,
compared with 4.1%, the highest level in 1996 The
prevalence in CSWs increased significantly in four of
seven Mekong delta provinces from 1996 through 1999
(Table 1, Fig 4) Outside the southern region, HIV
prevalence among CSWs is still very low and stable (10
of 14 northern and southern provinces have rates less than 1% in 1999) The exceptions are in the north: Hanoi (from 0.1% in 1996 to 6.0% in 1999) and Hai Phong (from 0.8% to 2.6%) HIV infection also seems to be increasing among STD patients (who are mostly men) in some of the southern sentinel provinces, although the increase is significant in only two (An Giang and Dong Nai; Table 1) In 1999, the prevalence among STD pa-tients in the central region continued to be as low as it had been in 1996 In the north, the prevalence among STD patients in 1999 is generally low, except in Hanoi (2.0%), Hai Phong (5.5%), and Quang Ninh (3.9%)
FIG 4. Significant increases* in HIV prevalence among injection drug users, commercial sex work-ers, and sexually transmitted dis-ease patients in sentinel prov-inces, Vietnam, 1996 through
1999 Map does not illustrate small offshore islands.
Trang 6During the past 3 years, Quang Ninh, in the northeast,
has emerged as the province with the second largest
number, and the highest cumulative incidence rate, of
reported HIV infections in the country Serosurveys
con-ducted by the provincial AIDS Committee have shown
an explosive pattern among IDUs: from 0% in 1996 to
62.4% in 1997, 65.9% in 1998, and 64.9% in 1999 (data
provided by Quang Ninh provincial AIDS Committee),
prevalence levels that are consistent with case reports in
that province and with the serosurveillance data from
nearby sentinel provinces (Table 1) Of 206
HIV-infected persons detected in the first half of 1997, 203
(99%) were male, the median age was 22 (range, 15–37) Risk information was available for 155 persons, of whom
149 (96%) were IDUs (National AIDS Committee, un-published data) In the neighboring port city of Hai Phong, an upsurge in HIV prevalence among IDUs in
1998 occurred 1 year after that in Quang Ninh, jumping
to 32.5% from 0.9% in 1997 Similar to the pattern in Quang Ninh the previous year, of 101 persons in Hai Phong who had been diagnosed with HIV in first 3 months of 1998, 91% were <30 years old, and 84% were IDUs (National AIDS Committee, unpublished data) In
1999, HIV prevalence began to rise among IDUs in
Ha-TABLE 1 Changes in HIV seroprevalence among injection drug users, commercial sex workers and sexually transmitted disease (STD) patients
in Vietnam, 1996 through 1999, a by province
Injection drug users percentage positive
(n)
Commercial sex workers percentage positive
(n)
STD patients percentage positive
(n)
1996 1997 1998 1999 p Value b
1996 1997 1998 1999 p Value 1996 1997 1998 1999 p Value
Northern region
Hanoi 0.6 2.4 3.3 13.5 <.0001 0.1 0.8 3.8 6.0 <.0001 0.4 0.0 0.0 2.0 NS
(538) (419) (400) (200) (1035) (357) (400) (200) (909) (366) (400) (200)
Ha Tinh — 0.0 5.2 9.6 012 0.0 0.0 0.0 0.6 NS 0.0 0.0 0.0 0.0 NS
(0) (15) (439) (281) (283) (460) (548) (163) (279) (450) (434) (225) Hai Phong 0.1 0.9 32.5 64.0 <.0001 0.8 0.0 1.1 2.6 044 0.2 0.0 2.8 5.5 <.0001
(942) (325) (496) (203) (251) (361) (354) (192) (1370) (373) (400) (253) Lang Son 9.2 21.7 14.5 8.5 NS 1.0 0.0 — 0.0 NS 0.0 0.0 4.2 1.0 002
(761) (641) (234) (200) (96) (15) (0) (32) (737) (222) (48) (200) Lao Cai 0.0 0.0 0.0 1.2 NS 0.0 0.0 0.0 0.5 NS 0.0 0.0 0.0 0.0 NS
(296) (581) (615) (603) (171) (87) (301) (206) (139) (83) (199) (55) Nam Dinh 0.5 0.5 2.5 12.4 <.0001 0.0 0.0 0.0 0.0 NS 0.1 0.6 0.5 1.9 017
(655) (431) (404) (170) (228) (222) (375) (16) (781) (502) (439) (162) Quang Ninh 0.0 62.4 65.9 64.9 <.0001 — — 0.4 0.5 NS 0.0 2.1 9.5 3.9 <.0001
(95) (210) (545) (444) (0) (0) (450) (402) (631) (869) (506) (412) Thai Nguyen 0.0 2.7 70 7.6 <.0001 0.0 0.0 0.5 0.0 NS 0.0 0.0 0.0 0.0 NS
(273) (701) (427) (264) (214) (410) (206) (202) (201) (425) (201) (200) Thanh Hoa 0.0 0.0 0.3 9.5 <.0001 0.0 0.0 0.0 0.0 NS 0.0 0.0 0.0 0.0 NS
(82) (288) (696) (433) (1034) (743) (132) (62) (546) (1213) (397) (190) Central Region
Binh Dinh 23.3 56.7 62.9 71.1 <.0001 0.7 1.2 2.1 1.1 NS 0.0 0.0 0.0 0.5 NS
(60) (231) (175) (152) (146) (333) (190) (174) (405) (207) (181) (184)
Da Nang 38.5 68.6 85.3 48.8 NS 0.0 0.0 0.5 0.0 NS 0.0 0.0 0.0 0.5 NS
(65) (121) (75) (80) (422) (450) (200) (200) (500) (450) (153) (195) Dac Lac 24.1 45.2 41.8 41.0 003 1.4 1.7 0.0 1.7 NS 0.0 0.0 0.0 0.0 NS
(191) (188) (110) (122) (70) (182) (73) (60) (35) (44) (23) (15) Khanh Hoa 50.8 67.6 81.8 89.4 <.0001 0.5 0.0 0.5 0.5 NS 1.1 0.0 1.0 0.6 NS
(65) (111) (121) (47) (184) (333) (208) (212) (263) (289) (201) (154) Thua Thien-Hue 0.0 0.8 2.5 0.0 NS 0.0 0.0 0.9 0.0 NS 0.6 0.0 1.0 0.9 NS
(84) (260) (79) (66) (88) (352) (116) (69) (172) (242) (98) (110) Southern Region
An Giang 4.7 5.1 16.3 12.8 <.0001 4.1 3.7 14.7 13.2 <.0001 1.3 3.6 6.0 6.5 <.0001
(665) (526) (516) (313) (660) (512) (532) (326) (909) (504) (315) (185) Binh Duong 5.7 5.6 4.3 7.7 NS 0.9 1.0 1.0 1.7 NS — — 0.7 2.5 NS
(652) (342) (600) (300) (433) (582) (600) (300) (0) (0) (138) (200) Can Tho 1.4 2.2 2.0 5.6 039 2.8 1.6 5.5 5.3 003 0.2 1.5 2.0 0.0 NS
(213) (320) (196) (124) (291) (1004) (236) (206) (622) (259) (202) (70) Dong Nai 28.8 22.7 23.7 16.3 NS 0.5 1.5 0.8 1.4 NS 0.3 0.6 0.0 2.9 013
(80) (308) (338) (135) (386) (458) (372) (71) (402) (332) (241) (137)
Ho Chi Minh City 36.9 28.3 44.8 26.9 NS 1.2 2.8 3.8 4.9 0001 0.8 1.0 1.8 1.0 NS
(1199) (924) (250) (238) (1397) (834) (399) (81) (1549) (1192) (221) (105) Kien Giang 1.0 13.6 14.3 16.5 <.0001 1.3 12.1 1.3 2.5 NS 0.3 1.1 2.5 1.0 NS
(984) (376) (400) (200) (541) (387) (400) (200) (383) (275) (400) (200) Vung Tau-Ba Ria 6.5 5.6 16.7 37.5 <.0001 0.8 0.8 2.7 5.0 0003 0.4 1.2 0.0 0.0 NS
(245) (450) (395) (200) (248) (497) (402) (200) (243) (422) (400) (200)
a
1999 Data were provisional.
b 2
for linear trend; p value shown if a significant difference found NS, not significant (pⱖ 05).
Trang 7noi and other provinces in the region (Table 1, Fig 4).
Although the time lag varies from province to province,
the pattern of HIV prevalence in IDUs indicates a rapidly
expanding HIV epidemic in the north, which may extend
beyond IDUs to those at increased sexual risk
Serosurveillance indicators of HIV in the population at
large (pregnant women, military recruits, blood donors)
continue, in general, to indicate a relatively slow
exten-sion of HIV beyond those at high risk Of 14,921
preg-nant women tested in the 20 provinces (1999 data from
Hanoi not available), only 18 (0.12%) had positive
re-sults in 1999, a slow but significant increase (p⳱ 017)
over the past 4 years (0.04% in 1996; 0.12% in 1997;
0.09% in 1998) The highest rates for pregnant women in
1999 were in Quang Ninh (0.7%) in the north, and in An
Giang (0.4%) and Binh Duong (0.3%) in the south,
whereas the highest rates in 1996 were both in the south
(HCMC, 0.2%; An Giang, 0.2%) There is no statistically
significant change in HIV prevalence among pregnant
women in any individual province from 1996 though
1999, despite the significant increase for the provinces as
a group For military recruits, among approximately 800
tested per province, the overall rate in 1999 was 0.61%
(92 HIV positive of 14 989 tested), significantly higher
(p < 0001) than the rates in 1996 (7 [0.04%] of 17,430),
1997 (23 [0.13%] of 17,273), 1998 (34 [0.20%] of
17,281) The highest rates were found in three northern
provinces (Quang Ninh, 5.0%; Lang Son, 2.5%; Hai
Phong, 0.6%) and in two southern provinces (Kien
Giang, 1.5%; Vung Tau-Ba Ria, 1.0%) All five
prov-inces had either significantly increasing trends in HIV
prevalence from 1996 to 1999 among IDUs or already
had prevalence rates higher than 20% during this period
Because IDUs are not excluded from medical screening
for military service, some IDUs may be included in the
tested population HIV among blood donors remains
in-frequent: 108 (0.08%) positive results from 128,808
units tested in 1996; 114 (0.09%) positive of 133,832 in
1997; 181 (0.12%) positive of 152,094 in 1998; and 260
(0.20%) positive of 132,705 in 1999 The increase over
the 4-year period, although small, is statistically
signifi-cant (p < 0001).
Serosurveillance among TB patients gives an indirect
and lagging indication of the evolution of the HIV
epi-demic Through 1996, HIV prevalence among TB
pa-tients was very low At that time only in HCMC (1.3%)
and Khanh Hoa province (1.4%) were prevalence rates
>1% (1) In 1999, HIV prevalence among TB patients
remains generally low, mostly <3%, with 12 sentinel
provinces’ rates at or near 0% Only two provinces had
higher HIV prevalence, Quang Ninh (6.8%) and An
Giang (3.8%) HCMC had previously had a high
lence (11.8% in 1998), but in 1999 the measured preva-lence was down (2.9%) Thus, this surveillance indicator
of the duration, as well as of the clinical impact, of the epidemic confirms that HIV has been established rela-tively recently in most parts of the country and is just beginning to have a clinical impact
MOLECULAR EPIDEMIOLOGY
The virus responsible for the epidemic in Vietnam remains almost exclusively HIV-1 subtype E (1,6–8) This is similar to, and presumably an extension of, the pattern in adjacent Cambodia (9–11), and other countries
in the southeast Asian region, including Thailand, (al-though Thailand also has subtype B⬘ infection, particu-larly in IDUs in central Thailand) (12–14) Indeed, the viral isolates from Vietnam are genetically very close to those from Cambodia and from Thailand (7,10,11) In Quangxi, the Chinese province bordering Vietnam on the north, subtype E also predominates in IDUs, although subtype B⬘ has been found in blood donors (15)
SEXUALLY TRANSMITTED DISEASES
STDs indicate the degree of sexual risk for HIV in-fection and facilitate its transmission STD treatment re-mains an important component of HIV prevention (16) Reported STDs, although assumed to underestimate the true frequency significantly, have increased rapidly in the 1990s There were large increases in case reports in
1993 and in 1997 to 1998, after extensive training courses in the diagnosis and treatment of these diseases The total of reported STDs for the country was 71,274 for 1997 and 102,277 in 1998 However, the National Institute of Dermatology and Venereology estimates that the true figure was closer to a million cases (Pham Van Hien, personal communication) STD services are pro-vided through government-supported primary health care facilities at provincial level (61 facilities), district level (597), and at local (commune) level (>10,000) Because syndromic STD management is used in primary health care, as recommended by the World Health Organization (17,18), specific STD diagnoses are usually available only from larger clinical facilities at the provincial and national levels Many STDs are treated through the pri-vate sector, but little information is available to national authorities on either the methods of diagnosis or the numbers of patients seen
A few surveys have been done to enhance STD sur-veillance Among pregnant women in 1995 in Hanoi and HCMC, STD prevalence rates were low: syphilis, 0.2%
in Hanoi and 0.5% in HCMC; gonorrhea, 0.3% in Hanoi
Trang 8and 0.7% in HCMC; chlamydia, 2.2% in Hanoi and 2.5%
in HCMC Not surprisingly, STD prevalence rates are
much higher among CSWs in rehabilitation centers than
among other women; for example, syphilis rates range
from 20% to 40% in HCMC and Hanoi (unpublished
WHO Report, Summary of Rates for Sexually
Transmit-ted Disease, Vietnam, Aug 1998)
PREVENTION
The HIV prevention strategy in Vietnam begins with
the structural organization and coordination of the
prin-cipal AIDS-related activities through the national and the
provincial AIDS committees As noted earlier, these
committees include multiple sectors of the national or
provincial governments Leadership of the AIDS
com-mittees is at the second highest level of the civil
admin-istrative authority for the country or the province, a
deputy prime minister, to ensure collaboration between
sectors and consistency of approach The total current
annual government allocation for HIV/AIDS control
ac-tivities ranges from $4 to $5 million U.S Additional
support has been provided through international and
non-governmental organizations
In addition to HIV surveillance, the major prevention
activities are as follows:
Mass information and health education regarding HIV
risks and how to avoid them
Peer education and outreach among groups at increased
risk, particularly IDUs and CSWs
Voluntary HIV counseling and testing through each
province’s center for hygiene and epidemiology
Ready availability of low-cost needles and syringes
through pharmacies
Needle exchange pilot projects for IDUs in Hanoi and
HCMC
A pilot methadone maintenance program in Hanoi
Availability of condoms at low cost ($0.02–0.05 U.S per
condom) at pharmacies throughout the country
Desensitizing the discussion of condoms through public
education campaigns and social marketing
Widely available STD treatment
Antibody screening of blood for transfusion
Free medical treatment at provincial hospitals, including
zidovudine (AZT), some didanosine (ddI), and
treat-ment of opportunistic infections
In 1995, a study was conducted on the feasibility and
effectiveness of needle exchange programs in Hanoi and
HCMC (19) Recent studies indicated that needle sharing
remains frequent among drug injectors (20) A
small-scale trial of methadone treatment was conducted by the
Vietnamese National Institute of Mental Health In 1999, the Vietnamese National AIDS Committee began a large-scale intervention, including peer outreach, among IDUs and CSWs in 20 provinces
The safety of blood for transfusion is ensured through routine screening for HIV as well as for hepatitis B, syphilis, and malaria, plus (in some areas) hepatitis C Transfusions are performed at 84 provincial and other major hospitals as well as at 442 district hospitals All these facilities perform HIV testing (particle agglutina-tion or a rapid test in most facilities, enzyme immuno-assay in some) Surgery requiring transfusion is occa-sionally performed at other district hospitals, which de-pend on blood screened at better equipped facilities in the vicinity
In 1997, approximately 300,000 units of blood were collected and screened Although an appreciable propor-tion of donapropor-tions is made by paid professional donors, it
is the policy of the National AIDS Committee to encour-age voluntary donation In 1996, 62% of donations were from professional donors; in 1997 and 1998, this propor-tion decreased to 53% and 37%, respectively (Napropor-tional AIDS Committee, unpublished report) Fortunately, as mentioned, HIV remains relatively rare in blood donors About 7% of the total AIDS budget is applied to the treatment of HIV-infected persons, primarily patients who have clinical AIDS In 1998, government facilities provided free treatment for 690 patients Antiretroviral therapy at this time is monotherapy (primarily with zid-ovudine: 33% of patients) or dual therapy (AZT, ddI, and/or indinavir: 54% of patients) Prophylaxis is not routinely offered for opportunistic infections; however, the treatment of such infections is part of clinical care Before the HIV epidemic, TB was already a challeng-ing problem in Vietnam, where an estimated 130,000 cases occur per year By mid-1997, when 882 AIDS cases had been reported (among 6588 HIV-infected people reported by that time), 561 (64%) of these pa-tients had diagnosed TB Of TB papa-tients, 70% had spu-tum-positive pulmonary disease, 15% had sputum-negative pulmonary TB, and 15% had extrapulmonary
TB TB screening, treatment, and preventive therapy of HIV-infected persons and either TB treatment or preven-tive therapy, have not yet been routinely instituted
DISCUSSION
The HIV epidemic continues to intensify among those
at high risk, particularly IDUs, in the central and south-ern regions of the country, areas that were affected by
1996 Of even greater concern, HIV infection has dra-matically increased among IDUs in the north in the past
Trang 93 years, as shown by both HIV case reports and
serosur-veillance
Although secondary to infections associated with drug
use, sexually transmitted HIV continues to increase
slowly, largely in the southern areas that had been most
affected several years earlier Despite the increase in
sexually transmitted HIV, the prevalence for the groups
at highest risk is much lower than those for similar
groups in neighboring countries However, the recent
increases in prevalence rates in sentinel surveillance in
Hanoi and Hai Phong indicate the potential for
increas-ing transmission in the north
Despite increases in HIV infection in persons at high
risk, the indicators of HIV in the population at large
(antenatal women, military recruits, and blood donors)
suggest that HIV infection is only slowly reaching the
population outside those at specific high risk However,
with the geographic expansion and intensification of
HIV prevalence in higher risk populations, the danger is
increased, as is the reservoir of infection, for the wider
spread of the epidemic The shift in many parts of the
country toward a younger infected population, primarily
male IDUs, increases the risk of sexual transmission as
these men expose their wives, sex partners, and,
poten-tially, CSWs
More systematic data on STD frequency and trends in
Vietnam would be helpful in evaluating the potential for
expanded sexual transmission Special studies and
sur-veys may be required to supplement case reporting to
obtain a clearer indication of the STD risk patterns in the
population
Consistent with the early picture apparent several
years ago (1), HIV seems to be relatively recent in
Viet-nam, and the clinical impact is only beginning to be
measured The rate of HIV among TB patients remains
quite low However, the increase in TB associated with
HIV in the south, where HIV was first prevalent,
indi-cates what lies ahead as those infected with HIV become
sicker and more subject to opportunistic infections A
reasonably large proportion of AIDS patients, 64%, has
been reported to also have active TB, which is typically
the principal opportunistic infection in many developing
countries (21–23) With the estimated 120,000 to
140,000 HIV infections by 1999, virtually all of whom
will develop AIDS, if 50% to 60% develop TB, there
would be at least 60,000 to 80,000 additional TB cases
over the next few years as a result of existing HIV
in-fections, and more TB cases can be expected from new
HIV infections Considering that the current burden of
TB is 130,000 new cases per year, most not associated
with HIV, the HIV epidemic will have a major impact on
TB services
The almost exclusive finding of subtype E virus is unchanged from previous studies and is consistent with the molecular epidemiologic pattern elsewhere in the re-gion, including countries where the epidemic is much more intense Although the HIV epidemic in Vietnam has developed more slowly than in some nearby coun-tries, Vietnam has been quick to establish surveillance and undertake prevention activities Despite the political complexity of the principal risks for HIV, the govern-ment and the public sector have been open and pragmatic and have kept the public well informed regarding the epidemic, the risks, and the role of prostitution and drug use, and have made the discussion of condom use very public
The HIV epidemic in Vietnam continues to evolve rapidly, although erratically, with recent expansion of the virus into the north and a shift to infection of increas-ingly younger people For most of the country, injection drug use remains the principal risk However even among IDUs, HIV in some areas is still comparatively low Moreover, the epidemic does not seem to have ex-panded very quickly to the broader population, although the potential clearly exists It is equally clear that strenu-ous intervention remains critical in slowing and contain-ing the epidemic That the epidemic has developed later and more slowly in Vietnam than in some other countries
in the region provides cause for hope, as well as the stimulus to maintain and reinforce prevention and moni-toring The people and the government of Vietnam are committed to succeed in this endeavor
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