Improving the drug rehabilitation system in Vietnam: a two-track strategy Yen Hai Vu, M.A.

1. Improving the drug rehabilitation system in Vietnam: a two-track strategy Yen Hai Vu, M.A. Theodore M. Hammett, Ph.D. Tung Duy Nguyen, M.D., M.P.H. Abt Associates Inc./HPI Vietnam, Hanoi XVIII International AIDS Conference, Vienna MOAF0204: July 19, 2010

2. Background • Vietnam’s HIV/AIDS epidemic is driven primarily by injection drug use • >200,000 IDUs; HIV prevalence ~30%, higher in some provinces • Therefore:addressing drug use is critical to controlling HIV.

3. 06 Centers • Administrative rather than judicial procedure (~90% compulsory, 10% “voluntary”)– no due process • 1-2 years + 1-2 years post-rehabilitation management • Detoxification, moral education, work/vocational training • Interviews with former residents indicate that mistreatment is common • Little/no evidence-based substance abuse treatment • Basic HIV/AIDS education but little VCT (often mandatory testing) or ARV/OI treatment • High relapse rates post-release (reportedly 70-90%) • A moral/punitive approach to medical/psychosocial problem • CONCLUSION: BASED ON THE EVIDENCE, THE SYSTEM SHOULD BE CHANGED. PEPFAR PwP Coordination

4. 06 centers (2) • 123 drug treatment centers: • 80 MOLISA/DOLISA • 10 Youth Union/Voluntary Youth Force • 33 district Peoples’ Committees • Capacity 50,000-60,000 • ~33,000 detainees (out of a total of 180,000 registered drug users, >200,000 total)

5. The Debate • Should entire focus be on completely changing the system? • Does improving conditions/services in the centers legitimize/perpetuate the system? • Should there be “principles of engagement” for donors and partners working in the centers? • What services are essential? • Which legitimize the system? • What are the harms and benefits of specific engagements? • Should center staff be trained? • Who should provide services in centers?

6. A two-track strategy for change 1) Build evidence base and advocate for systemic change – away from Center-based compulsory detoxification and toward voluntary, community-based treatment; 2) Realistically, the entire system will not change soon: in the meantime, work to improve conditions and services for people caught up in the system.

7. 1) Building evidence/advocating for policy change • Proposed: cost effectiveness study comparing community-based treatment (e.g. MMT, now in 4 provinces, planned expansion to >30 by 2015) v. 06 center approach • Collection of evidence on mistreatment of residents and relapse rates post-release from centers • Intensive policy advocacy using evidence • But…powerful political and economic interests support maintenance of system – can evidence change this? • What about funding conditions from donors?

8. 2) Improving conditions/services • Improve legal framework • Improve humanitarian response by expanding and strengthening needed services in centers • Address issues of mistreatment of residents

9. Improve legal framework • HIV/AIDS Law (2006) and Decree 108 (2007): strong foundation for evidence/rights-based HIV/AIDS programs, including harm reduction • Revised Drug Control Law (2008): inconsistencies with HIV/AIDS law (confinement v. harm reduction); maintains 06 center + post-detox management (up to 4 years) • Decree 94/Circulars: Post-Detox Management (2009)– focus: reduce numbers sent to centers and length of commitment • Family- and Community-Based Detoxification (2009) --basis for expanding voluntary, community-based treatment.

10. Improve services in centers • Expand and strengthen HIV/AIDS services (prevention, care, and treatment) in closed settings, including 06 centers and prisons (Inter-ministerial circular for implementing Decision #96 (2007)) • Expand evidence-based substance abuse treatment in centers: • MMT (currently prohibited by Decree 108); • Addiction counseling (FHI curriculum); • Relapse prevention; • Meaningful vocational training; • Transitional programs; • Such services should be provided by outside organizations rather than building capacity of Center staff (latter approach could perpetuate the system).

11. Address mistreatment of residents • Legal bases for action: • Decree 135 prohibits mistreatment of residents, provides for punishment of officials guilty of mistreating residents • Various international instruments also prohibit mistreatment of any detainees. • Encourage/facilitate administrative and legal action • Legal Clinics: mobile services in centers, take statements from former residents • Possible UN avenues: UN rapporteur (health issues); ILO (restriction on import of goods produced by forced labor); lack of due process (Working Group on Arbitrary Detention). • Surveillance of centers by independent organizations • Unannounced access needed • Confidential, private interviews • Protection of informants.

12. Acknowledgements • Funding support: USAID/PEPFAR Vietnam (Ngo Minh Trang, HPI COTR) • Ideas and input: • Simon Baldwin: Family Health International Vietnam • Zoe Hudson, Roxanne Saucier, Daniel Wolfe: Open Society Institute • Human Rights Watch

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