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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

 

The Threat of HIV/AIDS on Viet Nam's Youth:

Meeting the Challenge of Prevention

A Report on the 1996 Viet Nam Youth Union Conference

by Dr. John B. Chittick

with additional commentary on the

Government's Approach to the

TeenAIDS Epidemic in 1997

by

Dr. John B. Chittick

Boston, USA © 1997

http://www.hsph.harvard.edu/Organizations/healthnet/HIV/docs/sea-aids/pvsex/pvsex17.txt

Foreword

The author has written two versions of this report on the Viet Nam Youth Union's HIV/AIDS Conference on youth vulnerability that was held in Hanoi on September 23 and 24, 1996. The author attended the 1996 gathering in Hanoi as the invited guest of the sponsors in the capacity of youth AIDS consultant.  An abridged version of the report was edited for promotional use by the conference co-sponsor, Health and Education Volunteers of McLean, Virginia.  This unexpurgated version contains an expanded conference report, plus independent research, and professional observations on the government's new approach to the growing youth AIDS epidemic.  The opinions in this paper solely reflect the views of the author.

Dr. Chittick's analysis of the current situation suggests that the risk to country's young people is real; HIV/AIDS is spreading more rapidly than surveillance reports acknowledge.  Warnings from both domestic and foreign AIDS professionals are making an impression on influential government leaders and predictions of a major youth epidemic are no longer being summarily discounted as exaggerated hype.  The conference deliberations demonstrate that a major shift in official opinion has been underway since early 1996.  Already new policies have been introduced and more aggressive prevention programs have been proposed that specifically target vulnerable teenagers and young adults.

Research confirms that the national leadership is especially concerned about the socio-economic impact of a serious epidemic on the developing nation's future, its labor force and agricultural base, its sexually active young people of child-bearing age, and importantly, its pool of military recruits.

To combat youth AIDS more effectively, members of the party, the national assembly, and the government are proposing recommendations which include: expanded HIV/AIDS education and awareness in schools and youth clubs; community networks of peer

AIDS teachers, greater mass media coverage of teen's vulnerability to HIV, and a substantial increase in condom distribution and safer sex instruction for young people.  Some officials have stated also that they support the controversial concept of clean needle exchange for injecting drug users.

In light of Vietnamese society's traditional avoidance of the public mention of sexual issues and the desire to punish social evils, these policy proposals are significant.  Based on new data, including interviews with top officials, the report concludes that 1997 could be the pivotal year for Viet Nam to implement more effective actions.

Previously, Dr. Chittick had spent three months in 1995 working with government AIDS professionals in Ho Chi Minh City.

His 1996 book, The Coming Wave of HIV/AIDS in Vietnam reported on the full range of official AIDS prevention programs with a focus on youth.  With a doctorate (Ed.D.) from Harvard University in human development and psychology, Dr. Chittick specializes in TeenAIDS issues and has lectured on the subject at Harvard.

Viet Nam's 1996 Youth AIDS Conference and theGovernment's Approach to the TeenAIDS Epidemic in 1997by Dr. John B. Chittick

"In the fight against AIDS, youth should be the main shock force and a strategic army determined to win final victory.  Youth should save themselves and society from an HIV/AIDS catastrophe."   Dr. Pham Gia Khiem, Deputy Chairman of the National AIDS

Prevention Committee, VNYU Conference, Hanoi, September 23, 1996

Introduction:

On September 23 and 24, 1996, Viet Nam's  top ministry officials, health professionals, and AIDS workers gathered in Hanoi for the country's first AIDS Conference on Youth.   Co-sponsored by the 21 million member Viet Nam Youth Union (VNYU) and the American non-government organization (NGO) Health and Education Volunteers

(HealthEd),  the conference promised to be of great importance because its theme focused solely on the threat of HIV/AIDS among young Vietnamese.  "The fact that the Youth Union is co-hosting this conference and that the Vietnamese health care community is represented here at such senior levels," said Mr. Ca Van Tran, President of HealthEd, "is a strong signal that [Viet Nam] is ready to take the next step up in its battle for the well being of its people."   Professor Do Nguyen Phuong, Minister of Health and Permanent Vice Chairman of the National AIDS Prevention Committee (NAC) called the meeting, "of great significance... now that Viet Nam has been selected by the United Nations as one of the priority countries in its global AIDS prevention strategy."   Only a few years prior, the nation had paid limited attention to outside reports of an impending epidemic.

However, conclusive evidence now exists which points to the growing vulnerability of young people to HIV -- especially in Asia.  The Director of UNAIDS, Dr. Peter Piot recently said, "The largest increases [are] now expected in China and Vietnam."   The threat of an AIDS epidemic in Viet Nam is no longer a theoretical possibility but is an emerging reality.  Although it is recognized that some officials continue to doubt foreign and domestic warnings, the government is welcoming foreign assistance for HIV/AIDS prevention efforts.  Worried by news of growing problems in neighboring countries, public health advisories are being proffered to alert the population and avert more serious trouble.  The question is no longer how to stop the epidemic from entering the population but how to limit its spread among the nation's young people, Viet Nam's single most important resource.

While outside observers and concerned Vietnamese medical professionals might believe that Viet Nam's youth-oriented AIDS conference has been long overdue, it should be noted that the U.S.government's first national youth conference on HIV/AIDS was convened only a few months earlier (in spring 1996) at the White House.   Indeed, eleven international conferences on AIDS have yet to make the spreading youth pandemic their primary focus.  Certainly, the response to adolescent HIV has been slow in coming globally, and then, only when the epidemic has grown too apparent to be ignored.

AIDS represents a profound threat to humankind -- not just medically but psychologically and socially as well.  Almost universally, sex and death are two of our greatest cultural taboos.  Consequently, these critical issues are often privately addressed and publicly ignored.

We fear HIV because the virus is transmitted through one of life's most natural and pleasurable activities -- sexual relations.  Although the impulse is a normal part of human existence and essential for the propagation of the species, its role in passing HIV onto unsuspecting partners is insidious -- like the Trojan Horse.  When other social prohibitions are added to the AIDS mix such as: unmarried teenagers engaging in promiscuous sex; STDs (sexually transmitted diseases ); homosexuality; unwed pregnancies; illegal drug use; and prostitution, then HIV/AIDS is seen as not only harming individuals but is recognized as a major threat to revered family values and traditional tenets of society.  "The Government considers drug addiction, prostitution and the HIV/AIDS pandemic as the key social issues threatening national socio-economic development and national construction,"  stated Dr. Pham Gia Khiem, Deputy Minister of Planning and Investment in Viet Nam.

For parents everywhere, the reality that adolescent sexual experimentation could lead to the early death of their children is alarming.  Yet many adults act as if silence is preferable to frank discussion.  Thus, the root causes of youth AIDS remain a difficult subject to broach in most cultures -- including in Viet Nam.  The VNYU has exhibited civic responsibility in sponsoring this first national conference by bringing a difficult issue to the forefront of public attention.

The key issue addressed by various speakers at the Hanoi conference was HIV's spread into the younger population.  As Master Le Ngoc Yen of NAC put it, "Young people are active with less experience who are sensitive to new things and easily attracted by good and bad behaviours, affected by bad cultural activities such as freer sexual behaviour, drug addiction, and enjoyment... thus easily falling into social evils."    Placing the blame on adult anti-social behaviors for the spread of AIDS continued to be a popular notion among many Vietnamese conferees.  Conversely, youth vulnerability was attributed to a weakened resolve on the part of impressionable youth.

Considering the troublesome societal and political problems involved with AIDS prevention efforts in a culturally-conservative country, the deliberations were as candid as the key recommendations proved remarkable.  The conference was not the strict ideology-based performance as some international observers had expected.  Instead, real problems were addressed and new solutions were proposed and discussed.  A renewed sense of resolve about how to handle the AIDS crisis was evident throughout the official proceedings.

The open exchange of ideas was important news for Viet Nam's young people and their future.

Background:

In the recent past, many Vietnamese have assumed that HIV/AIDS was a problem of "bad" people who engaged in social evils such as injecting  drug users (IDUs) and commercial  sex workers (CSWs).  To a superficial degree, their impression was accurate.  Similar to Thailand and Myanmar, HIV first spread among Vietnamese drug users sharing contaminated syringes.  Ms. Chu Thi Xuyen of the VNYU's AIDS Prevention Fund stated, "The number of young intravenous drug users is increasing very rapidly, as 70% are under 30 years of age and many are even adolescents."   To pay for their expensive habits, many people turned to illegal activities such as drug dealing while, "Poverty and hardship have driven some people to risk activities like prostitution."   Whatever the reasons, there is no doubt that HIV is beginning to infect members of the younger generation.

Mrs. Nguyen Thi Than, a member of the National Assembly admitted, "As we all know, there are now hundreds of thousands of drug addicts in Vietnam (and the number of sex workers is similarly high)....Young people account for a large proportion of the afore-mentioned two groups."   And when these high risk activities are illegal and conducted sub rosa, it is difficult for the authorities to address the problem, let alone contain it.

Mrs. Than explained HIV's progression in Viet Nam as coming in three waves, "We are now at the end of the first stage of the development and transmission of HIV/AIDS (the stage of HIV/AIDS transmission through injection) and are entering the second stage (transmission through sexual relations).  We will be in the third stage when HIV/AIDS spreads to the general population groups."   While some professionals might not agree on which stage Viet Nam is in currently, most conferees appeared to accept that their country has already entered the final stage.  Undeniably, AIDS is a threat to the public, especially young people.  But because HIV infection has been labeled a consequence of social evils, it has been difficult also for many citizens to see HIV as a human virus that could potentially infect anyone who engages in high risk activities.

It is necessary to reiterate that the public mention of sex is not customary or encouraged in Viet Nam.  Most adults neither accept nor discuss the possibility that "innocent" young children could be engaged in risky behaviors known to transmit HIV.  Perhaps, it could be argued, that old-fashioned values have protected today's teens from a far greater (and earlier) exposure to AIDS.  Many parents wish that the traditional influence of culture and customs would continue to play this role in the future.

Despite years of international isolation and no reported HIV/AIDS incidence, Viet Nam was not immune to the global pandemic.  It was simply late in arriving.  Since the first incident of AIDS was reported in late 1990, the official number of HIV-infected cases in Viet Nam has grown exponentially to 5,000 cases by the beginning of 1997  (see Appendix A).  Although only a few cases of full-blown AIDS are known to involve young Vietnamese in their teens, some speakers reported the average age of HIV infections has been steadily declining.  This shift mirrors global trends suggesting that more than half of all new infections are occurring among 15 to 24 year olds.

Undeniably, the causes for this change remain a socially-charged issue.

According to Mrs. Xuyen, "of the number of HIV cases from 1990 up to now, 60% are young people who are in the main working age group."   Another speaker, Deputy Health Minister Nguyen Van Thuong stated, "The age of the majority of HIV infected people are in the 30 - 39 bracket, but this tends to shift to the 20 - 29 and under 20 age brackets.  In general, they are normally of a young age."   For those attending the conference, it was evident that AIDS has already begun to spread rapidly into the younger population (see Appendix B) -- within five years of its first appearance in Viet Nam.

Most official surveys report that the majority of Vietnamese youth do not engage in sexual intercourse before marriage.   Cultural prohibitions and familial shame are usually given as the main reasons why young people choose to abstain.  Yet independent questionnaires and anecdotal information suggest that attitudes are changing and teens are becoming more sexually active.  The Pill is being introduced to women in Viet Nam and experts predict the incidence of premarital sexual relations will increase among young females as a result.

Increasingly, reports from in-country studies by AIDS workers warn that ordinary Vietnamese youth are adopting the new lifestyles.  Young laborers and university-age students are enjoying increased sexual experimentation.   Phan Thi Le Mai, National Project Officer of the AIDS project of UNAIDS/UNICEF, told the conferees, "a social survey showed that the number of adolescents aged 14-15 with premarital sexual experience is increasing."   This trend among Vietnamese teens appears to be mimicking the practices of young people worldwide as once sacrosanct cultural taboos are marginalized by modern, outside influences.

The danger for unsuspecting and ill-informed youth lies in having unsafe sex when HIV transmission routes are neither adequately understood nor made relevant to their lives.  This is true for heterosexual or gay youth, both boys and girls, whether living in cities or rural areas.  As the pool of sexually-active teenagers becomes increasingly HIV-contaminated, the likelihood of contracting the virus grows greater with each new intimate partner.  Teenagers who engage in unprotected sex (and bodily fluids are exchanged) need to be made aware of the medical consequences of their actions.  The risk is no less problematic for the unsuspecting virgin who one day chooses a spouse from within the infected group.  For Vietnamese youth in the future, this situation could be the rule -- not the exception.

Many young males, both students and workers, say they have their first sexual experiences with CSWs because their girlfriends are virgins.  Vietnamese culture has a tolerant tradition of quietly accepting the male prerogative to engage in commercial sex.  The practice of young men paying for sex with prostitutes is often emulated -- not put down by other youth.  It should not be assumed however, that Vietnamese teens lack moral values because some of them engage in commercial sex.  Rather, many boys think of it as a practical alternative to premarital sex prohibitions.  Among a growing minority of young women, sex work is seen as a practical employment choice in an increasingly expensive, more consumer-oriented society.

One conference speaker stated that HIV poses "a threat to the increasing number of sex workers and intravenous drug users of whom young people account for 75 - 85%."   However, that recognition is only part of the story.  Teenage boys with little education or skills find work as cyclo drivers or day laborers to pay for living expenses, including drugs and sex if desired.  Newspaper reports talk of girls from the countryside, serving as household workers for urban families, who are forced into sex by their employers  -- there are even stories of the kidnapping of young women for the sex trade.   How many of them become infected is not known but presumably their numbers are high.

Many young military recruits are also vulnerable to HIV.  The head of the Secretariat of the AIDS Committee for the Ministry of Defense said, "Army men from 18 to 25 years old, occupying 60 - 75% of the total force are in the group of age which has the high [sic] risks of being infected by HIV at present and in the coming years."   Only one case of HIV in the army was reported in 1995; less than eight months later, ten more cases had been discovered. Although relatively small, these numbers tell the tale of Viet Nam's emerging youth epidemic.

Reports are increasing of greater youth prostitution as the gap widens between Viet Nam's rising working class and its very poor.  The United Nations Children's Fund (UNICEF) had previously estimated that there were 40,000 child sex workers throughout Vietnam.   Apprehensive about the inability of the government to provide for homeless street children, many AIDS workers are noticing that the international sex trade is making its presence felt as Viet Nam opens its previously-closed economy to outside investors (similar to the earlier experiences of Thailand and the Philippines).  According to Pham Van Du, of the Vietnam Tourism Administration, "The development of the market economy creates wide exchanges and the increase in the number of local tourists are often accompanied by prostitution."   The opportunity to earn hard American cash (Viet Nam's official second currency) often attracts susceptible youth to make contact with international businessmen and travelers.  Mr. Du stated the official concern about the increasing amount of foreign visitors, "No one knows how many of them carry the HIV virus." Although it is not easy for party leaders to discuss, Mrs.

Nguyen Thi Thuong, member of the Central Committee of Young Women told the conference, "Bars and cafeterias which in reality are brothels have mushroomed in Ho Chi Minh city....There are a number of women, mainly young girls who live on illegal income by selling sex."   Also apparent is a sex trade involving teenage boys although homosexual activity is rarely discussed in Viet Nam.  Throughout the country, CSWs are known to operate out of establishments catering to both tourists  and Vietnamese men  -- often with the tacit approval of local authorities.  The media has reported extensively on the problem of late.  A government-conducted survey, "made in restaurants and cafes in Ho Chi Minh City showed that about 5,700 waitresses were involved in prostitution....Worst still, 12 percent are only 13 - 16 years old."   Commercial sex workers have lovers and families, facilitating the passage of the virus into the general population and the younger generation (HIV is transmitted in the same way to the partners of IDUs).

Prostitution is a major focus of the country's social evils campaign.  At the Thu Duc Women's Vocational Training Center in an outlying suburb of HCMC, sex workers who have been arrested for engaging in social evils are incarcerated for six month sentences.  Of the total number of inmates, "some surveys have identified as many as 10% of the residents as under the age of 16 years."   Most of the young women say their line of work is crucial to support their families.

Unfortunately, girls who are involved in the sex trade are at even greater risk of contracting HIV/STDs due to their physiological immaturity and repeated acts of unprotected sexual intercourse with numerous clients.   Throughout Viet Nam today, young CSWs are highly visible to the casual observer in cities, resorts, and along the highways.

Viet Nam's leadership has yet to come to grips with its thriving sex business and the money it generates for the economy.  Despite the fact that prostitution is technically illegal and police campaigns against social evils are popular with the government and the public, it appears that some people in authority prefer to maintain the status quo.  In the recent past, a number of foreign reports have commented on the possibility of high level involvement with prostitution.   However, such complicity is not official but rather is a practice sanctioned by a few, well-placed officials interested in personal, financial rewards.  In fact, General Secretary of the Communist Party Do Muoi acknowledged a serious problem when he said, "Corruption and smuggling keep developing seriously, causing high indignation among the people and greatly eroding their confidence in the Party and the State."   Certainly, any collaboration with the sex trade could not be conducive to an effective AIDS prevention campaign.  To some conferees, any compromise of social policy is short-sighted because it is the sex trade that is fueling the explosive growth of HIV/AIDS.  Unless the situation can be brought under control -- and soon, Viet Nam will pay a heavy price one day.  Youth in particular will bear the brunt of the errors of their elders.

Because most Vietnamese had assumed they were not vulnerable to a threat that seemingly targeted only social undesirables, the misconception did much to delay early prevention efforts aimed at susceptible youth.  Yet teens are becoming HIV-positive due to risk behaviors  they have in common -- not because of their personal identification with "suspect" groups.  Some experts are predicting that a new global wave of HIV/AIDS has begun to infect a significant number of sexually active youth who frequently have unsafe sex with multiple partners.  Consequently, this emerging pandemic among the younger generation, referred to by some as TeenAIDS,  would be more noticeable by the turn of the century.

Parental and societal denials about youth engaging in sex and drug use present serious problems for the government, its medical experts, and youth educators.  In the face of public apathy and with little visible evidence of a widespread youth epidemic, why then would Hanoi want to promote a high profile conference on the HIV/AIDS threat to the country's young people?  Undoubtedly, international warnings of a major catastrophe are making an impression.  As detailed by various speakers, Viet Nam's leadership understands well the lessons of history and the need for total preparedness to defend their nation from foreign invasion -- in this case from the global AIDS pandemic.

In numerous speeches, the threat was described using potent metaphors of conflict and national survival.  Ms. Xuyen stated, "At present, the HIV/AIDS epidemic is considered an enemy causing a new world war.  What is different is that in this war the enemy is attacking us without gunshots and silently exterminating us leaving behind serious consequences whose long-term effects will be even worse than those of war."   Statements of this kind are not made lightly in a country that has suffered nearly three million deaths as the result of armed conflict and wartime famine in this century alone.

Because of Viet Nam's liberalized "economic renovation" plan called doi moi, its society is no longer isolated from international interaction or immune to universal health concerns as it was from 1975 to 1986.  During that period, AIDS was thought to be a problem of foreigners.  But this perception has changed.  As a result of official foresight and planning, Viet Nam can take pride in the fact that it was one of only a handful of countries that set up its national prevention programs (between 1987 - 1990) before a single case of AIDS had been reported (in December, 1990).  The government's actions undoubtedly limited a wider spread of HIV/AIDS.  Yet, the news is not all positive -- follow-up prevention measures have left much to be desired.

Similar to other governments worldwide, the leadership in Hanoi chose initially to frame its stop-AIDS campaign in stark, uncompromising terms.  Specific groups were targeted which were stereotyped as the gateways for the transmission of HIV/AIDS into the society at large.  Only a modicum of prevention information was geared to teens, in or out of school.  Much manpower and resources were expended in punitive efforts aimed at eradicating social evils, with the main emphasis on the arrest and detention of CSWs and IDUs.  But as one Vietnamese delegate admitted: "We have fought very hard against social evils but risk [of HIV/AIDS is] still growing."   Consequently, valuable time was lost in the first few years of the epidemic.

Research suggests that teenagers need to witness the reality of AIDS before they could accept their own vulnerability and take the necessary precautions to protect themselves.  After all, adolescence is the formative stage for growing independent from adult control and restrictions.  Taking risks such as experimenting sexually and using drugs could be considered a normal, albeit unwise, manifestation of feelings of youthful invincibility.  In this regard, modern Vietnamese teens should not be considered different from their counterparts internationally.   Yet a problem of perception exists.  In a 1995 survey of HCMC youth, the great majority (82.6 percent) agreed that AIDS was a real problem, but only 61.7 percent believed AIDS could be considered a "personal threat."   According to Ms. Xuyen, "Every year... millions of adolescents begin to exercise their reproductive function.  They lack knowledge about reproductive health and have neither life skills nor skills for safe sex to prevent AIDS."   Due to inadequate AIDS education, many youth have continued to engage in unsafe behaviors without understanding their vulnerability to HIV.  Dr. Bui Hien of the National AIDS Bureau (NAB) points out, "there is a gap between knowledge and practice."

This situation is especially true today for Viet Nam's young people such as students, laborers, military recruits, street kids, service employees, and young professionals.  On the plus side, some studies have found a high degree of AIDS knowledge among youth (approximately 90 to 95 percent accuracy ) -- a sign that Vietnamese educators have done a good job of providing a basic awareness of HIV transmission routes.  Yet the conferees were told that the present campaign strategy has been of limited effectiveness.   Recent research data suggests that many youth do not equate their own unsafe practices with those actions of people involved in social evils.   A large part of the problem is due to a common societal belief that "good" youth become infected unwittingly through error. They are seen as victims  -- not as perpetrators of social evils.

Due to limited surveillance and testing,  the government greatly under-reports the true number of HIV-positive individuals.

Consequently, too many Vietnamese youth still believe that HIV/AIDS remains a problem of "others."  Out of a population of 75 million, 5,000  cases of HIV/AIDS could seem minuscule to the average person.

Although higher numbers are being mentioned on occasion in the official media, it appears that most youth have little reason to accept that AIDS could be a danger to their health or future livelihood.  Yet it is among these youth that Viet Nam's epidemic will have its severest impact.

There is little doubt among experts that the actual numbers of reported cases are only, "the tip of the iceberg,"  according to Roy Morey, the UN Resident Coordinator stationedin Hanoi.  Recently NAC has made a more concerted effort to be realistic about its figures.

It currently estimates the 1996 countrywide figure to be 22,527 cases.   Yet in 1995, two different sources suggested higher numbers.  A medical specialist from the AIDS Committee in HCMC (the epicenter of the national epidemic) estimated that the total number was closer to 35,000 cases.   Another set of official figures placed the estimated range between 30,000 and 60,000 for 1995-1996  -- considerably greater than the 4,300-plus cases reported in conference speeches (see Appendix C).

The higher numbers were based on both surveillance data and additional information which NAC supplied to Professor James Chin of the University of California at Berkeley.  Chin, along with his collaborator Jeffrey Dean, produced an epimodel that analyzed numerous reports, statistics, and trends to determine their projections.

However, Chin has cautioned that his estimates should be considered, "on the conservative side."   The conference report included a sheet with the estimate of 120,000 cases of HIV/AIDS by 2000.

According to one international NGO representative who accompanied the Vietnamese delegation to the 1996 International AIDS Conference,  the government chose not to release estimates that would be greater than 25,000 - 30,000.   Similar to other countries faced with limited resources, expanding epidemics, and an inadequate surveillance network, the official line gave the appearance of minimizing the potential severity of the problem -- if for no better reason than to buy time and avoid having to make difficult decisions.  However, knowledgeable AIDS professionals in Vancouver questioned the logic.

In Hanoi, the American co-sponsor advised his hosts, "The worldwide problem is so immense that... donors are looking for evidence that the health care leadership of a country has a well developed understanding of the threat posed to its people by HIV/AIDS... it must be prepared to address the hard questions."   According to the bulk of the speeches presented, Viet Nam is demonstrating that it is aware of the need to make reliable projections in order to plan wisely and to receive their share of international assistance.

What is the reality of Viet Nam's epidemic?  If 25,000 to 60,000 cases of HIV/AIDS are approximate, then a United Nation's Development Programme (UNDP) 1994 projection that predicted 570,000 cases by 1998  would be at the liberal end of the scale.  As originally outlined in a working paper for the UNDP and World Bank, the estimates are now discounted by the UNAIDS/UNDP office in Hanoi as inflated  although the nation's press continues to report the number without correction.   The truth, of course, is that the precise size of Viet Nam's invisible, spreading epidemic is not known.

Although sentinel surveillance is improving in Viet Nam, the situation remains particularly problematic when attempting to estimate the number of HIV-positive youth.    Because many teenagers do not see themselves being at risk, few ever get tested.  Yet without better knowledge of the true extent of teen infection, how could prevention efforts be effective?

Dr. Tran Hien, director of epidemiology at Hanoi Medical College and the government's chief estimator, said his estimates basically agree with Chin's higher numbers (60,000).  Hien personally believes that 300,000 to 350,000 Vietnamese could be expected to have contracted HIV/AIDS by the year 2000.   Without implementing more efficacious actions soon, the actual figures could yet go higher, perhaps closer to the high end estimate of 570,000 cases.  Among the future cases would be a large number of youth, especially many young women,  who would have been infected in their teenage years.  Whichever prediction eventually proves more accurate, there is no doubt that Viet Nam is facing a serious threat to the health and lives of its youngest generation.

There is a lingering perception among AIDS observers that the bureaucracy is slow in reacting to the developing pandemic.  As early as 1993, Thailand's most famous AIDS crusader, Dr. Meechai Viravaidya, came to Hanoi and warned, "React early, react strong and the problem will be small.  But do like my country, reacting late and weak, and the problem is so, so big."   The Thai government's earlier reluctance to accept outside warnings predicting a large scale AIDS epidemic is recognized today as a major mistake.   Despite recent successes in prevention, Thailand is still paying the human, social, and economic costs of that official myopia and societal denial.  For most Vietnamese conferees, the 1996 VNYU conference was a positive sign that the government would not repeat their neighbor's errors.  In this light, Vietnamese and international conferees gathered in the impressive Government Meeting Hall in Hanoi to discuss realistic ways to confront the crisis.

Conference Agenda:

As the officially-mandated representative of Vietnam's young people, the VNYU has the major responsibility to speak out on issues of importance to youth.   The Vice Chairman of NAC, Le Dien Hong acknowledged this relationship when he stated, "We hope that the Youth Union, which has rendered great services to the nation in all revolutionary stages, will show even stronger concern over the problem that directly impacts the young generation and that it will continue to make great contributions to the current drive against AIDS."   Since the inception of NAC, the mass youth organization has been the primary conduit for the dissemination of AIDS prevention information to millions of young Vietnamese (in lieu of school-based AIDS instruction and a limited media campaign).  Under the direction of Vu Trong Kim, Permanent Secretary of the VNYU (and member of the Party Central Committee), the leadership in Hanoi endorsed the conference concept in conjunction with the Ho Chi Minh Communist Youth Union, the nation's oldest and most powerful organization for young people.

Another important factor behind the impetus for the conference resulted from important discussions held at the 8th Party Congress  in June 1996.  Grassroots concern was reportedly expressed by delegates from many of the local peoples committees, especially from impacted urban areas.  Their role in protecting workers' interests is paramount within Viet Nam's political system.  Dr. Hong reminded the VNYU conference, "The People's Committee is fully accountable to the Government concerning activities and outcomes of HIV/AIDS prevention and control." The idea for an expanded nationwide meeting began with Mr.Tran, founder of two American-based NGOs active in Viet Nam since 1991.  Concerned about the spread of AIDS in his native land, he decided to help as he has done previously with his group, Viet Nam Assistance for the Handicapped (VNAH).  Mr. Tran worked with representatives of various government ministries on plans for coordinating and financing the conference.  He envisioned an NGO-supported effort that would link outside consultants with the country's own experts on the current AIDS situation as it directly pertained to youth.  In introductory remarks, Tran said: "We hope that it will provide a useful forum for... bringing together the Vietnamese leadership with a variety of international experts and funding agencies... [to] highlight where the programmatic gaps may be made in the implementation of such initiatives and what further funding needs may be."

 

Simultaneously, the VNYU had been pushing for greater responsibility to establish aggressive AIDS prevention programs for youth.  The union also requested increased funding from the central government to make their plans feasible.  On both counts the mass organization was granted more autonomy.  However, due to budgetary restrictions imposed on all sectors of the government, as well as a recognition of the need for external expertise, the VNYU decided that foreign support would be essential to an expanded national effort.

Thus, in spring 1996, VNYU and HealthEd signed an informal agreement to seek ways in which the two organizations could cooperate.  The first plan was a joint sponsorship of a youth AIDS conference.  It was agreed that the conference agenda would be controlled primarily by policy-makers in Hanoi.  Without that measure of control, government cooperation would have been limited.

As often happens with ambitious ideas dealing with controversial issues (such as the public discussion of government policies dealing with premarital sex, teen prostitution, and illegal drug use), bureaucratic complications had to be overcome before the conference became a reality.  Sixteen different government ministries and mass organizations, all members of NAC, were invited to participate.  The logistics of securing their combined involvement over the summer were monumental.  Recent changes in government personnel and policies as a result of the Party Congress further complicated the organizers' work -- especially with leadership changes made at the Ministry of Health and subsequently, at NAC.

Additionally, the greatest challenge was to secure the approval of the Politburo for the VNYU to hold the gathering.  This was eventually received.

Shortly before the start of the conference, a few foreign AIDS groups began urging that the meeting be postponed but the co-sponsors persisted in their efforts, convinced that the time was right.  Some international professionals were concerned that the national conference was hastily planned by the VNYU in conjunction with an NGO with limited experience in the AIDS prevention field.  One Vietnamese official associated with NAC later confided that the government found it more comfortable to work with a Vietnamese-American organization because "their understanding would be good."   This relationship appeared to be a key consideration in the government's acceptance of the VNYU's conference co-sponsor.

Ultimately, the conference opened as scheduled, bringing together high-ranking government officials, Vietnamese health providers, NGO workers, and outside specialists in one combined effort.  Last minute negotiations were needed to iron out the speakers' schedule as more government agencies (than had been expected) wanted to participate, a good omen.  Their interest in speaking on the topic of youth AIDS was a sign of official recognition of the importance of the VNYU gathering.  With much of the country's media present to record the event, Viet Nam's first national gathering on youth AIDS was convened to discuss: "The Threat of HIV/AIDS on Vietnamese Youth: Meeting the Challenge of Prevention."

Vietnamese Representatives:

With more than 150 Vietnamese representatives in attendance, many sectors of the government, party, and local health institutions actively participated in the deliberations of the conference.  Twenty-six of them made speeches outlining major proposals designed to combat youth AIDS.  It was acknowledged that the VNYU's experience in carrying out national goals and its country-wide network could do the most effective job of targeting youth.  In her capacity as Deputy President of the VNYU's AIDS Prevention Fund, Ms. Xuyen said, "Over the 65 years of operation, the Youth Union at all levels has made great efforts in education to effectively mobilize young people to take part in implementing socio-political and economic programs for the country.

 

They have always been among the vanguard in all difficult and hot areas of the country."   In fact, many of Viet Nam's current leaders began their social and political activism as members of local youth unions, another important consideration behind the government's support of a VNYU-sponsored conference.  The organization's network stretches throughout all provinces of the country,   including every rural commune and city ward.  In this regard, Viet Nam is most fortunate to have a ready structure of committed social activists to fight AIDS -- a major reason for hope in curbing the country's growing youth epidemic.

Among the key people at the conference were the six moderators: Ms. Xuyen; Vu Trong Kim, Permanent Secretary of the Youth Union Central Committee; Do Nguyen Phuong, Minister of Health and a Vice Chairman of NAC; professor Le Dien Hong, also a NAC Vice Chairman; Duong Xuan Nam, an executive committee member of the Youth Union Central Committee; Tran Dac Loi, acting Director of the Youth Union's Center for International Development; and the newly-appointed Standing Vice Chairman of NAC, Dr. Chung A.  A list of the Vietnamese speakers and many of the official ministry representatives are attached to this document (see Appendix D).

Expatriate Representatives:

Accompanying Tran were three board members of his organizations (HealthEd and VNAH): Shep Lowman, retired American diplomat, as well as Thang Do and Dr. Do Tuan Duc, advisors.  Also on HealthEd's team were Dr. Duong Nguyen, associated with John Hopkins and a Colonel in the U.S. Army specializing in tropical medicines and Dr. Richard Moore, Vice President of John Snow, Inc.

(JSI), a major funder of the conference. Dr. Moore was accompanied by Jenny Dahlstein from JSI's Boston headquarters.

Joining the group was Dr. John Chittick, an educational specialist who has lectured on youth AIDS at Harvard University and who had recently completed a comprehensive book on the HIV/AIDS situation in Viet Nam.   Paul White, senior representative of the U.S.

Agency for International Development (USAID) at the American Embassy in Tokyo, came to lend his official support to the efforts.

White predicted that USAID would be more involved in helping Viet Nam in the future as official relations continue to improve between the two countries.  Attorney Julie Hamblin, a legal consultant to UNDP with experience in human rights issues, also joined the team from Sydney.

Roy Morey, the UN's Resident Coordinator in Hanoi and UNDP representative (one of the six combined UNAIDS agencies ) delivered a speech that emphasized the global threat of youth AIDS.

Steve Kraus, the UNAIDS Country Program Officer, and Jamie Uhrig, UNAIDS/UNDP advisor, also spoke.  In addition, United States Charge d'Affaires Desaix Anderson (acting Ambassador) gave a welcoming address which acknowledged the experience of American agencies in AIDS prevention work and their willingness to assist Viet Nam in its present efforts.  Two other representatives from the embassy, Yvonne Eaton and Ted Osius also participated.

A number of international NGOs doing work in HIV/AIDS prevention were also in attendance.  James Kurtz, Country Director for Population and Development International - Thailand (PDI) was selected to give an address on behalf of the more than 30 foreign NGOs doing AIDS work in Viet Nam -- including representatives from: Save the Children Fund/UK; CARE International - Australia; World Vision International; DKT International; Medicins Sans Frontieres - Belgium; Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ); Swedish International Development Agency (SIDA); Australian Red Cross, Path Canada, The Population Council, Oxfam - Hong Kong, Cebemo -

Netherlands, Medicins de Monde, and World Environment and Peace (WEP) among others.  It should be noted that these outside funders have played an increasingly effective role over the years despite bureaucratic regulations that restrict some important NGO initiatives.

By most expatriate accounts, however, the situation is improving as Viet Nam increases its AIDS prevention efforts and loosens restrictions.

Main Conference Speeches:

The conference opened with an ambitious agenda for the 200 conferees in attendance.  Assisting the delegates and coordinating official operations were scores of VNYU volunteers, staff from various ministries, and government interpreters.  The official language was Vietnamese with simultaneous English translation  via headphones.

At first, there was concern among some international conferees that their hosts would not be predisposed to an open and possibly controversial discussion of official policies and cultural taboos.  Foreign delegates specifically wondered how the Vietnamese would react to outside criticism of the "social evils" component of their AIDS campaign with its punitive focus on high risk groups.  Without an open debate, many people in the hall wondered if the national prevention message could be made more inclusive to target all Vietnamese youth.

By exclusively concentrating attention on the actions of individuals engaged in social evils, the authorities have assumed that teenagers would be scared into being safe.  But in surveys and interviews, many young people said that they do not accept the harsh warnings as being relevant to themselves or their friends.

By most measures, Viet Nam remains a conservative culture where people who break custom or law are often seen as socially undesirable.  Individuals who engage in illegal drug activities are routinely rounded up by the police and imprisoned in treatment centers (similar to the previously mentioned camp for CSWs).  According to the Vice Director of the Binh Trieu Drug Treatment Center, approximately 70 percent of the current inmates are HIV-positive.  Of that figure, 80 percent are young men.   With more than half of all reported cases of HIV in the country, the camp serves as the nucleus of the spreading epidemic.

A recently announced directive requires the isolation of ill people living with HIV/AIDS (PWAs ) at the treatment center.  Those who show signs of opportunistic infections are segregated into a special ward where basic medical care is available.  Present regulations also mandate HIV testing for all interned IDUs.  However, prisoners are not notified of their test results by camp personnel.  Thus many seropositive young men return home to family and friends upon their release -- without adequate warning of how to protect themselves or their partners.  It is not clear how this nondisclosure policy benefits AIDS prevention efforts since it is the unsuspecting partners who then become highly susceptible to contracting HIV.  But for many young Vietnamese who come in intimate contact with former inmates (and contaminated bodily fluids are exchanged), there could be little denying that these youth would be negatively impacted.

In addition to the complicated issue of social evils, there was concern that the Vietnamese delegates would prefer to avoid controversial reports of increasing adolescent sexual experimentation, particularly as it might be influenced by the government's "Market-Leninist” reform policy -- better known as doi moi.  In private conversations, it was evident that Viet Nam has been undergoing radical economic changes which impact heavily on the social and sexual mores of youth.  Vu Trong Thieu of the Ministry of Culture and Information's AIDS Prevention Committee stated, "It is necessary to let young people understand the side-effects of a market-oriented mechanism on all people in the society, especially young people."   A number of the conference speakers expressed the conviction that the adoption of destructive social habits and loose personal morals are the main cause of HIV/AIDS in Viet Nam.  In the words of Mrs. Than, "At present, young people are influenced by modern lifestyles and decadent culture and films.  Young people are converging on urban areas to find jobs but since they rarely are able [to] find jobs with sufficient income they easily fall prey into high-risk groups.  At the same time, young people have the least access to HIV/AIDS information." However, any initial apprehension that the conference would sidestep these sensitive issues dissipated quickly as many speakers spoke about the reality of the country's epidemic.  VNYU Permanent Secretary Kim repeated a powerful analogy to make his point: "If effective preventive measures are not taken in time, its consequences will lead to a destruction no less atrocious than that of war."   Having set a somber tone to the conference theme, other speakers talked about 400 people living with AIDS, more than 200  deaths, and estimates of at least 4,340 reported cases of HIV in 41 of the country's 53 provinces.   From each official speaker could be heard a sense of alarm and urgency that had not been noticeable to this observer a year earlier.

In Viet Nam as elsewhere, there has been a predilection to blame the introduction of AIDS on outsiders.  Professor Hong spoke about the problems caused by migration due to economic considerations: "[Movement] provides opportunity for HIV/AIDS to infiltrate into Vietnam which is strongly spreading in neighbouring Thailand and Cambodia."   In the past, this "foreign" argument regarding the introduction of HIV/AIDS was used to absolve government planners of responsibility for not taking controversial or expensive corrective measures.  But lately this rationalization carries less weight as greater attention is being paid to the seriousness of Viet

Nam's own internal crisis and its relationship to its neighbors.  Today, fewer Vietnamese are apt to discount reports of the Thai epidemic as being alien to their own future.  The news is especially encouraging among younger people.  A 1995 survey of 334 HCMC young people found that only 15.9 percent of those questioned answered "yes" to the rhetorical statement: "AIDS is not a Vietnamese problem -- it is a foreigner's problem" (while 73.9 percent answered "no.")   Certainly, prejudice still exists but denial is less pervasive.

However, there is growing concern about the number of youth migrating in search of employment, whether between countries of the Mekong River region or from rural areas to the cities.  One speaker put it succinctly: "Every year, more than 1,000,000 young people enter the workforce.  Apart from employment provided by the State and their families, a section has to go and find jobs away from home.  Ninety percent of rural [to] urban labour migrants are young people who pose a threat to the increasing number of sex workers and intravenous drug users of whom young people account for 75-85%."    Further exacerbating the situation are the thousands of young people crowding into the main urban areas where HIV is already present.   One NAC official said, "Young people from the countryside flow to major cities to seek jobs, and many do not intend to return to their native villages.

Many of them are non-skilled people, with low education and unstable jobs and easily susceptible to bad practices such as drug abuse, prostitution, robbery, gambling and violence." Most conference speakers were candid when speaking about the culturally difficult topic of youth sexuality.  Mrs. Thuong admitted, "Pre-marital sexual traditions are unacceptable by the ethical traditions of Vietnam, but [are] an undeniable fact."   Collaborating with the University of Economics, Mrs. Thuong conducted a survey of 300 students in HCMC that found 34 percent of respondents thought premarital sex was "acceptable."   Although not considered high by most global standards, the statistic drew audible murmurs from the largely Vietnamese audience.  The conferees appeared to be more comfortable with NAC survey results that suggested only, "10.3% of men and 1.4% of women have sexual intercourse before their marriage."   The author's 1995 youth survey found that 57.5 percent of respondents said they did not plan to have sex before marriage (while only 14.7 percent replied in the affirmative).   During a conference break, a delegate from the central highlands worried about the declining moral standards of city youth spreading to his province.  He said, "Our children should not know about those problems."  In the past, teens did not need to know much about the consequences of sexual experimentation except for unplanned pregnancies.  But Vietnamese youth, especially in rural areas where formal health and sex instruction is not prevalent, are at a major disadvantage if the problem of HIV/AIDS is not discussed.

Sex education has been limited because of Viet Nam's traditional bias against the public mention of anything sexual (HCMC schools were the first to introduce a truly comprehensive AIDS and sex curriculum in fall 1995 ).  In many other school districts and locales, the subject is rarely discussed.  Although this situation may seem similar to other countries, in Viet Nam much of the opposition to "sex ed" comes from administrators and teachers of whom many are reportedly too embarrassed to discuss intimate sexual matters with youth.   Ms. Xuyen noted the problem and said, "Education on healthy and safe sex for youth has not been included."   Also confronting the cultural dilemma head on, Mrs. Than recommended, "Sex education is one of the subjects to be introduced into school curricula.  It will contribute to HIV/AIDS prevention among youth....The Youth Union should formulate suitable sex education programmes to popularize sex knowledge to different groups of young people."   Learning more about sex appears to be a popular concept with young people as well.

In the 1995 survey, 82.1 percent of youth answered "yes" to the question: "Should AIDS education include information about ways in which people can have safer sex?"   Arguments for teaching reality-based sex education were repeated by various speakers.  This push for school-based instruction appeared to be coordinated.  One NGO representative commented, "if so, it [sex ed] must now have official backing" of the top leadership.  The VNYU conference was selected as the most appropriate vehicle for promoting the message to a skeptical public.

Professor Phuong stressed the epidemic's diffusion "among ordinary people who have direct or indirect relations with the high risk groups."   It became evident as the conference proceeded that the national prevention message would no longer be based solely on "who you are" (groups) but rather, on "what you do" (behaviors).  The significance of this shift away from the traditional focus and towards a more health-oriented approach was not lost on the conferees.  The change also suggested the possibility that punitive policing actions would be relegated to less prominent roles in future AIDS campaigns -- especially after the public spectacle of organized street burnings of "anti-social" music tapes, CDs, and other materials suspected of endangering public morals (preceding the 8th Party Congress in early 1996).  However, few observers discount the power and influence of conservative elements in the government to resist progressive changes even if the actions were known to be beneficial to stop-AIDS initiatives.

Professor Phuong's point of greater inclusivity is crucial to a more effective prevention campaign.  By making the AIDS prevention message more youth-oriented, teenagers should be able to recognize more clearly their vulnerability to HIV/AIDS.  Once it is understood that HIV is transmitted by behaviors, not group identity, teenagers could better make the connection that promiscuous, unprotected sex is unwise for anyone.  As the UNDP's Kraus put it: "It is at that level that infection is transmitted, and at that level that prevention takes place."   Xuyen stated, "the number of youth having safe sex is very low in urban areas -- 41% of men and 21% of women (data of the National AIDS Committee in 1996).  The figures are much lower in rural areas.  Pre-marital sex is increasing."   Other research suggests that abortions (sanctioned as a population control tool) are on the rise.   It was reported that HIV infection among women, especially younger females, is spreading rapidly.  While the number of HIV-positive women in Viet Nam appears to be relatively small (approximately 15 percent  of the total presently), the anticipated cases of seropositive women are expected to reach parity with men within the next decade.  Much of this trend is attributed to the succeeding stages of Viet Nam's epidemic which first infected IDUs (mostly men), followed by CSWs (mostly women), and now into the general public.

Dr. Phuong made two key recommendations, one for the foreign delegates and one for his fellow Vietnamese.  First, international funding agencies should "step up their cooperation and assistance"  to the VNYU -- an official signal to NGOs and multilateral organizations that the government would like the Youth Union to be the vehicle for the nation's new emphasis on teenAIDS prevention.  Second, Phuong stated that Vietnamese families of PWAs as well as local communities and youth especially, must accept more responsibility caring for ill PWAs.   His admonition was a comment on the traditional importance of familial loyalty in Vietnamese culture.  It also acted to reassure people that they should not fear the casual transmission of HIV/AIDS.

Yet when a top NAC official promised medical help for PWAs, the clear perception was that care would be minimal out of economic necessity.

Vice Chair Hong said, "The AIDS committee will focus on... providing counseling for HIV carriers and AIDS victims in the community as well as concentration camps"  (although a poor choice of translation, the connotation, nevertheless, remains one of very limited medical assistance).

One of the most interesting speakers proved to be Dr. Chung A who referred to the prepared remarks only in passing, preferring to speak about why he recently chose to accept the government's highest AIDS prevention position: Standing Vice Chair of NAC.   A research scientist and medical doctor by training, he spoke of moving NAC towards more progressive action -- including the implementation of better behavioral intervention strategies based on methodological and scientific research designs.  Dr. A emphasized his commitment to improving training programs for peer educators.   He stated that NAC would closely scrutinize prevention materials to ensure that the information is medically-accurate, youth-relevant, and socially responsible.  Speaking directly to an audience mainly comprised of government employees, Dr. A stressed the view that each sector should institute their own AIDS programs.  He strongly endorsed local capacity building by granting greater autonomy.  This view was seconded by Hong, another Vice Chairman who said NAC was committed to, "Building an anti-AIDS network at all rural communes and villages and urban wards."   To reiterate, socialist Viet Nam is fortunate to have the pre-existing structure in place for implementing better AIDS prevention efforts at the grassroots level.

Dr. A made it clear there was a strong medical necessity to include safer sex instruction as part of the abstinence message preferred by Vietnamese adults.  A number of international observers suggested that his appointment was a positive sign that the national leadership wanted the best technical expertise in the government's primary AIDS prevention slot.  They also hoped that Dr. A would prove to be a convincing, hands-on agent of change.  His leadership is coming at an opportune time as Hanoi has publicly acknowledged the potential severity of a growing epidemic.  Importantly, Viet Nam also appears to be willing to allocate greater resources to youth prevention efforts (funding for NAC has increased from VND 300 million in 1992 to VND 5 billion in 1996 ) -- at a time when it is most needed.

Other speakers brought up the question of the socio-economic cost of HIV/AIDS to the nation.  Dr. Khiem reported that VND 50 billion (approximately US $4.5 million) has been spent to date in 1996 (having received approximately US $10,000,000 from outside donors in the last three years ).  Khiem warned, "When a person is infected by HIV/AIDS, he or she is not only addicted [sic] in terms of health and financially, but also leaves great and unpredictable consequences to society....An AIDS patient who dies at the age of 25 - 30 causes society to lose about 20 - 30 working years from that individual."   Currently, the government allocates approximately four percent of Vietnam's national budget to health care (down from previous years before market reforms were widely instituted).  Annual budget estimates for HIV/AIDS, however, have been constantly rising -- what is now $US 5 million annually could be $US 8 - 10 million in the next decade.  If Thailand's experience could be applicable, then Viet Nam would be burdened by greater AIDS expenses after 2000.  For a developing nation in the highly competitive Asian-Pacific region, the scenario could spell economic disaster.

Current estimates of the average daily cost of providing for a PWA is between VND 200,000 to 300,000  (about US $18 to $27).  This figure represents a minimal standard of AIDS care.   As one of the world's poorest countries where the average annual income is approximately US $220,  Viet Nam's leadership understands it is presently unequipped to deal with the consequences of a massive public health catastrophe.  Recent international developments in HIV/AIDS therapies are not expected to directly benefit Vietnamese patients because the cost for the medicine remains prohibitively high.  As with many developing nations, Viet Nam could be forced to watch many of their young people die prematurely while richer countries would see their PWAs live longer and more productive lives.  While the shift to an expanded market economy promises rewards for the average Vietnamese, the changes are also exacerbating the AIDS situation among all sectors of the populace -- with sexually active and unprotected youth paying the heaviest price.

Despite the dire forecasts, Professor Thuong conceded, "In Vietnam, there has not been any fundamental study on the socio-economic influence of AIDS."   Clearly, it is more difficult to plan for an emergency if the ramifications of a coming crisis like AIDS are not fully known.  When the World Bank and UNDP collaborated on its preliminary report in 1993-1994,  their estimates of 570,000 seropositive cases by 1998 were thought to be exaggerated.  Thus, their original economic projections were suspect too (although it is possible that their analysis could still prove accurate).  What is needed now is a new study of the expected impact of a youth-driven epidemic based on Chin's and Hien's research and revised epimodels.  A new study would take time, expertise, and of course, money.  Presumably, Hanoi chose to highlight this problem at the VNYU conference in the hope that international organizations would be encouraged to underwrite the costs -- primarily because the main focus would be on youth AIDS, of obvious empathetic concern globally.

On the whole, conference speakers were open to the discussion of the shortcomings of earlier government-sponsored, anti-AIDS efforts.

The effectiveness of IEC (information, education, and communication) was broached and the criticism was direct.  In speeches throughout the first day, most speakers concurred that the country could no longer treat the growing threat of HIV/AIDS as routine.   Xuyen admitted, "Achievements of the Youth Union in the past five years are... far from meeting young people's demand for communication and education on HIV/AIDS prevention."   However, more criticism was directed at the intersectoral problems between competing ministries  -- a factor that hinders program coordination and often, is endemic to bureaucracies protecting their own fiefdoms.  Yet HIV/AIDS appears to be finally making its presence felt after years of spreading silently and generally unnoticed by the public.

Khiem stressed the importance of a targeted prevention message for all young people, "The Youth Union should broaden its scope.  It is not enough to only educate its members at schools and army units.   What is more difficult is the education of street youth, rural youth... as well as unemployed youth and drug addicts."   Focusing greater attention on rural youth was a popular theme throughout the conference.  Mrs. Than urged, "Youth organizations in rural areas need to develop programmes to help young rural people avoid falling into the traps of urban social skills."   There was a real sense of empathy for youth in the countryside.  Many boys and girls must leave school at early ages to work in the rice paddies to support their families.  Even if their parents could spare them, attending public school in Viet Nam costs money now, another factor in the high number of out-of-school teenagers.  Hence, many young people miss out on the HIV/AIDS prevention message due to an interrupted education.

In response to a lack of individual and societal responsibility for AIDS prevention, the Anti-AIDS Fund Steering Committee (FAPA) of the Youth Union Central Committee was founded in 1995.  Duong Xuan Nam, President, said the purpose was to have youth volunteers assist PWAs and promote knowledge and awareness in the community to alleviate needless fears.   Despite stated goals preaching nondiscrimination, the stigma against anyone or thing related to HIV/AIDS remains strong in adult society.   The problem is so great, Professor Thuong noted, "HIV/AIDS carriers are deserted by their own family members,"  placing additional pressures on the local peoples committees with already limited means of support.  A Western-style welfare state does not exist in Viet Nam with its safety nets for the poor or sick.  Yet Professor Dong referred to a survey that found, "A large proportion of people (72.2%) have non-discriminatory attitude towards people living with HIV/AIDS."   While the findings were an encouraging sign of evolving sentiment, some international observers mentioned that altering public prejudices against PWAs is an ambitious goal by any society's standards.

Another problem in disseminating the AIDS prevention message to youth is the lack of access to a consistent message through the mass media (there are few televisions or radios in poor homes or worksites in rural areas).  Vu Trong Thieu, a representative of the Ministry of Culture and Information's AIDS Prevention Committee noted, "Most newspapers, radio and TV programs have recently mentioned AIDS prevention but have rarely determined youth to be the major target group of communication campaigns."   Thieu's point: if the public does not recognize that the younger generation is vulnerable, then the threat remains hidden.  Instead of urging children to take specific precautions and avoid obvious dangers, many parents have been lulled into a false sense of security by a complacent media, leaving Viet Nam's youth at greater risk.  However, speakers also praised the VNYU's newspapers for being aggressive in their reporting of teen AIDS.

One consensus among conferees was that the youth prevention campaign should increase its focus, "on the poor, high risk groups who do not have the opportunity to be reached by general information: non-state workers; porters; construction workers; street youngsters; and poorly-educated women who work in hotels, restaurants, private sectors."   Peer teaching (training young people to be AIDS prevention teachers in service to other youth) was strongly endorsed as the best way to reach out to a most vulnerable population which lacks critical information.  One speaker said, "Peer education is needed....They [youth] like to pour out their hearts, to hear love affairs, sexuality and safe behavior from their peers more than [from] adults or their parents.

They also prefer to receive information and skills on anti-AIDS from their peer educators....If one changes his/her behavior, it will affect the other."   The VNYU has already successfully promoted peer teaching (including for AIDS prevention) under the guideline: "Youth talks to youth.  Youth provides guidance to youth and peer education." When students in the previously mentioned University of Economics survey were asked what they thought of peer education, the study found, "It is noteworthy that 69.7% of them said they were ready to act as motivators on HIV/AIDS prevention when invited."   In another youth survey, 86.8 percent of the respondents answered affirmatively when asked: "Do you believe you have a responsibility to warn your best friends about the dangers of AIDS?"   Already a number of NGOs in Viet Nam have sponsored peer programs as have private consultants working outside the establishment.  The author has conducted "PeerCorps" training in HCMC and found that youth can be effective teachers of the AIDS message by learning interactive techniques that emphasize one-on-one communication, medical facts, and non-judgmental peer support.  The peer education proposal resonated well among the Vietnamese conferees because of the valuable contributions youth cadres have made in past struggles of national survival.

On the politically-sensitive matter of social activism, concern was expressed about the independent agendas of NGO workers and peer educators.  Because public meetings cannot be held in Viet Nam without prior permission, AIDS advocacy has occasionally resulted in police interrogation and detention of volunteers.  Some authorities believe that street outreach undermines official efforts aimed at eradicating social evils.  By distributing free condoms to CSWs, the reasoning goes, commercial sex is encouraged; exchanging contaminated syringes for clean needles enables IDUs to continue their habits; and promoting safer sex techniques to teenagers increases experimentation and risk. Therefore, it was noteworthy when Master Yen recommended, "These social activists may conduct their activities on the streets or locations where out-of-school youth regularly gather." The delegates heard about the introduction of the first condom cafe ("Thanh Nien") located in the Youth Culture House in HCMC.

Originally conceived by a young Canadian woman  who was doing volunteer work with street children, the idea was supported by Mr.

Luan, Vice Director of the Culture House.  Following negotiations on the details of the culturally-sensitive proposal,  the operation was approved by Dr. Le Truong Giang of the HCMC AIDS Committee and funded by two NGOs, Cebemo and Medicins de Monde.  The cafe finally opened to youth in March 1996 although distribution of condoms was delayed until July.  Now unmarried young people can go to the resource center for safer sex counseling and to the cafe for refreshments and free condoms.  According to the manager, Bui Chi Cuong, "At the beginning, young people hesitated to go into the Cafe.  However, now it seems normal to have a condom on the table and to talk about it in public." In addition, the conference was told about the success of the "Evergreen Shop" in Hanoi where gifts and everyday commodities are sold along with condoms, some of which are available at no cost.  At first glance, these ventures might not seem extraordinary to foreign observers.  However, even in countries which have lived with HIV/AIDS since the early 1980s, specialty outlets (whose primary mission is to promote the sale or dissemination of condoms for HIV and STD prevention, not family planning) are relatively new and rarely sponsored by public entities.  While some nations might provide community health clinics that service the safer sex needs of adolescents, the officially sanctioned distribution of condoms to unmarried teens still remains a highly controversial practice in most societies.  Indeed, in many places it is illegal.  Yet on this subject, the leadership in Hanoi has chosen to prioritize medical necessity over cultural sensibilities.  Their approach could be expected to help further AIDS prevention goals among youth.

Until recently, the government had promoted condoms solely as a family planning tool for couples to meet the national goal of not more than two children per family.  Now public billboards are prominently displayed along major thoroughfares urging all people, including youth, to use "bao cao su" for the prevention of HIV and STDs.  Occasionally, condoms can be found for sale at the sidewalk stands of HCMC street vendors, along with cigarettes and lottery tickets -- although a NAC-sponsored survey of 4,200 young people found, "21.1% of men and 24.3% of women still do not know where to buy condoms."   When asked, many youth reported that they found it embarrassing to buy condoms from neighborhood pharmacies where they are known.   Consequently, youth-oriented sales venues like the condom cafe and Evergreen shop should prove popular if located in more areas.

Proposals for both concepts had initially met with opposition from the local peoples committees and the police.  But in the conference hall where "Trust" and "OK" brand condoms were available (donated by DKT, the social marketing NGO), young, unmarried delegates and conference workers were taking the free samples.   However, accepting condom usage in theory may be different from actually using them in practice.  As Binh reported, "The percentage of women from 15 to 49 years who accept contraceptives is 64.97%... the percentage of people who use condoms -- an effective method for HIV/AIDS prevention, only accounts for 4.03%."   To be effective, condoms must be made attractive to consumers since pleas by social planners often fall on deaf ears.

The VNYU was credited with "changing the image of condoms and raising the number of condoms used from 40 million in 1991 to 97 million in 1995."   According to Mr. Binh, "In 1996, 53 provinces and cities throughout the country received an amount of more than 7.1 billion dong worth of condoms....The supply and use of condoms are aimed at young people, and young couples."   For a society with a longstanding history of discouraging premarital sex, the present emphasis on protecting unmarried youth is the result of greater fear of teenAIDS than unwanted pregnancies.  Aware of the cultural conundrum, Binh added, "However, how to control and supervise this work is still a thorny question."   Most sexually active Vietnamese youth report they do not use condoms regularly (and for many, not at all).

It should be noted that not all condoms are made of high quality latex rubber and consequently, a number are defective and break.  Their efficacy is diminished further if the user does not know the proper way to use or store them.  OK and Trust condom packages include a visual diagram of how it should be worn on the penis (Appendix F).  Based on international studies conservatively suggesting that 200-to-300 cases of HIV transmissions are prevented for every one million condoms used,  thousands of young people are saved from HIV infection each year in Vietnam.

While more than one speaker mentioned the complicated cultural problems posed by issues of sex and drugs, a number of progressive ideas were put forth by Vietnamese representatives speaking in their official capacities.  According to Mrs. Nguyen Thi Hang, Vice Minister of Labour, War Invalids and Social Affairs (MOLISA), "we should attach importance to social solutions in addition to technical solutions... such as mobilization of condom use; safe needle and syringe use; and blood screening."   Progress has been made to ensure safer supplies of blood but it is known that many people who sell their blood also engage in high risk behaviors.

If the issues raised in the speeches are an indication of official thinking, then a policy of exchanging IDUs' contaminated needles for clean ones is under consideration.  Mrs. Than urged, "We must also take urgent measures to help drug addicts use safe needles and syringes."   One speaker suggested that the United States should be a role model because of its "policy" promoting free needle exchange among IDUs.   Obviously, incorrect information had been given to the speaker about a specific American locale or else the issue had been confused with the medically-regulated use of sterilized syringes in U.S. health care institutions.  But it was further evidence that the topic of clean needles for IDUs was on the government's agenda.

On another key issue, a cultural difference was apparent.  The Vietnamese strongly favored the use of mandatory blood testing as the most logical means of identifying HIV-positive individuals in the interest of public safety.  Kraus argued against mandatory testing, saying, "People don't like to be placed in a box...Would you want to be put in a box?"   He emphasized the experience of Western countries which have found that thepolicy, "drives underground those at highest risk."   Yet a member of NAC said all Vietnamese favor the practice because it allows the government to keep PWAs under surveillance.

The concept of human rights for people living with HIV/AIDS is different in every society.

On the whole, the speakers put many important recommendations on the table for discussion.  What was important about the suggestions was that the VNYU conference proved willing, indeed eager, to confront cultural issues raised by youth vulnerability -- in ways other nations still find troublesome to address.  Yet Mr. Binh was realistic when he stated the government's quandary, "This also leads us to question how we can control, and assist the young labour force in their sexual behaviour.  We have to look it straight in the face and not evade it."   Throughout the proceedings, international observers were supportive and complimentary about the conference's willingness to tackle tough questions.  By the end of the first day's session, it was evident that many Vietnamese conferees were more convinced than before that only radical and immediate changes could save youth  from the quickly-spreading epidemic.

Conference Deliberations (Break-Out Sessions):

A scheduling change was made on the morning of the second day by the VNYU and HealthEd.  Conversation during the first day's breaks and the previous night's dinner had been so animated that the organizers devoted the entire morning to four separate meetings moderated by Vietnamese facilitators.   International conferees chose the break-out session they wanted to attend while the VNYU organizers selected one for each delegate based on their area of responsibility and expertise.

Approximately 20 to 40 people were involved in the smaller groups.  Designed so that individual participation would be maximized, the sessions provided everyone an opportunity to present their ideas for a better AIDS prevention campaign for youth.  Following a brief introduction to the proposition under discussion, cultural differences were soon apparent in the way conferees presented their opinions.

Vietnamese delegates preferred making short speeches when addressing their specific concerns while foreign expatriates favored debating the issues.  With the help of the trained moderators, both sides adapted quickly to each other's style.  The result was a spirited discussion of ideas and a list of key recommendations (Appendix E).

At the conclusion of the break-out sessions, the conferees returned to the main hall to hear summations by the four raporteurs.

Very specific proposals were raised: sending trained peer corps into the countryside and onto the streets; putting a greater emphasis on safer sex instruction and condom use; mandating comprehensive sex education in the schools (as well as continuing to encourage premarital abstinence and "loyal love," the preferred euphemism for monogamous relations); and promoting greater AIDS awareness in the mass media.  It was recognized that Vietnamese youth are tempted by the new lifestyles and need more guidance from the state (via the VNYU).  Each session discussed the consequences for society when young people contract HIV and succumb to AIDS-related opportunistic infections at early ages.

In addition to these reports, the final afternoon's wrap-up meeting also heard from a few remaining speakers.

Conclusion:

The two-day conference on AIDS was unique.  As the first government-sponsored forum to specifically target youth, the meeting investigated novel ways in which the HIV/AIDS prevention campaign could be strengthened.  The collective impressions of the conferees appeared overwhelmingly positive although their mood was somber.

For many, it was the first opportunity to hear a variety of opinions on a topic that had received little public attention.  For the international participants, the openness with which the government spokesmen criticized existing program shortcomings in order to improve them was encouraging.  As the conference ended, there seemed to be a greater sense of self-empowerment and national pride because the conclusions reached were Vietnamese-generated.  If this spirit and commitment are acted upon posthaste, then 1997 could prove to be the pivotal year -- with implications of the highest import for Viet Nam's youth.

The leadership in Hanoi has traditionally promulgated a series of proclamations in the belief that the power of central authority could mandate social problems out of existence.  In the past, many national crises have been dealt with effectively in this manner.  But AIDS has proven to be a formidable challenge due in large measure to HIV's invisible nature and the public denial surrounding its possible transmission among young people.  Often, the official position has been appeals to an individual's sense of civic responsibility  or national pride.   It was assumed that information couched in these terms would suffice as HIV/AIDS prevention in lieu of more controversial, science-based approaches that directly confronted longstanding cultural precepts.  Although intentions have been good, results have not been -- as evidenced by the recent reports of the rapidly expanding epidemic.

The problem is especially obvious when looking at the figures for HIV/AIDS cases by age of infection.  Evidence clearly points to HIV infecting ever younger segments of the population.  Within the near future, a majority of all new infections will be among teens and those in their twenties.  The trend will accelerate as outside influences affect lifestyles.  The tourist trade in Viet Nam is considered essential to prospects for a healthy economy -- although because of the world pandemic, it might not prove healthy for its young people.  As Hanoi continues to open its borders in the coming decade, "beside [the] positive aspects, development of tourism will also pose negative aspects in security, social order such as prostitution, diseases, environmental pollution and particularly the HIV/AIDS epidemic."   Today Viet Nam recognizes Thailand's previous successes and mistakes when Thai military rulers first began pushing for increased tourism and overseas investment in the years immediately prior to the emergence of their AIDS epidemic in 1984.  However, one major difference exists between the two: Thailand could say it was not aware of the threat in the beginning.

The majority of conference speakers made clear that a more sophisticated approach is requisite to combat teenAIDS.  By acknowledging that Viet Nam's earliest plan (1990 - 1993) had focused too narrowly on increasing AIDS awareness among youth,  NAC's next national push (1994 to present) was designed to put greater emphasis on changing personal behaviors, a more ambitious and difficult task.  The National Assembly passed and President Le Duc Anh signed "Article 1" which succinctly states: "HIV/AIDS prevention is the responsibility of every individual, every family and of the entire society."    The proclamation is seen by observers as a significant benchmark in official thinking.

However, moral admonitions and legal dictums against premarital, promiscuous, and unprotected sex have not proven convincing to many young Vietnamese.  Despite the failure, a large number of the delegates expressed the desire to continue to promote a Vietnamese-specific, morality-based argument -- with a punitive component.  Professor Hong argued, "Inter-sectoral IEC programs on HIV/AIDS prevention and control must be... integrated with other existing social programs... [such as] social evil control."   Yet at a break-out session, one participant was more concerned that, "Youth must be given the ability to say 'no' when necessary."   In Viet Nam there is a compelling need to find adult consensus on AIDS education aimed at youth.  Integrating traditional cultural values with medically-sound information is imperative if HIV/AIDS prevention efforts are to be acceptable and have a reasonable chance of succeeding.  Support from parents and the community is a motivating factor in encouraging youth to make wise choices regarding lifestyles and intimate behaviors.

Herein lies the dilemma for Viet Nam's AIDS prevention campaign.  On one hand, there is public anger towards people who flaunt society's rules; thus, penalties are assessed for engaging in social evils.  On the other hand, cultural shibboleths inhibit the open discussion of safer practices that could save lives.  Instead of helpful advice, too often there is blame.  As a result, the entire nation suffers when anti-AIDS campaigns fail to do their job.  Yet for many Vietnamese, promoting public morality and family values is integral to maintaining a strong sense of community.  Conference speakers raised the question whether social evils are being used primarily to punish unpopular, high risk groups rather than to prevent high risk behaviors.

Despite the many positive messages emanating from the conference, it is unlikely that the public would quickly discard its traditional biases and social fears -- unless it becomes overwhelmingly apparent that HIV/AIDS does not discriminate and adults see the toll it takes on their children.  In short, the message needs to be: everyone is potentially vulnerable but only a segment of the population is at highest risk due to personal choices that they make.

Until recently, Vietnamese PWAs were essentially hidden from public view.  The official reasoning behind the blackout  was the expressed need to protect PWAs' identities from discrimination and prejudice.  As previously mentioned, human rights issues have not been a significant factor in Viet Nam's AIDS prevention agenda (it remains a controversial political issue).  So it was noteworthy that the conference heard from its only HIV-positive speaker, Do Kim Son, who was described as a, "drug-addict-turned HIV patient [who] wants to become useful to society."   For many of the Vietnamese conferees, his speech was both electrifying and eye-opening.  Blaming his heroin addiction on contact with "American GIs" at Long Binh American military base when he was just 16, Son admitted to continuing to inject drugs after the fall of South Vietnam in 1975.  Making periodic and unsuccessful attempts to quit, he discovered his seropositive status in 1995.  He went through a suicidal period before he "rallied friends of the same fate into the 'Peer Group' to share their sorrow, joy, [and] difficulties in life." Once treated like a pariah by his family and community, Son has the opportunity now to lead by example.  His advice to youth: "Please lead a healthy life, care for your health, and stay away from social vices.  Do not let yourself be infected by HIV like us."   Even if his message fails to dissuade all listeners, his personal story is a powerful tool to convince youth of the reality of HIV/AIDS.  The national media has publicized his story and the public appears to be intensely interested in hearing more about Son and other Vietnamese PWAs -- an extraordinary change in attitude in just a few years.  But would this interest continue once the novelty has worn off?  Could Son's story influence behavioral decisions made by teens?  Experiences in other countries suggest that youth respond best to reality-based prevention information when presented in person.  In the 1995 survey, HCMC young people reported that they wanted to see and hear from PWAs directly -- by more than a three-to-one ratio.   The HCMC Youth Culture House has invited speakers on occasion (to packed audiences).  Undeniably, a nationwide HIV-positive speaker's bureau would prove most effective in reaching unconvinced teens.

If the government decides to legalize the exchange of safe needles for IDUs, it is not because Viet Nam wants to encourage harmful drug use.   Rather, it is due to the egregious impact that contaminated syringes have in transmitting HIV among susceptible teens and young adults.  The shift in official thinking (although not yet implemented as policy) is important and should not be underestimated when analyzing the new push to prevent youth AIDS.  Still it is of consequence that these progressive proposals could be running counter to a more conservative mood that recently appears to be emerging among some older members of the Politburo over the pace and extent of its liberal doi moi policy and political reforms.   Already, key changes in leadership posts due to serious illnesses or political shifts could further alter AIDS prevention efforts over the next few years.  Few observers expect that the national debate would ever deviate from what is obligatory for Viet Nam's economic health and national security.

Nguyen Ngoc Bau of the Ministry of Defense spoke of the intensive anti-AIDS and safer sex training that all military recruits receive currently.  He made an interesting proposal in support of peer education that has benefits for the entire population, "Young army men... can transfer this knowledge to other people in the community including their friends, relatives and local people.  Therefore they are a target group that needs to be protected, but at the same time they are effective and reliable soldiers in the AIDS prevention campaign."   Viet Nam would not be alone in using its military personnel to assist in AIDS prevention efforts.  Currently, American naval observers are involved in HIV surveillance detection in Viet Nam.   When U.S.

Charge D'Affaires Desaix Anderson offered American help to Viet Nam, he emphasized, "US military research units have done extensive work on possible vaccines for HIV/AIDS."   In addition, military health care experts from the two countries met for discussions at the conference although a planned seminar on the topic of the military and AIDS was dropped unexpectedly.

The threat of HIV/AIDS to military preparedness is of real concern to governments internationally.   In Viet Nam, it acts as a powerful incentive to improve official AIDS prevention efforts targeting youth, particularly among socially conservative elements in the leadership.  They are cognizant of Viet Nam's past reliance on the battle-ready strength of its armed forces to protect lives and ensure survival.  Indeed, one of the main reasons why AIDS could prove devastating to the country's ability to defend itself is because it has one of the youngest populations in the world (partially, a legacy of war casualties).  More than 50 percent of all Vietnamese are under 21-years old  and healthy young men are expected to serve time.  Until recently, Viet Nam boasted one of the world's largest standing armies.

Since the end of the American war, it has fought wars in Cambodia and along the Chinese border.  For the nation to feel truly secure, its pool of potential recruits must be HIV-free and its blood supply must be safe on the battlefield.

In toto, the list of recommendations was ambitious.  But this question must to be asked: are they doable?  In HCMC, where the municipality's youth union is recognized as the largest and most active one in Viet Nam, the director of its Social Division admitted, "It is necessary to have a contingent of motivators and counselors who provide counseling about AIDS... [yet] the Youth Union has only 13 teams and groups out of 3,000 wards and communes throughout the city."   On the national level, another VNYU speaker warned there were only, "65 Youth clubs on AIDS prevention... [and] 7 pilot models and condom marketing shops and peer education on AIDS prevention."   Obviously, resources are limited and funding remains a major consideration in implementing the bulk of the recommendations.

Yet  adequate levels of assistance now could make the difference between a serious epidemic -- and a major public health catastrophe.

Dr. Chittick suggested that the PeerCorps concept is the most effective approach economically to slow the spread of teenAIDS  because the VNYU's network of youth volunteers is already in place.  NAC's new chief, Dr. Chung A has indicated that he favors this approach.

Some in the international donor community are not comfortable with providing funds to government entities which promote strict, morality-based ideology over medically-accepted information to fight HIV/AIDS.  Therefore, outside aid is often made conditional upon compliance with rules based on attitudes and beliefs derived from other cultures.  Those requirements, of course, are the prerogative of the individual NGOs and multilateral organizations which formulate them.

However, requirements for receiving foreign assistance could prove problematic for a developing nation like Viet Nam -- especially if it feels pressured to choose between maintaining its indigenous culture or losing needed aid.

Pressure of this kind appears hypocritical if the same conditional actions are not in force in the donors' home countries.  For example, many wealthy nations that contribute funds for AIDS prevention to developing nations: 1) do not allow clean needle exchange for IDUs; 2) prostitution is illegal and CSWs are often arrested and incarcerated; 3) comprehensive sex education with condom availability is not allowed in public schools; and 4) in some cases, human rights abuses of PWAs are overlooked or ignored.  Indeed, a majority of UN members do not follow many of UNAIDS' recommended actions even though a preponderance of medically-sound information strongly suggests the proposals would help to stem the spread of global AIDS.

This double standard is unfortunate and only serves to irritate poorer nations in need of major assistance.  Achieving a consensus of scientific fact and respect for societal traditions would further youth AIDS prevention goals globally.

  While appreciative of the support of multilateral donors, Vietnamese government and party officials have good reason to carefully study the advice of foreign expatriates before undertaking major social changes.  A reluctance to accept new, potentially disruptive customs is understandable.  Outside professionals should be sensitive to issues of cultural imperialism as not all modern ways are good for every country.  In fact, it could be argued that many developing societies are at greater risk of HIV/AIDS currently because of the adoption of outside mores by their impressionable youth.  Mrs. Than stressed, "Public opinion is against drug addiction and easy life styles which are unfamiliar to Vietnam's traditions and customs."   Is it any wonder that Vietnamese are worried when they hear about Western nations' high rates of teen drug use, school violence, sexual initiation at early ages, unwanted teen pregnancies, and youth suicide?  Or the lack of respect for traditions, families, and the elderly?It would be difficult to deny that young Vietnamese are changing their thinking and lifestyles as the direct result of doi moi bringing about economic reforms and greater international interaction.

This cultural shift deeply troubles older Vietnamese.  Mrs. Hang, a representative of MOLISA, one of the more conservative ministries, warned in her speech, "Moral degradation, family instability and the deterioration of community health cause general unrest in society."   Perhaps this warning is prescient if the public were to blame a devastating epidemic on perceived government inaction or the anti-social actions of unpopular groups.  Historically, plagues have been known to foster social disruption.  Already in Nonthaburi, Thailand  and in some central African countries hard hit by AIDS, there have been reports of civil unrest and violence among the populace as a result of frustration and fear.

In a tightly-controlled, highly centralized society like Viet Nam, great concern exists regarding public discontent -- especially if it could reach a stage of critical mass, thereby threatening established institutions.  Major social changes brought about by doi moi worry many in the party hierarchy because of the threat from "peaceful evolution."  New York Times correspondent Henry Kamm recently wrote, " 'Peaceful evolution' is a catchphrase for what the party fears most: that the foreign influences to which it had to open the door from economic necessity will peacefully evolve toward a dilution of its total power."    Already many young people have eagerly adopted "new fashion" and are showing less respect for time-honored customs and authority.  HCMC's unexpected soccer riots in 1995 (officially blamed on anti-social youth) was described by Reuters News Service as "some of the worst civil violence seen in years."   In private discussions older Vietnamese complain that the lawbreakers were urban youth who have become "spoiled" with too much money and time on their hands.

Others worried about an upwardly-mobile generation of self-absorbed young people with little sense of history and past struggles.  As the sexual revolution infiltrates Viet Nam with its health consequences, young people become increasingly vulnerable to HIV.  A serious youth epidemic would put great pressures and demands on adult society and consequently, the nation's leadership.

Thus, issues raised at the conference highlighted the Catch-22 dilemma faced by government leaders -- the need to find a balance between science and morality, between individual empowerment and public order, and between encouragement and castigation of youthful aspirations.  Speeches by top educators pointed up the cross-currents at work in designing better prevention campaigns.  Tran Xuan Nhi, Deputy Minister of Education and Training (MOET) stated, "Another concrete AIDS prevention mention is to praise and present awards to collectives and individuals who have made outstanding achievements in the prevention of HIV/AIDS and social vices.  At the same time, duly punish collectives and individuals which are involved in transmitting HIV and social vices."    Can a policy of this kind be expected to succeed in curbing the youth epidemic?

According to many Vietnamese at the conference there appeared to be no inherent conflict in endorsing a more aggressive AIDS prevention policy  by the VNYU while at the same time insisting that the union help the authorities enforce social evils laws.  A member of the National Assembly said, "The Youth Union can join efforts with cultural and security agencies in limiting the impact of decadent films and cultural works, and prevent drug trafficking."   The question for AIDS planners is whether the VNYU could be expected to do either task well after complaints that the VNYU is "far from meeting young people's demand for communication and education on HIV/AIDS prevention."   Placing too many tasks on the agenda could mean that fewer goals would be met.  Is the Youth Union's main job to educate young people on ways to avoid HIV?  Or is it to eradicate social evils which contribute to the spread of the AIDS epidemic?  Experience suggests that one theme must chosen.

Thus, a number of AIDS educators disagree with the punitive element of current AIDS prevention efforts because they believe adolescent behaviors are ultimately beholden to personal choices, not collective fiats.  One conference speaker recognized this reality by concluding: "We can't use force to control the problem."   It is noteworthy, therefore, that despite strong support for promoting cultural prohibitions against "easy" lifestyles, the rationale behind the social evils eradication campaign was questioned for being counterproductive and ineffectual to HIV/AIDS prevention efforts among youth -- a major turn-around from previously unquestioned policies.

Top government representatives now appear more open to instituting major reforms to fight AIDS.  Underscoring the leadership's urgent desire to find workable solutions to a very difficult issue, the conference witnessed the appearance of many influential ministry spokespeople together with prominent coverage by the mass media.

Importantly, the 8th Party Congress had earlier placed the HIV/AIDS issue on its proactive agenda and changes made in key personnel in the health ministry and NAC have had a positive impact.  But do these events suggest that major social recommendations will be quickly implemented despite longstanding cultural traditions?  Perhaps not as fast as some conferees would prefer to see happen.  Yet keen observers of the local scene suggest that a reasoned, broad-based approach is the best (and only) way of effecting gradual but nevertheless, seismic changes in Vietnamese society.

As a stated goal for the year 2000, NAC has proposed, "reducing the anticipated number of HIV/AIDS infections by 50 percent, and ensuring safe practice among at least 80 percent of sex workers and intravenous drug users."   The optimistic goal would mean cutting Hien's estimate of 300,000 HIV cases to 150,000 -- still a large number but making a potentially devastating epidemic more manageable.  Most of the individuals who would be saved belong to Viet Nam's younger generation with highly productive lives ahead of them.  Clearly, the government is looking to the VNYU and its vast network to play the leading prevention role in the fight against AIDS.

In turn, Viet Nam's educated peer leaders could emerge as the most effective vehicle of change to curb the further spread of HIV/AIDS among all Vietnamese, now and in the future.

An interesting idea that emerged from the break-out sessions was a proposal to find a better term for the anglicized word "AIDS" which is difficult to pronounce for most Vietnamese.  Whether or not the suggestion, "Liet Khang,"  is eventually adapted for common usage, it is important to note that there was great enthusiasm among many of the Vietnamese conferees to select an indigenous phrase for AIDS.  By not embracing foreign terms merely out of convenience or to please outsiders, the conferees showed a spirit to accept HIV/AIDS as their fight through a Vietnamization of the global pandemic.  Certainly, international experiences could be of tremendous value.  Important lessons should be shared among nations.  But until AIDS truly becomes the united struggle of the Vietnamese people, on their terms, then prevention efforts would lack the national resoluteness necessary for self survival in the era of HIV/AIDS.  As Mr. Kim cautioned, "It is especially dangerous that AIDS strikes mainly the 'youth' -- a force with an important role and position in society, with the disease impacting not only on health but directly on the socio-development of the country." Based on official speeches presented at the conference and private conversations afterwards, Viet Nam's AIDS professionals are demonstrating a determination to push society towards a greater understanding of the AIDS threat.  As the epidemic grows more evident daily, the conference served to warn the country that the problem can no longer be ignored -- only aggressive action could prevent future hardships.  Already, changes have been instituted and calls for greater anti-AIDS efforts are legion.  Can it be predicted that the national policy is getting on the right track and the government and party are taking youth AIDS more seriously?

During the author's first workstay in Viet Nam in 1995 he had noted a more cautious approach to the problem among both AIDS professionals and government personnel than was apparent in 1996.  At that time, arguments for maintaining cultural prohibitions against sexual activity among unmarried youth were de rigueur.  Now, changes in official policy and key personnel signaled a new tack.

As the nation's top leadership ages and retires, a younger group of party bureaucrats are waiting to assume new responsibilities.  While it is understood that succeeding generations may not differ in outlook on important issues, it appears that new social activists are emerging politically -- and HIV/AIDS prevention for youth is a top priority for them.  One young NAC member stated, "Because of the big news [about AIDS] we talk more about it.  Now they think it is necessary to listen...so it's not too late."  Viet Nam is not unlike other countries which originally ignored developing local epidemics.  But this fact remains: Viet Nam started its national prevention campaign even before the first case of HIV had been reported.  And the ministries of Health, Education, and the Military have been consistently in the forefront of the early AIDS prevention efforts.  With similar foresight, an effective intersectoral prevention campaign still could be implemented in time.

As far as youth AIDS in Viet Nam is concerned, a remarkable shift in policy has occurred.  The 1996 Youth conference proved to be a convenient forum for all ministries to show their solidarity with a more determined national campaign.  Even the more socially conservative departments exhibited a greater willingness to approach AIDS as an education issue, and not simply as an issue of punishment.  Viet Nam now possesses the critical information necessary to mobilize a major effort to combat youth AIDS.  It also has the existing infrastructure to implement a nationwide campaign.  Whether the Politburo will rise to meet the challenge is still uncertain.  But surely, a lack of will now will only reap tremendous human suffering in the near future.

It is hoped that Viet Nam is ready to tackle the problem in a way that is effective in curbing a larger epidemic without disrupting the core of its cultural traditions of society.  If Viet Nam's national leadership chooses to fight AIDS with a mobilization of resources and citizenry as it has done in wartime, the nation could emerge as an archetype for other vulnerable societies.  Instead of recounting its defeat to an insidious foreign invader, history would record a Vietnamese victory over seemingly insurmountable odds.  This scenario is possible.

But the window of opportunity is closing as many speakers recognized.

Undoubtedly, the coming wave of teenAIDS can only be arrested if forthright action is undertaken now.  Otherwise, Vietnam could join the list of other nations that apparently and sadly, are losing the war to this inexorable global pandemic.

Might future accounts describe the VNYU Conference as a major turning point in Viet Nam's war against HIV/AIDS?  In the opinion of many conferees, 1997 will be the pivotal year.  Vietnamese youth can only hope that their nation gives them the requisite tools to make safe and life-sustaining choices in this time of AIDS.

PeerCorps training in HCMC park begins with a dedicated cadre of volunteers

Appendix D

List of Conference Speakers,

Break-out Session Facilitators and Raporteurs

(in random order)

Vu Trong Kim, Permanent Secretary of the Youth Union Central

Committee

Do Nguyen Phuong, Minister of Health and a Vice Chairman of NAC

Professor Le Dien Hong, a NAC Vice Chairman

Duong Xuan Nam, an Executive Committee member of the Youth

Union Central Committee

Chu Thi Xuyen, Deputy President of the AIDS Prevention Fund of the

VNYU

Tran Dac Loi, Acting Director of the VNYU's Center for International

Development

Dr. Chung A, newly appointed Standing Vice Chairman of NAC

Dr. Pham Gia Khiem, Deputy Minister of Planning and Investment

Nguyen Thi Hang, Vice Minister of Labour, War Invalids and Social

Affairs

Le Ngoc Yen, member of NAC

Nguyen Thi Than, Chairwoman of Committee for Social Affairs of the

National Assembly

Tran Xuan Nhi, Vice Minister of Education and Training (MOET)

Do Kim Son, Head of "Friend Helps Friend"

Vu Trong Thieu, Member of the AIDS Prevention Committee of the

Ministry of Culture and Information

Dang Van Khoat, Head of NAC's Information-Education-

Communication

Dr. Phan Thi Le Mai, HIV/AIDS project staff, UNICEF and Group 2

Facilitator

Bui Chi Cuong, head of the Motivator's Group at Condom Cafe

Nguyen Thi Thuong, member of Central Council of Young Women

Appendix D (continued)

Dr. Nguyen Van Kinh, Hanoi Medical School, AIDS Division, MOH,

and Group 4 Facilitator

Nguyen Thi Ngoc Hong, Director of the Social Division of HCMC

Youth Union

Nguyen Viet Binh, National Committee for Population, Information-

Education

Associate Dr. Nguyen Ngoc Bau, Ministry of Defense, Head of the

Secretariat of AIDS Committee

Dr. Nguyen Van Thuong, Deputy Minister of Health

Nguyen Van Du, Director, Department of Hotels, Vietnam Tourism

Administration

Bui Van Toan, Assistant Field Representative, HealthEd and VNHA

Dr. Nguyen Viet My Ngoc, World Vision Vietnam

Dr. Nguyen Tran Hien, Deputy Director, Dept. of Epidemiology, Hanoi

Medical College, and Group 1 Facilitator

Dinh Hong Minh, Group 1 Facilitator

Dr. Nguyen Minh Tam, Group 1 Raporteur

Lam Phuong Thanh, Group 1 Raporteur

Dr. Bui Dang Dung, Educational Center on Health, VNYU, and Group 2

Facilitator

Nguyen Thi Lien, Group 2 Raporteur

Dr. Duong Duc Chien, Group 3 Facilitator

Dang Khao Trang, Group 3 Facilitator

Nguyen Van Buom, Group 3 Raporteur

Phung Chi Tai, Group 3 Raporteur

Appendix D (continued)

Doan Thi Tien, Group 4 Facilitator

Nguyen Thi Mai, Group 4 Raporteur

Dr. Nguyen Huu Duong, Director of Social Affairs, Parliament Office

Dr. Doan Ngu, Manager UNDP Project, National AIDS Prevention

Committee (NAC)

Vu The Long, Ph.D., National Center for Social Sciences and Humanities

of Vietnam

Nghiem Xuan Tue, Director, Programs for Displaced Children, MOLISA

Dr. Le Dang Ha, Director of National Institute for Clinical Research in

Tropical Medicine

Le Ngoc Hai, Assistant Project Officer, UNAIDS/UNICEF

 Appendix E

Break-out Sessions' Recommendations:

The following are among the key recommendations (from either

all or some of the four sessions):

1) More effective education materials should be designed that

specifically target youth needs and concerns.

2) All relevant materials should be developed from research

based on direct input from youth themselves using proven qualitative

and quantitative methodologies.

3) Prevention arguments should be based on medically-sound

information that answers questions honestly and openly.

4) Behavioral intervention strategies should be designed to

convince young people to choose to postpone sexual initiation to a later

age, and then to avoid unsafe sex.

5) Simplistic, moralistic arguments should not be the first line of

attack.

6) Scare tactics are not effective for long-term behavioral

interventions and should be used sparingly.

7) Messages should be designed to specifically target different

sub-groups of youth (i.e., girls, boys, street kids, laborers, rural youth,

etc.).

8) It is the government's belief that the VNYU is the most

appropriate organization to carry out training and education efforts for

youth because of its proven history of accomplishments and established

countrywide network.

9) The central government should continue to grant more

autonomy to the VNYU's AIDS prevention efforts.

10) A greater share of national funds should be allocated to

youth AIDS campaigns.

11) International donor organizations should specifically

earmark HIV/AIDS prevention funds for VNYU use.

12) Intersectoral disfunction is a serious problem that must be

corrected to improve the delivery of prevention information to youth at

risk.

Appendix E (continued)

13) In the fight against youth AIDS, aggressive, medically-

designed interventions that target high risk behaviors, not high risk

groups, should take precedence over social evils eradication efforts.

14) The Fund for AIDS Prevention Activities (FAPA) should be

given a larger and more independent budget to finance its activities.

15) The VNYU Central Committee should give more autonomy

to local unions and clubs to implement their own activities.

16) A network of youth peer educators should be organized at

every level.

17) Peer AIDS teachers must receive excellent medical training

before reaching out to their peers.

18) Peer educators should be a mobile "shock force" in service

to the nation and their communities, especially in rural and

mountainous areas where AIDS education is not readily available.

19) Modest stipends should be provided to assist in the support

of traveling peer educators.

20) A convincing rationale should be devised to support

traditional and cultural prohibitions against premarital and commercial

sex.

21) Youth must accept their social responsibility to help the

country protect its well-being by individual example and community

action.

22) Youth should assist families and communities in the care of

PWAs.

23) Youth should be knowledgeable about AIDS so that public

fear of the casual transmission of HIV could be eliminated.

24) All Vietnamese share the same rights as citizens (including

PWAs).

25) Local unions and community clubs should provide more

wholesome recreational activities for youth with AIDS awareness as

part of the activities.

26) Cultural and sports events (such as concerts, plays, and road

races) should be organized to attract youth attention to the anti-AIDS

message.

Appendix E (continued)

27) Local organizations at the ward (urban) and commune

(rural) levels should take the lead in building sustainable programs

independent of centralized management, including local fundraising.

28) The nation's media should focus more attention on the

growing problem of youth AIDS to better educate the general

population.

29) VNYU media organs should disseminate more real life

information about young PWAs and their personal stories.

30) A PWA speakers network should be organized to bring

firsthand information about the reality of HIV/AIDS vulnerability into

classrooms, clubs, community meetings, and as a vital part of street

outreach.

31) The VNYU should increase efforts to promote the use of

condoms among youth as a safer sex technique to prevent HIV

transmission.

32) More dependable supply and distribution outlets must be

developed and subsidized to increase the dissemination of inexpensive

and quality condoms.

33) Local youth unions should form stop-AIDS awareness clubs

and "condom cafes" where youth could get safer sex information,

especially in areas where there are university students and young

laborers.

34) The Party and local People's Committees should consider

adopting clean needle exchange to stop the spread of HIV among IDUs

and into the general populace.

35) "Letter boxes" could be placed in public areas (parks,

markets, schoolyards, etc.) to encourage youth to anonymously solicit

prevention information, with public boards posted with the answers.

36) Local youth unions and clubs should provide one-on-one

counseling to both young people at risk and PWAs, in person or by

telephone (especially in urban areas where this action is more practical).

37) AIDS prevention messages on public billboards and posters

should be made more appealing, less wordy, and more understandable

for all people, regardless of level of education.

38) Adults should do all in their power to protect the younger

generation from HIV/AIDS

Endnotes

For additional copies of this report please send US $10 to:

Dr. John B. Chittick

TeenAIDS-PeerCorps

43 Charles Street

Boston, MA 02114, USA

Telephone: 617-742-1325

FAX: 617-742-3499

or email: chittick@tiac.net

 

 

 

Dr. Chittick specializes in youth HIV/AIDS prevention

programs and delivered a speech on the topic at the 11th International

Conference on AIDS in Vancouver in 1996.  He is an independent

consultant working primarily with international NGOs and

governments on AIDS education initiatives. Harvey V. Fineberg, Dean

of the Harvard School of Public Health recommended his book, The

Coming Wave of HIV/AIDS in Vietnam: "Thank you for sharing with

me your searching, sensitive and remarkably comprehensive report on

HIV/AIDS in Vietnam. Your 23 recommendations, if heeded, will surely

help protect the health of the people of Vietnam.  Congratulations on

your very impressive achievement."

 

 

Dr. Chittick is currently completing a new book: Teen, Sex, and

AIDS for parents of teens. In addition, he devotes a substantial amount

of time training inner-city teens to be PeerCorps teachers for other

minority youth in and out of school (similar to his peer trainings in

Vietnam, Japan, and the Dominican Republic).  For more information on

his work and the PeerCorps training concept, visit his internet site

which focuses exclusively on the coming wave of teenAIDS and the new

risk to the world's sexually-active teenagers.  The worldwide web

address is:

 

http://www.teenaids-peercorps.com

 

Please note that the footnotes and bibliography that accompanied the origianl

file can be obtained from:

 

Dr. John B. Chittick

TeenAIDS-PeerCorps

43 Charles Street

Boston, MA 02114, USA

Telephone: 617-742-1325

FAX: 617-742-3499

or email: chittick@tiac.net