Field Note

Vietnam's Condom Revolution

By Annmarie Christensen
Director of Publications & New Media
Global Health Council

For a country as steeped in tradition as Vietnam, the debut of the country's first condom vending machine in Hanoi's Lan Chin Beer Garden several months ago was a major media event.

Approving socially-marketed condoms marks a major shift for the communist government, which must approve all forms of reproductive health methods and messaging. And it is one of many signs that Vietnam's government is waking up to the knowledge that HIV/AIDS has swept from traditionally high-risk groups to threaten its mainstream population.

Crude street signs dotting the roads in Hanoi's Old Quarter show scare-tactic cartoons of a skull, naked woman and the words HIV – attesting to the long-standing perception that AIDS is both a contributor to and result of 'social evils' like commercial sex work and drug addiction. But, increasingly, the nation is liberalizing its attitude towards sexual education and sexually transmitted infections (STIs). There also have been increasing signs of top-level political commitment to face the country's growing epidemic. In August, Vietnamese President Tan Duc Luong met with several infected patients at Bach Mai Hospital, and was quoted as saying "All of us should have a correct attitude and not discriminate against HIV/AIDS carriers."

Although Vietnam's evolving response to HIV/AIDS has been slowly coming on its own, it has now been hastened by the June announcement that this Southeast Asian nation was selected as the 15th recipient of the US$15 billion promised by the U.S. government's President's Emergency Plan for AIDS Relief (PEPFAR). In addition to the US$8 million Vietnam was already receiving from the U.S. government, PEPFAR will add an additional US$10 million this year to the country's AIDS effort.

Vietnam's ministry of health says it has recorded more than 81,000 cases of HIV, out of its total population of 76 million; but many health officials estimate the number is closer to 200,000 infections. Although the first reported case of HIV didn't emerge until 1991, from 1999-2001, the country's HIV/AIDS prevalence rate doubled.

Vietnam has been diversifying its family planning program as one critical means to combat the virus. For decades, women have relied on intra-uterine devices (IUDs) for contraception, due mainly to the strong campaigns conducted in Vietnam in the 1980s to promote their use, followed later in the 1990s with a government campaign for sterilization. The government's programs were so successful that 80 percent of women are now using IUDs for contraception, and they are wary of trying other modern contraceptive methods.

But with the rapid rise of HIV, the government is now doing an about-face. Officials are trying to promote condoms, which would provide Vietnamese with dual protection against STIs and unwanted pregnancies. But, as with any bureaucracy, change is slow in coming.

Pathfinder International has been in Vietnam for the past 10 years, working with the government to improve reproductive health strategies. Le Ngoc Bao, senior program officer with Pathfinder in Hanoi, says there is a lot of bias toward IUDs because they are inexpensive and last for five years. But, the government realizes that it must diversify its methods of family planning. "The government realizes the importance of integrating HIV and reproductive health programs," he said.

Currently in Vietnam, it is the National Committee of Population, a cabinet-level post, which controls the contraceptive methods promoted throughout the country. Pathfinder is working with this committee, as well as with the ministry of health, which must sanction all technical programs in the country, and owns all the health facilities.

Pathfinder is using a three-pronged approach to change the country's reliance on IUDs: diversify its methods, promote education and identify key service-delivery programs.

During the first phase, four of Vietnam's 61 provinces were targeted for improved family planning training by introducing best practices that included the entire range of modern contraceptive options. At the end of 2003, Pathfinder had trained 2,300 health providers and has five to seven trainers in each province.

Although condoms were introduced into Pathfinder's trainings, ensuring they were actually part of practical applications was a larger challenge. Not only did the Vietnamese government not have the financial resources to provide condoms to its populace, but there were also geographic distribution challenges, with the country's only two condom factories located in the south, in Ho Chi Minh City. Another problem has been that the local provinces were given control of running their training programs, and were apportioned money from the central government to purchase condoms for their local communities. But, according to Le Ngoc Bao, local officials have used the money designated for condoms for other purposes that they deemed more important, such as training. Family Health International estimates that there was a shortage of 80 million condoms in 2000 in Vietnam.

Also, cost and availability, especially in rural areas, is a factor. Since the country's economic renovation – called doi moi – began in 1986, health care has grown in cost, and private clinics are replacing many of the government-run facilities. Although this has increased the availability of contraceptives, cost is a hurdle in a country where the GDP averages US$400 per year in rural areas, and US$1,000 in the cities.

The government's family planning campaign has been aimed mainly at married women, to the exclusion of young men and women. An increase in premarital sexuality has led to more unwanted pregnancies and a staggering abortion rate among young women. Bao says there are one million abortions per year in Vietnam – one of the highest rates in the world – even though abortion is not among the government's official reproductive health strategies.

As the Vietnamese government wants a national reproductive health curriculum in its schools, Pathfinder is also helping to train students about family planning, and STIs such as HIV.

With this marked shift in attitude, the government developed a national AIDS policy this year that takes a multisectoral approach on HIV/AIDS, involving numerous government agencies. One of the key advances in this framework is the government's codified attempt to destigmatize HIV/AIDS, and to remove its longstanding association with social evils.

Given the difficulty the government has had in driving condom distribution, the nongovernmental organization DKT International is now taking the lead. Lin Menuhin, DKT's deputy director in Hanoi, says that condoms used to be promoted in a negative fashion in Vietnam. "Basically, the message was 'use condoms or you will get that nasty HIV,' which added to the stigma," he said.

Now, Menuhin says, the message they are crafting is more positive, and targets youth with the idea that condoms can and should be a part of their lifestyle. "We need them to use condoms just as they use toothpaste," he said. DKT's social marketing team has brought in a new line of condom flavors and colors that are 'hipper'. Actors are being recruited to promote the condoms, and DKT is trying to get commercial airtime on popular shows. They are even trying to launch condoms at fashion shows, which are popular in Vietnam. Still, stigma persists, and some models have refused to participate. Newspapers, he said, are no problem because by and large there is good coverage of the HIV/AIDS issue.

Menuhin says they have also hired 55 'sales motivators,' who work on commission. DKT warehouses the condoms and is in charge of the sales force, which is staffed in both North and South Vietnam. The sales force targets karaoke clubs, bars, nightclubs and hotels in an effort to focus on traditionally high-risk groups. In Vietnam, both injecting drug users and sex workers face the threat of forced rehabilitation and, due to the need for secrecy, are often difficult to communicate with. According to UNAIDS, the infection rate for sex workers is 5.2 percent, and among intravenous drug users, 31 percent.

DKT International markets its OK and Super Trust condom brands and NewChoice oral contraceptives in more than 10,000 pharmacies throughout Vietnam. But, even so, people are reluctant to openly purchase these items because of the country's traditional values and the stigma many feel for purchasing them.

Still, the cost of condoms is a barrier, even though they cost as little as 200 dong each (US$1 = 15,000 dong), as all contraceptives used to be free and distributed by government clinics. In an effort to promote their use, the socially marketed condoms are being sold below cost, and subsidized by the UK's Department for International Development, DKT, the Asian Development Bank, UNAIDS, the Norwegian government, and others.

Despite all of the difficulties DKT, Pathfinder and the Vietnamese government have faced in their efforts to broaden dual protection and promote condom use, Menuhin remains optimistic. "We hope to ramp up 20 vending machines this year," he says.

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