Type of Review: Project Completion Review
Project Title:
HIV/AIDS Prevention Programme
Date started:
March 2009
Date review undertaken: November 2013
Instructions to help complete this template:
Before commencing the review you should have to hand:






the Business Case or earlier project documentation.
the Logframe
the detailed guidance (How to Note) - Reviewing and Scoring Projects,
the most recent annual review and other related monitoring reports.
key data from ARIES, including the risk rating
the separate project scoring calculation sheet (pending access to ARIES)
Two scores are produced at project completion - one based on achievement of the outputs and one
based on achievement of the outcome. You should assess and rate both the individual outputs and the
overall outcome using the following rating scale and description:
Output Description
Outputs substantially exceeded
expectation
Outputs moderately exceeded
expectation
Outputs met expectation
Outputs moderately did not meet
expectation
Outputs substantially did not meet
expectation
Scale
A++
A+
A
B
C
Outcome Description
Outcome substantially exceeded
expectation
Outcome moderately exceeded
expectation
Outcome met expectation
Outcome moderately did not meet
expectation
Outcome substantially did not meet
expectation
Introduction and Context
What support did the UK provide?
The HIV Prevention Project supports the Government of Vietnam to implement the National Strategy
on HIV/AIDS and scale up harm reduction. It helps deliver DFID’s commitment in the Vietnam
Operational Plan to keep the HIV prevalence rate below 1%. It helps Vietnam accelerate progress
towards achieving the Millennium Development Goal of reversing the spread of HIV/AIDS by 2015 one of the two off-track MDGs of Vietnam. It also contributes to improved coordination of resources
and policies on the national response to HIV/AIDS.
The project aims to do this by reducing transmission of HIV/AIDS among vulnerable populations,
including injecting drug users (PWIDs), female sex workers (FSWs), men who have sex with men
(MSM), and people living with HIV/AIDS (PLWHA) and their clients and sexual partners and between
these groups to the general population. It focuses on scaling up harm reduction to curb the spread from
high risk groups as the epidemic in Vietnam is still concentrated in this population. The Programme is
jointly funded with the World Bank, to which DFID will contribute £23.5 million in total (in addition to
significant DFID funding of £17m to HIV prevention in an earlier project). It covers 32 provinces where
HIV prevalence is highest out of 63 provinces.
1
The project was originally planned to start in mid-2009 and end in December 2012 for the original
budget of GBP 17.3 million, with crucial HIV prevention activities handed over to programmes funded
by other donors (mainly the Global Fund) and by domestic resources (the National Targeted
Programme - NTP for HIV). However, Vietnam faced an unprecedented and unexpectedly rapid loss of
donor resources. The Global Fund cancelled Round 11 and delayed on granting phase 2 of Round 9,
leaving a significant funding gap for the first months of 2013. At the same time the US Government’s
PEPFAR programme reduced its financial commitments to Vietnam much faster than originally
planned. Furthermore, Vietnam’s National Assembly cut financing to the National Targeted
Programme by 50% due to Vietnam’s own domestic economic problems.
To help avoid a sudden interruption to prevention activities in 2013 to sustain the project impacts, DFID
decided to add GBP 6.2 million and one year extension for the project to bridge funding for some
essential activities in harm reduction for 2013, with expectations that Global Fund can take over from
mid – 2013 onwards. This increased the total contribution to the programme to GBP 23.5 million.
What were the expected results?
At the impact level, the project ensures that HIV prevalence among most-at-risk populations in Vietnam
continues to decline and maintained at low levels, i.e. keeping the prevalence rate among adults aged
15-49 at below 0.5%; the prevalence rate among people who inject drugs below 13%; the prevalence
rate among female sex workers below 3% and the prevalence rate among men have sex with men below
17%.
It aims to scale up and institutionalize best-practice models of HIV and AIDS control which can then be
sustained in the longer term by the Vietnamese Government. It is not possible to measure prevalence
rates accurately every year, but these will be measured in due course through periodic surveys.
Annual performance of the project is measured in terms of maintaining low levels of high-risk behaviours.
At the outcome and output levels, there have been two set of targets. The first were the targets set in the
beginning of the project in 2009 with target year of 2012. The second was set in 2012, when the project
was extended for one year with target year of 2013.
At the outcome level, specific targets for the original project, set in 2009 are: 1) consistent use of clean
needles by people who inject drugs maintained at over 70% in the 32 participating provinces;
(2) consistent use of condoms by female sex workers maintained at over 80% in the 32 participating
provinces. These targets have been agreed with the World Bank and the Government in the beginning of
the project in 2009 in a common monitoring framework.
In 2012, when extending the project, we revised the targets and added one new indicator:
1) consistent use of clean needles by people who inject drugs maintained at over 80% in the 32
participating provinces;
(2) consistent use of condoms by female sex workers maintained at over 90% in the 32 participating
provinces; and
3) consistent use of condoms by men who have sex with men brought up to over 60% in the 10
provinces targeted for this work.
This set of new targets was not agreed with the Government and the World Bank. Setting higher
outcome targets was based on the fact the project has already achieved its original target in 2012.
At the output level, we expected to distribute 60 million condoms and 60 million needles to PWID, SWs
and MSM and 2400 methadone patients by 2012. In 2013, the targets were 82 million needles, 102
million condoms and 2200 patients under methadone maintenance treatment (MMT). The reason for
reducing MMT patients target in 2013 was because in 2012, when the logframe was revised to reflect the
extension period, actual MMT patient was only 2000.
2
While setting up new outputs targets is valid, changing the outcome targets has proven not to be
rational.
 First, outcome takes time to be achieved, especially when it relates to human behavioural
changes (safe sex and safe injection habit)
 Second, one year extension aimed to support a transition period for project activities to be taken
by NTP and Global Fund. The project focused on maintaining key activities and gradually
transferred its activities to the Globlal Fund project for sustainability. It was not aimed to scale up
any activities or deepen any intervention. Hence outcome targets practically could not be
increased.
 Third, the new set of outcome targets has not been agreed with the Government and the World
Bank.
We therefore propose to assess the results of this project against the original impact and outcome
targets and revised output targets. The follow review is done on that basis.
What was the context in which UK support was provided?
Epidemiological context
The first HIV case was reported in Ho Chi Minh City (HCMC) in Vietnam in 1990 and a HIV sentinel
surveillance system was instituted in 1994. As of 31 May 2013, HIV cases had been reported in all 63
provinces and cumulatively 213,413 reported HIV cases. Currently estimated 190,795 people are living
with HIV (PLWH), 74,401 of whom are receiving antiretroviral therapy (ART), and an estimated a total
of 65,133 AIDS-related deaths. The HIV epidemic in Vietnam is a concentrated one. Prevalence
among pregnant women attending antenatal care is 0.19%, whereas the overall adult HIV prevalence
(ages 15-49 years) is 0.33% in 2012. However, the epidemic comprises many sub-epidemics across
the country and remains concentrated primarily among three most at-risk populations: people who
inject drugs (PWID) (predominantly men), female sex workers (FSW) and men who have sex with men
(MSM). According to 2012 sentinel surveillance data, HIV prevalence among PWID decreased to
11.6% in 2012 from 29% in 2001-2002. Prevalence among FSW was 2.7%, down from 6.0% in 2002.
Integrated Biological Behavioural Surveillance (IBBS) 2009 data indicate that prevalence among MSM
was 16.7% (6). There are twice as many men diagnosed with HIV as women. New HIV cases reported
in women represent 34% of newly reported cases (4), reflecting a slow but steady increase of HIV
transmission from highly at-risk men, such as married male PWID and MSM, to their female partners.
Political, institutional and social context
Overall leadership and coordination of Vietnam’s response to HIV and AIDS is provided by the National
Committee for AIDS, Drugs and Prostitution Prevention and Control, chaired by one Deputy Prime
Minister. Currently, Deputy Prime Minister Nguyen Xuan Phuc is steering a progressive path, gradually
dismantling the old “social evils” agenda (which focused on removing drug users and sex workers from
society by locking them up in detention centres for forced rehabilitation) and promoting more modern
(and proven effective) methods. The new law no longer requires sex workers to be detained, but
provides for their voluntary rehabilitation. Since 2012, rehabilitation centres for sex workers (05
centres) have been abolished. Significant improvements in rehabilitation centres for drug users (06
centres) have been made towards making it more voluntary detoxification than compulsory detention.
The Government is now promoting the rapid scale-up of methadone maintenance therapy and
community-based treatment and rehabilitation of drug users. The project, working together with the UN
agencies and US Government agencies, continues to advocate for more effective approaches and a
greater level of domestic resource allocation.
3
Of the three high-risk behaviours (commercial sex, injecting drug use and anal sex between men), sex
work by FSW is the least stigmatized in Vietnamese society. Despite there being no law against sex
between consenting adult men, all kinds of homosexual behaviour are highly stigmatized in Vietnam.
Until very recently the majority of Provincial AIDS Centres were in denial about the existence of gay
communities in their provinces. The hidden nature of MSM communities makes the sub-epidemic
among them much more dangerous. Given the high rates of HIV prevalence recorded among MSM,
developing effective ways of working among MSM needs to be a high priority in Vietnam’s HIV
prevention strategy.
HIV prevention work in Vietnam
DFID and the World Bank have been the main financiers of HIV prevention programmes among the
highest risk groups in Vietnam. DFID started funding the £17 million “Preventing HIV in Vietnam
Project” in 2003 with the purpose of reducing vulnerability to HIV infection in Vietnam primarily through
harm reduction programmes involving increased availability of condoms and needles/syringes, coupled
with behaviour change communication and advocacy work. The project covered 21 provinces. This
project ran till 2009 and was found at the time of end-of-project evaluation to have been highly
successful.
The World Bank launched its own “HIV/AIDS Prevention Project for Vietnam” in 2005 with a credit of
US$38.5 million. This provided more comprehensive support for a range of prevention and treatment
activities in 18 provinces, some of which overlapped with the DFID provinces, as well as national
components on policy studies and research, training, and innovation.
In 2009 when DFID was designing a follow-on project, it was decided to add resources to the existing
WB project, instead of having another stand-alone DFID project. DFID added another £18.3 million
grant to the WB project, which was extended until the end of 2012. The two sets of provinces were
combined, making 32 provinces. These include most of the provinces with highest HIV transmission
rates. A requirement of the DFID funding was that 60% of the combined project resources must be
allocated to harm reduction activities. The project is run through a Country Project Management Unit
(CPMU) based in the Vietnam Association for HIV/AIDS Control (VAAC) in the Ministry of Heath.
Vietnam also currently receives significant funding for HIV and AIDS programmes from the US
Government (PEPFAR) and from the Global Fund (Round 9). PEPFAR is now reducing its budget in
Vietnam much faster than originally planned, and is currently transitioning from a focus on programme
delivery to a focus on technical assistance.
Domestic funding for HIV and AIDS is very low, at around 13% of the total funding for HIV/AIDS in
Vietnam, less than half of which is provided by central government. The Vietnam Authority for
HIV/AIDS Control (VAAC) lobbied successfully with the Government leadership to have HIV/AIDS
included as a new National Targeted Programme from 2012. However, the National Assembly cut
back the proposed budget for 2012 by 50% due to nationwide budget constraints. Funding gap for
HIV/AIDS in 2014 will be even more serious as the Government only allocated VND 84 billion (around
GBP 3 million) against VND 300 billion proposed state budget while donor financing is fast decreasing.
Section A: Detailed Output Scoring
Output 1: Needles and syringes provided to people who inject drugs, linked to on-going
behaviour change communication activity
Output 1 score and performance description: A, output met expectations
Summary
4
The project is the biggest one in Vietnam on harm reduction, targeting distribution of needles and
syringes to injecting drug users and condoms to female sex worker and MSM. The project used a
number of channels to make needles available to drug users. These include peer educators, commune
health clinics, fixed boxes at certain places and pharmacies. The distribution is coupled with
behavioural change communication. Result is very positive.
Progress against expected results:
On average, each PWID received 152 clean needle-syringes per year from needles and syringes
programme (NSP) funded by DFID/WB. Out of the 32 DFID/WB project provinces, 26 demonstrated a
declining trend and six stabilized, none shifted to a higher prevalence category. HIV prevalence among
PWID at the national level declined from 21.3% in 2003 to 9.6% in 2012. If the trend continues, it is
expected that by 2020, prevalence in PWID by 2020 will be 6.2%1.
Indicator 1: Number of needles and syringes distributed
Target: 18 million for 2012 and 22 million for 2013
Progress: achieved
The actual number of distribution for 2012 is 23 million and first six month of 2013 is 10 million. (Final
figure for 2013 will be available in early 2014). This is an overachievement of target, evidenced by
2012 figure. For 2013, the actual distribution only started in April 2013, due to some delay in finalising
the extension agreement.
Year
2012
2013
Target
(number of needles distributed)
18 million
22 million
Actual
23 million
10 million (distributed in 3 months,
from April till June 2013)
The project has adopted varied and creative channels for distributing needles, from pharmacy
vouchers to exchange for needles to fixed and mobile boxes of needles located at places accessible at
all time for IDUs.
In the last 6 months the project is focusing on transition and closing the project, mainly gradual transfer
of project activities to other projects (Global Fund, Life-Gap) and the national targeted programme.
Indicator 2: Percentage of provincial annual work plans meeting targets on clean needles
distributed
Target: 80% for 2012 and 85% for 2013
Progress: achieved
The 2012 statistics indicates that 100% of the provinces achieved their annual plans on clean needles
and syringes distributed2.
The 32 project provinces made significant progress in implementing their approved work plans and met
targets. The commitment of local authorities (People’s Committees) ensures the continuity of needles
provision to promote safe injection among PWIDs throughout the project.
In 32 provinces, number of communes implementing harm reduction interventions for PWID increases
gradually year on year.
1
2
Impact Evaluation Report (New South Wales University – 2013)
CPMU report October 2013
5
Year
2006
No of
287
communes
2007
2008
2009
2010
2011
2012
534
634
1094
1472
1593
1823
It is estimated that IDUs in the targeted provinces received an average of 152 clean needle/syringes
per year from needle and syringe programs (NSPs) funded by DFID, at an annual per-capita
investment of US$25.40 per PWID. This is considered to be mid-level coverage according to
WHO/UNODC/UNAIDS technical guidelines. However, this level (152 needles/PWID/year) although
very good compared to most countries in the region and around the world, falls short of the high
threshold target of 200 needle-syringes per IDUs per year3 .
The challenge in the future is sustaining the availability of needles and syringes to PWID after the
project ends. Both domestic and external budget for harm reduction is severely cut. There has not
been viable plan to fill in the gap in the short term. The project was able to procure 16 million4 of
needles to be distributed in 2014 to allow additional time for the Government to seek new sources for
harm reduction.
Impact Weighting (%): 35%
Revised since last Annual Review? NO
Risk: Medium
Revised since last Annual Review? No
Output 2: Condoms provided to men and women who engage in high risk sex, including
commercial sex workers and their clients, men who have sex with men and people who inject
drugs, linked to on-going behaviour change communication activity.
Output 2 score and performance description: A, performance met expectations
Summary
The project makes condoms available to high risk groups to ensure safe sex through two key channels:
free distribution to sex workers and social marketing condoms through pharmacies and non-traditional
outlets, such as hotels, guest houses, karaoke bars etc.
In the free distribution programme, it is estimated that FSW received an average of 326 free condoms
each year. Condom distribution among FSW exceeded the World Bank harm reduction standard target
of 240 condoms per year per FSW.
The condom social marketing program has started in project provinces since April 2012. As of
December 2012, 39,360,000 condoms, equivalent to 93,6% target were sold out5. VIP Plus, the
program’s brand name of condoms has been known to the distribution agencies and consumers. It is
significant that the percentage of social marketing condoms distributed through the non-traditional
channel has reached 49,31% against the targeted 50%.
3
Impact Evaluation Report (NSWU 2013)
Project Completion Report by CPMU (October 2013, ppt, page 48)
5 Project Completion Report by CPMU (October 2013)
4
6
Progress against expected results
Indicator 1: Number of condoms distributed through non-traditional outlets
Target: 18 million in 2012 and 16** million in 2013
Progress: exceeded.
In 2012, actual sale through NTOs is 19.2 million, exceeding the plan of 2012. The total distribution
through NTO is 17.4 million in 2013.
Before 2012, condoms were distributed for free to FSW, coupled with behavioural change
communication. Since 2012, in addition to free distribution, condoms were made available through
social marketing of the VIP plus – a brand owned by the Government as the result of the DFID-WB
supported project.
Social marketing of VIP plus condoms is going well. There is high appetite and absorption of VIP plus
condoms in the market, where there are many other available brands. Hence the project is
recommending the Government to let the private sector drive the marketing and commercialising
without further subsidising, to save the scarce resource for other prioritised needs.
** There is an error in the logframe. In the logframe, the target for this indicator was 42 million
condoms distributed through NTO in 2013, based on the fact that in 2012, nearly 40 million condoms
were distributed. However, out of the total number distributed, only 50% to be distributed through
NTOs, as a target agreed by DFID, WB and the project. Hence, it should be only 21 million, instead of
42 million. In addition, due to delay in finalising the project extension agreement, activities could only
started from February 2013, reducing time for implementation. The project set the target for condoms
distribution for 2013 as 32 million, with 50% to be distributed through NTO. This should have been
recorded earlier this year as the new output target in the logframe (16 million), but was overlooked.
Indicator 2: Percentage of provincial annual work plans meeting target on condoms distributed
through non-traditional outlets
Target: 90% in 2012 and 90% in 2013
Progress: 82% - nearly achieved
All the 32 provinces are active in condom distribution programme. Number of participating communes
also increases yearly
Year
2006
# of
176
communes
2007
310
2008
322
2009
626
2010
1079
2011
1128
2012
1229
Most of the provinces have met the targets in condom sold. Two out of 32 provinces (Lang Son and
Son La) could not meet their targets (only 8% and 24% completed respectively). 4 other provinces
(Cao Bang, Lai Chau, Hai Phong and Kien Giang) met from 50% to 70% of the targets while the
remaining 26 provinces fully met the targets (82%).
There have been a lot of activities to support the roll out of social marketing of VIP plus brand. This
ranges from reaching consensus with owners of entertainment venues like hotels and guest houses to
introduce VIP Plus to focus group communication for PWID, FSW and MSM about safe sex behaviours
and HIV/AIDSs, from mass media communication to promote VIP Plus to marketing with promotional
items. As a result, there is a good uptake of VIP Plus condoms in the market.
However, at the time being, the challenge is shifting from free condoms to social marketed condoms,
and later on fully commercialised condoms. In addition, if the Government couldn’t let the private sector
own and commercialise VIP Plus by themselves, it would be difficult for the Government to sustain the
7
budget to subsidise the procurement of condoms.
To help partially address this issue, the project has recommended the Government use the
proceedings from selling social marketed condoms (VND 15 billion in 2012 and expectedly VND 11
billion in 2013, equal to GBP 450,000 and GBP 330,000 respectively) to buy new condoms for
continuous social marketing activities in coming years. This will support a transition from subsidy to full
commercialisation of condoms, accompanied by continuous awareness raising.
Impact Weighting (%): 25%
Revised since last Annual Review? NO
Risk: Medium
Output 3: Methadone provision to PWID
Output 3 score and performance description: A, output met expectations
Progress against expected results:
Summary
The project has made a great effort in collaborating with other donors and networks to provide
Methadone Maintenance Treatment (MMT) for PWID. Policy advocacy has been successful in assuring
the Government’s commitment in supporting MMT during the transition period before the withdrawal of
donor funding. Decree 96 and Circular 163 on Methadone Maintenance Treatment were issued in
November 2012 and 2013, relaxing eligibility criteria and simplifying application processes; not
arresting PWIDs who are using MMT services and therefore could encourage and enable more PWIDs
to access MMT clinics.
The main challenge ahead is the financial resources and capacity for the actual expansion and
maintenance of the program.
Indicator 1: Number of new patients enrolled in methadone maintenance treatment (MMT)
Target: for 2012 is 2000 MMT patient and 2013 is 2200.
Progress: on track to be achieved
In 2012, the number of patients reached 1,927. Figure for 2013 is not yet available until January 2014.
There are 11 methadone treatment places located in 7 provinces, Hai Phong, Thanh Hoa, Nam Dinh,
Thai Nguyen, Yen Bai, Lai Chau and An Giang.
The review of MMT programme has provided positive evidence of its effects. 90% of MMT patients
comply with treatment plan after 12 months. After 3 months with MMT, only 10% of patients still use
drugs. The health and life quality of MMT patients are significantly improved. The rate of crimes among
this group sharply reduces.
Impact Weighting (%): 10%
Revised since last Annual Review? NO
Risk: Low
8
Output 4: Policy and capacity strengthened to support the national response to HIV (implemented
through provincial work plans)
Output 4 score and performance description: A+, output exceeded expectations
Summary
The project has supported policy improvement and capacity building as one key component. This
includes training and awareness raising for policy makers and health workers, consensus building
among central and local authorities to support HIV/AIDS response, formulation of policies, regulations
and technical documents on HIV/AIDS.
DFID/WB programmes significantly increased organizational capacity and resulted in a more skilled
and professional prevention workforce. Health workers reported acquiring new skills through project
training activities in planning, project management and coordination, report writing and monitoring and
evaluation
Progress against expected results
There has been a number of policy improvements since the project started in 2009. Highlight included:

In 2009, a new law, the Law Amending and Supplementing a Number of Provisions of the
Criminal Code No. 37/2009/QH12 (13) removed Article 199 on the illegal use of narcotics from
the Panel Code. The revised code defined drug use as a social problem, and drug addicts as
patients rather than criminals, and removed the legal basis for arrest and imprisonment of drug
users for drug use.

2010: The Vietnamese government announced its decision to expand access to MMT for
80,000 people in 30 provinces and cities by 2015.

2012: The National Assembly passed a new Law on the Handling of Administrative Sanctions
which effectively ended the practice of detaining sex workers in ‘05’ centres. This Law also
allowed drug users who were subject to compulsory treatment in drug detoxification centres to
have court hearings on their cases and legal representation at the court.

Over the past 10 years (2003-2013), an additional 118 regulatory and technical instruction
documents were issued by the Prime Minister, Ministries, and mass organizations to support
the implementation of HIV and harm reduction interventions through strengthening government
leaderships, enhancing the HIV prevention and control system, and mobilization of internal and
external resources and participation of the public. Notably, the inter-ministerial Circular No.
03/2010/TTLT-BYT-BCA issued on 20/01/2010 by the MOH and the Ministry of Police
stipulated the issuance, provision, management and use of work permits/identify cards for
outreach workers involved in harm reduction activities. The provision of this card recognised the
activities of outreach workers and safeguarded them from being arrested by local police.
Moving ahead, the translation of these policies and legislations into practice has been facing a number
of challenges: (1) inconsistencies between legal documents; (2) reluctance and scepticism of the
government authorities and law enforcement sectors; (3) continued reliance on compulsory
incarceration of drug users; and (4) shortage of skilled human resources
Indicator 1: Percentage of annual target met on capacity building
Target: 90% in 2013
Progress: fully achieved
9
Most of the training was carried out in 2012. By the end of 2012, close to 100% of all staff at all levels
involved with HIV and AIDS work in the supported provinces will have been trained by the project.
1,513 IDU peer educators (PE) and 998 collaborators were trained. Most of the training were carefully
selected such as communication to most-at-risk populations, using Unified Identifier Coding notebooks,
inter-province study tours on learning experience on harm reduction preventions among MSM were
prioritised, care and treatment to patient of voluntary counselling and testing (VCT), sexually
transmitted infections (STI), and managing and social marketing skills. 72 master students received
the Programme’s scholarships. In which, 45 students completed the training programme in Mahidol
University in Thailand, and the other 27 in the Public Health University in Hanoi, Vietnam. The Master
programme training funded by the project is considered the highlight of this project. It significantly
strengthened the capacity of the public health system across the country.
During 2013, the officers of CPMU, PMUs has been trained and empowered to involve in the transition
process in which the activities would be gradually transferred to the management of the Global Fund
project.
Indicator 2: Percentage of annual target met on strengthening M&E system
The target for 2013 is 85%.
Progress: Fully achieved
All project provinces set up their plan for M&E and fully implemented activities and reached their
targets. In addition to regular monitoring and strengthening their local M&E systems, some additional
activities have been carried out, for example:

Most provinces conducted baseline and follow-up IBBS among targeted populations, based on
which, provincial officials developed implementation plans and provided clear instructions to
local offices.

In 2012, 14 project provinces conducted Integrated Behavioural and Blood Survey (IBBS)
among ethinic groups to prepare data for project final evaluation.

7 provinces also conducted rapid assessment among MSM groups. This is very challenging
work providing valuable data for evaluation and planning purpose. CPMU is also drafting
guideline of MSM rapid assessment for project provinces/cities.
Indicator 3: Percentage of annual targets met on advocacy, including HIV laws and their guiding
circulars to be reviewed and updated
The target for 2013 is 100%.
Progress: fully achieved.
All provinces made clear plans for communication and advocacy and fully implemented them.
Advocacy has been prioritised by targeting leaders of People’s Committees and Public Security. The
result is very positive. The project has mobilised strong support for its activities. Notably, the interministerial Circular No. 03/2010/TTLT-BYT-BCA issued on 20/01/2010 by the MOH and the Ministry of
Police stipulated the issuance, provision, management and use of work permits/identify cards for
outreach workers involved in harm reduction activities. The provision of this card recognised the
activities of outreach workers and safeguarded them from being arrested by local police. It was a big
jump compared with the starting point, when peer educators still faced the risk of being arrested by
police.
Impact Weighting (%): 30%
Revised since last Annual Review? NO
10
Risk: Low
Section B: Results and Value for Money.
1. Achievement and Results:
1.1 Has the logframe been changed since the last review? No
1.2 Final Output score and description:
The project achieved its targets on all 4 outputs and even exceeded its target on output 4.
Overall, the project score A.
1.3 Direct feedback from beneficiaries:
The project received highly positive commendation and acknowledgement from high level Government
officials, local officials, service providers and direct beneficiaries. Vice Minister of Health and leaders of
VAAC repeatedly commended the project for empowering provinces in planning and deciding what to
do, based on the local needs and situations. As a result, the implementation and disbursement rate of
this project is high, always reaching 95% of target and spending.
“The overall plan was designed centrally then sent to us. It was here that we could develop our
detailed plan. We were active in both the technical activities and funding the implementation of the
activities(Service Provider, Bac Giang).”6
Service providers also commended the project for bringing new ideas of harm reduction.
“Years ago we and the health staff at the district levels and stakeholders only knew about information
and communication for HIV prevention and had no idea of harm reduction. DFID/WB hosted advocacy
meetings from city to district levels to make harm reduction known. That was a huge contribution of
these projects for HCMC. When talking about HIV prevention for high risk groups, the DFID/WB project
is very well-known7”
The following areas have received particular positive feedback from beneficiaries over the last year:
social marketing of condoms, expansion of HIV prevention activities to MSM, and the continuation of
needle syringe programme for people who inject drugs.
The increased availability of high quality subsidised condoms through non-traditional outlets in 32
provinces has been highly appreciated by entertainment establishment (EE) owners, EE based sex
workers and their clients. The condoms are more available, affordable, higher than usual quality and
with a higher than usual quantity of lubricant - all features articulated as appreciated by beneficiaries.
The identification of the HIV transmission risks amongst men who have sex with men in Viet Nam is a
relatively new phenomenon and the DFID/WB project contribution to the identification and response to
this risk and early epidemic has been appreciated by the members of the networks of MSM in the 22
6
7
Impact Evaluation, NSWU 2013
Impact Evaluation, NSWU 2013
11
provinces. These provinces are in the process of initiating peer led interventions focusing on condom
and lubricant promotion/distribution and support to MSM peer networks. Current MSM HIV prevalence
is around the 5% mark.
The promotion and distribution of free needles and syringes by peer outreach workers remain
important activities in 32 provinces with ringing endorsement by local people who inject drugs as well
as the community based agencies providing support to them.
1.4 Overall Outcome score and description:
Overall the project has met expectations. We set the targets for having 70% and 80% of PWID and
FSW reporting clean needles and condoms use by 2012, plus 60% of MSM in 10 provinces reporting
consistent condoms use. By the end of 2012, we achieved 82.7% and 85.2% of clean needle use and
condom use respectively, exceeding the target.
Ecological analysis indicated that 26 out of 32 project provinces showed a declining trend in HIV
prevalence among PWID, six had stabilized prevalence levels and importantly none indicated an
increasing trend. Needle and syringe programme seemed to be more effective than condom
programmes. In 8 out of 32 project provinces, there was an increasing trend in HIV prevalence
among SWs, a decreasing trend in 16 provinces and stable prevalence in 8 provinces.
1.5 Impact and Sustainability
Impact
The project has had a significant project completion evaluation on HIV prevention, according to the
Impact Evaluation.
-
If the Programmes had not been implemented, significant increases in HIV incidence and
prevalence would likely to have been observed. It was estimated that HIV prevalence would have
been increased by ~18% among PWID by 2012 without the DFID/WB funded harm reduction
programmes and ~3.4% among FSWs.
-
Overall, during the period 2003-2012, it was estimated that the Programme averted 33,054 HIV
infections, 924 HIV-related deaths, and 17,392 disability adjusted life years (DALYs). The vast
majority of these health benefits were attributed to needles and syringe programme for PWID.
-
The benefits over 2003-2012 will accrue to greater benefits in the longer term: an estimated
aversion of 300,183 lifetime DALYs.
-
The project was significant in demonstrating the value of harm reduction to the Vietnamese
government and contributed largely to the legal framework for harm reduction interventions in
Vietnam over the past 10 years. Current laws on HIV/AIDS prevention (specifically 64/2006/QH11
and associated decree 108/2007 ND-CP) are ‘back-bone’ determinants for a supportive
environment for harm reduction and conducive for on-going implementation.
The project has contributed to alleviating stigma and discrimination against most–at-risk populations
and people living with HIV. Harm reduction interventions delivered by the project were well aligned
with intensive advocacy activities in Vietnam during the past 10 years, challenging the use of the
‘social evils’ approach to drug use and sex work. The project established credibility with key
stakeholders at all levels of the government jurisdiction and health system. Collaboration with local
communities and authorities was essential to successful programme implementation
-
The Project significantly increased organizational capacity and resulted in a more skilled and
professional prevention workforce. Health workers reported acquiring new skills through project
training activities in planning, project management and coordination, report writing and monitoring
and evaluation.
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Sustainability
There was general consensus among service providers that the breadth of activities funded by the
project would be impossible to sustain without on-going donor funding. It was reported that the
national HIV/AIDS programme could only cover a limited number of HIV prevention activities for the
most easily accessible PWID and FSW within each province. The project has influenced STI
programmes for FSWs and generic educational information funded nationally. The private sector has
engaged in the social marketing programme of condoms, which also eases off the pressure on the
Government on ensuring wide coverage of condoms to target population.
However, there are concerns in relation to sustainability and, in particular, the lack of a clear pathway
or transition strategy for harm reduction interventions, including financing resources. Due to domestic
economic difficulty and budget constraints, the Government budget for 2014 has been severely cut.
The Government is asking local Government to be more proactive in financing HIV/AIDS programme
in their provinces.
As part of our responsible exit strategy, DFID has made early communication with the Government,
over 2 years ago, about our exit in 2012, then actual exit in 2013 (with the extension), to allow
adequate time for the Government to prepare a transition towards self-financing harm reduction
programme. In addition to the one year extension of the project, DFID has maintained continuous
dialogues with the Government and other partners in HIV/AIDS to push for a feasible plan for
sustainable HIV/AIDS prevention. We actively advocated for both increasing domestic budget, both
central and local, for HIV prevention and increasing efficiency in spending in this area. After the
project ends in 2013, in the coming next six months, DFID will remain engaged in policy dialogues to
make sure we see a more visible and feasible plan is put in place for sustainability.
2. Costs and timescale:
2.1 Was the project completed within budget / expected costs:
Yes
2.2 Key cost drivers
According to the original design, the largest single element is harm reduction activities (60% of the
budget) for (i) people who inject drugs, including needles/syringes programmes and methadone
maintenance therapy; (ii) female sex workers including condoms distribution or sold through traditional
and non-traditional outlets; (iii) work among men who have sex with men. Other major components are
training and advocacy (18%), strengthening the national monitoring and evaluation system for HIV and
AIDS (5%), programme management (15%) and DFID-managed international consultancy support
(2%).
2.3 Was the project completed within the expected timescale: Y/N
The project originally was planned to complete by the end of 2012. DFID then decided to extend one
additional year and add £6.2 million to support the Government in the transition period, especially
financing the harm reduction work. The new end date is December 2013 and the project is well on
track to complete all activities by 2013.
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3. Evidence and Evaluation
3.1 Assess any changes in evidence and what this meant for the project.
The harm reduction intervention is highly effective in containing and reversing the HIV trend among
PWID and FSW. HIV prevalence among PWID at the national level declined from 21.3% in 2003 to
9.6% in 2012 and HIV prevalence among FSW declined from 3.7% to 2.6% in the same period.
In the early 2000s, sharing of injection equipment among PWID and heterosexual exposure were the
leading routes of HIV transmission in Vietnam, but the mode of HIV transmission has shifted to sex
between men, which is rapidly increasing. By 2020, up to two-thirds of new infections could be
attributable to sex between men. An estimated 50% of new infections are now due to sex between
men.
In 2013, intervention among MSM group started as a result of great efforts after many years. We
acknowledge that intervening with MSM groups is very challenging, because they are still a hidden
group and relatively difficult to access to. However, despite a late start, there was positive progress,
including quick assessment of MSM groups in 7 provinces, targeted social marketing and distribution of
condoms to MSM.
HIV prevalence data in MSM in Vietnam are scarce as sentinel surveillance for MSM was only
established in 2009. Based on limited data, the estimated HIV prevalence in MSM increased from 4.1%
in 2003 to 6.5% in 2012. The project is ending. But this change in evidence suggests that the
Government should prioritise its own intervention in the MSM group.
3.2 Set out what plans are in place for an evaluation.

By the end of 2012, the original completion date of the project, a project completion evaluation
was commissioned to the Research Centre for Rural Population and Health to (1) assess
achievements against the original specified project indicators and targets; (2) evaluate project
design, implementation and additional outcomes and impacts in 32 provinces/cities; and (3)
document best practices and draw lessons learnt for HIV/AIDS prevention and control activities
especially harm reduction interventions from the project implementation. The evaluation
provided rich and valuable data and information, which are valuable in assessing project results
and inform future policy formulation.

By the end of 2013, DFID commissioned an independent evaluation which has three main
purposes (1) to inform Vietnam’s policy makers whether these DFID/WB-funded interventions
have been cost-effective, and thereby to inform decisions on future allocation of domestic
resources; (2) to document whether the programmes have any best practice lessons that could
benefit other countries with similar concentrated epidemics; and (3) to demonstrate to the UK
Government, Parliament and public whether the use of UK funds has had a significant
developmental impact. Kirby Institute of the University of New South Wales is contracted to
deliver this evaluation.
Findings of these two reports have been and will be shared and disseminated to the Government and
other partners to inform future policy decisions and interventions in HIV/AIDS response.
4. Risk:
4.1 Risk Rating (overall project risk): Medium
Did the Risk Rating change over the life of the project? No
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When the project started, the main risk is lack of a conducive environment to support project activities,
including police intervention in harm reduction, lack of local government’s support, hence lack of local
resources mobilised.
By the end of the project, we have seen positive movements in terms of local government support.
However, a new challenge emerges, which is shortage of funding from both donors and government,
as a result of worsening economic situation – an identified risk in the beginning of the project. Vietnam
is facing economic difficulties, hence budget is significantly reduced, including that for HIV. This
poses a major risk to sustain project achievements, if no feasible and viable solutions to secure funding
from other resources are put in place.
4.2 Risk funds not used for purposes intended
This risk is minor. There has been no misspending or risk of misspending identified. The World Bank is
keeping a close financial monitoring on the project, including annual audit. Findings of the audits in the
last 3 years have confirmed that final management of project is satisfactory.
4.3
Climate and Environment Impact
Key environmental concern of the project is the dismissal of used needles. Up to December 2012,
nearly 23 million clean needles and syringes were distributed to high risk groups through different
channels, (peer educators, fixed boxes and pharmacies). More than 13.5 million of used needles and
syringes were collected and treated, accounting for nearly 64%. There has not been a benchmark
against which to assess whether the level of collected used needs is sufficient. However, there is high
awareness among both project implementers and PWID about the importance of collecting used
needles to protect the environment.
5. Value for Money:
5.1 Performance on VfM measures
The project document was developed before the Business Case format was introduced Therefore VfM
measures were not specified explicitly in the project document. As assessed by the independent
evaluation, the project provides good value for money.
Economy: The project used the World Bank’s procedures for its procurement, mainly competitive
bidding, to ensure transparency and good VfM in procuring inputs.
Efficiency: On expenditures that were spent, overall outputs were generated as planned and
proportionate to the costs involved. There was also a good track of positive fluctuations of exchange
rate between GBP and USD, resulting in some remaining fund after the project has achieved all its
outputs. This left-over has been well spent on procuring needles to stock for outer years when budget
is cut and needle and syringe programme is at risk of lacking fund.
Effectiveness: The independent evaluation assessed that the project, especially the NSP has good
value for money.
For every dollar spent on needle and syringe programme, the estimated rate of return in healthcare
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costs saved was 1.93. This means every dollar spent was returned and provided close to an additional
dollar not requiring to be spent. The cost of preventing one DALY was US $917. If the life-time impacts
of NSPs are considered, the return-on-investment ratio was 42.82 and the cost required for one DALY
aversion was US $270.
In comparison to needle and syringe programme (NSP) in other international contexts, NSP
implemented by DFID Vietnam have been cost-effective. The estimated required cost of US $486 (
$319-861) to avert one new infection through NSP is comparable to findings reported in developing
country settings, such as China (US $560-810) and Belarus (US $359, $234-1054). Notably, this
amount is much lower than the amount in developed country settings (typical cost of US$ 3,00020,000 per infection averted).
The epidemic benefits derived from condom distribution programmes for FSW are unlikely to be costeffective during the implementation period (2003-2012). However, when the life-time impacts of the
condom distribution programme are considered, the return-on-investment ratio was 4.53 and the cost
required to avert on DALY was US $425, demonstrating good long-term cost-effectiveness.
5.2 Commercial Improvement and Value for Money
Contracting and procurement of goods and services under the project has been conducted in
accordance with World Bank procedures. The World Bank with key partners including DFID conducted
monitoring missions twice a year every year and follow-up dialogue with key partners based on mission
findings for continuous improvement to ensure all aspects of project operations, including contracting,
procurement and financial management are well handled.
5.3 Role of project partners
The Government is the project beneficiary and also key partner of the project. It is crucial for the project
success that the Government has been fully supportive and cooperative during the whole project
process.
DFID co-financed the project with the World Bank who plays well the Team Leader role with a strong
team supporting daily management of all aspects of the programme including procurement, financial
management and social safeguards. This significantly contributed to the success of the project.
The World Health Organisation (WHO) provides technical advice to the project from the beginning. The
assistance by WHO has been very effective and not only limited to support this DFID- WB project, but
also extended to other projects and the National Programme.
UNAIDS and other international partners, especially PEPFAR have been cooperated with us very well
in the policy influencing work. They will also remain in Vietnam for longer term after this project ends.
Hence they continue playing an important role in advocating for a sustainable response to HIV/AIDS.
5.4 Did the project represent Value for Money : Yes
Independent evaluation assessed that the project presents good value for money, especially with the
needle and syringe programme. The project achieved all intended results.
6. Conditionality
6.1 Update on specific conditions
Not applicable to this project
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7. Conclusions
Overall, the project has achieved its purpose and created positive impacts in helping Vietnam to halt
the transmission of HIV/AIDS among high risk populations and from these populations to the general
public. The two major groups of intervention are PWID and FSW. There is evidence of declining
infection rate among this group attributable to the work this project has done. The third group, MSM, is
more difficult to access, hence results is less than expected. But the good thing is we have been able
to identify groups of MSM for future interventions and started the work among this group in 2013. Quick
assessment on MSM has also been carried out in 7 provinces, providing basic data for future planning
and monitoring.
On the project’s impact, the independent report shows that if DFID/WB project had not been
implemented, significant increases in HIV incidence and prevalence would likely have been observed.
The greatest increase would have been among PWID and FSWs with elevated prevalence of 18.1%
and 3.4% in 2012, respectively. HIV prevalence among MSM did not change substantially as DFID/WB
project could not deeply access to this group. According to the report, during the period 2003-2012, the
DFID/WB projects have averted an estimated 33,054 HIV infections, 924 HIV-related deaths and
17,392 disability adjusted life years (DALYs). The majority of these benefits were due to NSPs among
PWID. NSPs alone have averted 30,957 infections, 872 HIV-related deaths and 16,395 DALYs.
Condom distribution programs among FSW have averted 1,585 infections, 42 HIV-related deaths and
788 DALYs.
The project also contributed effectively to HIV prevention policies and legislations facilitating a shift
from repressive and punitive control measures to a more pragmatic approach to HIV prevention and
control, in line with internationally recognized legislative and policy reform. The promulgation of the
National HIV Prevention and Control Strategy –2004, the HIV Law-2006, and the amendment of the
Drug Law-2008 are significant benchmarks of this evolution. These strategies and legislative changes
have provided a strong legal foundation for the implementation of harm reduction interventions: needle
and syringe and condom distribution, peer education, and MMT that were previously prohibited in
Vietnam.
The project has been assessed as having good value for money. In comparison to NSPs in other
international contexts, NSPs implemented by DFID/WB in Vietnam have been cost-effective.
DFID/WB programme has helped to reduce stigma and discrimination by improving advocacy for harm
reduction interventions and challenging the perceptions of drug use and sex work as ‘social evils’. The
project established credibility with key stakeholders at all levels. Collaboration with local communities
and authorities was essential to successful project implementation .
DFID/WB programs significantly increased organizational capacity and resulted in a more skilled and
professional prevention workforce. Health workers reported acquiring new skills through project training
activities in planning, project management and coordination, report writing and monitoring and
evaluation .
The project, jointly funded by DFID and the World Bank, provides a good example for effective donor
coordination and harmonisation. The project end evaluation has consolidated important lessons learnt
and recommendations for the Government to take forward in their future programme planning and
policy formulation.
Recommendations
Maintain pragmatic health policies

DFID/WB programmes have facilitated some changes in the Vietnamese legal and health policy
environment. However, further reduction of stigma and discrimination against at-risk group and
HIV-positive individuals are required. Despite the completion of projects, DFID/WB could
potentially continue their influence by maintaining an advisory and technical support role to the
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Vietnamese government in enacting evidence-based HIV policies in the future.
Sustain effective programs and strategic investment

Our findings indicate that DFID/WB harm reduction programmes in Vietnam are highly effective
and cost-effective in both the short and long-term. The programmes should be continued. It is
imperative that the Vietnamese government assume responsibility for continuing these
programmes. Given that the DFID/WB programmes have already established the necessary
infrastructure, capacity building, monitoring and evaluation systems, there are significant
advantages for the Vietnamese government to continue these programmes through strategic
investment.

The Vietnamese government will need to re-focus current DFID/WB HIV prevention
programmes by location, prioritizing selected provinces where greatest impact is likely to occur.
This should be based on current epidemiology as well as infrastructure and ability for
community mobilization. Future programmes should also focus on MSM and high-risk
subgroups of PWID and FSW, including HIV-positive PWID and FSW.

Vietnam’s current HIV response is highly dependent on foreign aid. With the gradual withdraw
of DFID/WB projects, domestic support from the Vietnamese government is increasingly
important. This also implies that sustaining the current level of response or increasing the
response may be unlikely in the near future. There is a need to identify optimal resource
allocations that maximize the potential benefits of these programmes.
Facilitate innovative programme implementation and management

The DFID/WB programmes have employed a number of innovative approaches for commodity
distribution. Secret spots were viewed by focus group service providers and PWID as
complementary and part of a range of strategies designed to maximise access to, and
availability of, sterile needle-syringes. Incentivising pharmacies to distribute needle-syringes to
PWID and social marketing for condom distribution to FSWs are also effective models of
commodity distribution. Close public-private sector collaboration is essential in STI screening
and management for FSWs. DFID/WB’s experience in facilitating collaborations with national
and international health organisations, flexible target-driven management at the local level,
effective coordination, and regular communication are valuable and are recommended for
future programmes.

Needles and syringes in Vietnam have been shown to be a very effective and cost-effective
intervention. The Vietnamese experience also indicates that an open and supportive legal
environment is essential for the implementation of harm reduction programmes. However,
social stigma and any police harassment will limit the full potential of these programmes.

Interventions need to be aligned with the trend of the epidemic. It is likely that there will be a
trend of epidemic emergence in MSM group, which received little intervention in the past.
Future programmes should be more focused on MSM.

Sustainable financing is essential. If current programs are not maintained then it can be
expected that HIV epidemics will increase substantially, particularly among PWID, with the
potential for further spread outside the populations most at risk. Vietnam’s current HIV
response is highly dependent on foreign aid. With the gradual withdraw of foreign investment,
domestic support from the Vietnamese government is increasingly important.
8. Review Process
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This review has been conducted by the MDG Team Leader, Tu Thu Hien, and Programme Officer,
Tran Thu Hang. This PCR is based heavily on evidence from the independent evaluation on project
by NSW University in 2013, the independent project end assessment made in 2012 by the Centre on
Population and Rural Health Research, and project progress reports of 2012-2013. We also
consulted with the Project Management Unit, M&E officer and WHO Technical Adviser and technical
officer. This PCR has been peer reviewed by the Evaluation Adviser and Economic Adviser of DFID
Vietnam. More detailed analysis and information can be obtained from the original reference reports.
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