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Researches Medical sociology and HIV/AIDS

Vũ Thị Minh Hạnh, Vũ Thị Mai Anh, Phan Hồng Vân, Trần Thị Hồng Cẩm,
Nguyễn Thị Minh Hiếu, Hoàng Thị Mỹ Hạnh, Vũ Văn Hoàn, Đậu Thị Hà Hải
Place of publication: Health Strategy and Policy Institute
Project 00040232- Central Commission for Popularization and Communication
Year of publication: 2008
1. To describe the process and outcomes of the implementation of  the Directive 54-CT/TW and 3 related guiding documents in 12 provinces/ municipalities (including 3 project provinces); challenges and drawbacks, and causality of achieved outcomes as well as challenges and drawbacks; 
2. To evaluate the impact of Directive 54 and the three documents on HIV/AIDS control leadership in 12 provinces, including comparison of the 3 Project provinces and 9 non-project provinces (Project 40232); 
3. To draw lessons learnt and recommend measures to further improve the effectiveness of Directive 54 and the three documents in the coming time, and strengthen local and national leadership in HIV/AIDS control.
Methodology: Cross-sectional 
Natural, economic, social conditions and HIV/AIDS epidemic context in survey sites: The economic and social difference of the 12 provinces was the premise for the significant variance in the HIV/AIDS epidemic situation between the provinces. HIV/AIDS transmission in these provinces also reflected notable difference. Outbreaks not only took place in better-off provinces, but spread to upland and remote provinces.
Directive 54-CT/TW implementing process 
the outset of Directive 54-CT/TW, a distinct difference could be seen between the provinces. 
Orientation and dissemination of Directive 54-CT/TW were conducted in diverse forms, with numerous types of activities. In Project provinces, the introduction of Directive 54, though later than other provinces, seemed to be more frequent and diversified in methods. 
Scope and targets of the Directive propaganda activities: 100% of Party units in 10 provinces and 12 districts/towns in 9 provinces (except Dien Bien) received orientation on Directive 54-CT-TW. The Directive was also been disseminated to about >90% of public officials and Party members, and >70% of community members. 
Implementation: Numerous leadership and guiding documents were released in the provinces. These documents were under different types. District Party committees introduced their leadership guidelines for HIV/AIDS control in the new context. About 66% (8/12) of commune/ward Party committees issues specific guidelines for AIDS control. In Project provinces, a strong political commitment of the leadership at all levels to AIDS control were seen: more leadership and guiding documents for the implementation of the Directive 54 in details were issued.  
Inspection, monitoring and evaluation: 7/10 surveyed provinces monitored and evaluated the implementation of Directive 54. Compared to the Directive 52, monitoring activities for Directive 54 were paid more attention, , especially in provinces under Project 40232. In these locations, monitoring were done on a more regular basis and in more flexible ways than non-project ones.
Initial influence of Directive 54-CT/TW: The awareness on local responsibilities involvement in the HIV/AIDS program of Party committees, governments, mass organizations and community have impressively improved. The legal framework for the HIV/AIDS program has been consolidated over time. Behavioral change information, education and communication on HIV/AIDS control has been done in increasingly innovative and diverse ways, in a harmonized mix of firsthand and indirect communication, mass media and community-based outreach communication. The AIDS control apparatus has been fine-tuned over time: All the surveyed provinces had their AIDS control centers formed in 2006 and 2007 (except Hau Giang). In districts/towns, the AIDS control function was integrated in the Epidemic control department of district Preventive health centers. Communes had dedicated AIDS control staff. Available finances for HIV/AIDS control has been increased. Public private partnership in HIV/AIDS control has been intensified with the more and more effective engagement of people living with HIV and their families. The HIV infection rate tended to slow down, especially in provinces under Project 40232.
Challenges and drawbacks: Orientation, dissemination and implementation of Directive 54-CT/TW in places seemed to be done not in a routine and consistent basis.. The issuance of leadership and normative documents pertaining to the implementation of Directive 54 has been  less than optimal. Monitoring and supervision of the implementation of Directive 54 lacked formulism. The AIDS control legal framework remained to be in-completed. HIV/AIDS information, education and communication in places appeared shoddy. Messages were slow to be renewed, lacked details and largely failed to meet the requirements of supporting behavioral change in HIV/AIDS control for the community, or helping people with HIV to gain easier access to care and treatment. Interagency coordination in AIDS control fell short of expectation. The AIDS control system seemed unstable, with various staffing deficiency, both in number and quality. Community-based harm reduction and patient support activities were facing numerous challenges due to resources scarcity, lack of public consensus, and so on. 
Causes of the challenges and drawbacks
External causes: The epidemic was still raging on more and more complicatedly. Entertainment services at disguised establishments, social evils and crime were growing. Discrimination against people with HIV in the community remained a heavy burden, even among health workers.
Internal causes: The support and commitment of the leaders and the leadership role of various Party committees and authority governments in HIV/AIDS control were not as strong as expected, particularly at grass root level. Knowledge on HIV/AIDS control and management skills of staff at various levels felt below the required standards. Some harm reduction interventions, until now, had not received the consensus from relevant authorities. A large portion of HIV/AIDS control workers was on a part-time payroll, with high turnover, while staff capacity remained a question. Resources for the program remained scarce.
Lessons learnt: Various Party executive committees and government levels needed to have  right and profound understanding about the danger of the pandemic and ways to promote social measures in an interagency approach for  prevention and control. Leaders and managers of various levels and agencies needed to add resolve and take the lead in AIDS control efforts. The executive unit of the Steering committee for AIDS, drugs and prostitution control should have in place an interagency coordinating scheme, assigning specific responsibilities to individual members and cooperation mechanisms. Social mobilization to attract both domestic and international resources, as well as internal and external resources for HIV/AIDS control, in close connection to the “Universal unity in building cultural neighborhoods” movement. HIV/AIDS control should be integrated into combating social evils, drugs and prostitution, through systematic solutions linked with social programs. More innovation and diversification of behavioral change IEC in HIV/AIDS control are needed. 
The Central Party Secretariat: Releasing leadership notices to provinces on further consolidation of leadership and implementation of Directive 54-CT/TW; Directing provinces/cities to continue the implementation of Directive 54-CT-TW on a regular and specific basis.; Directing the Party Commission and Government to enhance both central and local resources (manpower, equipment, funding etc.) for HIV/AIDS program; Leading the screening, enhancement and improving the performance of the Steering Committees for AIDS, social vices, drugs and prostitution control; Guiding relevant agencies in further introduction of normative instructions, mechanisms and policies to  enable a favorable legal framework for the implementation of Directive 54-CT/TW; Endorsing Guidelines for the “3 self-help” movement among people with HIV/AIDS.
Central Committee for Popularization and Education: Further maintenance of regular  monitoring and supervision for the implementation of the Directive 54-CT/TW in all provinces/municipalities ministries, line agencies and mass organizations; Further promoting innovation of behavioral change IEC in HIV/AIDS control; Continuing guiding provinces/municipalities to  develop intersectoral coordination in AIDS control in line with the principles of Directive 54-CT/TW; Launching movements and providing guidelines for the “3 self-help” movement among people with HIV in various locations.
Ministries, line agencies, civil society organizations: Ministry of Health should press ahead communication efforts and closely monitor anti-discrimination against people with HIV/AIDS among health workers at health care facilities. The Ministry of Labor-Invalids-Social Affairs should counsel the Government to revise Decree 167 on social support for marginalized groups. The Ministry of Planning and Investment and Ministry of Finance should give priority in resources allocation to poor and upland areas and localities with high HIV infection prevalence. Line ministries and civil social Organizations need to expressly release guidelines for the implementation of the Directive 54 across in their areas.
Provinces/cities: Continuing  an effective and specific implementation of orientation and dissemination of Directive 54 to local Party units and people in community; Increasing the leadership, supervision and monitoring role of Party committees and governments for the implementation of Directive 54; Active and self-motivated mobilization of domestic and international resources for HIV/AIDS control, with preferences in using local budget; Issuing and closely monitoring the implementation of the intersectional cooperation mechanism in HIV/AIDS control; providing favor condition and mechanism enabling people with HIV and their families to take part in local AIDS control programs; Quickly developing a targeted provinces project for HIV/AIDS control for the government’s approval; In respect of provinces under Project 40232, Party executive committees and governments should further support local AIDS programs and provide relevant mechanisms to guarantee sustainability for project outcomes.
International organizations: Provision of financial and technical assistance for the implementation of HIV/AIDS interventions in targeted provinces;

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