A Ticking Bomb
"It’s like a ticking bomb here in Vietnam,” says Dr Serge Gradstein from Family Medical Practice, a foreign-operated multidisciplinary medical practice in Vietnam.
“It’s a serious problem that needs addressing.”
Dr Gradstein believes the true scale of HIV infection rates is unknown despite some official reports stating otherwise.
“I think if we had the numbers, they would be very alarming.”
HIV remains a public health threat in Vietnam despite efforts to reduce new infection rates over the past two decades.
Dr Serge Gradstein worked at Israel's largest HIV clinic in Tel Aviv in the 1980s and 1990s. Photo by Mike Palumbo
UNAIDS, the leading global organisation that supports a coordinated response to HIV and AIDS, reports that national estimates point to an increasing proportion of new infections among key populations of people at risk of contracting HIV.
It is estimated in Vietnam there were around 11,000 new HIV infections in 2016 and 8,600 AIDS-related deaths in 2017.
The prevention needs of high-risk populations in Vietnam are either not being fully met or have no specific interventions tabled to combat HIV
Estimates point at somewhere between 220,000 and 280,000 people were living with HIV in Vietnam in 2017
While UNAIDS reports the prevalence of the disease among Vietnamese adults between the ages of 15 to 46 as being at just 0.4%, there isn’t enough reliable data to paint a clearer picture of the scale of new infection rates in Vietnam.
This concerns medical professionals like Dr Gradstein who are at the frontline of the diagnosis and treatment of people with HIV.
"I’ve seen an increase in numbers [of people being diagnosed with HIV in Vietnam], but in the absence of hard data, I can’t say if it means anything or not,” he explains at Family Medical Practice in central Ho Chi Minh City.
"It may just be that we have a service with specialist doctors for HIV that accounts for the increase in people presenting at the clinic with HIV.
"But from our experience, we know there are people who don’t use condoms and people who don’t get tested for STIs (sexually transmitted infections), including HIV."
The late night bars and karaoke venues of the Thai Van Lung neighbourhood or "Japan Town" in Saigon. Photo by Olga Rozewin
Dr Gradstein’s observations correlate with data reported by UNAIDS on the number of people living in Vietnam who know their HIV status.
There just isn’t a definitive number.
What is fairly certain however, is that the highest incidences of HIV are estimated to be among populations who inject drugs, men who have sex with men, and sex workers.
A 2016 estimate states that 3.7% of sex workers in Vietnam have HIV, while for men who have sex with men it is 12.2%, and 14% among people who inject drugs.
“I see more men [than women for consultations], but I’m certain there is a huge unknown population under the carpet,” Dr Gradstein says of the possible epidemic confronting Vietnam.
Before coming to Vietnam in 2012, Dr Gradstein worked at Israel’s largest HIV clinic in Tel Aviv during the 1980s and 1990s when Israel experienced its first and second waves of Ethiopian immigrants fleeing war and famine.
Ethiopia was already in the midst of an HIV epidemic and so it was only a matter of time before HIV-positive Ethiopians began to present at his clinic.
Dr Gradstein had trained initially as a paediatrician before training to specialise in infectious diseases.
It was around this time that he headed up the paediatric department of the HIV clinic in Tel Aviv and for the first time began treating HIV-positive patients on a scale much larger than he ever had previously.
Many of his patients included children.
"It was then that we started to learn ‘real’ medicine,” recalls Dr Gradstein.
"We saw lots of malaria, tuberculosis and HIV [among the immigrants]. It took a while for them to come to our attention because of the time it took for their resettlement.
"The first priority was to house and feed them and then they were referred to the health system for medical examinations."
"The turning point was in the mid-90s when we started to give the ‘cocktail’, which brought about a dramatic fall in mortality and morbidity, including mother to child transmission rates. I saw it right before my eyes. It was impressive," he says.
The cocktail that Dr Gradstein referring to is the combined drug treatment known as HAART or Highly Active Antiretroviral Treatment.
It is also sometimes referred to as cART (combination antiretroviral therapy) or ART (antiretroviral therapy).
In addition, there is increasing awareness, at least within the gay community says Dr Gradstein, of the existence of PrEP (pre-exposure prophylaxis).
PrEP is a newly-accepted means of prevention which is a combination of two antiretrovirals branded as Truvada that can be taken on a permanent basis by individuals at risk of exposure to HIV.
As a result, the prospect of being diagnosed with HIV today is much less traumatic than it was 20 or 30 years ago. According to Dr Gradstein, people have become less fearful of the disease as a result, especially given the likelihood of fewer complications and serious side-effects from modern day HIV treatments.
In many ways, he says, someone who has Diabetes, may actually experience greater complications with their health than someone with HIV.
"There was hysteria, absolutely," says Dr Gradstein, of the impact the emergence of HIV and AIDS had on communities in the 1980s.
"In certain communities, everybody knew somebody who had died from AIDS, but today that doesn’t exist as much."
Vietnam, however, has been a new and different learning curve for Dr Gradstein.
When he arrived here back in 2012 to take up his position with Family Medical Practice, he was struck by the cultural difference, particularly by what he believes is an overarching Vietnamese cultural norm to suppress certain things, including issues related to health.
While he is at pains to highlight that this is merely his personal perception from his experiences of living and working here, he is confident that it has played a role in ensuring that HIV remains a public health threat in Vietnam.
Expatriate gay and straight men are sometimes guilty of lowering their guard during sexual encounters
"For instance, in industrialised countries, people are more proud and open about being a gay man, but in Vietnam there is more of a stigma attached to sexuality. If it doesn’t fit within the social norms of society, it tends to get covered up more. Men might be married with children, but be unofficially gay, which can potentially be a threat to their wives and children (if they take risks when they have sex)," says Dr Gradstein, who goes on to clarify that high-risk sexual behaviour isn’t just isolated among men who have sex with men.
As figures show, sex between heterosexual partners carries high-risks as well if appropriate precautions aren’t taken.
Some expatriate gay and straight men are at times guilty of lowering their guards during sexual encounters leaving them exposed to a greater risk of contracting HIV.
It is something he finds baffling given that it is assumed in general that expatriates would have a better knowledge of the associated risks of having unprotected sex with multiple partners.
"Coming here to Vietnam, for some reason many seem to forget about the risks," he says. "It’s quite incredible sometimes. They seem to stop using protection because they are geographically in Vietnam."
Left on the shelf. "They seem to stop using protection because they are geographically in Vietnam." Photo by Mike Palumbo
On the flip-side, there are men presenting with HIV phobia.
While the reluctance of people wanting to get tested for HIV has long been documented and understood, there is a type of patient who over-tests, sometimes for good reason because of the choices they have made, but often without good reason, except that in their minds they have contracted the disease.
"HIV phobia is one of the classic ones now. It’s not a question of logic. It’s more of an emotional problem that should be addressed on an emotional level," explains Dr Gradstein. “Because people can suddenly find themselves exposed to higher risk here, some people have a tendency to become more anxious than others and so they use an encounter to fuel their anxious state."
The curious thing about HIV phobia, says Dr Gradstein, is that while there is perhaps a higher chance of contracting HIV through sex in Vietnam than in countries like Australia, people can misguidedly attribute much of their anxiety to HIV.
They forget other more prevalent and serious STIs, like Hepatitis B which, unlike HIV, is easier to contract and can survive outside the body for a long period of time.
It is believed that Hepatitis B infection rates in Vietnam hover somewhere between 8% and 40% of the population depending on geographic location. Yet, HIV still attracts all the hype."If you just focus on HIV, you’re likely overlooking other major communicable diseases, like Syphilis for example, which is making a comeback because it’s much more infectious than HIV," says Dr Gradstein.
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