Drug Harm Reduction in Vietnam: A Review of Stakeholders’ Perspectives and Implications for Future Interventions

Abstract

Objectives. To determine how harm reduction should be applied in low-resource countries such as Vietnam by exploring the perspectives of people who use drugs (PWUD), health care professionals, and policymakers regarding methadone treatment and harm reduction strategies.

Methods. We conducted 2 qualitative studies in Vietnam between 2016 and 2021. We interviewed 62 PWUD and 22 experts in drug policy development and drug treatment programs, conducted observations at methadone clinics and harm reduction program meetings, and analyzed drug policy documents.

Results. PWUD considered methadone treatment only as a transition to a drug-free life. Policymakers deemed harm reduction ineffective and continued to enforce arrest and incarceration of PWUD. Drug intervention programs are not yet geared to providing specialized services. Effective communication strategies and information on evidence-based harm reduction models are inadequate to help policymakers make the right decisions.

Conclusions. Harm reduction principles have not been fully adopted in Vietnam. A harm reduction strategy based on a more humanistic approach that goes beyond a biomedicalized approach is urgently needed in Vietnam and other countries in the Global South. (Am J Public Health. 2022;112(S2):S182–S190. https://doi.org/10.2105/AJPH.2022.306764)

Starting in the 1980s, harm reduction became a pillar of drug policy in different parts of the world, including Australia, Canada, and Western Europe, as a rational policy response to the HIV public health crisis.¹ In many Western countries, the AIDS epidemic introduced a radical shift. Harm reduction replaced the accepted vision of care for people who use drugs (PWUD), which only considered abstinence as an adequate response. In this new framework, abstinence could be considered integral to recovery, but only if PWUD themselves chose abstinence and not if external forces imposed it.^2,3

Since its implementation worldwide, harm reduction has proven successful over time. A notable benefit of harm reduction programs is that they facilitate the dialogue of PWUD with harm reduction and drug treatment professionals about drug use and harms and their access to treatment and social services.⁴ The following principles make harm reduction successful⁵: humanism, meaning that services are patient centered and personalized according to their needs; pragmatism, or understanding that abstinence is not a priority unless patients choose it; individualism, or recognizing that decisions about medications, treatments, and health behaviors should be left to the individual; autonomy, or leaving the choice of medication, treatment, and health behavior to PWUD based on their preferences, beliefs, and abilities; incrementalism, or recognizing that we all experience plateaus and negative trajectories at times; and accountability without termination, or accepting that people have the right to make harmful health decisions and that providers can still warn them about the consequences.

Despite the effectiveness of harm reduction, it was implemented late in Vietnam after coming under heavy criticism from some politicians and addiction professionals, who claimed that harm reduction interventions were too tolerant of drugs and that they contradicted abstinence.⁶ For decades, the official Vietnamese policy was detoxification of PWUD, with or without their consent.⁷ Drug-related harm reduction strategies were implemented in Vietnam starting in the early 1990s in response to a burgeoning HIV epidemic and in a context of international funding availability. At the outset of the epidemic, HIV prevalence among people who inject drugs rocketed from 10.1% in 1996 to 32.0% in 2002.⁸ The need to control the HIV epidemic led Vietnam to break from its traditional law enforcement approach to drug use to endorsing evidence-based harm reduction programs.⁹ Since 2004, as 1 of the 15 focus countries under the United States President’s Emergency Plan for AIDS Relief, Vietnam received international funding to implement drug-related harm reduction programs, including peer-based education, syringe exchange, and opioid substitution treatment using methadone or buprenorphine.⁹

Harm reduction has been successful at containing the HIV epidemic in Vietnam and shifting the country’s drug policy to a less prohibitionist stance.¹⁰ Data from the pilot implementation of methadone maintenance treatment showed only 1 new HIV seroconversion among 760 HIV-negative patients after 9 months.¹¹ Moreover, the proportion of methadone patients who reportedly engaged in criminal activities decreased from 40.8% to 1.3% after 2 years.¹² After almost 2 decades, HIV prevalence among people who inject drugs decreased to 12.7%.¹³ These achievements facilitated the government’s decriminalization of drug use in 2009 as well as the official recognition of addiction as a chronic disease and of people with drug use disorders as patients in need of treatment.^14,15

The prevalence of methadone treatment as a harm reduction strategy is particular to Vietnam. In the early 2000s, international organizations brought methadone into Vietnam with the aim of reforming national drug policies that the international community considered draconian and unethical.⁹ As a strategy to secure acceptance from the government of Vietnam, proponents of drug policy reform described methadone treatment, a voluntary, community-based treatment of opioid use disorder, as just another approach to reducing the risk of an injection-related HIV epidemic.⁹ The complex status of methadone treatment makes it a good example to understand the perspectives of health care professionals and policymakers on harm reduction.

Despite these early accomplishments, methadone treatment and other harm reduction programs face multiple challenges in attaining their optimal effect to reduce harm among PWUD and improve their lives. Since 2017, the number of PWUD on methadone has stagnated.¹³ Only 53 000 people who use opioids in the country are in methadone treatment.¹³ This number is low, given Vietnam’s commitment to providing methadone treatment to 80 000 people who use opioids by 2015.¹¹ Dropout rates shot up to 33.3% at 36 months,¹⁶ of whom 24% were arrested.¹² Moreover, the coverage of needle and syringe distribution programs has remained mediocre since 2008, and the number of needles and syringes distributed every year per person who injects drugs has gone down since 2013.¹³ Attempts to provide buprenorphine as an alternative at methadone clinics have met with reluctance from health care providers, who have to verify compliance by observing the patient until the medication has completely dissolved.¹⁷

Increased methamphetamine use among PWUD, including methadone patients, has further complicated the situation.¹⁸ Methamphetamine use is associated with lower uptake of methadone treatment¹⁹ and weaker viral suppression among HIV-positive PWUD.²⁰ People who use methamphetamine are stigmatized and considered paranoid, violent, and dangerous, resulting in significant social concerns.²¹ In addition, nongovernmental organizations have piloted harm reduction initiatives for people who use methamphetamine. However, peer workers who delivered group education and safe smoking equipment (e.g., bongs, pipes) in hotspots ran the risk of being arrested, as the government did not recognize their work.²²

In an international context that acknowledges the benefits of harm reduction policies, the struggles that harm reduction programs face in Vietnam led us to question what harm reduction means to different Vietnamese stakeholders by addressing the limitations of harm reduction implementation in Vietnam and the application of harm reduction programs in a specific Vietnamese context.

METHODS

Over 5 years (2016–2021), we conducted 2 qualitative studies on harm reduction implementation in Vietnam. The first project examined the experience of methadone patients, including their perception of the role played by methadone treatment in their personal recovery. The second project explored the opinion of addiction treatment specialists who are policymakers or service providers in Vietnam about the effects of policy on developing new addiction treatment services in Vietnam. Both studies included semidirective interviews and ethnographic participant observations in services that delivered methadone treatment. The similarities between the 2 studies enabled us to define the research question, define the original codes, and proceed with coding. Our findings come from the synthesis of the 2 studies, reflecting similar key points in the experiences and opinions of different stakeholder groups regarding methadone and harm reduction programs in Vietnam. The recruitment and interview questions are as follows.

Project 1

We interviewed 62 PWUD in Haiphong, a large city with a high prevalence of HIV and injection practices.⁹ This study was part of an intervention study called DRIVE (Drug-Related Infections in Vietnam) with people who inject drugs in Haiphong.²³ The intervention study recruited participants using respondent-driven sampling and provided them with harm reduction and referral to treatment through community support groups.^19,20 The semidirected interview guide included 2 main questions: “What have your experiences with methadone treatment been?” and “For what reasons did you decide to delay treatment?” As active members of the national technical assistance network for drug treatment, we also conducted participant observations in meetings with policymakers and harm reduction professionals and with patients, their families, and their providers at methadone clinics. Information from observation was dutifully recorded during our visits to the clinics. Thus, we analyzed information from meetings as an additional resource to reflect on the findings from interviews with patients.

Project 2

Between 2019 and 2021, we carried out a desk review of policy documents and interviews. We scanned 51 legal and policy documents, including 19 related to harm reduction and methadone. We invited 23 senior managers of key governmental agencies, international and nongovernmental organizations, and universities working in drug-related fields for interviews. Twenty-two of them agreed to participate in face-to-face semistructured in-depth interviews. Sample questions included “How is Vietnam planning to conduct harm reduction activities?” and “What conditions and resources are needed for harm reduction interventions in Vietnam now and in the future?” We applied the Delphi technique, in which Vietnamese experts (who were also study participants of the second study) reviewed the research findings before the article was published to improve the credibility of qualitative data

For data analysis, we developed initial codes based on the research questions and added emergent codes throughout the coding process. The initial codes were “PWUD’s understanding of methadone treatment and factors affecting their thinking,” “health care providers’ and policymakers’ understanding of a harm reduction approach and factors affecting their thinking,” and “current limitations to developing a harm reduction approach in Vietnam.” We then reviewed and categorized codes as they related to the research questions. We compared the themes from both projects and collated them to present the perspectives of different stakeholders regarding methadone treatment and harm reduction. The qualitative and social science approach allowed us to overcome the naturalistic, biology-based perspective of methadone and reveal the complex nature of methadone experiences and perceptions.²⁴

RESULTS

Table 1 presents the demographic characteristics of participants, and Boxes 1 and 2 present quotations that support the analysis.

TABLE 1—

Participant Characteristics of Two Qualitative Studies: Vietnam, 2016–2021

Characteristic	No. (%) or Median
PWUD (n = 62)
Gender
Female	19 (30.0)
Male	43 (70.0)
Age, y	40
HIV positive	35 (56.0)
Currently under methadone treatment	38 (61.0)
Never been on methadone treatment	17 (27.0)
Median length of methadone treatment, y	3
Marital status
Married/living with partner	29 (47.0)
Single/divorced/widowed	33 (53.0)
Occupation
Unemployed or odd jobs	34 (55.0)
Relatively stable jobs	28 (45.0)
Expert participants (n = 22)
Gender
Male	18 (81.8)
Female	4 (18.2)
Age, y	48
Workplace
National level (MOLISA, MOH, MOPS)	6 (27.3)
Local level (drug rehabilitation centers, methadone clinics, provincial centers for disease control)	6 (27.3)
UN agencies and NGOs, CBOs	6 (27.3)
Universities (addiction treatment networks)	4 (18.2)
Experience working with drug policies and drug users, y
5–10	4 (18.2)
> 10	18 (81.8)

Note. CBO = community-based organization; MOH = Ministry of Health; MOLISA = Ministry of Labour, War-Invalids and Social Affairs; MOPS = Ministry of Public Security; NGO = nongovernmental organization; PWUD = people who use drugs; UN = United Nations.

BOX 1—

Quotations From In-Depth Interviews With People Who Use Drugs (PWUD) and Expert Participants: Vietnam, 2016–2021

Quotation 1: “I had to do heroin since [the withdrawal] was too painful. I was too tired of it. When I saw my poor children, I only wanted to get off it but I could not. I feel so fortunate that we have methadone now.” (methadone patient, female, aged 38 y)

Quotation 2: “I told him he should take methadone for a few years then stop. We should not be dependent on anything. We must be the master of ourselves.” (wife of a methadone patient, aged 34 y)

Quotation 3: “My father says if I have strong willpower, I should stop getting methadone, then I would not have to go to the clinic daily.” (methadone patient, female, aged 33 y)

Quotation 4: “I’m not into methadone since I have no time to go to the clinic every day. If I have to spend time getting methadone, I won’t have time to make money for my family.” (non–methadone patient, PWUD, female, aged 44 y)

Quotation 5: “In the context of withdrawn funding from international donors, Vietnam does not have enough resources to build a comprehensive harm reduction program as in the past. The methadone model, which includes many components of psychological counseling, could be eliminated. The methadone program now mainly focuses on examining and delivering methadone to patients rather than providing intensive counseling support.” (expert participant, Ministry of Health)

Quotation 6: “Drugs bring benefits to people who use them. If we don’t ban illicit drugs, they will use them as popularly as cigarettes. Now there are warnings that smoking provokes harmful effects to public health, but many young people still do it. So harm reduction will not be practical to prevent drug use.” (expert participant, Lao-Cai Centre for Disease Control)

Quotation 7: “The Vietnamese discriminate against illicit drug use because there are too many cases involving drug users. Ideally, there should be a network or organization of PWUD in Vietnam immediately following such events to build trust and demonstrate that not all drug users are bad. Yet, despite public concern, representatives of organizations that work with PWUD remain silent. This allows PWUD to become subject to social prejudice. Harm reduction messages are nonexistent.” (expert participant, National Assembly)

Quotation 8: “Experimental harm reduction interventions often prove effective on a small scale, but they do not address the actual risk situations or how to deal with the risk when such measures are implemented. For example, having PWUD undergo addiction treatment in a community may cause fear, conflict, and instability in the community as a result of stigma and the lack of experience of local officials. How can we handle such an issue?” (expert participant, National Committee on HIV/AIDS, Drugs and Prostitution Prevention and Control)

Quotation 9: “It is not sufficient to provide evidence of the effectiveness of harm reduction programs to policymakers. When applying harm reduction interventions, it is important to examine potential undesirable situations and possible solutions. The harm reduction strategy proceeds in this manner. To develop such strategies, policymakers require professional assistance. However, the current capacity of specialized agencies is not sufficient to do this.” (expert participant, National Assembly)

BOX 2—

Quotations From Field Notes in Observations and Discussions Among Participants: Vietnam, 2016–2021

Quotation 1: “The representative of the Prevention AIDS Center of X started with a presentation of the city’s current methadone program. At first, she criticized the two articles in Decree 96 that required patients who test positive with nonopioid drugs to be kicked out of methadone treatment for not fitting the harm reduction principles. However, as the police depicted the methadone program as a harbor for addicts to avoid compulsory rehabilitation and complained that the dropout rates and concurrent heroin use were high, she suggested we should screen patients for their motivation. She argued that at the beginning, when the screening process of potential methadone patients was stricter, dropout was much rarer. She also criticized patients for picking “unsuitable” jobs that did not allow them to come to the clinics.” (Field notes, September 18, 2018)

Quotation 2: “I told the staff I wanted to call potential interviewees on the phone to invite them to the interviews, but they said we should call patients in when they come and force them to participate by insisting they must complete the interviews before taking their medication.” (Field notes, January 3, 2020)

People Who Use Drugs

To the PWUD who participated in our study, living a drug-free life independent of methadone remained the main desirable goal. All participants in methadone treatment had known about methadone for a long time. They knew peers who had undergone methadone treatment and gotten better, which gave them the confidence to enter methadone treatment, but they only decided to enter treatment after multiple failed attempts to quit drugs by themselves. Both women and men considered methadone treatment a last resort to find relief from opioid addiction and related financial and relationship issues (Box 1, quotation 1).

Although methadone patients experienced significant positive changes in their lives thanks to the treatment, during our visits to methadone clinics, patients and their families commonly asked how long it would take for them to stop methadone treatment and become abstinent. As many as 9 of 38 participants described detailed plans for leaving treatment to work and live what they envisioned as a “normal” life. Some tried to lower their doses by secretly cutting away a portion of the medication or even dropped out of treatment to see whether they could go without it. A few family members also encouraged patients to get off methadone (Box 1, quotations 2 and 3).

Among the 24 PWUD who were not in methadone programs, 17 had past experiences of treatment. The main reasons for leaving treatment were wanting to stay drug-free without medical assistance and wanting to be able to work (Box 1, quotation 4). It is interesting to note that these reasons were similar to the reasons for not getting into treatment cited by the 7 participants who had never undergone methadone treatment. This perception of methadone treatment might relate to the constraining methadone delivery regulations in many clinics in Vietnam.²⁵

Health Care Professionals

Health care professionals working in methadone programs were under constant pressure to secure funding for treatment in competition with law enforcement and compulsory drug rehabilitation programs, both of which also fall under the purview of the ministries of public security and social affairs. Although health workers promoted methadone treatment, they also seemed to neglect patients’ needs and challenges and did not fully adopt harm reduction principles. Our ethnographic notes reveal this ambivalence being manifested during a meeting among social workers, police, and methadone treatment workers (Box 2, quotation 1).

The related incident illustrates the challenges facing health care providers when, to defend the methadone program, they attempt to articulate harm reduction principles in response to law enforcement’s abstinence-based criticism. On the one hand, they called on the principle of reducing drug-related harms rather than prematurely terminating methadone treatment for those who relapsed. On the other hand, they tried to avoid further criticism by proposing to screen unmotivated patients out of treatment to reduce dropout rates—an action that goes against the low-threshold principle of the harm reduction approach. This discourse indicates that the medical system and its providers focus on abstinence from all drugs and retention rates as the main treatment outcomes without recognizing other challenges (e.g., unemployment) facing methadone patients.

In the clinics, providers’ distrust of patients became evident in their daily practices. Because of this lack of trust, methadone dosing was used to coerce patients into doing what the clinics wanted them to do. For example, in a methadone clinic in Northern Vietnam, all patients were required to take turns cleaning the clinic without payment because the clinic was insufficiently staffed. Patients who resisted this requirement were denied medication. This practice was widespread in other areas, as shown in our notes taken during a study trip to a clinic (Box 2, quotation 2).

Thus, there is a mismatch between the priorities of PWUD and their families and those of health care providers. PWUD and their families considered abstinence desirable because they equated it with a conventional, functioning life outside methadone treatment. Health care providers considered abstinence the only goal of treatment and neglected patients’ other needs.

Vietnamese Drug Policy

There is still no comprehensive framework for developing a harm reduction policy for PWUD in Vietnam. Harm reduction interventions for HIV prevention, including condom and syringe delivery and maintenance treatment therapies, were first regulated in 2007. They are the only 2 government-approved programs,²⁶ and no new harm reduction strategies have been mentioned in legal documents so far. Other initiatives, such as overdose response and peer-based mental health assistance, were implemented on a small scale with support from nongovernmental organizations.²² No national funding has been committed so far to scale up these initiatives. This lack of a solid national framework had a negative impact on harm reduction practices that consequently allowed stakeholders not to take into account the rights of PWUD as patients who may equally benefit from medication such as methadone.

The current Drug Prevention Law, passed in March 2021, briefly mentions harm reduction in 1 article and dedicates extended sections to the management of PWUD with center-based compulsory treatment and administrative sanctions.²⁶ Despite the positive impact of harm reduction strategies, policymakers in Vietnam remain reluctant to adopt them. They perceive harm reduction as a colonialist model imposed by the Western world without adjustment to the Vietnamese context and resources. Additionally, Vietnam’s legal documents still consider drug use to be a “social evil.”²⁶ As international funding for methadone treatment has shrunk, policymakers opted to keep the medication that directly helped achieve abstinence but to forgo other components that would support patients’ other needs (Box 2, quotation 5). Accordingly, it appears that a major limitation of the methadone treatment program is that it does not consider harm reduction principles to engage PWUD and only focuses on methadone distribution as a method of abstinence. Harm reduction principles include providing individualized support to each target group, which we did not observe in this study.

Refusing the Harm Reduction Approach

Policymakers worried that harm reduction was not powerful enough to meet the ultimate goal of ending illicit drug use in Vietnam (Box 1, quotation 6). This policymaker’s argument reflects the influence of abstinence-based ideology and shows that the evidence of harm reduction’s effectiveness was still not persuasive.

Additionally, policymakers’ perceptions of the effectiveness of harm reduction measures can be adversely affected by the lack of a sound communication strategy. Although there is too much information about drug cases and their consequences, actions for harm reduction are rare and news outlets disseminate little information about harm reduction activities (Box 1, quotation 7).

Furthermore, for policymakers, information about effective interventions was insufficient. They were looking for a comprehensive harm reduction strategy that outlined potential political and social risks and indicated how to deal with them (Box 1, quotation 8). The traditional strategies of harm reductionists to prove harm reduction interventions medically effective and feasible might not address this need of policymakers (Box 1, quotation 9).

DISCUSSION

Our data from different qualitative and archival sources contributed to describing how different stakeholders in Vietnam—including PWUD and their families, health care professionals, and policymakers—view and experience harm reduction, particularly methadone treatment. Our findings showed that methadone treatment is now recognized in Vietnam as one of the first harm reduction programs at the national level. However, it is still considered a treatment method with the exclusive goal of achieving perfect abstinence after 20 years of implementation and public health improvements, rather than as a real harm reduction approach embedded in a philosophy that recognizes the rights of PWUD without achieving abstinence unless that is their declared intention.² Developments and adaptations in harm reduction measures have yet to be made. Harm reduction still struggles to meaningfully integrate into Vietnamese drug policy, and abstinence continues to be the ultimate goal of PWUD and other stakeholders.

Shifting mindsets in favor of harm reduction principles is not easy, as shown in the examples of countries with more progressive harm reduction programs that are still embedded in repressive frameworks.^27–29 Medical professionals need to shift from the dominant biomedical tendency of “fixing” individuals to accepting that abstinence is not always an option, from stigmatizing PWUD to focusing on their needs, and from blaming individuals to enhancing their decision-making abilities.²⁹ Long-term negotiation between different actors is required to implement particular harm reduction initiatives and overcome political and social reluctance because of lack of information about harm reduction principles and the benefits of harm reduction.²⁷

The social and political construction of drug issues in Vietnam is complex. It involves concerns about not only public health but also national security.¹⁰ Thus, there is no simple way to shift Vietnam to a tolerant approach to drug consumption. Still, the example of methadone treatment in the country shows that sufficient evidence of the benefits of harm reduction interventions can successfully advocate policy changes.¹¹ International examples suggest that in countries that still endorse repressive frameworks for drug use, harm reduction innovations can start at the local level with meaningful pilot projects that are later expanded nationally.²⁷ Harm reduction initiatives must address current political concerns, just as methadone treatment was once adopted to deal with the HIV threat to national security.¹⁰ Harm reduction initiatives should also take into account local sociocultural characteristics, such as the role of families as both a critical resource and a source of stigma for PWUD and the lack of social welfare services to aid PWUD.³⁰

The framing of drug-related harm is important in achieving harm reduction principles.³¹ Drug-related harm has been widely framed as “harm to others,” which assumes that individuals’ drug consumption harms people other than the user. Although this approach has been effective in creating alcohol policies such as safe driving and prohibition of underage drinking, it elicits public opprobrium against the individual user and heightens stigma and discrimination of PWUD when applied to illegal drug use.³¹ New harm reduction initiatives should acknowledge the multiple difficulties experienced by PWUD and involve their families. When family members are informed about the positive effects of harm reduction approaches for PWUD, their social networks, and environments, they are more likely to accept this approach without focusing on abstinence, and PWUD are more likely to follow through when their families are convinced. This approach would allow programs to take into account the multilevel, multidimensional environmental risk factors for effective interventions.

Limitations

In analyzing data from previous studies, we were unable to conduct additional interviews and observations to enrich our findings. Our observations from this source may be influenced by our recall bias because we did not systematically take notes at all meetings.

The majority of our PWUD participants were middle-aged; only 2 participants were younger than 30 years. Thus, we were unable to explore the perceptions of methadone treatment for younger patients, who might have different needs than middle-aged patients.

Conclusions

Although harm reduction interventions have existed in Vietnam for 2 decades, harm reduction principles have not been fully adopted and an abstinence-based approach dominates, as shown in the perspectives of PWUD, health care professionals, and policymakers. This situation is common in other places in the world. It is worth noting that the failure to recognize the purpose of harm reduction solutions has contributed to increasing dropout rates from methadone therapy and to an inability to cope with emerging drugs. Policymakers can easily dismiss the mere idea of implementing harm reduction evidence because of ideological barriers.

A harm reduction strategy based on a more humanistic approach that goes beyond a biomedicalized approach focused on medication availability is urgently needed for Vietnam and other countries. International experiences show that shifting to a more tolerant drug policy takes time and negotiation between different actors, and initiatives that speak to the political concerns of those who advocate harm reduction would accelerate this process.