Institutionnalisation d'un continuum de prise en charge des séropositifs VIH/sida à Hanoï (Viêt-Nam)

Abstract

Caring for people living with HIV/AIDS (PLWHA) encompasses various tasks, from prevention to palliative care. It involves a set of consistent and coordinated actions. This article presents the first free-of-charge management programme including antiretroviral treatment in Vietnam (as opposed to research and evaluation programmes). It was launched in 2004 in Hanoi. Our study was conducted in 2003-2004 as part of a collaborative research programme led by IRD (Research Institute for Development) and the National Economic University in Hanoi and was funded by ESTHER (Together for a Therapeutic Solidarity in Hospital Network) group. Data collection included 68 qualitative interviews with patients, members of their families and members of the hospital staff, observations of outpatient consultations, and analysis of inpatient files. The results show that patients, their families and hospital staff members all perceive a comprehensive care and treatment programme as very important and consider that it should include social and psychological care as well as an integrated set of actions involving various types of participants. Outpatient and inpatient care are closely linked: they take place in the same hospital department, they involve patients with similar social and demographic characteristics marked by multiple risk behaviours and recourse to several kinds of healthcare services. The observation of outpatient consultations showed the limitations of strictly biomedical care to which social and psychological care were added only lately. One of the principal difficulties is patients' difficulties in keeping their outpatient appointments. Overall, patients consider themselves lucky to able to receive care and treatment with antiretroviral drugs. They nevertheless complain about the lack of social and psychological support, which they expect should help them to tolerate and adapt to their biomedical treatment and to include counselling and information about this treatment and its consequences. Hospital staff with the greatest contact with PLWHA report more frequent attempts to avoid this contact. This stigmatisation is due to lack of information, failure to implement workplace safety measures, and to pejorative representations of HIV/AIDS. Official and unofficial discourse still follows the Ministry of Health in associating HIV/AIDS with drug use and commercial sex, and HIV/AIDS prevention and control policy is still linked to the "social evils" policy. Hospital staff also emphasized the importance of community care for PLWHA in their interviews. Informal care for PLWHA by family, close relatives, close friends and members of non-official groups complements hospital care, which is sometimes limited to its biomedical component and provides the material, moral, financial, social, economic and relational care essential for PLWHA and their close relatives and friends. This informal care has also some pernicious effects and leads to internal contradictions due to the multiple social roles played by the many and various participants involved. HIV/AIDS prevention and control policy relies on a series of choices between more specificity through vertical programmes specialised in HIV/AIDS and the synergy that can develop through more integrated health services. Vietnam has developed links between HIV/AIDS prevention and control programmes on the one hand, and harm reduction programmes for injecting drug users (access to substitution products such as methadone) and condom distribution, on the other. Nonetheless, HIV/AIDS prevention and control policy faces difficulties in reaching its objectives. The results of this policy, intended to help achieve Millennium Development Goal (MDG) n degrees 6, depends partly on the success for other MDGs, including the fight against poverty, the promotion of gender equality and empowerment of women, and the improvement of reproductive health. To be able to succeed in implementing the continuum of care necessary for treating HIV/AIDS within its institutions, Vietnam can apply the lessons of international experience, adapted to fit local constraints and the social, cultural and political context. The shortcomings encountered in this endeavour shows how difficult it is for this country to implement such a complex set of measures at an accelerated pace. They should not, however, hide or minimize the great efforts, the vigour, and the capacity to adapt already demonstrated by local participants.