Focusing HIV prevention on those most likely to transmit the virus.

Despite some success in reducing HIV incidence, the global epidemic continues to grow. For every person with AIDS in developing countries placed on treatment in 2005, many others were newly infected. We need more effective prevention programs that focus interventions on those most at risk for HIV transmission (MART), particularly those with 1) high behavioral risk and 2) high viral loads due to acute or recent infection, co-infections with other diseases, high viral set points, or untreated AIDS. This article provides examples of how prevention programs can incorporate emerging testing technologies and social/behavioral approaches to reach these individuals, their partners, and the social networks where active transmission is occurring.

Sex workers in Vietnam: how many, how risky?

Because of concerns for HIV risks and need to plan effective programs, we assessed the number and risks of sex workers in Nha Trang City, Vietnam. Sex workers were contacted in streets, beaches, bars, and restaurants, and a capture-recapture method was used to estimate their number. An estimated 444 women worked on the streets and beach ("direct" sex workers) and 486 worked in bars and restaurants or other facilities ("indirect" sex workers). Direct and indirect sex workers engaged in sex work primarily to support their families. Direct sex workers were older and were more at risk for HIV risk than were indirect sex workers. Direct sex workers had more clients, were less likely to report always using condoms (67% vs. 81%), more likely to report a prior sexually transmitted infection (19% vs. 16%), and more likely to have clients who inject drugs (16% vs. 13%). This assessment has implications for planning programs to reduce sex work and its risks in Vietnam and potentially other countries.

Defining and assessing evidence for the effectiveness of technical assistance in furthering global health.

In an era when health resources are increasingly constrained, international organisations are transitioning from directly managing health services to providing technical assistance (TA) to in-country owners of public health programmes. We define TA as: 'A dynamic, capacity-building process for designing or improving the quality, effectiveness, and efficiency of specific programmes, research, services, products, or systems'. TA can build sustainable capacities, strengthen health systems and support country ownership. However, our assessment of published evaluations found limited evidence for its effectiveness. We summarise socio-behavioural theories relevant to TA, review published evaluations and describe skills required for TA providers. We explore challenges to providing TA including cost effectiveness, knowledge management and sustaining TA systems. Lastly, we outline recommendations for structuring global TA systems. Considering its important role in global health, more rigorous evaluations of TA efforts should be given high priority.

Factors associated with HIV testing, condom use, and sexually transmitted infections among female sex workers in Nha Trang, Vietnam.

This study examined predictors of HIV testing, successful condom negotiation with clients, and self-reported sexually transmitted infections (STIs) among Vietnamese female sex workers (FSW). Data were collected by using face-to-face interviews from a community sample of 610 FSW from Nha Trang city during October-December, 2000. Having had an HIV test was associated with having spent time in a rehabilitation center. Consistently successful negotiation of condom use occurred most among FSW who had few clients, understood how HIV was not transmitted, and had not reported ever having any symptoms of STIs. Migration to Nha Trang for sex work was a risk factor for an STI diagnosis; successful negotiation of condom use had a protective effect. Our results suggest the need for voluntary HIV counseling and testing, further promotion of condom use among FSW populations, and better use of rehabilitation sites to promote HIV prevention.

Peer education for HIV prevention in the Socialist Republic of Vietnam: a national assessment.

In 2000, the government of Vietnam conducted the first assessment of its national peer education program for HIV prevention. Twenty (32%) of Vietnam's 61 provinces and urban areas had functioning peer education programs, and program coordinators of all 20 were interviewed regarding their programs. In addition, on-site reviews were done for 10 of the 20 programs, including interviews of peer educators and high-risk persons in each program. The assessment found that a total of 500 peer educators were functioning either independently or as part of one of 79 teams. In the 20 provinces, the peer educators made an estimated 7,000 total contacts per month with high risk persons, but many persons were likely contacted repeatedly. Despite this, coverage was limited: some provinces with high numbers of persons reported with HIV/AIDS had few peer educators. Although most provinces targeted IDU and many targeted CSW, few provinces targeted sex partners of IDU or CSW. The definition of peer education and composition of teams varied substantially by province; only one province included persons living with HIV/AIDS as peer educators. The services provided by peer educators were primarily distributional: delivering information either through word of mouth, pamphlets, or brochures, providing condoms, and sometimes providing clean syringes and needles. Skills building or goal setting interventions aimed at HIV risk reduction were rarely provided. Most provinces had concerns about ongoing funding and sustainability of the programs. Based on the assessment, specific recommendations were provided for strengthening and expanding Vietnam's peer education programs.