Stigma and a Traditional Society

Viet Nam struggles to change attitudes, stanch emerging crisis

The Hanoi coffee shop we visited was located on a heavily trafficked, crowded, narrow lane, just off of a major road near the city center. There was nothing remarkable about the shop; just a few tables and chairs made up the serving area. A steep staircase with very shallow steps, typical for Hanoi, led to us up to a second floor room, with high windows at the front that keep the interior bright and cheerful. A group of seven young men and women were seated on the floor when we arrived.

The young Vietnamese are living with HIV/AIDS, and the coffee shop is run by Bright Futures, a non-profit network throughout the country made up of people living with the virus. This café provides work and income for some of the PWAs and, just as importantly, a community center for many more in Hanoi living with HIV.

These seven young Vietnamese are among several hundred thousand people in that nation living with the AIDS virus—only a very small fraction of whom yet have access to treatment options that have become the standard in the West.

I was part of a group of 15 Americans who each raised a minimum of $10,000 for the American Foundation for AIDS Research (amfAR). We were in Viet Nam, at our own expense, to learn about the group’s TREAT Asia initiative—aimed at helping the continent and the Pacific region overall build the prevention and treatment capacity to address a potentially devastating next wave of the HIV/AIDS epidemic—and also to participate in a trek through the countryside near Hanoi. We were joined by Andrew Green from AmfAR’s New York office and Stan Wong and Jennifer Ho, who work out of the organization’s Bangkok office implementing the TREAT Asia program.

Few of our hosts spoke English—and I guess it goes without saying that we Americans didn’t know Vietnamese—so one of their group acted as translator as each of them told us a little bit about their situation and their hopes for the future. Despite the language barrier, the Vietnamese youth were all quite poised, a fact all the more remarkable when we considered their stories about the degree of stigma they faced in their society because of their illness. In fact, they looked and acted much like their fellow youth we had run across the night before on a Friday evening out on the town.

Given the stigma that continues to be borne by those living with HIV in Viet Nam, those individuals living with the virus whom we encountered are unnamed in this article. Even an American doctor working there asked that her name remain confidential so that publicity not interfere with her efforts.

An estimated 225,000 Vietnamese live with HIV or AIDS. The prevalence of the virus among adults 15 to 49 is 0.5 percent, versus 0.6 percent in the United States, where 950,000 people are estimated to be infected, according to statistics from the United Nations’ AIDS initiative, UNAIDS. The frequency of infection in Viet Nam matches the lower end of estimates for India, where a staggering 4.6 million people are living with the virus and is four times the rate of China, which has an estimated 840,000 people who are HIV-positive. In Asia, only India, China, Thailand, and Myanmar have more of their citizens living with the virus.

Kevin Frost, amfAR’s vice president for Global Initiatives, who directs the TREAT Asia program, explained the importance of a focus on Vietnam.

“While the number of Vietnamese people infected is currently less than one percent of the adult population, many working in the region believe Viet Nam could be on the brink of an epidemic as serious as those elsewhere in Asia,” he said. “As the economy grows at one of the fastest paces in the world, poorer people migrate into urban centers in search of work. This displacement contributes to the vulnerability of people, including increasing commercial sex work and injection drug use.”

Those we met with and the statistics confirmed Frost’s observations and tell the same story behind the stigma surrounding HIV. In Viet Nam, the virus emerged as an affliction of IV drug users and those involved in the sex trade. An estimated 30 percent of needle-injecting drug users are living with HIV, with that ratio roughly double in some urban centers. According to amfAR, 65 percent of infections to date in Viet Nam have been among this population. The statistics on women working as prostitutes vary widely. UNAIDS says that six percent of this population has HIV, but according to amfAR, infection rates in some urban areas range as high as 24 percent.

A 2004 USA Today story on AIDS in Viet Nam reported that roughly 15 percent of Vietnamese men turn to sex workers every year. More than two thirds of those living with HIV in Viet Nam are men.

Yet, disease does not impact everybody in the same way, and for those in economically marginal positions in society, especially women in Viet Nam, the impact of AIDS can be devastating. After our meeting at the coffee shop, we met with five women from a government-sponsored AIDS/ HIV shelter and counseling center. These women were more reticent than the first group we encountered and only slowly opened up with their stories. Each, in different ways, reflected tales of social ostracism compounded by the denial of health care services until they were able to find placement in the shelter.

Despite the concentration of HIV in the IV drug user and sex worker populations in Viet Nam, the nation’s largely underground gay male population is not unmindful of the risks of infection. According to the Viet Nam News Agency, a group of 24 gay men in Hanoi, supported by SHARP, a non-profit organization that receives support from the United States Agency For International Development and Family Health International, do nightly outreach work at locales where the community gathers—a total of four dozen spots, including parks, massage parlors, and inns. They carry condoms and safer-sex literature, and hold fashion and singing programs once every two weeks as part of their education efforts.

A study of 600 men who engage in gay sex in Ho Chi Minh City, formerly known as Saigon, conducted this past spring, found that nearly all of them were unmarried and did not live with women, that 23 percent had more than three sexual partners in the previous month, and that two thirds of them said they used a condom in their last sexual encounter. Those who did not said they either thought it was unnecessary or that they would diminish their pleasure by doing so. One fifth of the men said they had been tested for HIV.

The study of gay sex in Ho Chi Minh City is significant in that the southern city, unlike Hanoi, is one of four urban “hot spots” identified by UNAIDS as locations of particular concern for the spread of the virus in Viet Nam. However, as is true in urban areas throughout the nation, Hanoi is a magnet for people living with HIV who hope to reduce the stigmatization they suffered living in smaller communities and attain better medical care as well.

Though HIV stigma in Viet Nam, unlike the epidemic’s early days in the U.S., is not linked to homosexuality, that is not to say that Vietnamese gay men do not face severe negative attitudes in their society. In August, Associated Press reported on the first survey of sexual attitudes and behavior among Vietnamese youth—which yielded responses from 7,584 people between the ages of 14 and 25, who reported that their average age of first sexual encounter was 19.6 years old. Of that group, only 60 percent said they knew about homosexuality, but in that portion of the population, 80 percent said they would not accept a gay person as a friend. Ninety-seven percent said they knew about HIV, with an equal number expressing awareness that condoms can prevent its transmission. More than two thirds, however, agreed with at least a portion of their gay peers that they also reduce pleasure.

The widespread knowledge in Viet Nam of condoms and their value in combating HIV transmission is something for which the nation has been commended by the World Health Organization. In April of this year, Dr. Dominque Ricard, a Frenchman who has worked for WHO in Viet Nam for the past five years, specifically lauded the government there for its “best practices” harm reduction efforts, particularly regarding prevention efforts with sex workers and IV drug users.

Ricard also lauded an appearance that President Tran Duc Luong made with PWAs, shaking their hands and talking about HIV as a health problem not a social evil, saying such leadership from top officials in society was important in educating the public away from stigmatizing those living with the virus.

Even as Viet Nam wins international plaudits for its frank approach toward safer-sex education, it has also won a coveted position in the U.S.’s global AIDS effort, which has been widely criticized for its over-emphasis on abstinence to the exclusion of other more effective strategies. Since mid-2004, Viet Nam has been the only Asian nation included in President George W. Bush’s $15 billion AIDS initiative (the President’s Emergency Plan for HIV/AIDS Relief, or PEPFAR) that is focused primarily on Africa and the Caribbean. According to Ambassador Randall Tobias, who heads up the American global effort, the choice of Vietnam was predicated on the fact that the virus is growing more rapidly there than in either China or India, two nations widely viewed as emergency zones in the war on AIDS.

“Viet Nam is a country where the disease is largely confined among sex workers and drug users but is on the verge of exploding into the general population,” Tobias explained to USA Today last year.

“Viet Nam’s inclusion as the 15th PEPFAR country has led to significant increases in funding,” amfAR’s Frost noted. “Coupled with new national treatment programs in China, Indonesia, and Cambodia, these developments emphasize the need to insure that healthcare workers in the region are prepared with the knowledge and skills necessary to deliver treatment to people with HIV/AIDS safely and effectively.”

Still, Americans may well be as suspicious of the Bush effort as anyone in the world—that was certainly true when our group met with doctors, including American government health officials, working on the ground in Viet Nam. At times, our questions were pointed, even overtly political. But U.S. support for the HIV efforts in this Asian nation works in tandem with a local government response that pays considerable attention to condom use and other safer-sex practices and most of the discussions we had focused on the enormous amount of work needed to build a proper health infrastructure to comprehensively tackle an emerging crisis.

The task is daunting, as became particularly clear in a dinner meeting we had with an American physician working in Viet Nam who said she preferred for purposes of the press to remain anonymous. According to a 2004 AmfAR estimate, there are only 20 doctors specifically trained in HIV care and treatment in Viet Nam—for a ratio of about one to every 11,250 people living with the virus. In mid-2004, USA Today put the number of Vietnamese receiving anti-retroviral treatment at less than 300; an estimate the same year from AmfAR put that figure below 2,000. Tobias, the head of the U.S. global fund, last year said that when he visited Hanoi’s Bach Mai Hospital—with 1,400 beds the largest in Viet Nam—he found some AIDS patients two to a bed.

The American doctor, who appeared before us with an official from the Vietnamese Health Ministry, spoke movingly of her experiences working to educate health care workers on the ground not only about the latest treatment options, but at a far more fundamental level about the fact they need not harbor undue concerns about the contagion of the HIV virus. The Vietnamese health official, also a doctor, spoke with surprising candor—and considerable humility—about the shortcomings of his nation’s health care system and the tall hurdles that remain before them.

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