HIV-related stigma in Vietnam : implications for the prevention and control of HIV in concentrated epidemic settings

Abstract: Background: Since the early days of the HIV epidemic, stigma has been recognized as strongly linked to HIV. In concentrated HIV epidemic settings such as Vietnam, stigma is also associated with key risk groups that are heavily affected by HIV, such as injecting drug users, commercial sex workers and men who have sex with men. The availability of HIV prevention and treatment measures has increased globally, but the prevention, testing and treatment for HIV has lagged, particularly in certain segments of the population. Aim: The overall aim of this thesis is to analyze and explore how HIV-related stigma influences HIV prevention and care in a concentrated HIV epidemic setting. Methods: Data for this study were collected from three locations in Northern Vietnam and are organized into four articles (I-IV). In article I, a structured questionnaire was used to identify factors associated with HIV-related stigma in a population-based sample of 1874 adult community members in the rural district of Bavi. The same study population was used for article II, where determinants of HIV testing were identified. In article III, qualitative interviews with women living with HIV in and around Hanoi explored how women cope with HIV-related stigma. In article IV, focus group discussions with persons living with HIV and their family members in Quang Ninh province were used to explore factors influencing adherence to antiretroviral therapy. Findings: Women, persons with less education, and those who had not migrated out of the rural area were significantly more likely to express stigmatizing attitudes toward people living with HIV, and HIV-related stigma was associated with not feeling at-risk for HIV among rural Vietnamese adults (I). Testing rates for HIV were low (7.6%), generally, and persons with less money, those living in more rural settings, and those expressing more HIV-related stigma were significantly less likely to have tested for HIV (II). Prevention of mother-to-child transmission programs seemed not to have had a large uptake in the study population, with pregnant women no more likely to have tested for HIV than non-pregnant women (II). Stigma appeared to affect the extent to which persons living with HIV could enact HIV prevention measures or disclose their HIV status to others (III, IV). Women living with HIV attempted to stave off HIV-related stigma by enacting culturally-prescribed feminine virtues of protecting others and appearing innocent in their infection with HIV (III). Family was identified as an important source of adherence and social support and those women who had more support from family members appeared to cope more easily with the stigma of living with HIV (III, IV). Organizations for persons living with HIV helped members to obtain health care and to manage stigma (III). Stigma was identified as one of the main barriers to adherence to antiretroviral medication, causing people living with HIV to hide or delay taking their medication (IV). Conclusions: Results suggest that stigma presents an obstacle to effective HIV prevention and treatment in the Vietnamese context. The provision of free, opt-out, high-quality HIV testing could help to normalize the process of HIV testing and make it more accessible within Vietnam, particularly in the antenatal setting. Family and peer support could help to encourage good adherence to antiretroviral treatment. Organizations for persons living with HIV can be used to increase access to health care, to reduce stigma in community and family settings, and to increase quality of life for persons living with HIV. Refined public health messaging that incorporates the cultural notion of protection of family and that de-links HIV from fear-based messages could be an effective way of reducing stigma and increasing effective HIV prevention and care in the Vietnamese context.