Center for the Study of Culture, Politics, and Health

Star I Pilot Studies

Social Organization of Masculinity and Sexual Risk ‘The Pillar of the Family’: Masculinities and Sexualities in Post-Doi Moi Vietnam

PI: Le Minh Giang
Co-PIs: Miguel Muñoz-Laboy and Richard Parker

Since the beginning of the epidemic in Vietnam, men have accounted for more than 70% of reported HIV cases, with the average age of infected men growing ever lower. Over the past twenty years, during the same period of time in which the epidemic has become more disseminated, Vietnam has undergone a complex set of rapid social and economic transformations that have changed Vietnamese men in many fundamental ways, including their life desires and aspirations. Little attention have been paid to understanding men as gendered and sexual subjects who are striving to live up (and negotiate) with socially and culturally proscribed ways to be men. Importantly, how new life desires and aspirations shape social and spatial practices of pleasure seeking among men in ways that might put them at risk is also not entirely understood. Towards the broad goal of developing better understanding of what places men in contemporary Vietnam at risk of HIV infection and what interventions might mitigate this risk, this pilot study sought to:

  1. Explore the life desires and aspirations of a diverse group of Vietnamese men, with particular attention to how interactions between these desires and aspirations and dimensions of inequalities (for examples, access to social, economic and political capital, and geographical locations) make certain groups of men more vulnerable to HIV infections than others.
  2. Describe how life desires and aspirations shape men’s social lives, their mobility and their practices of seeking pleasure, and explore the ways these practices shape men’s HIV risk.

The information generated from this study served as the basis for further research and interventions to address HIV risk among men in Vietnam. Furthermore, this research has enabled the initation of dialogue with Vietnamese and international policymakers about the roles of men in the fight against HIV/AIDS in Vietnam and about mechanisms that promote resiliency and preventive action among men in adverse situations.

The Social Impact of Anti-Retroviral Therapy (ART): Gender, Life Projects, and the Social Impacts of Anti-Retroviral Therapy (ART)

PI: Harriet Phinney
Co-PI: Khuat Thu Hong

The pilot study explored individual and family-level responses to ART, including the social determinants of uptake and the effects of ART on sexual strategies and the management of reproduction among couples in which one or both members use ART. It was also used to address clinicians’ perspectives on ART.

Throughout the project, we used two concepts – life projects and social risk – developed through previous multi-sited ethnographic research (which included one site in Vietnam) to understand how people engage with the availability of ART. Specifically, our aims were to:

  1. Examine and understand how ART affects the gendered life projects of people living with HIV, including their family and peer relations, sexual behaviors, marital intentions and trajectories, and reproductive goals and practices.
  2. Investigate and evaluate how these social, sexual, marital, and reproductive life projects, enabled by ART, interact with and influence the therapeutic itineraries and crucial health-related behaviors such as risky and protective sexual practices, and adherence to therapy.
  3. Explore clinician perspectives on ART, including their experiences of scaled-up access, their insights into the determinants of uptake and sexual risk, and their knowledge of and ideas about how their patients integrate ART into their lives.
  4. Use this pilot data to engage in a dialogue with Vietnamese and international policymakers about scalable community-level interventions to enhance uptake, minimize the risk of marital HIV transmission and enable adherence to therapy.

Vietnam, as a PEPFAR focus country, has been the recipient of a significant level of focused effort to increase the availability of anti-retroviral therapy (ART). As of November of 2006, about 5000 people were being treated nationwide. Emerging evidence from around the globe regarding sexual disinhibition, limited overall participation in VCT programs, gender differentials in access to ARVs, and continuing high transmission rates among zero-discordant couples suggest both that there are ongoing challenges to achieving universal access and that efforts to achieve universal access may have unintended (and in some instances un-wished for) consequences. Little is known, however, about how or even whether these same challenges are developing in the particular Vietnamese context. This pilot project begsn to fill a critical gap in the social science research on HIV by collecting and analyzing preliminary data about these social impacts of ART access. Attending more closely to the inadvertent results of scale up will increase the ability of the Vietnamese government to successfully achieve the clinical and public health goals of using ART to enhance population health.

Harriet M. Phinney, Khuat Thu Hong, Vu Thi Thanh Nhan, Nguyen Thi Phuong Thao & Jennifer S. Hirsch. (2013). Obstacles to the ‘cleanliness of our race’: HIV, reproductive risk, stratified reproduction, and population quality in Hanoi, Vietnam. Critical Public Health, (ahead-of-print), 1-16.

Politics of Harm Reduction in Vietnam Will "The King's Law Stops at the Village Gate"? Harm Reduction as a Case Study in Health Policy Change in Post-Doi Moi Vietnam

PI: Ronald Bayer
Co-PIs: Claire Edington and Nguyen Thi Mai Huong

Ever since the first HIV case was reported in 1990, the public face of the epidemic in Vietnam has been dominated by male drug users. As of 2005, while HIV prevalence among adults aged 15-49 was estimated at 0.53%, this prevalence was 34% among male injecting drug users (IDUs) according to nation-wide sentinel surveillance. In some locations such as Hanoi, Ho Chi Minh City and Quang Ninh province the prevalence rates are even higher. Although the share of drug users among people living with HIV/AIDS in Vietnam has declined from 75% in mid 1990s to about 50% in the mid 2000s, reports from sentinel surveillance have shown steady increases in prevalence rates in this population, from 9.3% in 1997 to the current level of 34%. The increasing number of cases among married women and newborns which account for declines in drug users’ overall share in total cases are primarily due to marital infection and the resultant vertical transmission; to the extent that prevalence appears to be increasing among female sex workers, this is also largely due to injection-related risk. Injecting drug practices and risks, which have played an important role in shaping the Vietnamese epidemic, will likely continue to do so in the years to come.

The purpose of this study was to learn about the circumstances and processes through which globally-shared concepts transform policy and to understand how such policy is playing out on the ground, especially in terms of its implications upon individuals and communities. Broader implications exist for understanding the policy process in general, as well as the specific constraints on public health policy in countries transitioning from socialist to market-based economy and social governance. Towards this end, this pilot study had the following specific aims:

  1. To describe and analyze the social and political processes that have led to Vietnam’s recent shift towards a harm-reduction approach to HIV prevention among IDUs, with a particular emphasis on the interactions among: a. Global external actors (advocates, program managers and donors); b. Government at the national level (such as the Ministry of Health and other ministries responsible for social management, including the Ministry of Labor, Invalids and Social Affairs and  Ministry of Police), in the National Assembl (Committee for Social  Affairs); and the Communist Party (Committee for Science and  Training)c. State agencies at the local level such as the People’s Committee, law enforcement, local mass organizations (such as Women Union  and Youth Union) and health services and elements of civil society (such as local NGOs, network of people living with HIV).
  2. To explore how tensions between the harm reduction approach and the prior ‘social evils’ approach play out programmatically, by  working ethnographically in two research settings (one urban, one rural)  to explore the variability of existing and emerging prevention programs;
  3. To use this case study to develop a deeper understanding of public health policymaking in a country transitioning from a centrally-planned socialist to market-based economy, with a particular focus on  developing generalizable and testable propositions about the relative role of evidence concerning the limits and efficacy of specifi intervention strategies in the adoption of those strategies.

Edington, C., & Bayer, R. (2013). When grammars collide: Harm reduction, drug detention and the challenges of international policy reform efforts in Vietnam. Global public health, 8(sup1), S75-S91.