Drug Abuse

CHAPTER 6

The cases of Chau and Chung, together with the life story of Ngan presented in Chapter 1, illustrate various ways IDUs manage their everyday lives, which are fraught with drug desire, risks, uncertainties and disease. Like Ngan, Chau has entered into different relationships with a number of men. For her, this is “normal”, as many IDUs will explore such options before settling on one partner. Each relationship has been of varying intensity and duration. Again, sharing syringes and not using condoms has become a normative feature of Chau’s relationships. As a result, she got infected with HIV without knowing the real cause. For Chung, there is something different. He is not promiscuous. He knows how to restrain his drug habit and he does not share syringes with his partner. He has a job and he is looking forward for a better life. In sum, these two stories help us to get more insights into the social contexts of AIDS risk and complex relationships IDUs have to confront. Furthermore, there are a number of issues inherent in their stories. Poverty, family break-ups, migration, employment, peer pressure are all negative factors which influence their lives. Paying close attention to the dilemmas faced by IDUs may lead one to a better understanding about the social construction of AIDS.

Case 1: Chau

Chau was born in 1980 in Nghe An, a rural province in the central part of Vietnam. She has one younger sister. Her parents divorced when she was ten. After finishing the ninth grade she had to give up school because “ my family was poor and my parents did not pay any attention to my study”. When Chau was 18, she fell in love the first time with Ngu. Both of them were opium smokers. But they soon divorced, because “ he beats me up frequently”. With the invitation of her friends and the attractiveness of the urban life, Chau decided to move to Hanoi with a hope to find a job. There she shared the room with three addicted friends in a cheap rent-house. As other drug users, she impressed me by talking about the way in which she became immersed in the drug life:

I began to smoke black [opium] in 1998. I was a heavy opium smoker when I began to inject white [heroin] one year later. I shifted to injection because after a long time of smoking, I seemed to get the “saturation status” which means that I did not feel good or get high anymore. Only heroin injection can make me feel good. I gradually increased the quantity of drug... from VND 50,000 (3.3 USD) to VND 300,000 (20 USD) per day. Then I decided to shift to injection. It is cheaper and quicker to get high.

To “feed the high”, Chau had to think of different tactics to make money:

For shooters [IDUs], we have various ways to earn money: working as a girl [sex worker], you know...when you become an addict, you don’t care anything but money...I also steal things or deceive different people...any way you can think of to get money, anything you can change into cash to satisfy your craving. I deceive all my acquaintances, relatives and friends who are not aware of my addiction, with all possible reasons: I need money to come back to my native village, go to hospital for health check up... I know that friends often show their sympathy when I say I have a disease so they would give me money if I say so. For the men who like me (and they do not know that I am on drug), I can exploit them as well, asking them for money you know, all sort of things... I also go to the parks to steal belongings of young couples, at the moment when they are fondling each other...When I was pregnant, I even practiced selling illicit drug because I knew that the law does not punish pregnant women...

In 1999, Chau met Tuan, the second man after her husband. Tuan was a heavy injector, just returned from prison. “He has a talent to earn money. I think I could bank on him to satisfy my craving for drug, that’s why I liked him...there was no love from me”. Tuan made money by “dap hop” (breaking into houses). They were living together for four months when Tuan was arrested because of a robbery. Tuan hit more heavily than Chau. From the beginning they used two syringes but then they shared one: “ we shoot to each other...he takes 10 dem (1cc) and I take 5 dem (0.5cc)1 . After a while I sort of increased my dose”. During the daytime they rarely met each other “He and I pursue different ways to earn money, we meet only at night. I often go to work [street prostitution] at 7 pm, but I hit and sleep during the day, I return from work at about 11pm, we play one [shot] and go to bed”. When Tuan is out, Chau also shared with her peers at home: “I also share with my peers... sometimes the drug is prepared in one syringe. After my friend finished the shot, I would remove the needle, shake off the barrel until no blood is left, then I put back the needle [to the barrel] and shoot.”

At that time Chau was 19 and Tuan was 25. Although Tuan was more heavily addicted than Chau, both of them were novice injectors in the drug scene. They both seemed to enjoy their sexual life. As Chau explained how heroin and sex went together:

...Very often, 30 minutes after the hit, we have sex... but with the condition that we play temperate [inject with a medium dose] and at the same time it should be our intention to have sex... then we can fuck right after the hit... If you take high dose, you can’t have sex right after the shot. Very often the injection makes your nerve sort of powerless so you want to sleep after that. But if you do something [having sex] right after the shot, you will be awake. Therefore after the fuck we have the need to take another shot so that we can get into sleep. Usually, we take a shot, fuck after that and then hit another shot: these three actions occur within one hour, continuously.

...When I’m sick I have a desire to have sex. The more you’re sick, the more you want to have sex, even when I have become a heavy shooter...very often, when the craving comes, I don’t have a desire for sex at once, but when I have suffered from the craving for 2-3 hours then the desire for sex will arise as well. Normally if I am full of it [drug] I am not interested in having sex with my partner or lover...in that context having sex is some kind of formality, nothing is orgasm...If you are in a normal state, your orgasm may need a longer time to be reached, but if you are in a sick [craving status], you will reach orgasm very quickly. By then you need something fast [quick sex] you know...if you have reached orgasm, nothing to be cared...

…Sometimes the weather is bad, rainy...I don’t have guests [clients], even if you have money but sometimes at night you can’t get the stuff [heroin] somewhere...sometimes you have been craving for the whole day...but even so sometimes in the day you still want to have sex...when you are on drug, sick is a normal thing...even when I am in detoxification period of one or two weeks, my need for sex is quite high. If my demand for sex is satisfied then, drug craving will be relieved for a while, I mean during the sex act only...right after that you miss the drug at once...

Chau did not use a condom with Tuan: “Once we love each other, we don’t use condom. Fucking without condom is normal for lovers or cohabiting couples. If I propose to use it, he may look down on me. He may think that I don’t love him truly, or consider him as a bad man [infected]. On the contrary, if he suggests to use one I would think so too”. According to Chau, dispensing with a condom is also synonymous with sharing a syringe: “We use one syringe and share, it means that once we are not afraid of unprotected sex so we share”.

Chau and Tuan were living together for six months when Tuan was arrested and sent to a detoxification center in the South. In the summer 1999, Chau entered the third relationship with Cuong, a drug smoker. Although they had different drug using styles, Chau seemed to “sympathize” with Cuong: “I think that I have experienced that period [smoking] already. Of course, injection is quick and smoking is long but it is no problem”. After two months, Cuong began to shoot as a result of the cohabitation with Chau. But for Chau, the shift from smoking to shooting is quite conventional: “...it is easier for a shooter to drag a smoker partner into injection more than a smoker to drag a shooter into smoking, because shooting produces more high and more directly absorbed into blood than smoking…once you have shifted from smoking to injecting, you don’t want to smoke anymore and even if you do smoke, you don’t feel high anymore...

Two months after Cuong was sent to prison for his involvement in a robbery, Chau met with Chu, a nonaddict, and lived with him for one year. Chau decided to hide her drug use with Chu right from the beginning. She explained about the motive for her concealment:

“You know we [drug addicts] are condemned by the entire society...even when I sit somewhere in a public place I can hear the condemnation from the crowd...therefore I feel afraid of disclosing my addiction status...they will not accept me...but there are some people who seem to be willing to help me even when I disclose but I don’t want to tell them the truth anyway... because I have fooled myself by shooting the fucking stuff so I am scared that I will not be able to stop...therefore I have to lie... when you are on drug, you become small-minded and selfish.”

Chau also thought of another plan if the hiding with Chu would not succeed “ if it fails [and he discovers my addiction], I would drag him into shooting with me”. This plan is based on her experience living with other men: “ There are some men who are not influenced by my ‘pulling’ [dragging him into injecting habit] and they still persuade me to withdraw...maybe from the beginning they still give me money and also during that time they persuade me but if I remain the same, they will feel tired and say good bye to me...except the case for men who love me truly, they have to accept the situation [by continuing to live with me]”. But Chau did not succeed in pulling Chu into the life with her. When Chu found out that Chau was using drugs heavily, he began to use a condom with her. However, Chu still showed his kindness by persuading Chau to withdraw “ He helped me a lot, so I felt I loved him truly and from that time I did not want to loi dung [exploit] anymore...however he will never be able to help me to stop...even parents, the most sacred relation can’t help me withdraw...so nothing can stop me”.

In April 2001, Chau was found to be infected with HIV. The test was confirmed after one week of her stay in Bavi rehabilitation center. She recalled:

I think I got the virus because of sharing rather than playing no condom”...When I was working girl [CSW] I did use condom most of the time. But there was the time when we gathered in T. commune for shooting. We were all sort of heavy shooters and that time policemen launched campaigns to arrest many addicts and drug dealers...that’s why white [heroin] became very scarce. We had to go to shooting galleries where black [liquefied opium] was readily prepared in syringes for sale. You know, that were all used syringes... they simply cleaned the syringes by water and pump in the stuff [opium] for us...we were all so sick [craving] that we did not think anything, and after the shot we gave the used syringes back to them. They then do simple cleaning again and prepare drug for others...

With regret, she told me how she understood about AIDS before being infected: “When I was a novice shooter, I was not aware of SIDA [AIDS]. I saw AIDS people on TV, at their last stage, with rashes, ulcers...Then I went to Hanoi and shared [syringe] with my peers. They looked healthy and I thought to myself: ‘nothing to be worried about’...now I know what it is…”

Case 2: Chung

“Since the day I began using drug, I have lost a lot of things. First I lost my own human dignity. Second I lost respect from others”.

Chung was 29 years old when I met him. Different from Ngan and Chau, Chung had a decent job: he is a freelance painter. Chung can earn USD 100 a month with his painting job. Like Ngan and Chau, he was brought into the drug scene when he was young. After finishing 10^th grade, he had to abandon his study in school because “ my family faced a lot of difficulties. We did not have any money to save my mother’s cancer. My father died one year after my mother’s funeral. I was very small then. I have three brothers. All of them can live on their own but they all are involved in gambling”. Chung began his drug career as a heroin smoker in 1996. The reason for his involvement in the drug scene was “ I began to use drugs and that is simple because my brothers were using drugs too. They were sort of hardened shooters, OK? And I would hang around them. They often shoot in the attic and socialize there you know. And I just sort of curious want to know what they were doing. So I started shooting with them”.

In 1999, about the time Chung returned from rehabilitation center, Chung met Thi at a binge in a karaoke parlor where Thi was working as a bargirl. Thi liked Chung because of his painting talent and manual skills “ I am good at painting. All of my previous relationships originated from my drawing capacity. In addition, I am sort of skillful person. I can repair TV and motorbikes, all those things in the house. That’s what a woman needs from a man”. He decided to live with Thi after some consideration

To rate myself, I think I am not a pure person who has a healthy lifestyle. In general, I don’t care what kind of girl she is. The main thing is we love each other. That’s all. I know that she is using the white [heroin]. But I am addicting myself so she is similar. I should accept my addiction and its consequences.

From the beginning both Chung and Thi hide their addiction status. Until one day Chung could not tell lies anymore because Thi saw him inject with his friends. But they already feel committed to each other, and thus try and go ahead, live with it.

They went on living together and had sex normally as before as if nothing had happened. Thi remained a bargirl. It seemed that both of them could predict what would happen. They have already gotten “in too deep”. For them risk is something fearful at the beginning, but readily acceptable later. The cohabitation is equivalent with the inherent risks. Risks require sympathy. With these rules they maintained their cohabitation:

In general, she is similar to me from the beginning when I met her and then I lived with her and had sex with her, I sometimes scared [about HIV risk]…But when we got married officially [we] don’t care. Each person should have sympathy to another. May be she thinks something but she does not say. So do I. Later both of us agreed that we don’t mention the past. We live in the present. Once we are as a husband and a wife, we should keep safe for each other.

About one week later, Thi revealed her habit of “chasing the dragon”[smoking heroin] and “sometimes preferring a shoot”. Chung described his cohabitation:

We rarely have meals together. The house is a place to sleep only. She and I pursue different goals. I am sort of self-indulgent. Let it be... It is no problems whether we live together or say good-bye. It is difficult to maintain a normal life, provided that each of us feels no obstacles in emotional life. Set it free. I spend what I can gain. So does she. It all depends on myself: If I want to have a good life, I have to restrict drug use. Otherwise I have to accept a depraved life even it can lead to a young death...So does she. She is sort of similar to me. One should be responsible for oneself. No other ways.

With that mandate, they compromise their cohabitation and pursue their responsibilities independently. Time spent together is short and unpredictable. They often meet each other at night when Thi returns from work. It is habitual that Chung goes out to buy drugs and two syringes. Then they take a shot and go to bed. Sometimes they have sex and sometimes they use condom “when [we] feel dangerous [she is on period] we use a condom. Otherwise [we] calculate [the safe] days to have sex. Often, both of us suggest using”. Although they are scared of AIDS, they went on having sex without condom because “ if one of us gets the disease [AIDS] we have to accept it. No other ways. You know having sex no condom, sharing…all kinds of risks”.

Different from many IDUs, Chung can control his drug use. As he goes to work everyday, he decided not to inject frequently because “ if you shoot daily, you will increase the dose and you never know”. He does not want to be a “ professional drug user” because he still has to work and he is scared of being vilified by other people. But taking drugs is something unavoidable. He said he could not stop it. So he has to manage a special habit of using drug “ I sort of playing moderate [inject with medium dose regularly]… I don’t shoot to a level, as I want. In this way I can balance myself. I usually shoot a small dose but I think to myself ‘it is enough’”. In this way he can balance himself in some way. But this “balance” is never complete, as he needs something more- that is sex: “ it’s always a combination between drugs and sex, I should say. Anytime when I shoot, sex is involved somewhere. I don’t know why but may be it’s the high. It seems like you need the sex to bring the high down. The high itself makes you just want to have sex”. Chung also wants to have sex during his “abstinent days”: “as you know I don’t shoot daily because sometimes I have to go to other provinces. So during these trips I am very busy and I have to stop using drugs temporarily. But I still need sex. I am sure about this feeling. It’s like sex makes you forget about drugs and makes you feel comfortable”. In this context, drugs and sex seem to have a positive relationship, which helps Chung to “balance the hardships”.

Previously Chung used to have multiple relationships with different prostitutes but now he is loyal to his wife. He does not have any intimate relationships with other women anymore. He does not need to have sex outside because for him “ it is not my need. My wife is enough. I still work and I have money. No need to partner with girls. It is a waste of time. Sometimes involvement in such relationships burdens you more, pulls you more into the drug life. The best way is that da trot thi phai tret [now that you had accepted you had to begin], I am still able to play it erratically [inject infrequently]…partnering is useless”.

Chung and Thi live together for three years but they don’t have any children. For Chung, thinking about having a child is something ambiguous. It does not mean that Chung and Thi don’t want to have a child. In fact, they do: “ you get married and you settle down. That is still a marriage life. You have a family when you have a child”. In his sense, a couple without children is not called a family. But it is not simple to have a child in his context. Having a child requires a lot of things and may complicate their life: “ I feel scared when I think about that [having a child]. If I have children I should change myself. I should work harder. Having a child is something to tie you up. Therefore I am not in a hurry. [She]’s still on the pill. We have not thought about it yet. My wife is working as a karaoke girl you know. Sometimes I ask her in what cases she uses condom...later if [we] want to have children [I] should consider [whether she is infected or not]”. On one hand, Chung is concerned about the possibility that his wife may be infected. On the other hand, risk is something acceptable to him: “ once you are deepened [in the drug scene] you should know how to cope with every kind of unluckiness. It is inevitable. You should have a strong will. Because you have decided to live with her, you should accept something unpredictable. She is sort of like you. No different”. Chung is not concerned about the break-up of their relationship because “we are still free. [We] don’t have children yet. Let it be. We don’t quarrel because we each have our own money”. Thus, Chung appreciates a relationship in which they are independent of one another and they don’t have to be burdened with childcare responsibilities. This is perhaps one of the ways to manage his cohabitation with Thi.

CHAPTER 7

The drug scene, which interacts with sexual relationships among IDUs, is accompanied by a kaleidoscope of folklore and argot, and a distinct set of rituals and rules around the acquisition and use of illicit drugs (see also Singer & Baer 1995; Grund et al. 1996). The drug scene is also the arena in which IDUs’ daily lives unfold, with a constant movement and hassle between drug-related social connections (cf. Kane & Mason 1992). The desire to get high, the scarcity of drugs and the secrecy required are three important parameters guiding IDUs’ behaviours.

Living in secrecy and being ostracized by the mainstream society, drug users need to develop trusting relationships in which they cooperate in the struggle to acquire scarce drugs. In order to survive, drug users have become mutually dependent for fulfilling basic human needs, but at the same time they play tricks on each other. Therefore they live under constant pressures; managing their drug and sexual habits as well as relationships, while trying to cope with the police and constantly estimating whether other drug users are a threat or a source of companionship. To satisfy the desire to get high, IDUs have to face a multitude of risks, of which sharing a syringe and not using a condom - the two ingredients of AIDS risks- are the most important (Freeman et al. 1994; Sibthhorpe 1992; Farmer et al. 1996).

Syringe Sharing

Sharing [syringes and needles] is an integral part in the daily lives of IDUs in this study. It does not mean a “social bond” between two injectors (Conviser & Rutledge 1988). Rather, it seems to be a normative feature of drug users’ social relationships (e.g. McKeganey & Barnard 1992; Schiller 1994). The traditional view that sharing reflects a culturally entrenched ritual has been expanded to acknowledge a pragmatic response of IDUs to the restricted availability of needles and syringes (Celentano et al., cited in Carlson 1999:267). As Connors (1992:597) notes:

Sharing drug injection equipment can be seen as a form of ‘life insurance’ among people with scarce resources if it helps to maintain a relationship with someone who can be called on in time of need.

I found ten patterns of sharing situated in different contexts. Sharing within intimate relationships is the commonest type. “Front loading” and “sharing a load” are the main techniques applied by IDUs. Sharing can be accidental or intentional, individual or multi-person, and anonymous or overt.

Reasons for sharing vary. In general, the immediate desire to get high and the unavailability of sterile syringes at the moment of sharing are the main one. Among close relationships, trust-the belief that a fellow is disease-free and thereby non-threatening - is the primary sufficient condition for sharing. In other contexts, the following reasons were mostly cited: lack of AIDS knowledge, lack of money right before a sharing event, having the same positive status, confusion, revenge. Carelessness has emerged as an important factor for sharing decision. Although 100% of the drug users in this study can name the two modes of HIV transmission (sharing a syringe and not using a condom), they can’t consciously control their behaviors. At the same time, they don’t care about the consequences of those careless actions. The majority of our respondents were sent to rehabilitation centers at least once, where they are provided with basic knowledge about HIV prevention, during a period of three months. In spite of this, many drug users continue to share. During FGDs, some IDUs say that carelessness has become some kind of personality or kieu choi [play style].

Sharing is gendered in character. Men are more likely to share outside the home (in a group), whereas women are more likely to share indoors. In addition, some studies show that female injecting partners of male IDUs may be more likely to be the receptive partner in a syringe event (Barnard 1993) and thus may be at greater risk of becoming infected with HIV by engaging in this behaviour (Grund et al. 1996). This is not confirmed in this study. Many women can inject themselves and many women inject after their male partner.

Sharing has some important functions. Often new relationships are initiated through sharing and existing ones are re-established. Some IDUs say when they are in withdrawal, they miss their sharing partner (whether the partner is male or female). Through sharing, the two persons renew and reinforce their common bond. Sharing is often found to be an important part of socialising. Sharing which is accompanied by other recreational activities helps to bring drug users together.

Sharing has several symbolic meanings. First, in a sharing event, the roles of donor and receptor are mostly determined by who furnishes the most money, carries a sterile syringe or possesses greater shooting skills. Often, those who have money and/or drugs have more power and hence, are the donors. In addition, the reciprocal character of sharing leads to mutual obligations resulting in more structural relationships. In addition to drugs, IDUs also share other commodities such as food and money. They care for each other in different ways (e.g., pooling to buy drugs; providing a friend in hunt a place to sleep; doing artificial respiration when one is overdosed; giving a tiny portion of drug to a partner before she goes to sex work). In a broader sense, as Grund et al. (1996:698-699) observed:

Syringe sharing is considered as a symbolic expression of an elemental interaction pattern of reciprocal exchanges of valued items among group’s members, which provide a practical and emotional balance to daily hardship.

Sexual Partnerships

Sexual expression is a fundamental feature of human relationships. The majority of IDUs in this study is no different in this respect. Many of them are sexually active and have at least one sexual partner. The searching out of intimate relationships among IDUs does not mean to be indiscriminate, but rather, rational. It provides a sense of security in the drug scene characterised by uncertainty. Seeking for a SP to live is also a means to escape social isolation. By and large, female IDUs are more likely to have a SP who is a drug user and to be living with another than male IDUs.

The drug scene brings IDUs and their SPs together. Shooting galleries are good for having a fun [a shot]. Besides selling drugs, drug dealers also provide an opportunity for IDUs to meet. By offering a homeless friend a place to live, by asking someone to buy a bag of heroin, by pooling money to have a shot, a new relationship is established. Having a sexual relationship between IDUs is thus significantly associated with engaging in drug using practices. In addition, IDUs may meet their SPs in other situations: in karaoke parlours, at sex work, in detoxification or rehabilitation centers.

The conditions of partner choice are often affected by drugs and money. Trading sex for drugs not only enhances risk for HIV infection but also increases number of SPs among the majority of women. Through sex work, women meet their clients who may become their “casual”, “regular” or “private sex partners”. Meanwhile, male IDUs, whose main job is often stealing or drug dealing, decide to seek drug-using prostitutes to cohabit. Some men who are incapable of earning money by these ways try to deceive [nonaddict] women to live on.

Selecting a SP is gendered in character. For women, manly characteristics, such as generous, caring, steadfast, are still important and appreciated. The meaning of manliness is beyond the scope of this study, however it is worth emphasising that manliness, as embedded in the traditional sexual culture, plays a very important part among Vietnamese women. During my interviews with drug users, especially with women, I observe that the phrase “co tinh dan ong” [manliness] was repeatedly cited. Manliness is an important criterion that many women use when seeking for their partners. For men, the selection for a sex partner seems to be more superficial and materialistic. Often, they are interested in the money of the woman, her appearance, and whether she shares a similar attitude in recreational activities.

When a drug injector and his/her sex partner feel that they are compatible, a new relationship begins. If the sex partner also uses drugs (whether injects or smokes), the couple would rent a house to live, enjoy their drug habits, and have sex. In case the sex partner is a non-user, the place to have sex often occurs outdoors: in hotels, guesthouses, cafes or karaoke parlours. In most cases, there is a high rate of changing sex partners. Depending on patterns of relationships, the conditions for this partner change vary: being arrested, violence over financial issues, conflicts in sex and/or drug habits, being discovered about one’s addiction. In the following sections, I discuss some specific features of each relationship type.

IDU-IDU Relationships

Having the same injecting habit is viewed as the most important element in forming and regulating the cohabitation between two IDUs. IDUs see their partner’s acceptance of drug use to be crucial in preventing relationship problems. This pattern of relationship is viewed as “safer” and “simpler” than other ones because IDUs don’t have to hide or to lie about drug use and consequently, they don’t have to deal with the risks associated with the failure to keep “the secret”. Because of this advantage, this pattern is the most prevalent among IDUs. Other types of relationships among IDUs, in the long run, will shift to this pattern.

Sharing a syringe and dispensing with a condom are the most salient risks in this relationship. These two behaviours are very frequent and seem to be a “norm” among injecting couples. Sharing occurs on a basis of trust between

two injecting partners. Trust here communicates a sense of relative security of a shared destiny. Trust is used as a means of risk survival. Such a tenuous relationship also entails risky sex. Sharing a syringe makes it easier to reject a condom because sharing (even once) implies getting an infection. So, “no need to be prudent”. For IDUs in this relationship, sharing or not sharing, using a condom or dispensing with it - these are not important choices. Risk is a relative concern in this context. Furthermore, IDUs must weigh the risks posed by AIDS against the benefits they receive from condomless sex and sharing. Taking such risks may therefore be felt as acceptable. The force of emotions in risk decision-making is highlighted here. The acknowledgement of AIDS risk challenges all patterns of uncertainties inherent in this relationship: uncertainty about risks in sharing events; uncertainty about risks of sexually transmitted infections and uncertainty about a sex partner’s sharing or having sex with outsiders.

Using a condom may be viewed as a risk itself because condoms hinder the development of meaningful relationships (Rosenthal et al. 1998). In the context of these relationships, a condom is used erratically at the beginning of the cohabitation. As the relationship becomes “stronger” or more “meaningful”, the tendency to reject a condom becomes apparent. Often, neither partner suggests condom use because they fear that such a proposal will denote infidelity on their part or suspicion of the other. Transitions towards unprotected sex thus help define or demonstrate relationships as both intimate and secure (Rhodes & Cusick 2000).

What we observe in these relationships are actions to prevent them from being broken. Love, trust, intimacy and loyalty are inadequate elements for a strategy to manage the relationship. IDUs and their sex partners have to work out other pragmatic tactics. First, there is a division of labour between the two partners in this relationship. Often, female IDUs have to prostitute in order to finance their own, and sometimes their sex partners’ injecting habits. To maintain a sex job, female injectors need to inject before going to work, usually in the evening. Many of them explain that they do not want to go to work in a craving status. In this context, if the amount of drug is insufficient for both, the male partner often has to “give in” some portion of drug to the woman before she leaves the home. This act of “concession” [chat nhuong nhin] has become an argot described by IDUs as an act of generosity and a way of caring. While the concession can be viewed as a means of managing the relationship, this has put the woman at a heightened risk because this situation occurs repeatedly. Meanwhile, most of the male IDUs tend to make money through criminal activities such as drug dealing, stealing, house breaking and robbing. Interestingly, these “jobs” are expected and admired by female injectors in the drug scene. If men can’t work illegally, the relationship seems to be more difficult to manage and it can lead to a break-up due to conflicts derived from financial issues.

Second, hiding one’s occupation as a sex worker has become a way of managing the relationship. Some female injectors even keep “this secret” from their injecting partner. The reason for this concealment is sculpted in the strong stigma of the society in general, and of the men in particular, towards women on drugs. Although this tactic seems to be fragile and this hiding is merely “superficial”, it reflects the women ‘s strong desire to be respected by the society.

In sum, the IDU-IDU relationship is notorious for its two most prevalent AIDS risks: sharing syringes and dispensing with condoms. These two behaviours are not simply a physical act; it is a symbolic act of great significance. Sharing is a product of trust and necessity. Not using a condom is a product of trust and a denotation of a true love. Especially among women, the pervasive idealisation of a romantic love is still of prime importance. However, risks and uncertainties often outweigh trust and love. This makes IDUs and their sex partners discontented with their hard life. Some IDUs say that their ongoing relationship is not considered as “love”, but is simply a “spontaneous”, “provisional” or “momentary” cohabitation. By comparing their ongoing relationship with a true love, they highlight the negative effects of drug use on the meaning of their relationship.

IDU-Smoker Relationships

In this type of relationship, IDUs and their sex partners have to face with a difference of two distinct types of drug-using patterns: injecting and smoking. In general, injecting procedures are simpler than smoking ones. An injection is said to get high faster and more “directly” (via vein) than a smoke (through mouth). While this difference may lead to some minor conflicts at the onset of their cohabitation, couples tend to acknowledge the reality, mark in practice the difference in their drug use, and work to negotiate their relationship in some ways. Everyday routines and rules are established to mitigate the potentially negative effects that a partner’s behaviors may actually have on a relationship (e.g., by setting an independent schedule between the two partners). Injectors seem to be more sympathetic to share the “feeling of difference” than their smoking partners because injectors “have just gone through” the smoking process. In contrast, some smokers cannot sympathize with their injecting partner because the feeling of shooting a drug into the vein is still new to them and therefore makes them feel uncomfortable watching the partner inject. This may force smokers to switch to injecting so as to have a “drug use harmony” with their partners.

IDUs and their partner not only have to work towards a harmony in drug use but also a harmony in sexual life. Our data shows that smokers often have higher sexual desire than injectors. Specifically, female smokers frequently report having high sexual desire during the smoking period. On the one hand, this high desire may lead to dispensing with condoms. On the other hand, the difference in sexual interest between injectors and smokers will “force” some IDUs to manage their sexual life with their smoking SPs by pretending to be “normal”. This can be seen as a key feature of relationship risk management made complicated by drug use (cf. Rhodes & Quirk 1998).

The social organisation of this relationship pattern is influenced by two processes: “onwards transition” (a move from smoking to injecting identity) and “reverse transition” (injecting to smoking). For some IDUs, the act of injecting is operated as a “risk boundary”. The smoking and injecting identities are not mutually exclusive, there is slippage and there are crossovers between them. In fact, many smokers can’t maintain their oral use for long and reflexively decide to “pass” this boundary to intravenous use. But more commonly, they are “pulled into” injecting as a result of being in this relationship. The motives for this onwards transition lie in the relationship itself. It is possibly a desire to feel close and similar to their partner or a wish to have an equal share of drugs (MacRae & Aalto 2000). This also means that IDU-smoker relationship pattern tends to shift to IDU-IDU type as a result of the smoking partner’s change in pattern of drug use. In other cases, however, some smokers can be positively influenced by their injecting partner so that they may sustain the oral habit for a long time. Furthermore, some novice injectors can return to oral use (reverse transition) as a result of the cohabitation with smoking SPs (although the likelihood of the success is very slim). Thus, changing pattern of drug use (from smoking to injecting) may lead to changing pattern of relationship (from IDU-smoking to IDU-IDU type); conversely, the relationship also has impact on the chance to change behaviours (from injecting to smoking).

IDU- Nonaddict Relationships

In the course of their drug career, an IDU may engage in relationships with a nonaddict partner. Female IDUs tend to live with nonaddict men more than male IDUs living with nonaddict women. This can be explained by the fact that there are many more men than women who inject. Further, our data suggests that it is more likely for nonaddict women than nonaddict men to accept an injecting partner. This gender difference in choosing a partner is rooted in the stigma men often attach to addict women. In some cases, even male IDUs defame their female counterparts. This stigma among men seems to contradict with the fact that some female IDUs still want to seek for a nonaddict man. For some of these women, the searching for such a relationship denotes an emotional need. For others, engaging in a relationship with a nonaddcit man can be viewed as a means to earn money and to form socially appropriate relationships. Similarly, young injecting men often see money is the most important motivation in their search for nonaddict girls. To achieve these goals, both male and female IDUs have to hide their identity as a drug addict, right at the formation of the relationship. But maintaining a non-disclosure strategy is more problematic because, at the same time, IDUs have to struggle with differences arising from two distinct lifestyles. Many male IDUs face a difficulty of hiding their addiction while pretending to have a “normal” sex life. In contrast, female IDUs complain that their sexual need is not satisfied and that their drug demand is not met and neither sympathised by the nonaddict partner. Usually, the “double difference” is seldom acknowledged and rarely discussed openly by either partner. This “closeness” also exerts influence on the initiation of condom use. In general, nonaddict partners are constantly assessing the risk of HIV. When they are not sure about their partners’ level of addiction (whether recreational use or smoking a drug), they may agree to have sex without a condom. During this phase of the relationship, the drug-using partner may have shifted to intravenous use but the nonaddict is possibly unaware. When nonaddicts find that their partner injects, rather than smokes, their concern for HIV rises. In general, when “hiding tactics” used by the injecting partners are still effective, the nonaddict partner may agree to dispense with condoms. As IDU-nonaddict relationships are usually short-lived and nonaddict partners may be involved in other sexual relationships after the break-up with injecting partners, this poses to the possibility of cross- transmission among IDUs and their nonaddict partners, and subsequently from these nonusing individuals to the populace.

Most studies examining variations in condom use between casual and regular/private sex partners reveal that safe sex practices decline markedly based on familiarity with the partner (Darke et al. 1990; Sherman & Latkin 2001; Wojcicki & Malala 2001; Pickering et al. 1993; Schoepf 1992; Wawer et al. 1996). These authors show that, for women, condom is often used with “casual partners”, but not with “regular” or “private partners”. However, data from IDU-nonaddict relationships in this study reveal that, in some cases, injecting women refuse condomless sex even when a [nonaddict] casual client has become their private sex partner. The reason for this denial is rooted in the social condemnation toward addict women as a whole. In this context, the woman is said to feel degraded or losing dignity because the man comes to her for the sake of penetrating her- thereby she is like a “sex tool”, rather than love. This also implies that she is “an addict” and thus “dirty”, and he is “a nonaddict” and thus “clean”. Her insistence on condom use does not mean that she wants to keep safe for someone she loves. Rather, it can be seen as the resistance against the stigma inherently residing in the man’s thought.

Our data shows that the possibility of reducing or stopping drug use for an IDU in this relationship is higher than the case in the previous relationship patterns. Injecting women seem to be easier to be persuaded by male partners than injecting men by female partners. While stopping is viewed as very challenging, the success of persuading an IDU to reduce gradually or temporarily “fix” at a low level of drug use should be considered as a promising intervention among IDU- nonaddict relationships. This finding mirrors other studies where this type of relationship was found to be protective against participation in drug use risk practices (cf., Miller & Neaigus 2001)

In sum, being in this relationship, IDUs and their nonaddict partner are constantly in the process of struggling with their differences associated with drug use and sex. The management of drug and sex conflicts is located in and affected by the management of the relationship. This type of relationship is thus viewed by drug users to be particularly difficult to manage, since these conflicts never end. The “double life” is felt to introduce uncertainty and mistrust between partners even if drug users have disclosed their addiction status. Due to all these obstacles, this relationship pattern can be considered as the most fragile in comparison with the two above mentioned ones.

The Meaning of AIDS Risk and Intimate Relationships

People who share a syringe and forgo condom use are often said to be “in denial” about AIDS risk. Though, the term “denial” hides more than it reveals: it constructs AIDS-related risk-taking as a self-evident, individual level, “micro-social problem” (Singer et al. 1992)- a problem without macro-level correlates or causes (Sobo 1998). My exploration of denial’s mechanisms reveals that IDUs’ denial of their risks for AIDS and their related practice of syringe sharing and condomless sex has “a level of meaning and cause beyond the narrow confines of immediate experience” (Singer et al 1990).

Of course, once one is aware of risk, risk avoidance is matter of choice (Douglas 1986). But the idea of a high-risk lifestyle can be seen as an accepted norm in the drug scene (see also Douglas & Calvez 1990). In fact, many IDUs have thrown in their lot with their partner. Even if they are aware of AIDS risk, they don’t seem to avoid them. Choosing risky behaviors is something normalized in the drug scene. There are different reasons that encourage IDUs to take risks either by sharing or having condomless sex with multiple partners. First, IDUs’ risk perceptions are often fraught with myriads of uncertainties inherently residing in a situational complexity attached to accounts of drug and sexual behaviors. There is always a contradiction between safe sex and safe drug use. IDUs often give themselves and their SPs more leeway around issues of safety when it comes to their discussions of sexual practices, than with their drug using practices. The risks of sexual transmission are not considered as serious as the risks of infection through sharing syringes (cf., Kane 1999; Sibthorpe 1992; Rhodes 1997). While sharing is attached more with physical pleasures, non-condom use is attached more with emotional meanings. Furthermore, perceptions of acceptable risk were said to shift in keeping with the length of relationships and expressions of commitment. As Kane (1999) notes:

Sex partners might choose to continue ignoring their risk or choose to transform their understanding of risk so that they feel more comfortable with it, personalising public health information so that it fits their situation, protecting themselves in some ways, but not adhering to any absolutes.

Second, AIDS risk is often left to chance once multiple choices and risk reduction attempts have been made. While IDUs and their SPs try to manage AIDS risk and their relationships in their own ways to prevent the infection and the break-up of their relationship, this endeavor often entails many obstacles. In the event of risk management being overly complex or impossible (e.g., a female partner has to agree to have condomless sex to show her fidelity; a couple has to share one syringe because the second one can’t be bought at night), it is then inevitable that recourse is made to alternative solutions of risk acceptability, destiny and chance.

Third, feeling secure in an intimate relationship is often a denotation of trust - a belief that one’s partner is disease-free and thereby “safe enough”. Trust, which is usually accompanied by love and intimacy, makes possible a sense of security and safety for both self and the relationship (Rhodes & Cusick 2000). Trust is the main reason given by IDUs as a justification for their risk acceptability and fatalism. In IDU-IDU pattern, trust is expressed by a mutual agreement to share one syringe. In all three patterns, trust is represented by consent to have sex without condoms. Choosing condomless sex is a prime expression of the trust that love is culturally constructed as entailing (Sobo1998)

Fourth, dispensing with a condom is a means to define the relationship as “intimate” and “committed”. This gives explanations to the fact that female injecting partners tend to use condoms with their clients at work; however, they tend to forgo the usage with male partners at home because condoms signal a distance that is inappropriate in the context of intimate relationships. Since trust, love and intimacy play such an important role, broaching the subject of condom use may be a violation of these elements and thereby brings suspicion and disequilibria to the sexual relationship (cf. Wojcicki & Malala 2001).

Yet our findings show that the process of managing relationships is contradictory. The crux of this contradiction is the fragility of trust, which is often accompanied by doubt. Risks, dangers and uncertainties are something out there. In IDU-IDU pattern, for example, suspecting one’s partner to share syringe outside or to have condomless sex outside is somehow inevitable. In IDU- nonaddict relationships, mistrust occurs when IDUs reveal their drug habit. Furthermore, love is not always a “true love”. There is also another type of love in the drug scene, that is the so-called “exploited love” [tinh yeu loi dung]. This often occurs in case of IDU-nonaddict relationships in which an IDU seeks for a nonaddict to cohabit for some purposes. For example, an addict woman may prolong her attachment to her partner if he is willing to take care of her through economic support as well as an expression of love. In Quang Ninh, I also talked with some male IDUs who viewed partnering with rich girls as a tactic to make money to feed their drug habit. In this type of love, a condom is given more chance to be rejected because “the scheme” should be maintained over time.

Thus, in the context of intimate relationships among IDUs, the meaning of AIDS risk and relationships interact with each other. AIDS risk, characterised by syringe sharing and condom denial, is an important determinant of relationship status. It is impossible to understand intimate relationships without mentioning the symbolic denotations that AIDS risk confers. Although trust, love and intimacy are sometimes confounded by the elements of doubts and uncertainties, AIDS risk should be re-configured as one aspect of relationship security, and not merely as a matter of self-protection. Finally, it is also necessary to recognise that knowledge of AIDS risk must be incorporated into the complex emotional and personal aspects of people’s lives.

CHAPTER 8

Implications for HIV prevention

In this chapter, I want to make a number of general points arising out of this study, which have a bearing on efforts to change IDUs’ risk behaviour patterns. I shall look more critically at some of the implications for HIV risk-reduction interventions in relation to gender and power, care and responsibility, drugs and sexuality, and social stigma. In the final section I shall make some comments on the typology of high-risk groups.

Gender and power

The literature on heterosexuality among IDUs generally ignores economic self-sufficiency among women while preferring to discuss behaviors deemed deviant or immoral (such as risky, premarital or non-monogamous sex). It is clear in this study that many women can support themselves and their male partners, albeit via sex work. Most women seem to have a firm sense of agency and consider themselves financially independent from men. Often, those men who depend on women for money are forced by circumstance to ignore the infidelities of and risks for their female partners while engaging in commercial sex. In this case, women don’t assume a subordinate role vis-à-vis these men and have considerable control over sexual decision-making and use of condoms. This implies that they are breadwinners so they have more power and assertion in sexual negotiation. This can be seen as social change accompanied by changes in the conceptions of sexuality and gender. The influence of Confucianism on women’ passive roles has become less valid in this context. Therefore, HIV prevention program should not always be based on a normative gender model of hierarchical gender relations and role expectations as it is commonly portrayed in contemporary studies about AIDS. Such generalized models often contradict with real life experiences, at least in the case of IDUs presented here. It is also critical to examine why some women apparently exercise control in their sexual decision making while others do not. As Klee (1996:167) notes:

 

There is danger here that, in an effort metaphorically to ‘rescue’ female drug users from ‘blame’ for their own circumstances, we collude in their disempowerment through an implicit assumption that they have no power and control over their lives.

 

Care and responsibility

IDUs are often blamed for their low self-esteem, high-risk lifestyle, and lack of care and responsibility for themselves. This is not always the truth. Our data shows that many IDUs don’t label themselves as such. In fact they have different ways to care for themselves and for others (e.g., taking risk-reduction measures in their own ways; taking care of one’ children when one is arrested; educating peers to inject safely; providing a homeless friend a place to live; providing first aid when a fellow IDU gets an overdose). Some other forms of care may be viewed by health officials as “negative”, such as: pooling money to buy drugs, lending injecting equipments to a close friend, assisting a friend with collapsed veins. Thus, in the drug scene, care and responsibility confer different meanings and may be considered as a symbolic expression of risk management. Responsible behaviors for the self and for others should be emphasized as the means to curb the spread of the AIDS epidemic. As Hassin (1994:397) has also suggested:

Interventionists need to engage the IV drug users’ ‘good selves’ in their discourse on responsibility. To do this, they must give credence to existing responsible behaviors, even if token gestures.

Given that so many IDUs have multiple relationships, there is a possibility for HIV strategy designers to build on existing identities (injecting, smoking or non-using) to encourage responsible drug injecting and/or sexual practices, rather than to bank on the ritualized slogans “don’t share” and “practice safe sex behaviors”.

Drugs and sexuality

In general, drugs and sex are highly interrelated (Iguchi et al. 2001; McCoy et al. 1996; Miller & Neaigus 2001; Flom et al. 2001; Rhodes et al. 1996). Drug use is associated with trading sex for drugs/money and often means unsafe sex (Iguchi et al. 2001; Latkin et al. 1994; Brummelhuis & Herdt 1995). Couples using heroin use opiates together to enhance sex (Lex 1990). Further to this, our data suggests that there is tremendous variability in the perceived effects of heroin on sexual experience. Some IDUs reported a positive relationship between heroin, other stimulating drugs, and sexual pleasure and performance. Some female smokers also report that smoking enhanced their sexual desire. In contrast, other IDUs confirm negative relationship between heroin and sexuality. While some male juniors prefer having sex right after the injection, seniors don’t. In addition, women seem to have a more positive attitude than men with respect to sexual pleasure. Thus, this variability may be a result of the physiological effects of the drugs, length of drug use, and/or other factors. The point is that the relationship between drug use and sexual experience is highly variable. This variability should be integrated into HIV risk-reduction counselling. As Carlson (1999: 71) points out:

“ A ‘one size fits all’ safer sex intervention is unlikely to meet individual needs satisfactorily, given the [above mentioned] variability in experiences”.

An experienced heroin injector may not respond to the message “always use condom” because sexuality for him is likely unimportant. Attention should be paid to situate the variability in sexual history as well as history of drug use, specifically with respect to the effects of drug use on sexual experience. NGOs and self-help organisations may reconsider such kind of work.

Social stigma

A common trope in the discourse of AIDS is that IDUs and FSWs are often presented as “vectors” or “bridging populations” of disease transmission. Because risk is defined on the basis of occupational description, being an IDU or a sex worker is synonymous with “high risk groups” or “social evils”. The chain of infection is often configured as IDU-sex partner-populace or FSW-client-wife and therefore perpetuate the negative image of these groups at risk . IDUs and FSWs have become the diseased other and responsible for AIDS in society while clients of FSWs are absolved of responsibility. As Schiller et al. (1994: 1344) point out:

This tendency [to distance the “high risk groups” from the “general population”] has acted as cross-purposes to public health goals, facilitating public definitions of the HIV epidemic as a problem which concerns others, not oneself and one’s own ‘group’

As a result, many women attempt to distance themselves from the stigmatised “sex worker” identity. In fact, they don’t situate themselves within this category. The account of “I have to work as girl [sex worker] to support myself” is partly a reflection of the felt stigma, to borrow the term of Jacoby (1994). The stigma is so strong that many female IDUs even conceal their occupation as a sex worker to their male injecting partners – the “secret” deemed unnecessary to keep among members of the drug scene. It is therefore unwise for the society to support tapping into the already existing and inappropriate negative stereotypes of risky sexual partners, such as “con diem” [the prostitute] or “thang nghien” [the junkie]. Instead, preventing stigma and discrimination towards IDUs and CSWs (and people with HIV/AIDS) should be put as an important component of the HIV prevention in Vietnam. A multidisciplinary approach is needed to reduce stigmatising attitudes, at least in the short term. Mass media campaigns on stigma, a combination of providing information and coping skill acquisition are examples of this approach. For a long-term strategy, a change in the law and public policy should be considered so that they censure this stigma rather than sanction it.

About the typology of high risk groups

The epidemiological statistics are silent on the prevalence of sex partners of IDUs. This is perhaps because the category “sex partners” of an IDU is too problematic in AIDS discourse. As Schiller (1992: 243) notes, IDUs commonly are “ described as having ‘sex partner’ rather than lovers or spouses”. Indeed, during interviews, most IDUs avoided mentioning the words “nguoi yeu” [lover]. Instead, they often refer to “ ban tinh”, “bo” or “ca” [sex partner]. Also, as Kane (1999) has emphasized, sex partner of a drug injector is not a natural category, it is not a social group, nor is it necessary a part of an individual’s identity. In fact, many people are the sex partners of IDUs and do not know it. From an epidemiological perspective, smoking and injecting sex partners of IDUs are in the same AIDS-related risk group. But from ethnographical perspective, the behaviour of these sex partners should be understood from the perspective of the drug culture. Novice smokers or even novice injectors are not considered by their peers as “addicts”. Needless to say, this makes prevention efforts targeted to people at risk very difficult and, as Herdt (1992:13) indicates, the notion of sex partner varies across cultures and can be the source of significant error in research design. Selection bias may occur if a clear definition of sex partner is not given. In her study among sex partners of IDUs in the USA, Kane (1999:302-303) suggests:

The categories of ‘sex partners’, ‘IV drug users’ and ‘general public’ can not be clearly separated in practice...there are limits to the usefulness of elaborating risk group typologies as a long term strategy and goal of AIDS research and prevention.

CHAPTER 9

Conclusion

As research on AIDS has developed, greater sensitivity to the complex process of the negotiation of AIDS risk and relationships between men and women has yielded new insights that contrast with prevailing views. Indeed, many IDUs share syringes not only because of syringe unavailability or drug scarcity but also because sharing is an expression of trust. Many women don’t use condom not because they lack negotiation skills but because the nonuse of condom is a denotation of love and attachment. It is emotional need that’s at stake (rather than financial gains) are important motivations for having unsafe sex among IDUs. Messages of prevention stress the use of condom in sexual relationships, but do not take into account the positive aspect of non-condom use in a loving, trusting union (Sobo 1993; Ratliff 1999). Beyond that, consistent condom use requires not only information dissemination and condom availability as well as negotiation skills but, as Ratliff (1999:91) suggests, “changes in the basic perceptions of sex and love in society”.

HIV prevention program merely emphasizes the risks of sharing syringes and telling IDUs to stop this behavior. This is inadequate. Instead, peer education, harm reduction and syringe exchange programs should be integrated with safer injecting training. Based on training techniques developed by Stern (cited in Grund et al. 1996), my own observations, and the Vietnamese context, I suggest the following pragmatic skills and information be provided for IDUs:

1. Applying safety and hygiene precautions for each and every step of the drug preparation and injection sequence.

2. Presenting all information in positive terms (“try it this way”), rather than negative ones (“don’t do that”).

3. Explaining that frontloading per se is not risky behavior, but that this can only be done safely with sterile/sterilized syringes.

4. Teaching IDUs how to clean injecting equipment before and after each use, which do not cost extra time, or disrupt injecting satisfaction, and permit re-use by same individual

5. Providing additional information on: preventing hepatitis, HIV and other infectious diseases; locating and rotating veins; distinguishing between veins and arteries, safe use of tourniquets, and abscess prevention.

6. Teaching needle re-sharpening and encouraging IDUs to retain at least one set until a new one can be acquired.

Furthermore, there is an advantage to utilize aspects of IDUs’ own culture to change behavior (McKeganey & Barnard 1992). Intervention programs that target this group must take into account the specific context of their lives; programs designed for ideal-type or generic IDU will be of little help (Sobo 1993)

Health promotion campaigns focus on IEC (information-education- communication) and encourage individuals to make healthy choices, with the assumption that risks are systematically calculated by individuals. Harm reduction, peer education, syringe exchange, and safe sex promotion programs are based mainly on theories of health behaviour which view risk perception and behaviour change to be product of individual decision making. Because they are theories of cognition, these theories are largely unable to conceptualise risk as being the product of social actions (Douglas & Wildavsky 1982). It is social interactions, rather than individuals, that do “a large part of the perceptual coding on risks” (Douglas 1986). In this study, we have seen how intimate relationships have impact on risk behaviors and vice versa. Therefore, we cannot underestimate the role of sexual relationships in risk decision-making. As Rhodes & Quirk (1998) suggest:

Relationships are themselves a form of risk management made complicated by drug use...viewing social relationships as the unit of analysis makes considerable advances over individual paradigms.

 

The findings of this study are preliminary and mostly appropriate to intimate heterosexual relationships among injecting drug users. I have not analyzed characteristics of bisexual and homosexual relationships among IDUs. Carlson (1999) suggests that describing and analyzing the models for negotiating and constructing relationships of various kinds is an important topic for future research. But perhaps more importantly, I have neither described how other factors other than sexual relationships influence behaviours among IDUs (e.g., networks, poverty, inequality). Finally, I suggest that ideological constructs regarding heterosexual relations mediate the impact of political and economy forces, albeit indirect and sophisticated, on IDUs’ drug use and sexual decisions. In order to cope with the emerging epidemic effectively, there is a critical need for long-term and more comprehensive approaches that address the root causes of the epidemic, causes that are embedded in the structuring of class, politics, economy and gender relations in contemporary Vietnamese society. /.

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