Injecting Drug Users in Vietnam:

The Dynamics of AIDS Risks and Sexual Relationships

Nguyen Tran Lam¹ and Pieter Streefland²

¹Amsterdam School for Social Science Research

Abstract*

Background: Currently, the transmission of AIDS in Vietnam is mostly linked to drug injection, but there is potential of a sexual epidemic. HIV education programs focus on the personal responsibility model of risk in their risk-reduction messages, yet failing to address adequately other aspects of HIV risks in social contexts. This paper examines the association between AIDS risks (unsafe drug use and unsafe sex) and gender relations among injecting drug users (IDUs).

Method: The study is based on ethnographic fieldwork conducted in 2002 in Hanoi and Quang Ninh, Northern Vietnam, with 56 audiotaped interviews (25 male IDUs and 31 female IDUs), 04 focus group discussions and 03 case studies. Three patterns of heterosexual intimate relationships are analysed: 1- IDU-IDU relationship; 2- IDU-Smoker relationship; and 3- IDU-Non-user relationship. The analysis is based mainly on social theories of risk. Results: Intimate relationships play an important role in managing AIDS risks among IDUs. The meanings of (non-) condom use and sexual relationships are discussed. Trust and love can be seen as solutions to dangers and uncertainties. In some cases, women could exert control over the use of condom in contrast with the stereotypic gender roles and the implied subordination of women. Care and responsibility confer different meanings in the drug scene. There is a significant variability in the perceived effects of heroin on sexual experience. The implications of these findings are discussed.

Conclusion:HIV prevention should take into account the positive aspect of non-condom use in a loving-trusting relationship. A safer injecting training, including some necessary skills and information should be provided for IDUs as an important complement to harm reduction program. It is advantageous to utilize aspects of IDUs’ own subculture to change behaviour. Of key importance, intervention programs must pay attention to the specific context of their lives. It is suggested that ideological constructs regarding heterosexual relations mediate the impact of political and economy forces on IDUs’ drug use and sexual decisions.

Introduction

In Vietnam, the current HIV epidemic is primarily associated with drug injection. In some areas, the proportion of HIV infection among IDUs is as high as 65% (A & Lam, 1999; Hien, 2002). The rate of syringe sharing (hereinafter sharing) among IDUs in some urban cities is high (Tuan et al., 1999; Hien et al., 2000). Some studies show that syringe sharing among IDUs is socially situated (Hien et al., 2000; Vinh, 2002). IDUs not only share a syringe but also buy sex and sell sex. Nearly 25% of IDUs in Hanoi said they had bought sex in the past year, and most did not use a condom (MAP, 2001). Another emerging problem is that sex workers (SWs) not only sell sex but also inject drugs. In sum, the AIDS epidemic in Vietnam is predominantly situated among IDUs, yet there is a worrying potential for the wider spread of HIV.

To respond to the epidemic the HIV prevention program focuses on IEC work (information-education-communication). While harm reduction programs for IDUs have been piloted, little is known about the impact of this approach on the spread of HIV among and from IDUs. There is a community backlash against needle exchange/distribution programs (Vu, 2001). The epidemiological literature is silent on the prevalence of HIV among sexual partners (SPs) of IDUs. HIV education merely focuses on the personal responsibility model of risk in their risk-reduction messages, yet failing to address adequately other aspects of HIV risks in social contexts.

Contemporary research on AIDS shows that IDU-SP relationships are sculpted in a double risk: unsafe drug use and unsafe sex (Kane, 1999; Farmer, 1996). Drugs and sex are highly interrelated (Iguchi, 2001). There is variability in the effects of drug use on sexual performance and sexual history (Carlson, 1999). Drug use and drug interdependence and sexual practices influence each other (Sherman & Latkin, 2001). But how do sexual relationships relate to risk-taking behaviours? A focus on drug-related relationships seems especially relevant when HIV risk behaviors are increasingly seen less as an individual phenomenon and rather as socially embedded and hence highly sensitive to the context and nature of the relationships between people (Singer, 1994; Sobo, 1993; Rhodes, 1997). The interplay of social factors such as the distribution of power and control, particularly the division of money and drugs between injecting couples, may influence the ways in which HIV risks are habitually managed (McKeganey & Barnard, 1992; Barnard, 1993). There are inconsistencies between sexual experiences and the stereotype of male dominance and control of women’s sexual decision making (Carlson, 1999). The perceived risks attached to both sharing and condomless sex may be reduced (Barnard, 1993). Injecting relationships have been found to have an equalizing influence on couples’ drug consumption (Rhodes, 1997). Emotional elements, such as love and trust, may play a key role in patterns of sexual and relationship risk management as well as HIV transmission (Rhodes & Cusick, 2002; Sobo, 1993). Furthermore, Rhodes & Quirk (1998) suggest that drug users’ sexual relationships should act as key sites of risk management and behavior change.

This paper illustrates the association between sexual relationships and AIDS risks among Vietnamese IDUs, focusing on intimate relationships (whether conjugal or para-conjugal). By examining the situational contexts of risk-taking behaviors within IDUs’ intimate relationships, I attempt to get insight into the dynamics of AIDS risk and gender relations among this population. Three patterns of intimate relationships are analysed: 1- IDU-IDU relationship; 2- IDU-Smoker relationship; 3- IDU-Non-user relationship. The analysis is based mainly on social theories of risk (Douglas, 1986; Douglas, 1992; Douglas & Wildavsky, 1982; Rhodes, 1997).

Methods

This paper presents findings from a three-month qualitative study of IDUs’ sexual relationships and risk behaviours. The research combines an exploratory and a descriptive approach. Emic views of IDUs and their SPs about AIDS risks and their relationships are analysed from a cognitive-symbolic perspective. The social contexts and meanings of their risk-taking behaviours are carefully taken into account. Study setting: This study was conducted in Hanoi and Quang Ninh. In Hanoi, of 2,879 cumulative HIV cases were reported in 2001, 76% were IDUs. Among IDUs, the HIV prevalence increased rapidly from 3.3% (1998) to 17.5% (2000). Among SWs, HIV prevalence increased from 0.8% (1997) to 10% (2000) (Hien 2002). Quang Ninh is ranked the third in Vietnam regarding the number of HIV cumulative cases per 10,000 inhabitants. Most of IDUs are male (99.2%) and very young (57% are under 20 years old); have a high prevalence of HIV (32%); and high rate of sharing (50.7%) (Hien 2002). Data collection: Four main methods were used for data collection: a) focused ethnographic interviews; b) FGDs; c) participant observation; and d) case study. Purposive Sampling: Standard multiple-starting point “ snowball sampling’’ outreach techniques were used in different locales to maximize the variation of subjects. The sample consisted of 75 individuals (53 in-depth interviews; 3 case studies, and 19 people participating in FGDs). Most of individuals described themselves as heterosexuals. Data processing and analysis: 54 individual interviews were tape-recorded and transcribed verbatim in Vietnamese where necessary. Data were organised and condensed according to the research themes. The emerging themes were used in subsequent interviews and in the FGDs. The data were processed by hand.

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.

Sharing and condom non-use 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 partners. Trust here communicates a sense of relative security of a shared destiny and is used as a means of risk survival. Sharing makes it easier to reject a condom because sharing per se implies to be HIV infected. 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 something acceptable. The acknowledgement of AIDS risk challenges all kinds of uncertainties inherent in this relationship: uncertainty about risks in sharing events; uncertainty about risks of STIs and uncertainty about a SP’s sharing or having sex with outsiders. In this context, using a condom may be viewed as a risk itself because condoms hinder the development of meaningful relationships. Condoms are usually used erratically at the onset of the cohabitation. As the relationship becomes “stronger” or more “meaningful”, the tendency to reject a condom becomes clearer. Often, neither partner suggests condom use because they fear that such a proposal will denote infidelity on their part or suspicion of the other.

What we observe in these relationships are actions to prevent them from being broken. Love, trust, and loyalty are inadequate elements for a tactic to manage the relationship. IDUs and their SPs have to work out other pragmatic ways. First, there is a division of labour between the two partners. Often, female IDUs have to prostitute in order to finance their own (and sometimes their SP’) injecting habits. To maintain this 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. 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 daily. Meanwhile, most of the male IDUs tend to make money by engaging in criminal activities, such as drug dealing, stealing, house breaking etc. 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 money matters. Second, hiding one’s occupation as a SW 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 hiding tactic seems to be fragile and merely “superficial”, it reflects the women‘s strong desire to be respected by the society.

IDU-Smoker Relationships

In this pattern, 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 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. Injectors seem to be more sympathetic to share the “feeling of difference” than their smoking partners. 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. Furthermore, IDUs and their SP not only have to work towards a harmony in drug use but also a harmony in sexual life. Smokers often have higher sexual desire than injectors. Female smokers frequently report having high sexual desire during the smoking phase. 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”.

The social organisation of this pattern is affected 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 later, 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 in ways 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- Nonuser Relationships

In the course of their drug career, an IDU may engage in relationships with a non-user partner. Female IDUs tend to live with non-user men more than male IDUs living with non-user women. It is more likely for non-user women than non-user men to accept an injecting partner. This gender difference in choosing a partner is rooted in the social stigma. As an emotional need, however, some female IDUs still want to seek for a non-using SP. For other female IDUs, engaging in a relationship with a non-user can be viewed as a means to make money and to form socially appropriate relationships. Similarly, young injecting men often see money is the most important motivation in their search for non-user 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 injecting partners also 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 their SP. 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, non-using partners are constantly assessing the risk of HIV. When they are not sure about their partner’ level of addiction, they may agree to have condomless sex. During this phase, however, the drug-using partner may have shifted to intravenous use but the non-user is possibly unaware. When non-users find that their partner injects (rather than smokes), their concern for HIV rises. In general, when “hiding tactics” used by the injecting partner is still effective, the non-using partner may agree to dispense with condoms. As this pattern is usually short-lived and non-using partners may be involved in other sexual relationships after the break-up with injecting SPs, this poses to the possibility of cross-transmission among IDUs and their non-using SPs, and subsequently from these non-users to the populace.

Another important point is that in many cases, injecting women refuse condomless sex even when a [non-using] casual client has become their private SP. This finding is different from other studies, which show that for women, condom is often used with “casual SPs”, but not with “regular” or “private SPs” (Sherman & Latkin, 2001; Wojcicki & Malala, 2001; Schoepf, 1992). The reason for this denial cited by female IDUs in this study 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 a lover. This also implies that she is “an addict” and thus “dirty”, and he is “a non-user” 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.

In sum, IDUs and their non-using SP are constantly 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. The “double life” is felt to introduce uncertainty and mistrust between partners. Thus, this relationship pattern can be considered as the most fragile in comparison with the two above mentioned ones.

The Meaning of AIDS Risks and Intimate Relationships

This study shows that IDUs’ denial of AIDS risks has, as Singer et al. (1990) draw, “a level of meaning and cause beyond the narrow confines of immediate experience”. Choosing risky behaviors is something normalized in the drug scene. This can be explained by several reasons. First, IDUs’ risk perceptions are often fraught with myriads of uncertainties inherent in the complexity of drug and sex 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 (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. 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 a 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 a syringe. In all three patterns, trust is represented by consent to have sex without condoms. 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 bringing suspicion and disequilibria to the sexual relationship (cf. Wojcicki & Malala, 2001).

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. 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.

Implications for HIV Prevention

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. It is clear in this study that many women can support themselves and their male partners, even via sex work. Most women seem to have a firm sense of agency and consider themselves financially independent from men. Often, those men dependent on women for money are forced by circumstances to ignore the risks, which maybe exposed to their female partners while engaging in commercial sex. In this case, women don’t assume a subordinate role vis-à-vis these men and exert considerable control over sexual decision-making and condom use. This implies that these women 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 (Streefland, 1998). 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.

Care and responsibility. In the drug scene, care and responsibility confer different meanings. Often, IDUs are 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). Therefore, responsible behaviors for the self and for others should be emphasized as the means to curb the spread of the AIDS epidemic. Given that many IDUs are involved in 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 ritualised slogans “don’t share” and “practice safe sex behaviors”.

Drugs and sexuality. In general, drugs and sex are highly interrelated (Iguchi et al., 2001; Miller & Neaigus, 2001). Drug use is associated with trading sex for drugs/money and often means unsafe sex (Iguchi et al., 2001; Brummelhuis & Herdt, 1995). Couples using heroin use opiates together to enhance sex (Lex, 1990). Further to these, our data suggests that there is tremendous variability in the perceived effects of heroin on sexual experience. Some IDUs report a positive relationship between heroin, other stimulating drugs, and sexual performance. Many female smokers also report that smoking enhances their sexual desire. In contrast, other IDUs confirm negative relationship between heroin and sexuality. While some male junior IDUs 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. This variability therefore should be integrated into HIV risk-reduction counselling. 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 SWs 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 SW is synonymous with “high risk groups” or “social evils”. The chain of infection is often configured as IDU- SP-populace or SW-client-wife-children and therefore perpetuate the negative image of these groups at risk. IDUs and SWs have become the diseased other and responsible for AIDS in society while clients of SWs are absolved of responsibility. As a result, many women attempt to distance themselves from the stigmatised “sex worker” identity. The account of “I have to work as girl [SW] 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 hide their occupation as a SW to their male injecting partners. 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” [SW] or “thang nghien” [junkie]. Instead, preventing stigma and discrimination towards IDUs and SWs (and PLWHAs) requires a new multidisciplinary approach, in which the resistance of stigmatised individuals and communities is utilized as a resource for social change (Parker & Aggleton, 2003). In the context of Vietnam, mass media campaigns on stigma alleviation, a combination of providing information and coping skill acquisition, greater access to treatment, providing training for health professionals on social aspects of AIDS, are examples of immediate measures. 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.

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 and necessity. Many women don’t use condom not because they lack negotiation skills but because the non-use of condom is a denotation of love and attachment. It is emotional need that’s at stake (rather than financial gains), which are motivations for having unsafe sex among IDUs. Paradoxically, messages of prevention stress the use of condom in sexual relationships, but do not take into account the positive aspects of non-condom use (and syringe sharing) in a loving- trusting relationship. Similarly, merely emphasising the risks of sharing and telling IDUs to stop this behavior is inadequate. Instead, harm reduction programs should be integrated with safer injecting training (Lam, 2003). There is an advantage to utilize aspects of IDUs’ own culture to change behavior. Intervention programs that target this group must take into account the specific context of their lives; programs designed for ‘uniformed IDUs’ will be of little help. In this study, we have seen how intimate relationships have impact on risk behaviors and vice versa. Finally, we suggest that ideological constructs regarding heterosexual relations mediate the impact of political and economy forces on IDUs’ drug use and sexual decisions. In order to cope with the emerging epidemic effectively, there is a critical need for more comprehensive approaches that address the root causes of the epidemic, causes that are embedded in the structuring of political-economy and gender relations in the contemporary society.

Acknowledgements

We are grateful to the Ford Foundation and Population Council for their funding and support. Nguyen Tran Lam would like to thank Dr.Han ten Brummelhuis and Dr.Dianna Gibson at Amsterdam Master’s in Medical Anthropology, University of Amsterdam, and Dr. Robert Miller at Population Council for their comments on an earlier draft of the thesis.

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