Methods
The following section describes the epidemiology, beliefs, and high risk sexual practices regarding Human Immunodeficiency Virus (HIV) and sexually transmitted disease (STD) infection among Vietnamese residing in Vietnam and in the United States. It is based upon a literature review of published studies and interviews with key informants. Key informants included (1) a Vietnamese general practitioner who works at a Maternal and Child Health and Family Planning Center in Nghe-An province, the third largest province in Vietnam, (2) a Vietnamese Community House Calls caseworker/cultural mediator at Harborview Medical Center, Seattle, and (3) a Vietnamese layperson who immigrated to the U.S. in 1975.
Epidemiology
Vietnam
According to the World Health Organization, in 1997, South and Southeast Asia accounted for an estimated 5.8 million (19%) of the 30.6 million adults and children living with HIV in the world. This represents more than double the total number of HIV-infected individuals in the entire industrialized world. Three main factors that appear to play a crucial role in HIV transmission in the Asia and Pacific region are commercial sex work, substance abuse, and mobility of people within the region.
HIV testing was started in Vietnam in 1988. HIV testing is mandatory for intravenous drug users (IDU), female sex workers (FSW), blood donors, and prisoners. It remains voluntary for other groups although pregnant women attending public family planning centers, sexually transmitted disease patients, army conscripts, and tuberculosis patients are frequently tested for HIV surveillance studies.
The first HIV infection in Vietnam was reported in December 1990 in Ho Chi Minh City (formerly, Saigon). In 1993 there was an outbreak in the central and southern parts of the country. There has since been an annual increase in the number of reported HIV infected cases. As of February 5, 1999, 12,115 HIV-positive cases were reported in all 61 provinces in Vietnam (Nguyen TH, 1999). The proportion of HIV patients was 65.7% for IDU, 4% for FSW, and 2.7% for STD patients. Males represent the great majority, accounting for 85.5% of total reported infections. The HIV epidemic also has spread primarily among young adults with 38.9% of patients aged 20-29 years old, 29.5% aged 30-39 years old, and 19% aged 40-49 years old. As of February, 1999, 2,301 AIDS cases were reported, of whom 1,236 died.
Commercial sex workers (CSW) in Vietnam have a lower reported HIV seroprevalence (aggregate rate 2.44% in 1998, Nguyen TH, 1999) than in neighboring countries such as Cambodia (40-50% during 1995-1996, WHO, 1996) and Thailand (33% among FSW working in brothels according to the 1996 Thai Ministry of Health sentinel surveillance report). There has been growing concern, however, that Vietnamese CSW represent a significant source of heterosexual transmission. For this reason, they have been the focus of research. One study from 1995-1996 used interviews and physical and laboratory evaluation to survey 968 FSW in three areas of Southern Vietnam including Ho Chi Minh City (HCMC), Can Tho, and An Giang provinces (Nguyen TTT, 1998). The seroprevalence of CSW in these centers of communication, economy, trade, and tourism was 5.2%. Independently statistically significant risk factors for HIV infection included age <or =30 years, sex>20 times per week, venereal warts, genital ulcers, inconsistent condom use, working in brothels, and working at the border area. The highest HIV prevalence of the three study regions was in An Giang province that borders Cambodia and receives the Mekong River as it enters Vietnam. The relatively high HIV prevalence in this province is thought to be in part due to the high rate of migration across this border.
In 1995, between 700,000 and 1,200,000 STD patients were estimated by the Vietnamese National Institute of Venereology and Dermatology. One study by the Maternal and Child Health Department in 1995 showed among women aged 15-39 years old in Hanoi and HCMC, the prevalence rates were 0.3% to 0.7% for gonorrhea, 2.2%-2.5% for chlamydia, and l.2%-1.5% for syphilis (WHO, 1996). A study using interviews and physical and laboratory evaluation of 804 male patients at STD clinics in two semi-rural provinces in the Mekong delta in southern Vietnam revealed the prevalence rates were 19.3% for urethritis syndrome, 10.2% for gonorrhea, and 2% for syphilis (Nguyen TTT, 1999). Although extramarital sex is frowned upon in Vietnamese culture, all of the men studied at this STD clinic had visited a CSW in the past and 58% had their first sexual experience with a CSW. 73% had visited a CSW in the last 3 years. Married men were equally likely as single men to have casual sex partners or to have visited a CSW. Low rates of condom use also were detected. Only 7% of the men used condoms consistently; 70% had never used them. Only 37% had used a condom the last time they had intercourse with a CSW.
These prevalence statistics, however, are thought by many researchers to be underestimates for a number of reasons. The IDU and CSW sentinel populations used in national HIV surveillance studies have been identified through periodic “street cleaning” campaigns by local police targeting illegal practices which are considered “social evils.” The individuals identified for surveillance studies only represent the fraction of IDU and CSW who attend rehabilitation centers. Most of these subjects were arrested or were forced to attend rehabilitation by family members. In addition, surveillance data from STD patients were gathered solely from patients attending government STD and dermatology clinics, to which a minority (an estimated 10%) of STD patients come for treatment. Because of the strong social stigma of STD infection and the widespread fear of lack of confidentiality at public clinics, most STD patients seek treatment from private physicians and are generally not included in research studies.
Vietnamese-Americans
Vietnamese immigration to the U.S. since the conclusion of the Vietnam War has been substantial with a large diaspora occurring in the late 1970’s and early 1980’s. By 1990 the U.S. Vietnamese population had grown to 600,000. Although the first AIDS case among Asian Americans was diagnosed in 1981, at present data on AIDS cases and HIV infection have not been collected systematically and sub-stratified by specific Asian ethnic groups of which there are more than 40. Americans of various East and Southeast Asian countries of origin have all been classified under the single category of “Asian and Pacific Islander.” For this reason there is no national Vietnamese-American seroprevalence data available.
In California, where 46% of Vietnamese-Americans reside, Vietnamese are the fastest growing Asian-Pacific minority (Census Bureau, 1990). As of the March 1,1991, study by California’s Office of AIDS (Jew, 1991), AIDS incidence among Vietnamese in California was 6.4 per 100,000. This was the second to the lowest rate among Asian subgroups, the lowest being 2.7 per 100,000 for the population of Korean origin, and the highest being 66.5 per 100,000 for the population of Thai origin.
In Orange County, California, the Vietnamese population represents the largest Vietnamese community in the U.S. and comprises 3% of the county’s 2.4 million residents. A survey was conducted in 1992 that targeted 223 potentially high risk Vietnamese-Americans at Orange County HIV/STD clinics. 2.3% of these patients were HIV seropositive (Gellert, 1994). In this study, all HIV-positive patients were men who had sex with men.
There is evidence which suggests that reported HIV-infection rates among Vietnamese- Americans may be underestimated. A Los Angeles study in 1997 showed lower rates of HIV testing among Asian Americans compared to other racial groups. 17, 617 telephone surveys conducted in seven languages found that Asian-Americans were significantly less likely than Caucasians to self-report being tested for HIV (odds ratio=0.75, 95% confidence interval=0.62-0.90; p=0.002, Miller, 1990).
There are no national STD prevalence data for Vietnamese-Americans.
Clinical Features
There are no published studies which describe pertinent history and physical exam findings that are unique, unusual, or particular to Vietnamese who have an STD or who are HIV-seropositive living in Vietnam or in the United States. Information from a limited number of studies, however, may be helpful in providing a framework to begin STD/HIV risk assessment.
A study of 804 male STD clinic attendees in two provinces in Vietnam showed that most were young: 23% were 20 years of age or less and 44% were between 20 and 31 years of age (Nguyen TTT, 1999). Most (63%) were currently unmarried and had at least a secondary or high school education (74%). Place of residence was classified as urban (31%), semi-urban (11%), or rural (58%). Most (79%) claimed an officially reported monthly income of less than US$50, although income from other sources may have been higher.
Mean age of first sexual intercourse was 20 years (range 13-32) and 11% had had their first sex at age 17 years or less. Fourteen percent currently had casual sexual partners. All patients had visited a CSW some time in the past, and 57% had visited a CSW from one to three times per year during the last 3 years. Condom use was low with only 30% of all subjects reporting having ever used a condom. Within a group of married men, 14% claimed to have used a condom the last time they had sex with their wife; 21% had used a condom during the last intercourse with their girlfriend, and 11% had used condoms during their most recent intercourse with a casual sexual partner. In this study, only 0.6% self-identified as being homosexual, and 0.1% as bisexual. 0.2% had had anal sexual intercourse with either men or women. Although 52.5% reported using alcohol before sex, other drug use was low with 4% reporting having ever used opium, marijuana, heroin, or sedatives. There were no differences in behavior between those men who were married and those who were single.
As far as presenting complaints and diagnoses, the majority of men had symptoms of urethritis (19.3%). Nine percent were gram stain positive for gonorrhea. The less common diagnoses included genital ulcer (12.9%), genital wart (12.2%), vesicular lesions (7.6%), and syphilis, defined as a reactive rapid plasma reagin test, (2.0%). According to the key informant who is a public health researcher working in a Maternal and Child Health and Family Planning Center in Vietnam, the most common presenting complaint for women with STD diagnoses is abnormal vaginal discharge.
Although no studies were identified which described clinical features of HIV in Vietnamese patients, a study examining 280 IDU enrolled in a rehabilitation center in Ho Chi Minh City, Vietnam, included 235 of whom were infected with HIV (Follezou, 1999). The prevalence of oral candidiasis (58%) and zoster infection (20%) were high. Oral hairy leukoplasia and Kaposi’s sarcoma, two other HIV-associated diagnoses reported in other populations, were absent. The prevalence of AIDS syndrome was 24%. More than 80% of the patients had infections with hepatitis C virus, hepatitis B virus, cytomegalovirus, or human T cell lymphotropic virus type 1. The CD-4 cell counts correlated well with viral load.
Gellert and his colleagues used face-to-face interviews with 532 randomly sampled Vietnamese living in Orange County, California, to document high risk sexual practices among Vietnamese-Americans for which there are scant published data (Gellert, 1995). Subjects were stratified into three groups for analysis: males 18-35 years; males 36-45 years; and females 18-35 years. High percentages of younger men and women denied any history of sexual activity (35% males aged 18-35 years; 5% males aged 36-45 years; and 40% females aged 18-35 years). This likely reflects the cultural taboo of premarital sexual activity.
Multiple high risk behaviors were identified. Men in both age categories reported use of a CSW of the opposite sex (10-11%) and use of a CSW during the prior 12 months (3- 7%). Four percent of sexual contact with a CSW occurred in another country; two-thirds of these occurred in Mexico and the rest in Vietnam. More men (6-8%) reported multiple partners of the opposite sex than did women (2%) during the past year. 46% reported never and 21% reported sometimes using condoms during vaginal sex. Only 1% reported every having anal sex, but none reported intercourse with a partner of the same sex. Three percent reported a past history of an STD. Only 0.4% (one male and one female) reported injection drug use. Fifteen percent of both male groups and 3% of women reported having used alcohol to the point where they did not remember what they did.
A separate targeted HIV seroprevalence study performed by the same research group (Gellert,1994) identified seven HIIV positive individuals from 874 Vietnamese-Americans attending Orange County, California, HIV/STD clinics, men’s jails, a juvenile hall, an injection drug abuse program, a syphilis screening program, and a drunk driving remedial program. Five of the seven HIV-positive individuals were men who had sex with men. These data suggest that the social stigma of homosexuality may have contributed to the inability to detect homosexual behavior in the self-reported community survey. These findings of high risk sexual behavioral within the largest Vietnamese-American community in the United States differ from earlier assumptions that Vietnamese-Americans have little or no risk for HIV infection. HIV/STD risk assessment and harm-reduction interventions may be effective and important components in the screening medical visit for Vietnamese-American patients.
Treatment
No English-language published data describing the systematic use of conventional Western biomedical treatments for HIV in Vietnam were found. One study was directed at understanding the preparedness of Vietnamese physicians in Vietnam regarding the growing HIV epidemic (Ha, 1996). One hundred physicians from hospitals in three areas in southern Vietnam were surveyed. These areas were urban (Ho Chi Minh City), provincial (Vung Tau), and rural (Binh Thuan). Twenty percent of respondents reported having no formal lectures on HIV/AIDS.
Among those who attended medical school after the first reported case of HIV in Vietnam, only 58% reported having had a medical school lecture on HIV. Although overall, the total sample averaged close to 80% correct responses to general questions on HIV, one-half of the questions were answered incorrectly by 20% or more of the respondents. 15% of the responding physicians believed that mosquitoes and casual contact can transmit HIV. Eighteen percent of respondents re-used needles and syringes. Twenty-five percent of respondents reported that they would refuse to treat a patient known to have HIV. Only three out of the one hundred respondents had ever treated a patient with HIV. In addition, HIV-counseling is neither widespread nor policy-driven, even in government-sponsored Maternal and Child Health and Family Planning Centers.
As for many developing countries facing a growing HIV/AIDS epidemic, it is unclear how Vietnam will tackle the financial burden of expensive, chronic anti-retroviral therapies. In 1996, Vietnam spent an estimated US$2 per person each year on health care (Ha, 1996). Given the fact that most Vietnamese STD patients who would be at a higher risk for HIV infection seek treatment at private physician practices, it seems unlikely that most patients would be able to afford long-term antiretroviral therapy. This suggests that Vietnamese physicians can expect HIV-infected patients to present with opportunistic infections associated with lower CD-4 counts and higher viral loads.
Translation or Language Equivalents
No vernacular translations for HIV/AIDS were found. This may be due to the relatively new appearance of this disease entity in Vietnam. Many Vietnamese-Americans learn about HIV / AIDS through the American media or by reading Vietnamese health journals and other periodicals. Vietnamese culture is characterized by strong taboos against open discussions or exhibits of sexuality. Perhaps because of this, there is an absence, in the Vietnamese language, of suitable terms for discussing sexuality.
One example is the subject of homosexuality. The Vietnamese technical terms for homosexuality, “nguoi dong tinh” and “nguoi dong luyen ai” (literally “people-same-love”) are meaningless to most Vietnamese people. A group of researchers from Doctors Without Borders in Vietnam found that the term “men who have sex with men” when translated into Vietnamese, had no meaning, either to doctors, homosexual men, female sex workers, or members of the Vietnamese Provisional AIDS Committees (Wilson, 1999). The most popular term for men who have sex with men, “lai cai,” reflects the association between perceived feminine traits, “walking like women, having soft hands, being talented in sewing, makeup, cooking, and singing,” with homosexuality in that it literally means “half man, half woman” (Carrier, 1992). This lack of suitable terms for homosexuality reflects the strong cultural taboo against homosexuality. It also represents the official denial by Vietnamese government spokesmen that there is no evidence for homosexuality in their country. This is in spite of a published report by Doctors Without Borders who piloted AID/HIV prevention outreach to men who had sex with men and described themselves as “gay” or “be de,” a slang word equivalent to queer.
Cultural Knowledge and Traditional Treatment
Studies involving the Vietnamese-American community in Orange County, California, the largest population of Vietnamese-Americans in the Unites States found a high level of knowledge with respect to the actual modes of HIV transmission (Gellert, 1995). A large majority of respondents, however, had incorrect perceptions regarding possible but highly unusual modes of HIV infection such by needles used in hospitals and by receiving a blood transfusion. A significant minority still believed that the virus could be contracted through casual contact such as touching, co-attendance at school with an infected child, working in occupational settings with an infected individual, and from toilet seats or shared utensils. These levels, however, were lower when compared to the US national survey (NHIS). In regard to the appropriate treatment of HIV-infected individuals, 36% of young men, 45% of older men, and 55% of women agreed with the statement that people with AIDS should be quarantined.
In their work with homosexual men in Vietnam, Doctors Without Borders found that misconceptions could increase high risk sexual behavior (Gellert, 1999). Most of their subjects were aware that body fluids were involved in the disease process. They believed, however, that AIDS somehow happened when body fluids came in contact with each other. Most of the study subjects thought that anal intercourse was safe because the anus is dry. Oral intercourse was considered risky because the mouth is wet. They also thought that AIDS can pass through skin, so masturbation to orgasm was more dangerous than anal intercourse if semen landed on the skin.
In Vietnam, until 1993, the Vietnamese HIV/AIDS policy had been to see the infection as a threat from outside (Nguyen TH, 1994). National campaigns warned the public about the risk of AIDS from foreigners. There were several strategies that diminished the perceived risk of infection of the general population (Wolffers, 1997). One strategy involved portraying HIV infection as a problem mainly affecting IDU. Another is to distinguish between “normal” Vietnamese behavior and “deviant” behavior related to imported habits. The merger by the authorities in Hanoi of the three vertical programs for prostitution, drug use, and AIDS further increased the stigmatization of HIV-positive individuals (Nguyen TH, 1994). Sexual and HIV education, surveillance, and other activities have come under the control of those responsible for programs against prostitution and drug use, so-called “social evils,” In the interest of halting the spread of HIV/AIDS some researchers and international public health advocates have called for a renewed negotiation between dominant cultural interpretations and new understandings of intimate behavior, sexuality, and the pursuit of fulfillment in the Vietnamese way.
Other Considerations
When asked how health care providers could most effectively approach the topic of STDs, HIV / AIDS, and reproductive health with Vietnamese patients, each of the key informants emphasized the need to establish relationships first before delving into questions regarding intimate personal information. These topics include sexual orientation, sexual practices, contraception and family planning. The informants expressed the importance in considering the degree of acculturation of the patient by assessing the patient’s age, sex, number of years in the United States, former social status in Vietnam, current socioeconomic status in the United States, and education level.
Acculturation has pediatric implications as well. In contrast to what is popularly portrayed in American movies and television shows, in Vietnamese culture there is no tradition of a coming-of-age “birds and the bees” talk between parents and their children. Because explicit discussions about sex are taboo even within close-knit Vietnamese families, most Vietnamese adults learned about sex when they were growing up from peers and not from their parents, school, or the media. For this reason, parents who are less acculturated may be more resistant to public school-based sexual education. Similarly, when educating pediatric patients who are the children of less acculturated Vietnamese parents, it may become ever more important for the provider to explain to the parents the provider’s goals and expectations regarding discussions with adolescents about sex and sexually transmitted diseases.
References and Further Reading
- Bureau of the Census. 1990 U.S. population census. Summary tape file IA. Washington, D. C.: U.S. Department of Commerce, Bureau of the Census, 1990.
- Carrier J, Nguyen B, and Su S. Vietnamese American sexual behaviors and HIV infection. Journal of Sex Research 1992;29(4):547-560.
- Gellert GA, et. al. HIV/ AIDS knowledge and high risk sexual practices among southern California Vietnamese. Genitourinary Medicine 1995;71:216-223.
- Gellert GA, et. at. Targeted HIV seroprevalence among Vietnamese in southern California. Genitourinary Medicine 1994;70:265-267.
- Follezou JY, et. al. Clinical and biological characteristics of human immunodeficiency virus-infected and uninfected intravascular drug users in Ho Chi Mirth City, Vietnam. American Journal of Tropical Medicine & Hygiene 1999;61(3):420-424.
- Ha TP and Ickovics JR. Confronting the emerging HIV epidemic in Vietnam: social context and preliminary data on physician preparedness. AIDS 1996;10(10):1180-1181.
- Jew S. AIDS among California Asian and Pacific Islander subgroups. California HIV / AIDS Update, Vol. 4, No. 9, September 1991, Office of AIDS, Department of Health Services, State of California.
- Miller LG, et. at. High-risk sexual behavior in Los Angeles: who receives testing for Lily? JATDS 1999; 22:490-497.
- Nguyen TH and Wolffers I. HIV infection in Vietnam. Lancet 1994;343:410.
- Nguyen TH, et. at. HIV monitoring in Vietnam: system, methodology, and results of sentinel surveillance. JAIDS 1999;21:338-346.
- Nguyen TTT, et. at. Predictors of visits to commercial sex workers by male attendees at sexually transmitted disease clinics in southern Vietnam. AIDS 1999; 13:719-725.
- Nguyen TTT, et. at. HIV infection and risk factors among female sex workers in southern Vietnam. AIDS 1998; 12:425-432.
- Wilson D and Cawthorne P. Face up to the truth: helping gay men in Vietnam protect themselves from AIDS. AIDS 1999:10:63-66.
- Wolffers I. Culture, media, and HIV/ AIDS in Asia. Lancet 1997;349:52-54.
- World Health Organization: The HIV epidemic in the Western Pacific region: current status and future trends. STD/HIV/AIDS Surveillance Report. WHO No.8, November 1996. Manila: WHO; 1996.