Regional feature: Forgotten Voices – listening to HIV-negative partners in serodiscordant relationships in Vietnam

HIV Australia | Vol. 10 No. 1 | June 2012

In 2009, UNAIDS estimated that more than 90% of the 1.7 million women living with HIV in Asia had been infected by their husbands or partners while in long-term relationships.

Women are frequently infected by men who engage in high-risk sexual behaviours including unprotected sex between men, unprotected commercial sex, and sharing of contaminated injecting equipment.

Across Asia, most men engaging in high risk behaviours either are married or will marry. Domestic epidemics are changing as HIV infection risk is no longer isolated among small population groups engaging in high risk activities; infection rates among women reflect this change.

In 1990, women comprised 17% of all adult HIV infections in Asia. By 2008, that rate had doubled to 35%. Today, an estimated 50 million women in Asia are at risk of HIV infection from their intimate partners.¹

This pattern is reflected in Vietnam. Historically, most HIV transmission in Vietnam has been among men but data shows that women are increasingly at risk.²

HIV prevention efforts to address this trend face enormous challenges because they strike at the root of social norms and gender inequalities.

There are social and religious taboos and often legal penalties associated with high risk behaviours; social pressure to marry (requiring suppression of sexualities); social acceptance of men’s premarital and extramarital heterosexual sex; expectations of women’s ‘innocence’ in sexual matters; women’s responsibility for contraception without power to negotiate safe sex; domestic violence; and short-term economic migration, sometimes to regions of high HIV prevalence.

Increasingly, state and community actors are recognising that HIV transmission in intimate partner relationships require a sophisticated response, including more than a focus on the mechanics of prevention. This article outlines some of the innovative work being conducted in Vietnam to shed light on the experiences of HIV-negative partners in serodiscordant relationships.

Positive Voices – Vietnam

The Community Advocacy Initiative (CAI) is a partnership program that aims to strengthen community sector HIV advocacy capacity. CAI in Vietnam is funded by AusAID,³ with AFAO and APCASO as project partners.

A 2009 Vietnamese study⁴ found serodiscordant relationships were not uncommon, with almost half of the 1,300 HIV-positive men interviewed living with an HIV-negative partner. In October 2011, Vietnam’s CAI country partner, the Center for Supporting Community Development Initiatives, hosted a national workshop on ‘Forgotten Voices: The Issues of Negative Partners of PLHIV and Sero- Discordant Couples’.

The workshop aimed to highlight issues experienced by HIV-negative partners so that they might better inform the country’s national HIV and AIDS response. The workshop also provided a space for dialogue between advocates for, and networks of, negative partners and key government and development agencies in Vietnam.

The workshop was attended by representatives of groups of negative partners from all over Vietnam, UNAIDS, WHO, Vietnam’s Vice-Health Minister and members of the media. Following the meeting, the Vice-Health Minister expressed his support for initiatives that help address the needs of HIV-negative partners.

This article aims to promote the voices of negative partners of people living with HIV (PLHIV) in serodiscordant couples heard at that workshop, including their experiences reported in the 2010 survey on the sexual and reproductive health of HIV-negative partners of sero-discordant couples (the CSCDI⁵ report).

The CSCDI report reinforces analysis of surveillance data that HIV-negative partners are frequently women. In that survey, women comprised 88% of the HIV-negative partners among 307 serodiscordant couples. The data contained below has not been disaggregated by gender so it includes responses from both men and women.

Disclosure

Notably, only 18% of respondents in the CSDI report had been informed of their partner’s HIV status before making the decision to commit to the relationship.

The survey revealed many barriers to disclosure including fear of being stigmatised, isolated or abandoned; fear that confidentiality would be breached; and concern that a partner would refuse sex. Decisions not to disclose or to delay disclosure were not straightforward and often involved considerable anxiety and guilt:

‘He is suffering a lot. He’s miserable because he loves her too much. He is so afraid of losing her. Last time he lost a girl just like that, so now he is so afraid of losing this girl. We are all worried about him.

One thing that makes it worse was that they didn’t use a condom. He wanted to use one but she was upset. She said to him, “Do you only want to use me? Why do we need to use a condom? Do you want to avoid taking responsibility?”.

We keep telling him “you should tell her’” but he hasn’t been able to. We don’t know what to do. Poor guy.’

Some had given up relationships rather than disclose:

‘That girl is really sweet. I like her a lot but it’s over now … because I didn’t know how to tell her. I wanted to but I didn’t know how she would react.

I am afraid that she would look at me differently. And she could go tell other people … So I let go.’

Others had received reassuring responses after disclosing their HIV status to intimate partners:

‘Well, it was normal, because she had come back from school (at a drug centre) so she was used to hearing about HIV’.

And

‘Because we’re so in love … Yeah, when you are in love, you have no fear.’ (Male.)

Complexity of relationships

The survey found a range of factors informing HIV-negative partners’ experience of their serodiscordant intimate relationships. For the majority, romantic attachment was the primary reason for choosing to be in a relationship, out weighing HIV-related concerns⁶. However, for many couples fears about acquiring HIV had a dramatic impact on maintaining a pleasurable sexual life.

Condom use

In Vietnam, women are widely perceived as being responsible for contraception (it’s ‘women’s business’) but social mores mean they are often unable to negotiate effectively on reproductive issues. Many married women consider infidelity by their husbands to be common, but they rarely used condoms.

Condom use also remains low amongst serodiscordant couples; however, there is some evidence that health promotion initiatives are having an effect and condom use is increasing among serodiscordant couples.

Of those surveyed who had had sex in the previous four weeks:⁸

• 12% reported inconsistent condom use
• 13% reported no condom use
• 8% had never used a condom in their life.

Condoms had become an integral part of sex for some, as the following quotes illustrate:

‘At the beginning, it felt strange but as we use it all the time, it becomes normal. Now we use it all the time.’

‘Well, I am afraid that my wife will get pregnant then she would become weaker. And she is afraid of infecting me.’

Many couples in serodiscordant relationships also described fears about acquiring HIV and difficulties maintaining a sexual relationship, even when using condoms:

‘Sometimes while we are doing (sex), I stop and check the condom. I am so afraid.’

‘We have our own beds … I have a “body guard” so I am not afraid … our son (who sleeps with the father). When he goes to sleep, he uses a scarf to tie his wrist to his dad’s and tell him, “Don’t you go anywhere”’. (Female.)

For others, condom use remained a burden or was incompatible with their priorities:

‘I recognise that every time we use condoms, [my husband] does not enjoy it. He used condoms because he was afraid of infecting me but he doesn’t like it. I love him very much.

I don’t want to lose him. I‘m afraid that he may go and look for a woman with HIV to have sex with. And me too. I don’t like condoms. We both enjoy sex so much every time we decide not to use condoms. So, I have to admit to you that we have stopped using condom.’

Having children

The interface between HIV prevention and family planning strategies remains underdeveloped. There is a large unmet need for information on minimising HIV transmission risk while trying to get pregnant.

Of those surveyed, 75% had children, 75% had been pregnant to their positive partner, and 24% wanted to have/to have more children. A number of factors influenced respondents’ desire to have or have more children, including:

• compassion/responsibility to family
• wanting to contribute to family ancestry
• wanting to show commitment and love
• feeling encouraged after having one child ‘safely’
• being inspired by others who have children safely.

Many respondents had struggled to manage their HIV infection risk and their (and/or their families’) desire to have children:

‘At the beginning we used condoms. Then I heard his Mum say, ‘This family is so unfortunate. Every other family has grandchildren except this one’. So I stopped using condoms.

I made that decision on my own. I stopped for three months then I got pregnant.’ 

Numerous word of mouth ‘risk reduction’ methods had been used. Survey respondents reported strategies including:

Community advocacy and support