Background: Since the early days of the HIV epidemic, stigma has been recognized as strongly linked
to HIV. In concentrated HIV epidemic settings such as Vietnam, stigma is also associated with key
risk groups that are heavily affected by HIV, such as injecting drug users, commercial sex workers and
men who have sex with men. The availability of HIV prevention and treatment measures has increased
globally, but the prevention, testing and treatment for HIV has lagged, particularly in certain segments
of the population.
Aim: The overall aim of this thesis is to analyze and explore how HIV-related stigma influences HIV
prevention and care in a concentrated HIV epidemic setting.
Methods: Data for this study were collected from three locations in Northern Vietnam and are organized
into four articles (I-IV). In article I, a structured questionnaire was used to identify factors associated
with HIV-related stigma in a population-based sample of 1874 adult community members in the rural
district of Bavi. The same study population was used for article II, where determinants of HIV testing
were identified. In article III, qualitative interviews with women living with HIV in and around Hanoi
explored how women cope with HIV-related stigma. In article IV, focus group discussions with persons
living with HIV and their family members in Quang Ninh province were used to explore factors
influencing adherence to antiretroviral therapy.
Findings: Women, persons with less education, and those who had not migrated out of the rural area
were significantly more likely to express stigmatizing attitudes toward people living with HIV, and
HIV-related stigma was associated with not feeling at-risk for HIV among rural Vietnamese adults (I).
Testing rates for HIV were low (7.6%), generally, and persons with less money, those living in more
rural settings, and those expressing more HIV-related stigma were significantly less likely to have
tested for HIV (II). Prevention of mother-to-child transmission programs seemed not to have had a
large uptake in the study population, with pregnant women no more likely to have tested for HIV than
non-pregnant women (II). Stigma appeared to affect the extent to which persons living with HIV could
enact HIV prevention measures or disclose their HIV status to others (III, IV). Women living with
HIV attempted to stave off HIV-related stigma by enacting culturally-prescribed feminine virtues of
protecting others and appearing innocent in their infection with HIV (III). Family was identified as an
important source of adherence and social support and those women who had more support from family
members appeared to cope more easily with the stigma of living with HIV (III, IV). Organizations for
persons living with HIV helped members to obtain health care and to manage stigma (III). Stigma was
identified as one of the main barriers to adherence to antiretroviral medication, causing people living
with HIV to hide or delay taking their medication (IV).
Conclusions: Results suggest that stigma presents an obstacle to effective HIV prevention and treatment
in the Vietnamese context. The provision of free, opt-out, high-quality HIV testing could help to
normalize the process of HIV testing and make it more accessible within Vietnam, particularly in the
antenatal setting. Family and peer support could help to encourage good adherence to antiretroviral
treatment. Organizations for persons living with HIV can be used to increase access to health care,
to reduce stigma in community and family settings, and to increase quality of life for persons living
with HIV. Refined public health messaging that incorporates the cultural notion of protection of family
and that de-links HIV from fear-based messages could be an effective way of reducing stigma and
increasing effective HIV prevention and care in the Vietnamese context.