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. Author manuscript; available in PMC: 2016 May 25.
Published in final edited form as: AIDS Care. 2012 May 25;25(1):38–42. doi: 10.1080/09540121.2012.687808

Social environment and HIV risk among MSM in Hanoi and Thai Nguyen

MC Berry 1, VF Go 1, VM Quan 1, NL Minh 2, TV Ha 1, NV Mai 1, E Sarin 1, C Beyrer 1
PMCID: PMC4879820  NIHMSID: NIHMS765261  PMID: 22624852

Abstract

Little is known about the effect of the social environment on HIV risk in gay men in northern Vietnam, particularly in rural areas. This qualitative research study conducted 4 key informant interviews and 30 in-depth interviews of men in two northern Vietnamese cities: Hanoi, a large city, and Thai Nguyen, a smaller town. Hanoi has experienced a growth in the number of places where gay men can socialize, access HIV prevention services, and discuss health issues. Thai Nguyen lacks these open venues. However, homosexuality is still highly stigmatized in the general population in both cities. This stigma affects the number of partners and level of sexual risk of participants. Also, men generally reported little communication between partners about sexual risk. While stigma in the general community is difficult to change, social environments where gay men can openly communicate creates an opportunity for HIV prevention and social support.

Keywords: HIV, stigma, men who have sex with men, Vietnam, qualitative research

Introduction

Studies have consistently found that men who have sex with men (MSM) tend to be underserved, understudied, and have much higher risk of HIV acquisition than the heterosexual population (Baral, Sifakis, Cleghorn, & Beyrer, 2007; C. Caceres, Konda, Pecheny, Chatterjee, & Lyerla, 2006). HIV rates among MSM tend to be much higher than in the general population (Beyrer et al., 2010; Geibel, Tun, Tapsoba, & Kellerman, 2010). This increased rate of HIV has been exacerbated in countries where MSM face stigma and discrimination (C. F. Caceres, Konda, Segura, & Lyerla, 2008).

MSM have a higher prevalence of depression, panic attacks, and psychological distress than heterosexual men, stemming from stigma (Cochran, Mays, & Sullivan, 2003; Mustanski, Garofalo, Herrick, & Donenberg, 2007), which is associated with HIV risk behavior in MSM (Mustanski et al., 2007). Research has found sexual behavior and risk are “tied not simply to people’s personal behavior and thoughts but also to the social and ethnic groups that people belong to, and the limitations on the choices that they have to meet their sexual, romantic, economic and social goals” (Hobfoll, 1998). Therefore, the social environment that MSM live in affects their behavior and risk of being infected with STIs and HIV. In this context, social environment includes the structural factors present in the environment where the individual lives and over which they have limited control (Munoz, Adedimeji, & Alawode, 2010). Social environment can be thought of as the place where social, political-economic and structural factors (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005) interact with individual characteristics factors.

Most of the research on social environment and HIV risk has been conducted in western countries. Homosexuality is legal in Vietnam, but MSM in the country face other barriers. Stigma has been described as “an attribute that is deeply discrediting within a particular social interaction,” (Goffman, 1963). The concept of stigma has evolved over time, with further emphasis on how collective values (Reddy, 2005), socio-cultural environment and power dynamics affect stigma (Kleinman & Hall-Clifford, 2009). Stigma is interpersonal; it occurs between people, and in daily forms of social interaction (Yang et al., 2007). Qualitative studies of MSM in Vietnam found that homosexuality is highly stigmatized (Colby, Cao, & Doussantousse, 2004; Nguyen et al., 2008; Vu, Girault, Do, Colby, & Tran, 2008). HIV prevention programs, public officials and media reports about the epidemic ignore homosexuality (Colby et al., 2004; Hang et al., 2005; Nguyen et al., 2008). As a result, MSM in Vietnam tend to have poor HIV knowledge, high levels of risk behavior, and less access to HIV prevention and health care services (Ngo et al., 2009).

Little is known about the effect of the social environment on risk behavior among MSM in smaller towns and the northern region of Vietnam. A greater understanding of the situation of MSM in these locations will help identify health issues that can be addressed through interventions. This article uses qualitative research to describe how the social environment affects sexual behaviors of MSM in a major metropolis and a small city in northern Vietnam.

Methods

We conducted in-depth interviews and key informant interviews in Hanoi (Vietnam’s capital and second-largest city) and Thai Nguyen (a city 80 kilometers north of Hanoi with a population of 150,000). Key informant interviewees were selected from NGOs that work with MSM in Hanoi, and members of the MSM community in Thai Nguyen, where there are no organizations currently working with MSM. Inclusion criteria were that key informant participants: 1) be 18 years of age or older; 2) reside in Hanoi city or Thai Nguyen and 3) be capable of providing voluntary informed consent. Participants who provided in-depth interviews had the same inclusion criteria, and in addition: 1) were male; and 2) reported anal or oral sex with a man in the last 12 months.

Participants were purposively sampled. A team of four trained interviewers asked individuals who had multiple connections into networks of MSM in Hanoi and Thai Nguyen to find participants. Participants represented the range of MSM in those cities with regard to: age; HIV serostatus; injection drug use history; sexual identity disclosure; occupation; and marital status. Data collection occurred from June 2009 through August 2009.

Researchers conducted semi-structured interviews, using an interview guide. All interviews were recorded. Transcripts were translated into English, and a portion of the transcripts were back-translated for quality control. Data were analyzed in Atlas TI (version 6.0). Salient themes were developed by two investigators (M.B. and E.S.) based on the English translations, in conjunction with coauthors from Hanoi and the United States. This study received ethical approval from the Johns Hopkins Bloomberg School of Public Health and Thai Nguyen Centre for Preventive Medicine.

Results

Participants

Study staff interviewed 24 participants from Hanoi and 10 from Thai Nguyen, including 2 key informant interviewees from Hanoi and 2 from Thai Nguyen. The ages of in-depth interview participants ranged from 18 to 70. The median age was 26. Several participants – particularly Thai Nguyen participants - had not disclosed their sexual orientation to their families and/or coworkers. Participants’ occupations included: student, teacher, tour guide, vendor, makeup artist, businessman, model, marketing developer, state officer, doctor, accountant, tailor, club manager, sex worker, broker, disco serviceman, retired, and unemployed.

The following results describe how the social environment in Hanoi and Thai Nguyen affects how MSM find their partners, the types of partners that MSM have, and risk behavior with those partners.

How MSM find male partners

Among participants, the methods for finding sexual partners is more varied and open in Hanoi, compared to Thai Nguyen. It appeared that homosexuality in Hanoi - while still stigmatized - has become more accepted in the general public than in the past, and an MSM community has formed. Accessing the MSM community is easier for men living in Hanoi compared to men living in Thai Nguyen, which participants report has no venues for MSM to meet.

“It’s completely different (now in Hanoi compared to before). (In the past), MSM faced difficulties and barriers and they had few opportunities. Sex partners accepted difficulty. There were few meeting points – a lack of hostels, few private houses. MSM only secretly had sex in the public water closet. Now, there is more freedom, many meeting places, better conditions and fewer barriers, and social demand increases. This leads to good supply. Hostel staff get used to the scene that two men hire one room. When living conditions improve, many people own houses, making them have better conditions. Moreover, bars and cafés are mushrooming.” 42-year-old MSM club manager, Hanoi.

The lakes around Hanoi were historically the most popular cruising spots to find partners, but alternative venues have become available. Participants reported finding sexual partners at physical venues, such as parks, MSM-friendly clubs, and gardens, and through the Internet and cell phone. However, the increasing acceptance of same sex behavior was not found in all social networks in Hanoi. Participants with high-status occupations, older age and wives, were less likely to disclose their sexuality and find partners in MSM-friendly venues.

In contrast to Hanoi, no MSM physical venues in Thai Nguyen were reported. Due to the small social networks and high stigmatization against MSM in Thai Nguyen, some MSM travel to Hanoi to find sexual partners. Fear of inadvertantly disclosing their sexual orientation to the local community influences how men find and communicate with partners, including using phones rather than traceable emails.

“People in this small town, their knowledge and education is too low. People look, they discover me (as a homosexual) and then they consider me with cheap eyes [look down upon me]. Although before that, they respect me, but when they know that I am that way then they consider me nothing… It is not like that in a big city. People (in larger cities) are different because they have got into contacts with (MSM) so their view is different. They do understand what we are like.” 22-year-old vendor, Thai Nguyen.

Because of a lack of physical venues, participants tended to find partners through friends and on the Internet in Thai Nguyen. For university students, MSM-themed chat rooms and websites were the easiest way to access the MSM community in Thai Nguyen. MSM in Thai Nguyen also find other men through general dating websites by user names that indicate that they are gay.

In summary, stigma was reported to affect where MSM find partners in both Hanoi and Thai Nguyen, but the effect of stigma on partner selection appears to be particularly strong in Thai Nguyen, where men frequently need to either go online or to a major city to meet other MSM. The social environment in Hanoi has allowed MSM to find sexual partners, explore their sexual identity, and find acceptance. This seems to have allowed the development of gay-friendly venues in Hanoi.

The role of MSM social clubs in the lives of MSM

MSM venues are not only places to find sexual partners but also to explore one’s sexual identity. MSM clubs often provide HIV prevention materials, including informational pamphlets, lubricants and condoms. Men in Hanoi said being connected to other MSM socially at gay-friendly clubs has allowed them to talk to each other about HIV and prevention.

“At one time, I didn’t know what condoms were. Later, then, I went to this or that gathering place or went to this or that club, listened to health information. Then, I knew that it is compulsory to use condoms. I see that many people now deliver free condoms and lubrications at parks and clubs.” 28-year-old tailor, Hanoi.

The ability to talk openly about sexual health and the introduction of MSM-oriented health education seems to have empowered men to protect themselves against sexual risk. Some men in Hanoi reported practicing safe sex and showed high levels of knowledge and self-efficacy regarding condom and lube use. Those men were frequently well-connected to the local gay community, especially through MSM clubs. MSM in Thai Nguyen are less open, for fear of being stigmatized, which prevents a cohesive community from forming.

“If we do not publicize our status, I don’t think we will face any difficulties at all. The only difficulty is when one wants to meet a partner. I don’t have much contact with the community and with the MSM circle.” 22-year-old student, Thai Nguyen.

Thai Nguyen residents, some of whom are familiar with the MSM community in Hanoi, say there is not a comparable venue to discuss sexuality and HIV prevention in their town. As a result, HIV prevention messages are not as pervasive within this community and while condoms are accessible at the local pharmacies, fear of stigma prevented several participants from accessing lubricants.

“People (here) also don’t know how to prevent infection… Here there is no club like in Hanoi. If there were such clubs, people will have a chance to get more information about (homosexuality), about ways of protection and prevention. Here, if you want to get condoms, you have to go to the shop to buy yourself. In Hanoi, I see that clubs give condoms for free. They have a group of health education workers, scattering leaflets. Here I find that it is like an underground world, separate. They don’t have an address for counseling whenever they have difficulties.” 24-year-old teacher, Thai Nguyen.

Thus, our findings indicate that the openness of the MSM community in Hanoi has led to an increase in HIV prevention services through MSM clubs, which appears to have affected the kind of risk behaviors of men who can access those services.

Risk behaviors

In both Hanoi and Thai Nguyen, risky sexual practices are pervasive and participants tend to have poor communication about HIV prevention andinconsistent condom use. Condom use is affected by degree of openness - closeted participants felt uncomfortable carrying around condoms, and married participants were afraid of being caught if they kept condoms.

Openly self-identified msm men and men who were well connected to the MSM community said they were more empowered to use HIV protection and often were more knowledgeable about HIV transmission.

Thai Nguyen residents tended to perceive less risk of infection with HIV relative to Hanoi participants, but men in both groups were concerned about the risk of unprotected sex. Participants from Thai Nguyen reported little communication about sexual risk, which again was attributed to the lack of a connected MSM community. Thus, it appears that regardless of geographic location, having social connections with other MSM allowed men to talk about sexual risk, which in turn encouraged them to use HIV prevention materials.

Description and number of male partners

In both Thai Nguyen and Hanoi, MSM-related stigma affects the ability of MSM to find partners and influences their partner selection, according to participants. In Thai Nguyen, male sex workers were less visible, while the sex worker industry in Hanoi was larger and could be accessed using the internet and go-betweens called “ma mi.” Sex workers offered the possibility of anonymity: participants who were sex workers often said their clients were often married and/or had high profile jobs. The presence of MSM-friendly venues also allowed some MSM from Hanoi to have a larger number of partners than was commonly reported by Thai Nguyen participants.

Stigma affected the number of partners of men in Hanoi, but this stigma did not affect all participants equally. Fear of gossip and stigma led many MSM in Hanoi to suppress their sexual urges.

“It was about 6–7 years ago (the last time I had sex with a man). I sorrowed and suffered a lot and things have passed. In fact, I used to have young male partners. But I stopped that because of my family; my mother once warned me not to date with the male ‘lechers’, which would bring my family a bad reputation.” 48-year-old unemployed man, Hanoi.

In Thai Nguyen, an even higher proportion of participants said they rarely had sex with men, despite their sexual orientation. One government official in Thai Nguyen said he does not interact in public with men who are suspected of being MSM, because he was worried that his peers would also think he was gay. He said he only meets sexual partners at his home or another private place, and sometimes is pressured by friends to have female partners.

Participants from Hanoi and Thai Nguyen said that men who are feminine in appearance and typically openly MSM are known as “bong lo,” which literally means “open shadow” and masculine men who are often not openly MSM are “bong kin” (which literally means “hidden shadow.”). Other terms for MSM, particularly in Hanoi, were also used by both MSM and in the general community, according to participants. The English words “MSM” and “gay”, for example, were sometimes used, though a few participants said “gay” was typically used to describe effeminate men. Newspapers, according to participants, use the word “dồng tính luyến ái” as the Vietnamese version of the word “gay.” Participants frequently said they prefer that their partners be masculine in their behavior, partly because they were attracted to such men, but also because of a fear of being publicly associated with homosexuality.

“If an effeminate man comes to see me, I only meet and have a drink with him. I don’t have sex with such men. If I do, it is recognized easily. I have sex with the ones who are really stately and manly. Other people still think we only have purely normal friendship. They will never know.” 23-year-old student, Thai Nguyen.

However, bong kin also tend to be less connected to the MSM community. One Hanoi man said that being forced by societal pressures to hide one’s sexual identity limits the ability of the MSM community to organize and also makes them feel as though their sexual orientation is immoral.

“Emotion is not a problem for the bong los, but it is for the bong kins. The bong kins face numerous inner struggles. Being in love and having sex are supposed to be normal things in a person’s life, but the bong kins have to conceal their behaviors and feelings, as if they were doing something sinful. Being one person, they live with two faces in two totally different worlds.” 28-year-old businessman, Hanoi.

Thus, it appears that stigma affects not only the risk behavior of MSM, but also the type of partners and number of partners.

Discussion

This study adds valuable information on HIV risks among MSM in northern Vietnam. Stigma differs by setting, but is present in both urban and rural areas, and negatively affects risk behaviors among MSM and their access to HIV prevention services. MSM in northern Vietnam need more venues where they can talk openly to other MSM. Men who attended MSM-friendly venues often received HIV education and prevention, and were able to discuss HIV prevention with other men. However, men will continue to face stigma in the larger community unless community-wide interventions are developed to reduce discrimination.

Our study had several limitations. The participants were not randomly sampled, but were recruited through contacts, so MSM with larger social networks were more likely to be recruited. Sex workers and drug users were purposively sampled,so the study was not representative of MSM in Northern Vietnam. However, the purposive sampling allowed researchers to interview a diverse group of MSM.

Differences in social environments affect behaviors of MSM in Thai Nguyen and Hanoi. Prevention education and other interventions must take those differences into account. In Hanoi, social support networks exist for some MSM, but those who were not openly gay were limited in their ability to receive education and emotional support from peers. Open social support networks did not exist for MSM in Thai Nguyen. This creates an extra barrier to outreach activities in smaller cities in northern Vietnam, because prevention efforts cannot be coordinated with gay venues. However, men do communicate with each other in Thai Nguyen through friends and the Internet, so those outlets may be utilized for outreach. Stigma and discrimination were clear barriers to HIV prevention behaviors in the study participants. More work is needed to reduce stigma in the larger community, and to give MSM strategies to address stigma and cope with stigma.

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