Stigma as a barrier to integrated substance use and HIV care in Vietnam: A qualitative examination of patient and provider perspectives

1. Introduction

Injection drug use remains an important source of global HIV transmission, especially in the Asia-Pacific Region (UNAIDS, 2020). Globally, it is estimated that 82.9% of people who inject drugs (PWID) mainly inject opioids (Degenhardt et al., 2017). In the Asia-Pacific region, PWID account for 10% of people living with HIV, with an HIV prevalence of 12.5% among this population (UNAIDS, 2020). Antiretroviral therapy (ART) is an effective strategy for treating patients with HIV and preventing spread of the virus, worldwide (Messac and Prabhu, 2013). However, coverage of ART among PWID living with HIV remains less than 70% in the Asia-Pacific region as a whole, and is below 20% in some countries in this region (UNAIDS, 2020). Regardless of ART coverage, in both resource-limited and resource-rich countries, drug use represents a risk factor for delayed initiation of HIV treatment, which in turn is associated with costly hospitalizations and high mortality (Bath et al., 2019; Brännström et al., 2016; Jeong et al., 2016; Mukolo et al., 2012; Op de Coul et al., 2016).

The World Health Organization recommends integrating substance use and HIV care to improve access to care, treatment quality, and patient satisfaction among people with opioid use disorder (OUD) and HIV, especially in low resource environments (Go et al., 2016; Guise et al., 2017; Haldane et al., 2017; Korthuis et al., 2010). While the principles of integrated care are highly appreciated (Edsall et al., 2020; Guise et al., 2017; Korthuis et al., 2010), expansion of integrated care models has not yet taken place on a large scale (Edelman et al., 2012; Knudsen et al., 2017).

The extent to which stigma prevents widespread integration of SUD and HIV care is uncertain. Stigma towards people with OUD is both commonplace and complicated (van Boekel et al., 2015, 2013a, 2013b). One cross-cultural study showed that people with drug use disorders and HIV were consistently subjected to the highest levels of social disapproval in many countries (Room et al., 2001). Stigma may lead to social isolation of and hostility towards individuals using drugs, who may be considered dangerous (Callinan and Room, 2014; Olsen and Sharfstein, 2014; van Boekel et al., 2015). As a consequence, stigma has a negative impact on the physical and mental health of this population (Ahern et al., 2007). Drug-related stigma is complicated by the fact that many people with substance use disorders also have comorbid conditions such as HIV and mental illness, or face challenges of poverty or racial prejudice (Conner and Rosen, 2008). Each of these traits are associated with stigma that becomes entangled with opioid use.

This study presents patient and healthcare provider insights into the effect of stigma on integrated treatment of HIV and OUD in Vietnam. Provision of both ART and medication-assisted treatment for OUD (MOUD) has rapidly expanded throughout Vietnam over the past decade (Nguyen et al., 2013, 2012). The Government of Vietnam has implemented multiple strategies to increase ART access and treatment adherence among people living with HIV. The newest ART guidelines dated on 31 Dec 2021 indicates that people living with HIV can start their treatment on the same day they receive their HIV positive diagnosis instead of waiting until their CD4 counts fell to 500 cells/mm³ or fewer (Ministry of Health, 2021). ART decentralization at the commune level (district subdivision) and HIV-OUD treatment integration also facilitate access to care (Duc et al., 2012; Tran et al., 2015).

Previous studies in Vietnam demonstrate that patients believe integration of substance use treatment and HIV care is convenient and of higher quality compared to the receiving services separately (Nguyen Bich et al., 2016; Tran et al., 2015). Nevertheless, only 53.4% of people living with both HIV and OUD in Vietnam receive HIV care, while just 28% of this population are treated with MOUD (UNAIDS, 2019). Interviews and ethnographical observation with Vietnamese PWID also indicate that drug-related stigma is omnipresent in the families of PWID, the community, and methadone treatment settings (Trang et al., 2020, 2019). Stigma can prevent PWID from achieving a functional life and impede treatment adherence (Trang et al., 2020, 2019). Several factors affecting integration at both the clinic and structural levels have been identified (Go et al., 2016), yet the significance of stigma and its impact on such integrated services in Vietnam remains understudied. Against this background, Vietnam represents a unique context in which to explore the role of stigma, which may inform treatment integration in other countries and cultures.

2. Methods

2.1. Study setting

The study was conducted at 8 methadone maintenance treatment clinics and 7 HIV outpatient clinics across four provinces in Vietnam (Hanoi, Phu Tho, Thanh Hoa, and Bac Giang) as part of the Buprenorphine to Improve HIV Care Engagement and Outcomes (BRAVO) Randomized Trial (ClinicalTrials.gov NCT01936857). BRAVO compared integrated HIV clinic-based buprenorphine (n=141) to referral for methadone maintenance therapy (n=140) for people living with HIV and OUD (Korthuis et al., 2021). The study was approved by the Institutional Review Boards of Oregon Health and Science University and Hanoi Medical University.

2.1.1. Antiretroviral treatment and methadone maintenance treatment in Vietnam

In 2019, Vietnam provided ART for 160 000 patients in 432 clinics (UNAIDS, 2020; Vo, 2019) and methadone treatment for about 53 000 patients with OUD in 280 clinics (Ministry of Health, 2018). In the four study provinces, each HIV clinic has at least 300 patients and each methadone clinic has at least 200 patients. As the regulations of MOUD in Vietnam require directly observed MOUD administration, patients with OUD must present to the clinics every day or every other day (in the case of buprenorphine) to receive MOUD. HIV patients generally come to their clinics to pick up ART once a month.

Since mid-2010s, as an effort to reduce cost and enhance care quality, HIV and methadone clinics were relocated into district healthcare centres, together with other services (Nguyen Bich et al., 2016; Tran et al., 2012). ART has been covered by health insurance since 2018 (Hammett et al., 2018); Methadone treatment remained subsidized by the government and patients pay a monthly fee of about U.S. $15.

2.2. Participants

Between 2013 and 2015, healthcare providers and patients at 8 methadone maintenance treatment clinics and 7 HIV clinics were recruited and interviewed by trained study staff. We invited all providers of potential BRAVO study sites including nurses, physicians, counsellors, pharmacists, and clinic managers (Table 1). Some participants came from clinics that ultimately did not participate in BRAVO. A convenience sample of patient participants was selected from 281 BRAVO participants during the course of study participation to gain different perspectives including gender, age, employment status, and clinic type. No providers and three patients refused to be interviewed. The reasons for refusal was having time conflicts with work. Interviews were conducted with a total of 43 patients and 43 healthcare providers.

Table 1 –

Characteristics of patients and providers participating in the study

Characteristics	N = 43	%
Patients
Median Age (min-max)	38 (29–52)
Gender
Male	41	95
Female	2	5
Marital Status
Single	16	37
Married	16	37
Divorced/Separated/Widow	11	26
Employment
Yes	17	40
No	26	60
Years since drug use initiation
<5 years	16	37
5 – 10 years	9	21
>10 years	18	42
Education
Under high school	23	53
High school	17	40
College/University	3	7
Providers	N = 43
Gender
Male	18	42
Female	25	58
Work positions
MMT staff only	10	23
Medical doctors	6	14
Counsellors & Nurses	3	7
Pharmacists	1	2
HIV staff only	15	35
Medical doctors	5	12
Counsellors & Nurses	7	16
Pharmacists	3	7
MMT & HIV staff	14	33
Medical doctors	7	16
Counsellors & nurses	4	9
Pharmacists	2	5
Program leaders	4	9

2.3. Data collection and analysis

Interviews lasted between 30 and 60 minutes and were digitally audio-recorded in Vietnamese with the consent of the participants. Interview guides explored respondent opinions and experiences regarding integration of HIV care and OUD treatment services provided by the clinics, HIV and addiction treatment seeking experiences, and past and current alcohol drug use. Findings from some topics have been reported elsewhere (Edsall et al., 2021, 2020). All interviews were conducted and transcribed verbatim in Vietnamese. A codebook consisting of 25 different codes in Vietnamese, including codes developed prior to interviews and others which emerged from analysis of the transcripts, was developed by the study team. All data were iteratively coded using Atlas.ti 7.1 software (ATLAS.ti Scientific Software Development GmbH, Berlin). Two authors fluent in Vietnamese (DTT and HTN) coded separately the same transcripts and met weekly with an third author (KH) to compare their results and discuss discordances. An inter-coder reliability was assessed in a 10% of sample transcripts, yielding greater than 80% agreement between coders. The study team used thematic analysis with a mixed deductive and inductive approach at the semantic level to analyse key topics (Braun and Clarke, 2006). Stigma emerged as a major theme from both patients’ and providers’ perspectives. In this theme, we reported two subthemes of confidentiality concerns as a barrier to the uptake of integrated care and provider stigma experienced by providers and by patients.

3. Results

3.1. Participant characteristics

Demographics of study participants are presented in Table 1. The majority (95%) of the patient sample were male. Most patients were in their mid-thirties. Half (53%) of the sample had less than a high school highest educational attainment. About one third of patients were married, the others were single, divorced or separated. Sixty percent of participants reported being unemployed. Among the provider sample, 18 were male and 25 were female, and 15 worked in methadone maintenance therapy clinics, while 24 worked in HIV outpatient clinics; four were clinic medical directors.

3.2. Theme 1: Confidentiality concerns may pose a barrier to the uptake of integrated care

Both patients and providers worried that the daily observed administration of MOUD provided in an integrated HIV clinic might implicitly reveal patients’ HIV status to members of the general public coming to the healthcare centres, as well as to other people who used drugs and received care there. Providers with years of experience observed that HIV stigma has long represented an obstacle to treatment initiation and decentralisation. Avoidance of judgments towards people living with HIV was reported as a reason why many patients chose to receive HIV treatment in clinics far from where they lived.

We recently surveyed patients about HIV medications delivered at commune health stations but they didn’t want to be transferred to their communes. (Methadone-HIV pharmacist 1)

Patients don’t want to get treatment close to their home for fear that their status will be known. They’re afraid of stigma. (HIV nurse 1)

Fear of stigma was particularly acute among people with a job and a higher social status:

People working for the government, for example, they’ll be afraid. If only people know they are getting HIV treatment and methadone for drug use… (Methadone patient 1)

Among people who use drugs, HIV-positive status seemed to represent a moral failing. Among groups of people who had used drugs for many years, those who could maintain their HIV-negative status were regarded as superior:

Some people injected drugs but aren’t HIV-infected. The others do feel ashamed. (HIV doctor 1)

Although participants expressed relatively greater concern about HIV-related stigma, many also reported feeling uncomfortable when their opioid use disorder was revealed by the fact that they received daily doses of MOUD at the clinics.

People say: “Oh my god, the addict is coming to get medication.” […] They look at us differently. (Buprenorphine patient 1)

To cope with potential stigma, patients employed various strategies including disguising themselves, timing their clinic visits to avoid encountering acquaintances, or developing cover stories to explain why they were at the clinics. Providers recalled such examples among their patients:

Some patients covered their faces. […] Others only come in the afternoon when methadone patients are no longer around. There’s a girl who always tells me, “Give me the medication quickly.” I asked her, “Do you see friends here?” She said, “No, I don’t but if they see me here, what should I do?” (HIV doctor 1)

Fear of stigma was perceived as a potential reason why some participants were reluctant to participate in integrated HIV and OUD treatment at the HIV clinics.

Receiving buprenorphine here is quite challenging for some patients since they can come across their acquaintances […] Some patients ask to switch to methadone to go upstairs [to the methadone clinic]. (Methadone pharmacist 1)

I think you should separate the two treatments. [Why?] It’s to minimize the disclosure of one’s status. People from the same districts come here every day to get their [methadone] doses. No one would tell others, ‘Hey, I’m positive’ if they can do otherwise. (Methadone patient 2)

Still, one provider suggested that patients’ fear of stigma might be a good reason to integrate OUD and HIV treatment if their information can be kept confidential:

Some patients came here for methadone, then they found out they were HIV-infected. If we’d told them to go somewhere else, I don’t think they would’ve gone, because they didn’t want to disclose their information [to other providers]. (Methadone-HIV pharmacist 2)

3.3. Theme 2: Provider stigma existed, but was not reflected in patient narratives

Responses of providers revealed stigmatising attitudes towards people who use drugs. However, we did not find this echoed in patient narratives. Provider responses differed little between providers working exclusively in HIV clinics and providers working exclusively in methadone clinics. Providers did not express views stigmatizing patients with HIV, but did hold such views towards patients with opioid use disorder. Physicians often emphasized that addiction was a mental disorder that changed the personality of patients with opioid use disorder. One physician distinguished his different perceptions of patients with HIV and patients with opioid use disorders:

I am afraid of tuberculosis more than I am afraid of HIV. Patients who inject drugs… they are unruly. They aren’t like normal people. (HIV doctor 1)

This attitude also seemed to come from the view that addiction deteriorated one’s morals. Some providers criticized patients for their “lack of culture” or impolite manners. They attributed such manners to patients’ moral deterioration and perceived that stigmatization of this population was justified.

Because methadone patients have been addicted for many years, their morals have deteriorated. Their attitude, their communication are lacking culture, very annoying. […] They come to the clinic and throw rubbish everywhere. At the end of the day, we have to clean after them. (HIV doctor 2)

The ones who are addicted to drugs aren’t normal like us. […] They have limited conscience. (Methadone-HIV pharmacist 1)

Providers’ disapproval of patients also stemmed from their frustration with increased workloads. Not only were they charged with additional responsibilities of providing OUD treatment, but some patients’ lack of consideration (e.g., littering) also resulted in more work for providers.

Because of their “deteriorated morals” patients were perceived to be unpredictable, and to be approached with caution. Although greater exposure to people with OUD increased providers’ level of comfort with this population over time, they remained reluctant to work with patients with OUD.

These patients’ mood swings swiftly. […] If they get what they want, they’d be very smiling, otherwise, they’d flip out. (Methadone nurse 1)

There’re always some caution. We’re all very careful with them. (Methadone nurse 2)

As a result, many providers employed a range of measures to protect themselves from the perceived potential for being harmed by patients. Strategies included staying alert, maintaining a calm demeanour, and even bringing weapons of self-defence to work.

Although we treat addiction, I’m still very alert. […] That disease is a psychiatric one after all. (HIV nurse 2)

Our guards always bring electric batons. […] This is to protect ourselves, since sometimes [patients] would attack the guards and staffs. These people no longer have morals. (HIV doctor 2)

From another perspective, some providers reported feeling motivated to work with people who use drugs. They perceived that their help was meaningful to these patients. These providers were mainly nurses and counselors.

Some patients even didn’t talk to their parents or their in-laws but they sometimes call me to talk, saying that they feel relieved when they talk to me. I like that I could somehow help them. (HIV nurse 1)

4. Discussion

Stigma has long represented a barrier to the initiation of HIV care and treatment with MOUD. Models which integrate treatment for substance use disorder and HIV are expected to increase uptake of treatment among people who use drugs. The present study is among the first to explore the role of stigma towards people with OUD and HIV in the context of such integrated care models in low-to-middle-income countries. In capturing the perspectives of both patients and providers, this study sought to present a more comprehensive view of stigma in this context. Moreover, the relatively large sample size, spread across four provinces in Vietnam, allowed the study to elicit the views of participants in different settings, although there were no differences in the views of participants from different geographical areas or between participants in methadone or HIV clinics.

Concerns surrounding HIV-related stigma among people with OUD should not be taken lightly. Intra-group stigma may affect utilization of health services. Previous studies report that people who use drugs may impose hierarchies onto other drug-using individuals based on various criteria such as types of drugs used, routes of administration, or whether they were in abstinence-based recovery or utilized MOUD (Gunn and Canada, 2015; McCradden et al., 2019; McKenna, 2013; Simmonds and Coomber, 2009). Contracting HIV might be interpreted to signify that a person simply “does not care” or that a person had exhausted all resources available to them for obtaining unused needles and syringes (Simmonds and Coomber, 2009).

The daily dosing requirement for MOUD at HIV clinics may exacerbate the risk of revealing participants’ substance use disorder and their HIV status. Constraints on physical space at several clinics meant that patients had to wait outside for their turn to receive MOUD, thereby increasing patients’ chances of encountering an acquaintance and facing questions about their presence at an HIV clinic. While patients may appreciate the convenience of integrated substance use and HIV care in principle (Nguyen Bich et al., 2016; Tran et al., 2015), careful consideration clearly must be given to ensure patient confidentiality when implementing this model.

Stigma among medical providers in these HIV clinics was directed more towards patients with OUD than towards people with HIV. Criticisms that patients were ‘lacking culture’ reflected the different cultures and socioeconomic backgrounds of providers and patients. This may be explained by the results of a previous study using a cultural health capital framework, which found that providers’ attitudes towards patients who use drugs depended in part on whether patients possessed specific forms of cultural capital appreciated by providers, including awareness of medical issues, attention to their health and appropriate manners (Chang et al., 2016).

Provider stigma towards patients using drugs also seemed to stem from stereotypes that substance use caused moral deterioration, making patients unstable and potentially violent. This stereotype is not unique to Vietnam, and studies worldwide have shown that people who use drugs are considered to be dangerous and ready to commit immoral acts (Callinan and Room, 2014; Olsen and Sharfstein, 2014). A recent study in South Africa also reported that HIV providers viewed patients with alcohol and drug issues as ‘naughty’, ‘rude’ people or potential criminals (Regenauer et al., 2020). Conceptions of addiction as a chronic, relapsing brain disorder did not seem to dispel this stereotype (Meurk et al., 2014). To the contrary, some scholars have voiced worry that this may lead to the impression that the brains of people who have used drugs will never fully heal, thereby justifying the need for harsh treatment of these individuals to deter antisocial behaviours (Garriott and Raikhel, 2015). While integrated OUD and HIV care has been praised as a patient-centred approach to treatment (Guise et al., 2017), this has not necessarily led to lower levels of provider stigma towards people who use drugs.

Link & Phelan (2001) suggest that stigma results from the power differential between the stigmatizing and the stigmatized. Fraser et al. (2017) argue that stigma is centred on what is considered legitimate in contemporary society. In both views, criticisms of patients as ‘lacking culture’ directly imply that the provider’s culture is legitimate (as opposed to that of the patient), and emphasises the power of providers in healthcare settings.

The fact that provider stigma manifested as apprehensive treatment of patients may reflect providers’ existing fears of patients with OUD. Self-defence measures taken by providers against patients in this study echo other studies, in which methadone providers have endeavoured to separate themselves from patients with bullet-proof glass (Crawford, 2013). This apprehensive treatment, rather than active/explicit discrimination by providers, may be one reason why patients did not perceive provider discrimination towards themselves. Another explanation could be desirability bias among patients in our study, who may not have wanted to report negatively on their providers.

The requirement for daily observed dosing represented an important facilitator of stigma. First, this increased the risk of implicitly revealing patients’ HIV and OUD by requiring them to present to their clinics every day. Second, this requirement increased providers’ workloads, and thereby negatively impacted providers’ satisfaction with their work. Medical providers’ job satisfaction directly affects provider-patient relationships (Williams and Skinner, 2003). When providers are satisfied in their roles, they are more likely to provide patients with helpful information (Williams and Skinner, 2003). Given that most HIV outpatient clinics in Vietnam already provide HIV treatment to many patients, simply adding the workload of daily MOUD administration and OUD counselling may overwhelm existing clinic structures. As a result of recent decreases in funding for HIV-related programming in Vietnam (Hammett et al., 2018), clinics have faced difficulty recruiting new staff to assume these additional tasks.

4.1. Recommendations

The findings of this study suggest that in order to implement integrated treatment for OUD and HIV at existing HIV clinics, interventions at the clinic and policy levels must be undertaken to ensure appropriate staff compensation and improved workflows to minimize threats to patient confidentiality. Allowing take-home doses of MOUD could significantly reduce provider workload, minimize the risk of jeopardizing patient confidentiality, and thereby increase quality of care and patients’ satisfaction with treatment. Moreover, finding ways to integrate patients with HIV and OUD into the general patient pool while maintaining confidentiality would reduce the risk of implicitly disclosing patients’ HIV and OUD through their presence at specific times/locations. Reviews of strategies to reduce stigma in healthcare facilities confirm that concerted interventions such as these are both feasible and effective (Nyblade et al., 2019, 2009).

4.2. Limitations

The above findings should be considered in light of this study’s potential limitations. In this study, we were unable to interview patients who had dropped out of the integrated HIV and OUD treatment program. Fear of stigma among such patients may have been even greater than among patients who remained in treatment. In addition, since the overwhelming majority of patients interviewed were male, we were unable to explore the intersection between gender and stigma, which has been reported in other studies (Haritavorn, 2014; Spooner et al., 2015). The recruitment of provider participants during the site selection process might create some bias since some HIV providers might not have actually experienced the integrated care model and responded only to what they observed.

5. Conclusion

Stigma related to HIV and OUD continues to be an important issue affecting the integration of OUD treatment and HIV care in Vietnam, and may negatively impact utilization of these services. Provider stigma resulted from negative stereotypes of patients who use drugs. The current requirement of daily observed dosing for both methadone maintenance and office-based buprenorphine in Vietnam serves to exacerbate these challenges. Stigma reduction interventions at the clinic and policy levels may therefore serve to enhance patient utilization of integrated HIV and OUD care.