National Institute for Research Advancement (NIRA); Center for Policy Research
Prostitution, AIDS, Social Evils, Ho Chi Minh City
By Dylan Foley
Vietnam appears to be on the edge of a devastating
AIDS epidemic. The official figure for the number of HIV-positive people, 3,706 (with 148
deaths since the first case was recorded in 1990), is almost certainly underestimated by
several orders of magnitude. Aid workers from non-governmental organizations say that estimates
by the World Health Organization of 100,000 HIV-positive people in Vietnam are much closer to
reality. More ominous are WHO reports that estimate 500,000 people in Vietnam will be HIV
positive by 1998 unless massive education efforts slow the epidemic.
Vietnam still has time to prevent becoming another
Thailand, with its one million HIV-positive citizens. Vietnam's only hope is through decisive
and aggressive action: it must not only educate prostitutes and drug users--traditional sources
for AIDS infection-- but must also create massive, active education and outreach programs
directed at the mainstream population. The Vietnamese government has decided to fight the
epidemic through an extensive if passive AIDS prevention campaign using television and
billboards that explain HIV transmission, and by urging morality and monogamy.
The government is also setting up small programs for
high-risk groups using the "harm-reduction" model of AIDS education, a hands-on method that
uses outreach workers. Harm-reduction education teaches sex workers to use condoms and to avoid
high-risk sexual activity. Intravenous drug users are also taught to use clean hypodermic
needles and not to share injection paraphernalia with other users. Government AIDS policy also
focuses on educating government employees like police officers and medical workers about HIV
transmission. There is some education in the schools, but it is only on HIV and AIDS
transmission; no sex education courses exist. Moreover, there are no special hospitals for AIDS
patients. In the destitute Vietnamese medical system, where a patient's family must go to the
black market to buy medicine, the AIDS drug AZT is given only to pregnant women.
In Ho Chi Minh City (formerly Saigon), the
government and Save the Children both run similar programs using peer outreach workers,
employing former sex workers to teach safe sex to prostitutes, and using former intravenous
drug users to educate present drug users on how to avoid AIDS. Although the programs have the
same goal--to stop the spread of HIV and AIDS--the way that they are run says a lot about the
attitudes toward the sex workers and drug users whom they attempt to help.
The Vietnamese government has set up pilot
syringe-exchange programs in Hanoi and Ho Chi Minh City. Save the Children has created pilot
AIDS education and outreach programs with the hope that locally supported versions will
eventually be run in other provinces in Vietnam. The government is now hopeful that more
nongovernmental organizations will come into Vietnam to set up more projects.
Ho Chi Minh City is the epicenter of Vietnam's AIDS
epidemic, with half the reported HIV cases coming from the city. Police figures estimate 33,000
prostitutes and 150 brothels there, though these figures are at least three years old. An
estimated 10,000 IV drug users and 30,000 children live alone or with their families in the
streets. In the past five years, more than a million people have come to Ho Chi Minh City to
try to escape the crippling poverty of the countryside. Some women from the provinces
inevitably wind up working as prostitutes.
Dr. Thue Vinh is a member of the District One AIDS
Committee in Ho Chi Minh City. "When we first set the program up, in 1993, we had some
resistance from the police officials. They did not understand why we gave condoms to sex
workers; they said we were helping them to be prostitutes," Vinh explained. Attitudes are
better, according to Vinh, because of the massive government AIDS education campaign. Among the
general population, the knowledge about HIV transmission is high.
But the government campaign has some big holes. "We
have classes in the schools on how HIV is transmitted," said Vinh, "but no sex education
programs." Efforts to reach prostitutes who work in hotels are hampered by the hotels' refusal
to accept free government condoms. Accepting the free condoms, the hotel managers reason, is
the equivalent of pleading guilty to charges of promoting prostitution. They fear the police
will shut them down.
Last February the AIDS committee also restarted
their needle exchange, shut down two years ago because of conflicts with the police. The
exchange has 87 clients out of the 500 users in the district. Estimates for IV drug users are
bleak--the HIV infection rate may be as high as 80 percent. According to Aaron Peak, an
American AIDS policy consultant in Vietnam, the addicts of Ho Chi Minh City frequent "shooting
galleries," where they buy the opium they shoot and where one person injects all the clients,
often with the same needle.
The District One Women's Union runs the government's
peer outreach program to sex workers. At a recent meeting, eight former sex workers were
gathered around a long table. The meeting was led by Hoa Hong, a Women's Union official who has
never worked as a prostitute, and the mood was very serious. Hong asked each woman to make a
report. Several women said the new law against social evils, known as Local Law 87, has forced
prostitutes off the street because it is easier for the police to arrest them for vagrancy.
Many of the sex workers now work inside, and some have resorted to having an accomplice drive
them around on a scooter, allowing for quicker propositions with less danger of being arrested.
Local Law 87, which cracks down on gambling, prostitution, and drug use, was passed last winter
to appease Communist Party hard-liners in preparation for June's Party conference. It has put a
damper on safe-sex education and condom distribution.
At Save the Children, the atmosphere was much more
relaxed. The offices were in a large house and the sex workers' meeting was held on the floor,
with the half-dozen women volunteers, all present and former sex workers, sitting and
discussing their work while exchanging lively banter.
Truong is a former sex worker and staff member.
Although more than 100,000 Saigon bar girls and prostitutes were sent to communist
"reeducation" camps in 1975, that's when Truong's career as a sex worker started. Her father,
who had worked with Americans in Vietnam, was sent to a reeducation camp where he spent 11
years. To support her mother and brother, Truong sold her virginity at the age of 21 and spent
16 years as a prostitute. She stopped after she was recruited to do outreach for Save The
Children four years ago.
"I'd say about 70 percent of the commercial sex
workers start because of poverty," Truong said. "Most come from the provinces and are very
poor; they have a low education level and no stable job. The Women's Union hates commercial sex
workers. They don't try to determine the reasons why women sell themselves. They just
say it is a social evil without knowing the reasons why."
Harm-reduction education has to be done without
moral judgment, to actively address the needs of high-risk groups while appealing to their
ability to take care of themselves. This flies in the face of abstinence models of
HIV-prevention: don't have sex until you are married, don't have sex outside of marriage, don't
do drugs ever.
Harm reduction is still controversial in the United
States because it involves teaching members of groups at high risk for HIV infection how to
protect themselves from AIDS, and to prevent those who are already infected from spreading the
disease. Giving out needles and condoms acknowledges that drug addicts and prostitutes exist
and are a part of society in Vietnam (as well as in just about every country); they cannot be
simply disposed of by arresting them and sending them off to prison or reeducation camps.
Most AIDS education outreach efforts in Ho Chi Minh
City are directed at high-risk populations. Besides drug users and sex workers, Save the
Children also has projects doing HIV-prevention work with street children and gay men. In
Vietnam, homosexuality is illegal.
Vietnam should be aware that the country has already
entered a crisis. To slow the spread of HIV, the Vietnamese government should not merely wait
for increased spending on the part of nongovernment organizations; it should itself increase
spending on HIV prevention. For example, with new joint ventures between the government and
foreign corporations being formed every week, the government could impose a small corporate tax
to pay for increased AIDS spending.
The Save the Children program is small, with a staff
of just 24 in addition to its 50 outreach workers, but it is vital. By approaching the sex
workers with respect, they gain their confidence and give them tools with which to protect
themselves. Though some sex workers still have unprotected sex despite knowing about AIDS, the
outreach workers have changed attitudes, raised self-esteem, and helped sex workers convince
their clients to use condoms.
As a first step, the Vietnamese government should
expand the education and outreach toward high-risk populations. For example, the
needle-exchange program in Ho Chi Minh City should be expanded to include all addicts
interested, not just the five percent now involved. These education and outreach programs
should also be set up on a smaller scale in the capital of each province: as affluence spreads
through the country, attendant social problems such as prostitution will also become an issue
in the smaller cities and town.
The European nongovernmental organization Medicins
Du Monde has set up a "Condom Coffee Shop" in the city's youth center to educate young people
about HIV and AIDS. "We are targeting the heterosexual population with education, trying to get
to them before HIV spreads even further to the general population," said Martine David, the
23-year-old Canadian who runs the program. The coffee shop is staffed with young volunteers
trained to discuss HIV and AIDS prevention with their teenage and young adult clientele. They
stage puppet shows and dramas that address HIV and AIDS and distribute free condoms with names
like Trust and OK. David said they hope to start inviting high school classes to the coffee
shop. "There is no condom education in the schools," she said. "Mainly, the teachers are too
"The government does a good job on AIDS education
with TV and radio, but the attitudes don't change," said David. "People tell me 'I go out with
good girls,' or 'I'm a university student.' They see AIDS as a problem for prostitutes and drug
Programs like the Condom Coffee Shop, though
minuscule, are effective because they appeal to people's intelligence, as well as to their fear
of AIDS. Programs like these need to be expanded and set up in different areas of Vietnamese
society, such as bars catering to businessmen or farmers.
Government billboards and television announcements
that warn of the risks of HIV and AIDS are necessary, but this passive form of education is not
as effective as the more active, individual education that changes attitudes. In Ho Chi Minh
City, a married man who has unprotected sex with a prostitute may read a billboard on his way
home urging him to be faithful to his wife to avoid AIDS. But it is only by changing sexual
practices and ways of drug use that AIDS in Vietnam will be curtailed.
While the first part of Vietnam's AIDS strategy
should address high-risk populations, the second phase should deal with mainstream society. A
comprehensive sex education program should be set up for high school and university students.
If the teachers are too shy to teach it, specially trained instructors should be used. Outreach
programs promoting discussions of safe sex should then be developed and used with groups such
as labor unions and other professional bodies.
It is essential that the control of these programs
not be limited to "official mass organizations" such as the Women's Unions and the Youth Union.
There must be mass participation on a local level to promote active education, not just the
passive education from billboards and television. It is as necessary to reach the farmer in the
countryside with AIDS education as it is to reach the doctor or government clerk in the
Although cultural practices that prevent the candid
discussion of sex and AIDS remain strong in Vietnam, it is necessary to try to change these
traditions; it's also best if these changes are done by the Vietnamese themselves and not by
foreign nongovernmental organizations. Unfortunately for Vietnam, HIV and AIDS do not respect
Copyright 1996 All Rights Reserved Dylan Foley
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