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Addressing Stigma and Discrimination in HIV/AIDS Affected Orphans and Vulnerable Children in Vietnam

Thi Thu Nga Tran, Lillian Mwanri*

Discipline of Public Health, School of Medicine, Flinders University, South Australia

Abstract: Vietnam, like many other developing countries experiences over whelming challenges related to Human Immunodeficiency Virus (HIV) infections, including significant stigma and discrimination of people who are affected by HIV infections. HIV pandemic has resulted in increased numbers of Orphans and Vulnerable Children (OVC). Different strategies are required in addressing these challenges. The aim of this paper is to review the literature and describe interventions aimed to decrease HIV stigma and discrimination in OVC. The focus is to identify aspects of these interventions that are effective in Vietnam. The findings demonstrate that the Vietnam government and international agencies such as the UNAIDS and UNICEF are employing joint strategies to address the growing problems of OVC in the country. This has included increased care and treatment programs, provision of Information-Education-Communication programs, encouraging parents and peers in reducing HIV stigma and discrimination, utilizing Non- Governmental Organisations’ support, and improving policy intervention on HIV stigma and discrimination reduction.

Keywords: Vietnam, HIV/AIDS, stigma and discrimination, OVC, effective interventions

Received January 01, 2013; Revised September 28, 2013; Accepted September 29, 2013

Citation: Thi Thu Nga Tran, Lillian Mwanri, Addressing Stigma and Discrimination in HIV/AIDS Affected Orphans and Vulnerable Children in Vietnam. World Journal of Preventive Medicine, 1 (3). 30-35. January 2013. doi:10.12691/jpm-1-3-4

1. Introduction

The Human Immunodeficiency Virus (HIV) and the subsequent Acquired Immunodeficiency Syndrome (AIDS), hereafter to be referred to collectively as HIV/AIDS, remains one of the most significant public health challenges in our lifetime, and certainly one of the biggest obstacles to socioeconomic development especially in developing countries [1]. All nations across the world, particularly, low- and middle-income countries are significantly affected by HIV/AIDS and Vietnam is no exception. The World Health Organisation (WHO) reports that HIV/AIDS is one of the world leading infectious killers, claiming more than 25 million lives over the past three decades [2]. Of the estimated 34.2 million people living with HIV/AIDS world-wide, 2.1 million are children (defined as boys and girls up to the age of 18 years), with 280.000 deaths reported per year [3,4,5,6]. It is well recognised that HIV/AIDS epidemic affects children in many ways including, making them orphans (defined as parental loss: lost mother, father or both parents dead), increasing their vulnerability (defined hereafter as children affected by HIV/AIDS) and threatening their survival [5]. It is predicted that even if a leveling off of new infections occurred, due to the long incubation period of the virus, mortality rates will not plateau until at least 2020, and the proportion of orphans will remain strikingly high at least through to 2030 [2].

Disease stigma occurs when individuals or population groups are blamed for their illness because they are viewed as immoral, unclean, and/or lazy [7,8]. Furthermore, it has been acknowledged that throughout history, stigma has imposed suffering on groups vulnerable to diseases and impaired efforts to thwart the progression of those diseases [9]. It is well acknowledged that stigma and discrimination contribute to increased HIV/AIDS epidemic [10,11].

Compared to adults, children and adolescents affected by HIV/AIDS are disproportionally impacted by the HIV/AIDS epidemic and associated stigma and discrimination [12]. In HIV/AIDS, the detrimental role of stigma has become so clear that national and international health agendas explicitly identify stigma and discrimination as one for the major reasons limiting the access, care and treatment services, and is considered an overall major barrier to effective responses to the HIV/AIDS pandemic [13,14,15]. Children are particularly more vulnerable to stigma than adults, and are at a heightened vulnerability to discrimination because they are often not in control of their circumstances; and often do not know and/or are less likely to assert their rights [16]. Moreover, stigma can affect children in multiple ways when it leads to active discrimination. For example, a study of the Institute for Social Development Studies showed that children living with, and/or affected by HIV/AIDS in Vietnam can be refused entry to schools and/or are often isolated as school friends dissociate with them [10]. The affected children are also ridiculed, attacked and beaten by their peers [10]. It has also been reported that HIV/AIDS affected children find it difficult to access care and support due to negative attitudes by health care providers and other service and support workers [17]. Additionally, it has been noted that stigma can affect children indirectly when caregivers (e.g. parents) suffer from the effects of stigma and discrimination; or when children and/or parents take certain course of action like withdrawal to avoid expected stigma and discrimination [15,17]. UNICEF identifies tackling stigma and discrimination as one of five key imperatives for success of HIV/AIDS programs [18]. Addressing the needs of children affected by HIV/AIDS is particularly important in developing countries, not only because of the high proportion of young people infected by HIV/AIDS in these societies, but because young people are at a heightened risk of contracting HIV/AIDS as well [19].

1.1. Vietnam and HIV/AIDS Scourge

Located in Southeastern Asia, the Socialist Republic of Vietnam, commonly known as Vietnam, has a population of about 90.5 million people with more than two-thirds aged between 15-64 years [15]. Hanoi, the Capital city is located in the north of the country. Other major cities include Ho Chi Minh City and Can Tho in the South, Hai Phong in the North, and Da Nang in the Center. Vietnamese is the official language and English is increasingly referred to as the second language [20]. When the HIV/AIDS epidemic started in Vietnam in the mid- 1990s, it was concentrated among “adult males” and injecting drug users in Ho Chi Minh City. Today however, the epidemic has entered the sex industry, and has spread into what is often misleadingly known as ‘the general population’. The proportion of teenagers (10 to 14 years olds) living with HIV/AIDS is also increasing [21,22]. The Vietnam Administration of HIV/AIDS Control Program estimates inform that 9,800 children live with HIV/AIDS, and up to 457,700 children are affected by HIV/AIDS, including being orphans and others made vulnerable because of HIV/AIDS in the family [22]. A major assessment conducted by the Ministry of Labor, Invalids and Social Action (MOLISA) and UNICEF in 2005, reported that children who are affected by HIV/AIDS faced several problems including shortage of food and nutrition support, lacked shelter, had insufficient protection, had poor healthcare, suffered psychosocial problems, and had less access to education and vocational training compared to children who were not affected [22]. The same assessment affirmed that stigma and discrimination was one of the main causes that led to increase of HIV/AIDS epidemic in Vietnam. From May 2009, The Vietnam Government started the national plan of actions to a strategic HIV/AIDS response for the orphans and vulnerable children affected by HIV/AIDS [15,23]. Additionally, non-governmental and community-based organizations increasingly supported and offered a range of services to children affected by HIV/AIDS with the purpose of integrating orphans and other children affected by HIV/AIDS into mainstream society and to help them lead healthy lifestyle [15,23].

The aim of this paper is to review the literature and describe interventions aimed to decrease HIV/AIDS stigma and discrimination in Orphans and Vulnerable Children (OVC). The focus is to identify aspects of these interventions that are effective in Vietnam.

2. Methods

A systematic search of English literature was conducted to identify the current knowledge about the impact of social and peers support in reducing and addressing stigma and discrimination to Orphans and Vulnerable Children (OVC) in Vietnam [24]. Databases including PubMed, Scopus, ProQuest, Google Scholar and WHO (Statistical Information System) were searched. Hand searches were also conducted to identify gray literature including publications and reports from the Government and Non-Government Organisations (NGOs).

Inclusion criteria included publications during the period of 7 years from 2005 to 2012 to align with the time that the first national plan of action for Orphans and Vulnerable Children was launched in Vietnam [15]. The following search terms were used in combination and/or singly: HIV, AIDS, NGO(s), Orphan, social, support, peer, stigma, discrimination; children or vulnerable children, programs of care, treatment, policy, developing countries and Vietnam. References cited in relevant publications were also reviewed and used as appropriate.

Because of the methodological complexity and limited numbers of articles providing high level of evidence, a narrative as opposed to a systematic review was conducted. A contentanalysis of publications wasundertaken to identify emerging themes [25]. Emerging themes were identifedthrough recurrence or grouping of words in literature and byusing our own experiences and knowledge of public health related to this subject. Description of emerging themes isdetailed inthe results section below.

3. Results

Identified themes included: (i) impacts of care and treatment programs; (ii) impacts of Information-Education-Communication programs; (iii) roles of parents and peers in reducing HIV/AIDS stigma and discrimination; (iv) impacts of NGO’s support; (v) and impacts of policy interventions on HIV/AIDS stigma and discrimination reduction. Details of these are described below:

3.1. Care and Treatment Programs

Antiretroviral treatment rollout and prevention of mother-to-child transmission (MTCT) have direct benefits to children affected by HIV/AIDS. The antiretroviral (ARV) therapy significantly improves quality of life and enables people to live longer and healthier [4,15]. Ensuring that children and pregnant women have access to ARV therapy and other measures to prevent MTCT is one among important elements of many international initiatives. Evidence affirms that expanded access to ARV therapy would contribute to a reduction of HIV/AIDS stigma and its adverse consequences [3,26,27]. A study that examined the impact of treatment access on HIV/AIDS stigma in Botswana 3 years after the introduction of a national program of universal access to ARV therapy further supports ARV therapy access as one of necessary facets in reducing HIV/AIDS stigma. Results of this study suggest that effective HIV/AIDS treatment can transform a deadly and often invisible but blemishing disease into a manageable condition [28]. The accessibility to HIV/AIDS care and treatment changes public perception of the disease, normalises life with HIV/AIDS, and empowers people living with HIV/AIDS to take an active role in combating stigma and discrimination [28]. In Vietnam, care and treatment programs for HIV/AIDS affected OVC have been established since 2005 [10,15,29]. With the support from the Vietnamese government and Non-Governmental Organisations (NGOs), free medical care is provided to OVC in two public children hospitals in Ho Chi Minh City [10,29]. It has been suggested that the availability of low-cost or free antiretroviral medications, along with improved attitudes of health care providers, decrease discrimination against people living with HIV, especially Orphans and Vulnerable Children [29]. Furthermore, the advancement of ARV therapy has been noted to have extended life expectancy for children living with HIV and allowing them to attend school. The provision of care and treatment for patients affected with HIV/AIDS has also been described as crucial because it delays and prevents children from being orphans and improves parents’ capacity to care for their children [29]. Improved parents longevity keeps families together and the availability of supportive family environment reduces the effects of stigma to OVC from the surrounding communities.

3.2. Information-Education-Communication Programs

Information-Education-Communication (IEC) interventions have been identified as one of the most powerful instruments to impact on changes in knowledge, attitude, and practice among general population. For example, Bertrand conducted a review of the effectiveness of mass communication programs to change HIV/AIDS and related behaviors in developing countries and reported positive impact on knowledge of HIV/AIDS transmission and also on the reduction of risk behaviours [30]. Education campaigns through provision of factual information about children who suffer from HIV/AIDS have been reported to be an effective strategy underpinning IEC interventions [30]. Such campaigns include radio and television broadcasting targeting broad audiences. Media such as posters, pamphlets, dramas are also effective and could be aimed at local and for specific population groups [30]. Additionally, it has been stipulated that increasing children’s knowledge and dispelling myths about HIV/AIDS may reduce stigma and discrimination caused by inappropriate fear of transmission [31]. A study examining children's attitudes towards HIV/AIDS in Thailand showed that children's attitudes had become more supportive of their HIV/AIDS affected peers after HIV/AIDS prevention education was introduced in schools [32]. These findings suggest that HIV prevention education particularly delivered through schools can be effective in fostering a supportive environment resulting in the reduction of stigma and discrimination against HIV/AIDS affected individuals. In addition to work-shopping public health information in specific groups for children, Ogden and Nyblade recommended that knowledge–based interventions including mass-media, comic books and computer-based applications could be attractive and appropriate for children and youths in reducing stigma and discrimination impacting OVC affected by HIV/AIDS [33].

Local studies in Vietnam have demonstrated fear of HIV/AIDS infection and misperceptions about its transmission to be root causes of stigma and discrimination [34,35]. Fear of HIV/AIDS infection leads people to avoiding contact with infected persons. Additionally, poor knowledge about HIV/AIDS transmission may cause people to overestimate the risk of acquiring HIV/AIDS infection because of myths including that HIV/AIDS acquisition could be through casual contact such as hugging, feeding and bathing an OVC [35]. By focusing on changes in knowledge, attitude, and practices and encouraging compassion for OVC affected by HIV/AIDS among general population, IEC programs have been reported to have reduced stigma [15,23].

3.3. The Role of Parent and Peers in HIV/AIDS Stigma and Discrimination Reduction

Parents are known to provide care and protection against stigma and discrimination for their children [19]. It is also well acknowledged that the family is the primary focal point for socialization and stigma reduction in children. In the absence of the family support, society and the state have to undertake a certain responsibility to provide care and protection to orphans [19]. International evidence supports and acknowledges the role of families, communities and social networks in curbing social and health inequalities across the world, and should not be exceptional for children affected by HIV/AIDS in Vietnam [15,36,37,38,39]. A study of Home Based Care (HBC) services in Phnom Penh, Cambodia reported HBC services as effective in reducing stigma and discrimination through the provision of HIV/AIDS education to family members, neighbours and the general community [40]. Through HBC services, HBC staff do home visits and educate the community through undertaking daily life activities including eating, drinking, talking with OVC affected by HIV/AIDS [40]. Although there was no Vietnamese specific study found to support this assertion, other assessments in Vietnam have reported the support of families and social groups as the first line of response to HIV/AIDS stigma reduction [41]. Informal self-support groups of people living with HIV/AIDS in Ho Chi Minh City such as “Friends Helping Friends clubs” have been documented and are reported to provide effective social and psychological support [42]. It has also been noted that, although informally operated, support groups can promote community awareness of HIV/AIDS with positive effects in reducing stigma and discrimination for HIV/AIDS affected OVC [42]. Moreover, the United Nations Children's Fund (UNICEF) recognises that schools play an important role of providing protection and support against stigma and discrimination for children affected by HIV/AIDS because the school environment is one of the most important communities they belong to apart from their families [42]. Safe and inclusive school environment informally provides OVC with psychosocial support from peers and teachers [42].

3.4. Non-Governmental Organisations

NGOs are not only strongly positioned to provide support but also have significant influence on reducing HIV/AIDS stigma and discrimination [43]. NGOs play vital roles in developing and promoting strategic partnerships to care for HIV/AIDS affected children. In many developing countries where the prevalence of HIV/AIDS is high and a significant fiscal stress exists, NGOs support a wide range of HIV/AIDS programs [44]. Financial resources to assist HIV/AIDS affected OVC from a wide range of NGOs have significantly increased during the past decades. These resources support both OVC and their families in various ways in many developing countries. Vietnam has a relatively large number of NGOs including, UNAIDS, UNICEF, Family Health International, Global Fund, World Vision and Pact that target HIV/AIDS affected children [3,29,41,44]. In 2006, UNICEF Innocenti Research Centre enlisted NGOs’ activities and initiatives that collaborated with community leaders, government partners to promote policies, enact appropriate legislation, and release resources to overcome the challenges in fighting HIV/AIDS epidemic [43]. It has also been stated that to avoid stigmatisation and discrimination of HIV/AIDS affected OVC, NGOs must work to advocate for the development of child focused policies, mobilise the media to advocate for a responsible attitude and solicit appropriate actions by national governments [44]. Although no studies of effects of NGOs on reducing OVC stigma and discrimination have been performed in Vietnam, the contribution of NGOs in combating HIV/AIDS is well acknowledged [41].

3.5. Policy Interventions

There is paucity of published studies on policy interventions and programs designed to reduce HIV/AIDS stigma and discrimination. Despite this shortcoming, a few available interventions and programs have been evaluated and an overview of HIV/AIDS stigma reduction strategies summarised. For example, the report of Grainger and colleagues about rights and responses noted that in many developing countries, law and policies directly contribute to pre-existing stigma and discrimination associated with at risk groups including HIV/AIDS affected OVC [44]. It has been noted that Policy interventions provide a legal framework to respect, protect and fulfill the rights of children. For example, a national policy can mandate appropriate responses to the needs of vulnerable children at all levels from the local to the national levels [15]. A study about HIV/AIDS stigma and discrimination towards HIV/AIDS affected children in public schools in Kenya showed that the lack of empowering policy and inadequate resources led to limited support for HIV/AIDS affected OVC [11]. Furthermore, the same study demonstrated that stigma and discrimination were poorly addressed in Kenya leading to a number of negative effects including isolation of OVC [11]. In Vietnam however, although there is no study that investigated the effectiveness of policy interventions on HIV/AIDS stigma and discrimination reduction, certain rights of OVC are now protected by Vietnamese law. For example, Vietnamese’ education policy mandates the right to education and protection from all forms of discrimination to all children including HIV/AIDS affected OVC [21]. Additionally, HIV/AIDS affected OVC are given priority to the free access of ARV therapy. Moreover, they are adopted and provided with government sponsorship if parents have died of HIV/AIDS. Addressing HIV/AIDS through legislation of Laws has increased the willingness of health care workers particularly dentists to provide care for OVC and indirectly contribute to decreased stigma and discrimination towards HIV/AIDS affected OVC [15].

4. Discussion

There is a clear recognition of the historical and critical obstacles created by disease stigma, for which HIV/AIDS is not exceptional. For example, Bayer noted that in the closing decades of the 20th century a broadly shared view took hold that the stigmatisation of those who were already vulnerable provided the context within which diseases spread, exacerbating morbidity and mortality [9]. In this view, it was the responsibility of public health officials to counteract stigma if they were to fulfill their mission to protect communal health [9]. In the 19th century America, Irish immigrants were commonly believed to be responsible for epidemic of disease because they were “filthy and unmindful of public hygiene”. As large numbers of Irish born immigrants died of cholera and other diseases, many viewed their deaths as acts of retribution upon the “sinful and unworthy” [7]. When African Americans were dying from tuberculosis in the 20th century, rather than investing in prevention or treatment of tuberculosis, many cities’ authorities issued warnings to their white citizens against mingling with or hiring African Americans [7]. Even the stigmatisation of injection drug users and individuals with gonorrhoea has been denounced as a barrier to testing and treatment [8], and the situations are not dissimilar in HIV/AIDS pandemic to date.

The impact of HIV/AIDS on Vietnamese children and adolescents, and the need to prevent stigma and discrimination cannot be understated. It has to be recognised that each intervention alone cannot fully contribute to tackling HIV/AIDS scourge and to reduce stigma and discrimination [4,8]. Moreover, public health interventions identified in this review including care treatment programs; Information-Education-Communication; parent and peers, NGO’s support; and policy intervention on HIV/AIDS as a means to address this problem are incomplete. A focus on broader approach including poverty reduction as a fundamental risk factor of HIV/AIDS is required [22,35]. Similar to other significant socio-cultural issues, HIV/AIDS must be addressed holistically; from prevention to treatment, through to education about the disease and the creation of socioeconomic and development opportunities in order to eliminate risk tolerance [36,37,38].

While interventions identified in this paper have their place in reducing HIV/AIDS stigma, relying on public initiatives solely to address it is insufficient. Efforts are also required to uplift the children and young people and their significant others who are socially and economically vulnerable because these vulnerabilities are intrinsically linked to susceptibility of HIV/AIDS and associated stigma and discrimination [36,37,38]. Such up-liftment can be achieved through a wide range of strategies including international development initiatives such as Poverty Reduction Strategy papers (PRSPs) [5]. Although these are frequently set within a debt relief context and associated with the highly indebted poor countries (HIPC) initiative, focusing efforts on reducing poverty, improving human capabilities, survival, and social well-being; and containing extreme vulnerability among the poor [5] is necessary. So far, OVC, as one of the most significant consequences of the HIV/AIDS pandemic, have not been explicitly recognized in Poverty Reduction Strategy papers, a situation that is widely regarded as a lost opportunity [5,6].

While international development is often perceived as a top-down approach to progression, for the success and sustainability of such initiatives, it is imperative that input from the community is also desired from the designing to the implementation of programs. Through determining a community’s own perceptions of the HIV/AIDS problem, meaningful solutions can be achieved. In addition, by examining more closely the communities that are most vulnerable to HIV/AIDS, other risk behaviours may emerge, alongside the values which can best be appealed to address HIV/AIDS in Vietnam. By working with communities, a sense of ownership is impacted, not just in terms of the problem, but in empowering them and finding solutions [37]. International development efforts – whether governmental, multilateral or guided by non-government organisations as observed in this review, can then facilitate initiatives that are informed by, and perceived through a local lens. [5,6]. This interaction can also be used to plan and execute effective public health programs that can be identified by the targeted group. For example, social support to include many components from individuals, organizations and governments can be used to strengthen support systems for HIV/AIDS affected OVC [37]. Key strategies such as strengthening the capacity of families to protect and care for OVC by prolonging the lives of parents and providing means of economy, enhance the capacity of families and communities to respond to the psychosocial needs of orphans and vulnerable children are necessary. Additionally, supporting services including education, health care, and other services; ensuring that governments protect the most OVC through improved policy, legislation and by channeling resources to families and communities; raising awareness at all levels through advocacy and social mobilization to creative a supportive environment for HIV/AIDS affected children and families are not only equity issues but also human rights issues [39]. Involving young people as part of the solution and strengthening partnerships at all levels and among key stakeholders is also necessary in combating stigma and discrimination.

5. Conclusion

Policy-makers and civil societies can also be the focus to encourage community preparedness and social mobilization as well as engage relevant legal and public service organisations to minimise unintended consequences of stigma and discrimination for OVC affected by HIV/AIDS. Additionally, provider-initiated programs also address the problem of stigmatising attitudes of healthcare providers. It is necessary for program implementers to institute specific stigma and discrimination reduction interventions for healthcare providers and ensures consistent monitoring and evaluation of these programs. Although this review provide significant overview of interventions applicable to Vietnam and other similar settings, further research on impact of policy as well as NGOs interventions in reducing stigma and discrimination for OVC is needed. Further research will positively support Minister of Health and health policy makers to establish and enhance national strategies of action in fighting HIV/AIDS epidemic specifically for Vietnam.

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