Transmission

Document Sample
Transmission Powered By Docstoc
					                TO LOVE IS TO TRUST




 Seafarers, their
 Sex Partners and
   HIV/AIDS/STDs


    An analysis of HIV/AIDS/STDs
             knowledge,
attitudes and practices of seafarers
       and their sex partners
   in Kien Giang province,Vietnam




           CARE in Vietnam

              May 2002
                                       1
                                                 Acknowledgements

CARE Vietnam has worked with the seafaring community in Kien Giang province since 1999 and has
enjoyed a close and productive relationship with many people who have been involved in this project. Most
importantly, special thanks to the seafarers and their sex partners who participated in this research and the
project activities. The experiences and contributions they have shared have been invaluable.

This project entitled ‘AIDS Prevention for Seafarers and their sexual Partners in Kien Giang’ was
implemented by CARE in Vietnam and would not be possible without the financial support from the World
AIDS Foundation through CARE France. CARE Vietnam is grateful for the support, flexibility and
understanding during the project implementation period from both these organisations.

The local partners have been extremely co-operative and supportive throughout the project. CARE
Vietnam staff have developed a close relationship with the partners and greatly appreciate the support,
dedication and commitment in the field. Thankyou to the Kien Giang Department of Health, Kien Giang
Provincial AIDS Committee, the Preventative Health Unit of Phu Quoc Island, the Department of Fisheries
and the Kien Giang Provincial Women’s Union and the Phu Quoc District Women’s Union.

Thanks also to the evaluation team headed by Mr Pham Gia Tran from the University of Social Sciences
and Humanities for their work on the final evaluation. Thanks to all those who attended the final workshop
and contributed valuable feedback, ideas and opinions.

And finally the hard work of the CARE Vietnam project team must be acknowledged. Ms Nguyen Nguyen
Nhu Trang, Mr Bui Kim Huu, Dr Nguyen Anh Thuan and Ms Nicole Simons have all been dedicated to the
project and the production of this report. Thanks also to the whole CARE Vietnam team who have
supported this project and the production of this report. This report was written by Nicole Simons.


The Project Team




                                                                                                           2
                                                  TABLE OF CONTENTS
Acknowledgements .....................................................................................................................................2
Executive Summary .....................................................................................................................................5
Introduction ..................................................................................................................................................7
Methodology ...............................................................................................................................................10
Approach ....................................................................................................................................................10
KAP Survey..................................................................................................................................................10
In-Depth Interviews ......................................................................................................................................10
Focus Group Discussions ............................................................................................................................10
Observation/Site Visits .................................................................................................................................10
Sample ........................................................................................................................................................10
Baseline Survey ...........................................................................................................................................11
Evaluation survey .........................................................................................................................................11
Comparison of Samples ...............................................................................................................................11
Analysis ......................................................................................................................................................12
Limitations of the Study ................................................................................................................................12
Findings ......................................................................................................................................................13
Seafarers and Sex Workers .......................................................................................................................13
Transmission..............................................................................................................................................14
Knowledge of Transmission Methods ..........................................................................................................14
Sexual Transmission ....................................................................................................................................15
Blood Transmission......................................................................................................................................16
Maternal Transmission .................................................................................................................................17
Misconceptions ............................................................................................................................................17
Risk of Transmission ....................................................................................................................................18
Prevention ..................................................................................................................................................19
Changing Men’s Behaviour ..........................................................................................................................19
Condoms......................................................................................................................................................20
Men’s Dislike ................................................................................................................................................21
Purchasing ................................................................................................................................................22
Alcohol        ................................................................................................................................................23
Decision-Making ..........................................................................................................................................23
Lack of trust ................................................................................................................................................25
Gender Roles ...............................................................................................................................................26
Misconceptions ............................................................................................................................................27
UD             ................................................................................................................................................27
Washing        ................................................................................................................................................27
Antibiotics ................................................................................................................................................27
Manicure       ................................................................................................................................................28
Condoms ................................................................................................................................................28
                                                                                                                                                               3
Symptoms...................................................................................................................................................28
STDs            ................................................................................................................................................28
AIDS            ................................................................................................................................................29
Treatment....................................................................................................................................................30
Misconceptions ............................................................................................................................................32
Treatment Sources.......................................................................................................................................33
Stigma .........................................................................................................................................................36
Shame..........................................................................................................................................................36
Discrimination ..............................................................................................................................................37
Discussion ..................................................................................................................................................40
Partners .......................................................................................................................................................40
Sex Workers ................................................................................................................................................41
Community ...................................................................................................................................................42
Conclusion .................................................................................................................................................44
Recommendations .....................................................................................................................................45




                                                                                                                                                                4
                                                Executive Summary

This report explores the knowledge, attitudes and behaviours relating to HIV/AIDS of seafarers and their
sexual partners in Kien Giang province, Vietnam. The research was part of the ‘AIDS Prevention for
Seafarers and their Sex Partners in Kien Giang’ project which aims to lower the risk of HIV infection among
seafarers and their sex partners.

The report combines the baseline study, which was used to identify the issues that needed addressing, and
the evaluation study, which was done after the intervention to measure the success of these strategies.

Quantitative and qualitative methodologies were utilised. The baseline involved a KAP survey, focus group
discussions and in-depth interviews with seafarers, their partners and health service providers. For this
report, only data from seafarers and their sex partners was used which included the KAP survey and in-
depth interviews.

The findings suggest that the seafaring lifestyle determines conceptions of sexuality among seafarers.
Seafarers having contact with sex workers or irregular partners was considered a natural part of the
occupation and condom use with sex workers was not consistent.

Seafarers, in particular, and their partners’ knowledge of transmission was unclear. Lack of understanding
led to frequent misconceptions concerning transmission methods. Although this improved substantially
after training, there was still a tendency to define methods of transmission as behaviours, indicating a
misunderstanding of actual methods of transmission.

The seafarers’ wives relied on their husbands for protection but in fact their husbands were their greatest
risk. Seafarers’ lack of condom use coupled with the wives’ lack of power to influence their husband’s
behaviour or to refuse sexual intercourse, left them feeling helpless and their only resort was to ‘trust’ their
husband. With an increased understanding of transmission methods and the risk of HIV/AIDS, women
became more vigilant in prevention methods and the first step was to accept their husband’s extra-marital
affairs and to remove the idea that ‘trust’ must come at the expense of prevention.

Men better understood symptoms of STDs than women, creating issues for women who (because they
trusted their husbands) were unexpectedly infected with STDs. The symptoms of AIDS were not fully
understood in either the baseline or the evaluation and were overshadowed by the focus on the lack of a
cure for AIDS.

Treatment for venereal diseases required a high level of confidentiality to avoid the stigma. For this reason,
private doctors were preferred over public hospitals. However, due to the expense, pharmacies became
popular by providing confidentiality and reasonable prices. The popularity of pharmacies has resulted in
self-diagnosis thus curtailing proper medical treatment. Expense and confidentiality remain impediments to
treatment at health centres, despite recognition of quality treatment at the centres during the evaluation.

Although the study found changes in attitudes and knowledge as a result of the intervention strategies,
whether these develop into sustained practices is unknown. This report proposes recommendations, which
could increase the impact of the project and encourage safer sex and lower the transmission of HIV/AIDS
within the Kien Giang fishing community.




                                                                                                              5
                         List of Acronyms

AIDS      Acquired Immune Deficiency Syndrome

FGDs      Focus Group Discussions

GDP       Gross Domestic Product

HIV       Human Immuno-Deficiency Virus

IDIs      In-Depth Interviews

IEC       Information, Education and Communication

IUD       Intrauterine Device

KAP       Knowledge, Attitudes and Practices

NUD*IST   Non numerical Unstructured Data Indexing, Searching and Theorising

PLWAs     People Living With AIDS

SPSS      Statistical Package for the Social Sciences

STDs      Sexually Transmitted Diseases




                                                                               6
                                                                        Introduction

The research presented here was collected in 2001 as part of the ‘AIDS Prevention for Seafarers and their
Sex Partners in Kien Giang’ project by CARE in Vietnam in collaboration with the Kien Giang Provincial
AIDS Committee and funded by the World AIDS Foundation through CARE France. The project aims to
lower the risk of STD/HIV/AIDS infection amongst seafarers and their sexual partners in the target areas in
Kien Giang province through:
         increasing knowledge of health and HIV/AIDS
         promoting safer sex practices
         encouraging STD treatment seeking behaviours
         improving the quality of health facilities
         increasing the capacity of local partners in AIDS prevention

This research report incorporates two stages of the project, the baseline survey and the evaluation survey.
The baseline survey was designed to identify the knowledge, attitudes and practices relating to
STDs/HIV/AIDS amongst seafarers and their partners. The information gathered was used for the
development of messages, materials and strategies to facilitate the implementation of IEC activities. A
main component of this intervention was training sessions for seafarers and their partners, which involved
knowledge of HIV/AIDS/STDs transmission, symptoms, treatment and a focus on prevention methods. The
evaluation survey aimed to capture the changes in knowledge, attitudes and behaviours, if any, that
resulted from the intervention strategies.

Why Seafaring Communities Are Vulnerable

Research on fishing communities throughout Asia has highlighted the vulnerabilities of the seafaring
lifestyle. Seafaring is not just an occupation but a lifestyle. In most cases, men are the fishermen, the
women are involved in other aspects of fishing such as mending nets, selling fish, or indirectly through
industry related businesses. This participation of kin-based groups arranges social and cultural bases
around the fishing industry enhancing the importance of fishing in daily life.

Economic dependence on fishing creates vulnerabilities due to the seasonal nature of the industry. Fishing
communities often lack income diversity and diminishing fishing stocks can severely debilitate the whole
community. Geographically, coastal plains and isolated areas often limit the likelihood of successfully
managing alternative income generating activities. Fishing people usually have limited education levels
and skills, which further emphasises their reliance on fisheries.

Fishing technology has rapidly advanced creating pressures on small-scale fishers (Fabri, 1996).
Competition for limited, non-renewable resources has made it increasingly difficult for small-scale fishers to
survive. The advent of navigational equipment and fish finding technology has improved large scale fishing
operations to the detriment of those lacking the capital to invest in technology. Additionally, declining fish
populations are a cause for concern.

Seafaring is labour–intensive with relatively low and irregular incomes. Long periods at sea living in
confined areas with other men, lead to maximised rest and relaxation periods on land. Seafarers across
Southeast Asia enjoy drinking alcohol, gambling and having sex (Komonbut, 1995; Cambodia Seafarers
Research Team, 1998; CARE International Cambodia, 2000). In Vietnam drinking alcohol was seen as a
way to mollify homesickness (UNICEF, 1999). Seafarers’ indulgences can result in spending most of their
salary on entertainment. During research on Thai fishermen, the following phrase reflected this tendency;
Fishermen eat like pigs, sleep like dogs and entertain themselves like kings (Komonbut, 1995:15).
                                                                                                            7
This lifestyle increases seafarers’ vulnerability to health related problems such as alcoholism and venereal
diseases including HIV/AIDS. Seafarers’ risk to HIV/AIDS is largely through heterosexual contact as,
according to research by UNICEF (1999), seafarers are not more involved in drug use than other groups of
men in Vietnam. Entz et al, (2000) found that 15.5% of Thai, Burmese and Khmer fishermen in the Gulf of
Thailand and the Andaman Sea were HIV-1 positive. Although rates of infection for seafarers across
Vietnam are unknown, UNICEF (1999) research on seafarers in Vietnam found that levels of knowledge
concerning STDs/HIV/AIDS were superficial and were not effective in changing attitudes or practices.

Health is a concern for seafarers and their families. Seafaring is dependent on health and poor health
threatens the livelihood of the seafarers and their family. Seafarers are often the breadwinner within the
family. Their wives either provide a supplementary income or no income at all. This financial dependence
upon seafarers pressures seafarers to maintain job stability to continue to provide for the family.
Concomitantly, financial dependence dictates power relations within the husband-wife relationship.

External dangers of seafaring including storms and pirates were reported in Cambodia and Vietnam. The
Cambodia Seafarers Research Team (1998) found that few seafarers knew how to swim, further increasing
the risks during of storms or rough seas. The threat of pirates was a real risk for Cambodian and
Vietnamese seafarers. Cambodian seafarers reported being robbed at gunpoint for the fishing catch or
machinery such as the boat’s engine. According to the CARE International in Cambodia report (2000) these
attacks occurred fairly often. The Vietnam News (2001) also reported increasing piracy in the Gulf of
Thailand and the waters of Kien Giang province. The increasing violence of these attacks has culminated
in a captain being shot and killed. Seafarers in this area are fearful of being robbed or even killed by
pirates adding to the occupational dangers of the seafaring lifestyle.

Kien Giang Seafaring Community

Kien Giang province is located in the south west of Vietnam. Kien Giang borders Cambodia (54km) and
has 200km of coastline. The research was conducted in Rach Gia, the capital of Kien Giang, and Phu
Quoc Island, approximately 120km off the coast of Rach Gia. Fishing and sea products are the second
largest industry in this province, following rice production, and accounts for over 10% of the province’s
GDP.

It is estimated that 3.5% (54 000) of the population in Kien Giang are seafarers. This figure does not
account for those involved in sea products and those indirectly related to the industry. Officially there are
15 000 registered deep-sea fishing boats and numerous other small-scale fishing boats. Seafarers usually
spend between 15-20 days at sea per month and their average income is between 800 000-2 000 000 VND
(approximately US$50-$130) for this period.

The lifestyle of seafarers necessitates long periods away from home, a disposable income due to the
seasonal nature of the work, and mobility. These factors, in combination with notions of masculinity that are
promoted in a male dominated industry, encourage seafarers to visit sex workers or to have irregular
sexual partners. Sex workers come from Kien Giang and surrounding provinces, usually driven by financial
difficulties. Sex workers in Kien Giang province are often based in bia om bars1 or areas where men can
drink beer together and access sexual services. Sex workers are also based on the numerous islands off
the coast of Kien Giang province. Sex takes place in the bia om bars, hotels or in secluded areas, but not
on the boats as this is considered unlucky and thought to jinx the boat.

As Kien Giang shares a border with Cambodia, the risk of HIV infection amongst sex workers moving
between these areas is concerning. Cambodia is considered ‘a regional epicenter of the HIV epidemic in
Southeast Asia’ and it is estimated that 100 Cambodians contract HIV each day. Cambodia is estimated to
1
 ‘Om’ means hugging. Bia om bars are places where men go to drink beer and are served by waitresses who are
dressed and behave in sexually provocative ways and have some sexual contacts such as touching, hugging etc.
                                                                                                               8
have between 10 000 to 20 000 sex workers of which half are reported to be infected. Five thousand of these
sex workers are thought to be young Vietnamese girls (Son Thanh Nguyen, 2000). The HIV infection rate
among sex workers in provinces bordering Cambodia is significantly higher than other areas in Vietnam
(Chung A, 2000).

Mobility, coupled with multiple sexual partners, generates concern over the spread of STDs and HIV/AIDS.
In April 2002 the Kien Giang Provincial AIDS Committee reported 1239 cases of HIV infection within the
province and estimated that ten percent of these were seafarers. These estimates are clearly considered as
conservative and the infection levels are likely to be as much as ten times greater than the official estimates.

This research report examines the knowledge, attitudes and practices of seafarers and their sexual partners
(wives) prior to intervention and post intervention. Previous research which reported low knowledge and high
transmission rates generated the need for research into seafarers in Kien Giang province due to the
geographical proximity to the Cambodian border; the mobile nature of seafaring; and the incidence of HIV in
the area.




                                                                                                            9
                                                                     Methodology

Approach
The baseline and evaluation surveys were conducted 10 months apart – May 2001 and March 2002. The
study combined qualitative and quantitative research methodologies with observation and site visits to form
a comprehensive process of triangulation.

KAP Survey

The quantitative approach involved a knowledge, attitudes and practices (KAP) survey that collected
information regarding HIV/AIDS/STDs and demographic data. The baseline KAP survey was pre-tested
with male, middle aged motorcycle drivers in Ho Chi Minh City and after an extensive review process, was
pre-tested in Rach Gia with seafarers and their partners. The evaluation KAP survey also included
recommendations for training courses.

In-Depth Interviews

The in-depth interviews for the baseline and the evaluation explored HIV/AIDS/STDs transmission,
symptoms, treatment and prevention, including condom use. Additionally, women were asked about safer
sex negotiations with their partners whilst men were asked about sexual relations with irregular partners.
In-depth interviews for STD service providers inquired about the type of clients that seek STD treatment,
the difference between male and female clients’ attitude to treatment, the type of people who buy condoms
and ideas for future HIV/AIDS/STD intervention.

Focus Group Discussions

The focus group discussions questioned the women about their husband’s lifestyle, their husband’s
relations with irregular partners and condom negotiation. The men’s focus group discussions centred on
the seafaring lifestyle, condom use, relations with irregular partners and the perceived level of
HIV/AIDS/STDs risk. Focus group discussions were used only in the baseline survey, not the evaluation.

Observation/Site Visits

In addition to the more formal procedures of conducting in-depth interviews and group discussions, all team
members were also able to acquire information from more casual conversations with individuals in the
geographical areas of intervention or from daily direct observation from living in the area for a short time.

Sample
The baseline sample comprised a total of 201 seafarers, their partners and STD service providers whilst
the evaluation sample included 140 seafarers and their partners. All of the participants in the evaluation
had completed a communication training session on HIV/AIDS as part of the project’s intervention strategy.




                                                                                                          10
                             KAP Survey            FGDs             IDIs            Total
 Seafarers                      90                  15               5               110
 Partners                       60                  10               7                77
 Service Providers               0                  10               4                14
 Total                          150                 35               16              201

                            Table of the Sample Used in the Baseline Survey


                             KAP Survey             IDIs                    Total
Seafarers                        63                   8                       71
Partners                         62                   7                       69
Total                           125                  15                      140

                            Table of the Sample Used in the Evaluation Survey

The samples were selected using the snowball method. Local collaborators from the Women’s Union and
Red Cross introduced potential respondents from which the sample developed. The sampling procedure
did not distinguish between registered and non- registered respondents. As the sample is derived from a
given population, this convenient sampling procedure is appropriate.

Baseline Survey

A total of 90 seafarers and 62 of their partners were surveyed. Over 90% of both the men and women
were from Kien Giang. Most of the men were fishermen involved in offshore fishing and had worked in the
town for more than 6 years. Almost all of the men were involved in work related to the fishing industry
(77.8%). Although most of the partners work in town (87.1%), only half (52.5%) are involved in the fishing
industry. Fifty three percent of the partners had worked in the area for more than 10 years.

Three quarters (74.5%) of the men were older than 26 years old. The women were generally older than the
men with 90.3% older than 26 years old. The women’s education levels were slightly lower than the men’s
with most women having completed primary school and a smaller number having completed junior high
school. Most men and most women had completed primary school or junior high school. Only one woman
had completed senior high school compared to 12% of the men. Over half (64.4%) of the men and all of
the women were married.

Evaluation survey

The survey included 29 men and 30 women from Rach Gia and 34 men and 32 women from Phu Quoc.
The women were generally older than the men with an average age of 37 years old compared to 33 years
old. Education levels were fairly low with 77.2% of people completing either primary school or junior high
school. Women’s education levels were lower than men’s. Women had completed an average of 6.2 years
of schooling compared to 8.4 years by men. Most of the participants (84.2%) were married.

Comparison of Samples

A certain level of compatibility existed between the baseline sample and the evaluation sample. Although
the sample size was different and focus group discussions were not used in the evaluation, the samples
appeared to adequately represent the Kien Giang fishing community and appropriate for comparison.
Demographics of both samples illustrate similarities in age, education levels and marital status suggesting
a strong foundation on which to conduct a comparison analysis of the samples.

                                                                                                        11
Analysis
The KAP survey was analysed using SPSS statistical software. The IDIs and FGDs were transcribed and
translated into English. They were coded and analysed thematically, using NUD*IST software and through
a matrix system. This process of using dual methods allows for a more thorough analysis. The
combination of qualitative and quantitative data to support the research increases the reliability of the data.

Limitations of the Study

The translation of data is a limiting factor in this study. Misinterpretations and nuances of language can be
overlooked through the transcription procedure and again during translation. Efforts were made to
minimise misunderstandings and ensure accuracy in translation through employing professional translation
services and reviewing translated data.

Data from the baseline survey and the evaluation has been used to form a complete picture of the changes
resulting from the project. The use of these tools was problematic due to incompatibilities in design.
Differences in the focus of questions, at times made comparisons difficult. Furthermore sampling pre and
post training shows limitations in the sample size during the evaluation mainly due to the absence of focus
group discussions.




                                                                                                            12
                                                                                Findings

Seafarers and Sex Workers
Seafarers and sex workers represent two mobile populations that frequently interact. Seafarers travel to
different islands in the Gulf of Thailand and to Cambodia while the sex workers often move between
Cambodia and border provinces in Vietnam including Kien Giang and An Giang. The lifestyle of seafarers
seems to necessitate contact with sex workers and irregular partners.

           Most men have a great desire for sex. So if they are living far from home, they are
            highly improbable to resist the temptation of beautiful ladies. (Female, 26 years,
            Baseline Survey)

           Yes, it [infection] will happen sooner or later. I got married to a seafarer…Men, when
            living away from their wives, tend to fall into the hands of sex workers. (Female, Focus
            Group Discussion, Baseline Survey)

           Male seafarers are not exceptional. Such is the nature of seafarers that among ten of
            them travelling to the sea, nine often frequent prostitutes. (Female, Focus Group
            Discussion, Baseline Survey)

The seafarer’s need for sex is generally accepted as a necessary part of seafaring. Long periods away
from home and a belief that men have an urge for sex that is difficult to control, contributes to the men
blaming the sex workers for the transmission of diseases.

           Yes, if we have sexual intercourse with sex workers. They carry the virus and transmit
            to us. (Male, 25 years, Baseline Survey)

           …they [sex workers] organised ‘bia om’ bars and gave illicit services to male clients.
            When the seafarers earn some money, they tend to use theirs for drinking and visiting
            sex workers without thinking that they will be infected…Generally speaking there have
            been a lot of infection cases through this transmission route. (Male, Baseline Survey).

Although the men claim that sex workers are vectors of disease, condom use was very low and men’s
refusal to use condoms was a difficult issue for sex workers to negotiate. Of the men surveyed, 75.6%
believed that if they are paying for sex they should not have to consult with the sex worker on condom use
as condoms equate to diminished sensations. Sex workers recognised the need to avoid venereal
diseases, especially HIV/AIDS and advocated condom use. However, at times the need for money was
too great and sex workers were forced to relinquish condom use.

           Most of the cases, it is the women [sex workers] who ask their clients to put on
            condoms. Except for the rich clients, they have to work hard then they feel afraid of
            death. They bought condoms themselves and even insisted on using condoms. In the
            meanwhile, fishermen refused to use condoms, even when they were offered to use
            condoms free. They maintained they would rather die than use condoms. (Female,
            Condom Saleswoman, Baseline Survey)



                                                                                                       13
            Poor men often anchored their boats near the port there and went searching for sex
             workers…Most of them were very stingy. They did not want to rent rooms for sex,
             thinking that renting rooms, they had to wear condoms, that they would have to pay for
             three; girls, rooms and condom. They would rather have sex in the bushes without
             condoms …Urged by the money, even though being too cheap, the sex workers had to
             give their service to these poor clients (without condoms) at the cost of their life.
             (Female, Condom Saleswoman, Baseline Survey)

Men in the evaluation recognised the need to use condoms with sex workers. The perception that men
cannot control their sexual urges was a strong factor in justifying men’s need to visit sex workers, however
the need to protect from infection became a real concern among the men as knowledge of the effects of
infections increased. Prioritising protection as more important than sexual urges was clearly recognised
after the workshop.

            Yes we pay for this service but the disease is more dangerous than our need (Male, 38
             years, Evaluation Survey)

            I think I will go for the sex workers in case I can’t control [myself], but I will be careful. I
             will use condoms. (Male, 38 years, Evaluation Survey)

Perceptions of sex workers changed slightly during the intervention period. Although it was recognised that
sex workers are not entirely responsible for the spread of diseases, attitudes towards sex workers
demonstrated a lack of respect for these women. Their role was to fulfil men’s sexual needs and
conceptualisations of sex workers as anything but sex workers were non-existent.

Transmission
Initially, seafarers and their sex partners lacked a clear understanding of transmission methods. This lack
of knowledge and the resulting misconceptions shaped the attitudes and practices within the community.
After training it was apparent that seafarers and their partners had a more comprehensive understanding of
transmission but they still lacked clarity concerning very low risk transmission methods.

Knowledge of Transmission Methods

In the baseline survey blood and sexual routes were identified as the main means of transmission, although
often indirectly. Transmission methods were often identified through lifestyles or behaviours such as being
a drug addict or visiting sex workers and knowledge of exact means of transmission (through blood, body
fluids etc) was unclear.

            It is said that all people who live a debauched life, or who abuse intravenous drug
             injections or who frequent prostitutes, then they will be infected with AIDS. (Female, 37
             years, Baseline Survey)

            I cannot imagine how it can transmit. What I’ve heard from other people I just
             repeat.(Female, 37 years, Baseline Survey)

The evaluation found that knowledge of transmission methods had improved, however methods were still
defined according to behaviours. This definition is risky as those who do not consider themselves as
having a ‘debauched life’ but do visit sex workers occasionally may not consider themselves at risk of
HIV/AIDS.


                                                                                                          14
Sexual Transmission

There was a strong perception that sexual intercourse was the most likely means of transmission, as this
was the most prevalent form of transmission within the population (intravenous drug use was reportedly
low).

           HIV infection comes largely from sexual intercourse…while drug injection, blood
            transfusion or some other transmission routes occupy just a few cases (Male, Baseline
            Survey)

Transmission through sexual intercourse was a constant concern for the partners of seafarers. These
women identified their most likely source of transmission as their husbands.

           It is men who spread the infected disease to their wives and children….Men are the
            main source of transmission, not women who always stay at home. (Female, 38 years,
            Baseline Survey)

           For instance, someone whom my husband has sexual intercourse with is infected.
            Then he is accordingly infected through sexual contact with her. The infection was left
            unnoticed. Later he has sex with me and consequently transmits the illness to me.
            Altogether, we have three persons carrying the virus. (Female, 26 years, Baseline
            Survey)

           I often wonder whether my husband gets infected. Because every time he goes out to
            open sea he might then have the desire for sex. (Female, 33 years, Baseline Survey)

For many partners, their husbands determine their risk of transmission. This is widely accepted as the
most common form of transmission although some women ‘trust’ their husband and therefore do not see
themselves as part of this risk group.

           But what I am most concerned about is that my husband will go out with sex workers
            during the seafaring trips. And this has not happened. I trust him never to do so.
            (Female, 33 years, Baseline Survey)

           I don’t think I can become infected because my husband does not have any illicit
            relationships as others do. Therefore, I don’t think of the risk. (Female, 40 years,
            Baseline Survey)

Unfortunately, it seems that not all women can trust their husbands and they do become infected.

           Married women usually don’t know they get infected with social diseases. Just when
            they go to the doctor for an examination, they get to know that they become infected.
            Never in their life have they thought of themselves getting infected. (Phu Quoc General
            Hospital staff, Baseline Survey)

           Generally speaking, women don’t have any knowledge about that. Whenever they feel
            sore and painful, they go straight away to the private clinic. They undergo the
            treatment without knowing that they get infected from their husbands. Previously they
            simply think it is just a gynaecological disease in the uterus area. They don’t think they
            get gonorrhoea or syphilis virus from their husband. (Female, 38 years, Baseline
            Survey)

                                                                                                     15
The evaluation research showed that women still consider their husbands the most viable source of
transmission but there was a change in women’s attitudes concerning trusting their husbands. Women
expressed a lack of trust both directly and indirectly through insisting on condom use, even if she does trust
her husband. This change in attitude indicates a heightened sense of awareness of the seriousness of HIV
and recognition of prevention methods.

            No I don’t trust him. I cannot trust him because I know my words will go in one ear and come
             out the other. I just advise him again and again to remember to use condoms whenever he
             goes out. (Female, 28 years, Evaluation Survey)


            I insist on using condoms as he often goes out and I am suspicious of him (laugh). (Female 42
             years, Evaluation Survey)

Blood Transmission

There was an understanding of transmission through sharing injecting equipment with 78.9% of men and
91.9% of women reporting awareness of this transmission route. Whether all of these people clearly
understood that infected blood is the means of transmission is unknown.

            It means that drug addicts use the injection equipment for both the infected and the
             healthy. Then the contaminated blood from the infected will transmit to the healthy.
             (Female, 33 years, Baseline Survey)

Intravenous drug use was not a major concern to the participants as there was a low prevalence within the
community. Seafarers and their partners were able to identify other sources of blood based transmission
that were a potential risk, including blood transfusions and open wounds.


            HIV catches us through blood transfusion (Female, FGD, Baseline Survey)

            I live near the busy street. For instance one child or one woman or one man gets
             infected and they meet with an accident in front of my house. I rush out to help them
             without knowing that they are infected…Suppose my hands have a wound, what would
             happen then? I am also infected. (Female, 38 years, Baseline Survey)

After attending the workshop, participants were more likely to recognise blood transfusions as a means of
transmission. However, a strong association of ‘behaviour’ with ‘transmission’ resulted in drug use and
blood transfusion being considered separate means of transmission suggesting that blood, was not clearly
identified as the common transmission method in both drug use and blood transfusions.

            HIV/AIDS just transmits through blood transfusion, sexual contact and drug injection
             equipment. (Female, 28 years, Evaluation Survey)

            First via sex, then via drug injection, then via blood. (Female, 41 years, Evaluation
             Survey)

            It includes three ways: drug injection, having sex with sex workers and blood
             transfusion when we go to see the doctor. (Male, 26 years, Evaluation Survey)



                                                                                                           16
This suggests that the role of blood in sharing drug equipment was not clearly understood. Furthermore,
ideas about blood on clothes and manicure equipment also demonstrated a lack of understanding about
how HIV is transmitted through blood.

Maternal Transmission

Although some women acknowledged the transmission route from sex worker to husband, to wife and
children, maternal transmission was rarely mentioned. There was a perception that the husband can infect
the wife and children but the exact path of infection from father to child was not elaborated. Few women
spoke about the risks of maternal transmission and from these comments, it was clear that knowledge of
transmission from mother to child was limited.

           In my family, my children are too small to be involved in any sexual intercourse. Thus I don’t
            care about AIDS. (Female, Condom Saleswoman, Baseline Survey)

Post training analysis revealed improved knowledge about maternal transmission. It was often accurately
included in the three methods of transmission however exact means (such as embryonic fluids, breast-milk,
during labour and delivery) were rarely specified. Recognition of exact methods is paramount to prevent
infections spreading through maternal transmission.

           I said that after being drunk he might go to some brothels. He might forget to use
            condoms. He might infect me. And then I would make a maternal transmission. I
            convince him for the sake of my children. (Female, 23 years, Evaluation Survey)

           For example gonorrhoea does not transmit from mother to child but HIV is
            transmissible from mother to child. (Male, 23 years, Evaluation Survey)

Misconceptions

The participants also held misconceptions about disease transmission. After training these misconceptions
were less however there was still some confusion about means of transmission, especially with manicures.

Eating and Drinking
According to the preliminary survey data 38.9% of men and 22.6% of women believed that HIV could be
spread through eating and drinking utensils or were unsure.

           We should avoid drinking and eating together with them. They should eat at one
            separate place and the rest of the family to eat at another separate place from them. I
            still wonder whether or not the infection can go though bowls and chopsticks used by
            them or not. (Female, 37 years, Baseline Survey)

After the evaluation this misconception was substantially altered and only 1.9% of seafarers and 10% of
their partners believed that this was a method of transmission.

Beauty Treatment
HIV/AIDS cannot be transmitted through wearing make-up. The disease cannot survive for long (3
seconds) once exposed to air and needs to be transmitted through the direct blood stream, thus making it
virtually impossible to transmit through manicures.




                                                                                                       17
             …for instance manicure or facial treatment. But I am not concerned about these
              services. I do not often wear make-up then I don’t think I can be infected with such a
              disease. (Female, 37 years, Baseline Survey)

             For example, you have a trimmer. Using this trimmer, you give a manicure to the
              infected people. In this way, the trimmer gets contaminated. Not cleaning the trimmer
              with much care, you then start cutting your nails and unintentionally cut yourself. The
              infection occurs through the use of blood-contaminated instruments. That’s what I’ve
              heard, yet I don’t know whether it’s right or wrong. (Female, FGD, Baseline Survey)

Clothes
             The second case is that he should not wear the others’ [infected person’s] clothes. If
              they get scabies, they will spread to him. (Female 33 years, Baseline Survey)

             …but their [infected person’s] clothes should be left separately and should be washed
              in their own washtub. (Female 37 years, Baseline Survey)
Age
             It is said that old people won’t catch AIDS. (Female, Condom Saleswoman, Baseline
              Survey)

Risk of Transmission

Sex workers, seafarers and their partners were seen as the groups most vulnerable to HIV/AIDS infection.
Both the men and the women generally saw sex workers as the transmitters.

             If we have sexual intercourse with sex workers, they carry the virus and transmit to us.
              (Male, 25 years, Baseline survey)

             The group exposed to getting the virus the most is female sex workers. Our husbands
              travel far from us to work, then visit sex workers and become infected from them
              (Female, 50 years, Baseline Survey)

When asked to rank the most at risk group, both seafarers (51.1%) and their partners (54.1%) ranked sex
workers as the highest risk group. Interestingly, seafarers considered themselves as having less risk than
intravenous drug users whereas their partners saw them as the next high-risk group following sex workers.

                                                     Seafarers                          Partners
Sex Workers                                            51.1                               54.1
Seafarers                                               6.7                               34.4
Intravenous Drug Users                                  40                                11.5
Health Officials                                        1.1                                0
Other                                                   1.1                                0
Total                                                  100                                100

          Percentage of perceived level of HIV infection risk among seafarers and their partners.

Women were seen as vulnerable to infection even though they engaged in less frequent risky behaviours
than men. In the baseline survey 98.4% of the women compared to 65.5% of men recognised that women
are more susceptible to HIV infection than men. Furthermore, women’s lack of control over their husband’s
behaviours places them in a position where they are dependent upon their husband for safety. This
vulnerability is further exemplified by over 51.1% of men surveyed prior to the training stating that it would

                                                                                                           18
not be necessary to notify their partner if they had a STD, though an overwhelming majority of the women
(93.6%) felt that it was important to notify their partners.

            Generally speaking, women are most at risk of being infected [though] men have more
             chances to get infected. (Female, 38 years, Baseline Survey)

            I am so frightened at the thought that some day my husband will come home infected.
             About me, I am sure that I haven’t done anything to get infected. But I can not rely only
             on myself. (Female, 26 years, Baseline Survey)

The baseline survey found a large discrepancy between the seafarers and their partners’ attitudes towards
AIDS and foreigners. 78.9% of seafarers agreed that most people who get AIDS have spent time in a
foreign country, while the majority (61.3%) of their partners disagreed with this statement. This reveals that
the seafarers lack knowledge about their own level of risk as they have usually spent time overseas. The
recognition by the wives is indicative of the disparate levels of understanding between the seafarers and
their partners. After the evaluation, 11.3% of men and 15% of women still strongly associated HIV/AIDS
with being a foreigner’s disease.

Even though the women demonstrated more accurate knowledge transmission, prior to the training they
lacked the ability to adequately protect themselves from infection. An increase in assertiveness and
knowledge strengthened their prevention strategies as did increasing men’s knowledge of transmission in
order to stress the need for prevention.

Prevention
Initially the level of knowledge concerning HIV/AIDS prevention was low and the practice of prevention
techniques was alarming. Mostly women and some men reported that they had no knowledge of
prevention.

            Preventative method? I don’t know…(Male, 20 years, Baseline Survey)

            No I have not applied any [preventative] method. Today I come here with the hope
             that you will advise me how to do so. I just believe in myself, yet have no
             preventative method. (Female, 26 years, Baseline Survey)

            I have just got married, I haven’t had any experience about such matters. (Female,
             FGD, Baseline Survey)

Changing Men’s Behaviour

For many women there was a feeling that HIV infection could not be controlled as their biggest method of
prevention was to persuade their husbands not to visit sex workers. Women were helpless in controlling
their husband’s behaviours during seafaring trips and had to trust their husbands to practice safer sex.

            There are two ways of prevention: first we use condoms and second we advise our
             husbands not to frequent prostitutes. (Female, FGD, Baseline Survey)

            To use gentle words to persuade him not to do the same [visit sex workers] to prevent
             from being infected is the best way. (Female, 38 years, Baseline Survey)



                                                                                                           19
But others felt that their powers of persuasion were of no use and that they could not control their
husband’s behaviours. This feeling of powerlessness and lack of control was reflected in their inability to
protect their husbands and thus themselves from infection.

            Everything is predestined. If it [infection] is to happen, how can we prevent it? ”
            (Female, FGD, Baseline Survey)

           Only God can prevent him from visiting irregular partners”. (Female, FGD, Baseline
            Survey)

The evaluation study noted a change in women’s feelings of helplessness. Women came to accept their
husband’s extramarital affairs but in response became more vigilant about prevention as they recognised
this as their only form of control.

           She asked me if I had unsafe sex and I replied ‘No, not me’. She told me that she
            believed me but her motto is ‘care is better than cure’. She definitely has a good
            conception of prevention. (Male, Evaluation Survey)

Condoms

When talking about prevention in the baseline study, women were more likely to emphasise changing
men’s behaviours than using condoms. However, women did acknowledge the importance of condoms in
prevention.

           We might use condoms to make sure we will not contract such a virus.
            (Female, FGD, Baseline Survey)

           If we fear getting infected, we should use condoms. I don’t know any other
            method. (Female, FGD, Baseline Survey)

           If we wish to protect ourselves from contracting STDs, we should use condoms.
            (Female, FGD, Baseline Survey)

Despite this, condom use was alarmingly low.

The baseline survey data shows that 54.4% of men and 66.1% of women said they never practice vaginal
sex with a condom.

                                               Men                  Women
                       Never                   54.4%                66.1%
                       Sometimes               38%                  30.6%
                       Usually                 7.6%                 3.2%

        Table showing the percentage of men and women that Never, Sometimes and Usually use
        condoms in vaginal sex

           I have not yet used condoms so I don’t know anything about it. (Male, 38 years,
            Baseline Survey)

           No, I have never used condoms. (Female, FGD, Baseline Survey)


                                                                                                        20
After training the importance of condoms in prevention was highlighted by both men and women. There
was a greater recognition of condoms as the only reliable method of prevention against infection.

                        Previously when no promotion campaign has been conducted on condom use, I rarely
                         wear condoms. Later I heard a lot about opportunistic diseases resulting from sexual
                         intercourse without condoms, I become addicted to using condoms. (Female, 33 years,
                         Evaluation Survey)

                        In my opinion, if we cannot restrain we go to visit sex worker but we must be careful.
                         When having sex, remember to use condoms to prevent. (Male, 38 years, Evaluation
                         Survey)

All of the participants involved in extramarital relationships reported using condoms and there was a
substantial increase in condom use compared to pre-training (see Graph 1).


                             Seafarers and their partners' condom use during last sex, pre and post training

                                                                                       60
                                                57.5

                  60



                  50



                  40
    Percentage




                                                                                                               Prior to Training
                  30                                                                                           Post Training

                                     15.5                                  14.5
                  20



                  10



                     0
                                    Seafarers                              Partners




                Men’s Dislike

Men’s dislike of condoms was a major determinant in non-use. Half of the men surveyed expressed a
difference in feeling when using condoms and felt that condoms inhibited their ability to climax. Paying for
sex and using a condom, which reduces the sensation, seemed wasteful to many men, thus increasing the
difficulties for sex workers negotiating condom use.

                        Those who seldom use condoms are young men of 17-18 to 23-24 years old. They have
                         not yet got married, so they don’t use condoms, They thought that using condoms will
                         lose the feeling. (Male, Doctor, Baseline Survey)

                        My husband told me he lost his feeling when using condoms. He did not feel easy as
                         usual. (Female, Baseline Survey)

                        I find it easy [to use condoms] but my husband felt uneasy. He was rather annoyed
                         about it. (Female, 40 years, Baseline Survey)

                                                                                                                                   21
           During sex, I often imagine as if I was not wearing condoms so as to reach climax.
            (Male, 29 years, Baseline Survey)

The message that the consequences of not wearing a condom override the lack of feeling was strongly
reflected in the post-training evaluation, especially amongst the men. Using condoms was constructed into
a matter of survival and the diminished feeling was perceived as secondary to maintaining good health and
quality of life.

           Wearing condoms is uncomfortable but we have to accept because we do not know
            who the partner is and her status. With our own eyes we know nothing, we see
            nothing, so we must wear condoms. We have to be vigilant. If we want to survive we
            must accept this. (Male, 38 years, Evaluation Survey)

           Using condoms will [make us] lose our feelings but we never have to say ‘sorry’ later.
            (Male, 33 years, Evaluation Survey)

           It took 50% of the feeling away but we have to use condoms for safety. (Female, 23
            years, Evaluation Survey)

     Purchasing

Non-users dominated pre-training survey questions on condom access and affordability. Sixty six percent
of women and 35.6% of men were unsure of affordability as they never use condoms and 67.7% of women
and 33.3% of men reported that they never buy condoms so cannot comment on the most common source
of access. The shame associated with purchasing condoms contributes to non-use. About a quarter of the
women (24.2%) and men (25.6%) reported that buying condoms was embarrassing.

           Men always feel ashamed at buying condoms…Furthermore, men don’t buy condoms
            because they don’t request to use it. (Female, Condom Sales woman, Baseline Survey)

           No, most of the customers who come to buy condoms are indecent people. (Female,
            Condom Sales woman, Baseline Survey)

Although feelings of shame and embarrassment still existed after the workshop, there was a greater
acknowledgement that these feelings were unfounded and that safety was more important than public
opinion. The percentage of participants describing buying condoms as embarrassing dropped to 11.3% of
seafarers and 10% of their partners after training.

           Such is female psychology that women often feel ashamed when going out purchasing
            condoms. But to think it over, I don’t think we should take it as abnormal to buy
            condoms outside. (Female, 33 years, Evaluation Survey)

           It is said that you are unfaithful if you buy condoms so people get confused and
            hesitate to buy condoms. That’s really bad. It doesn’t make any sense at all. (Male, 38
            years, Evaluation Survey)

           No, I am not red when buying condoms. (Male, 23 years, Evaluation Survey)

Furthermore, purchasing condoms was justified in the evaluation through citing use for contraception
purposes. In this way it seemed that purchasing condoms was more legitimate as it situated condom use
within the husband and wife relationship. This removes speculation of extramarital affairs and is in
accordance with the government’s one-or-two child family planning policy.
                                                                                                      22
            We should not feel ashamed when buying condoms because condoms are not only
             used for HIV prevention but also pregnancy prevention. (Female, 33 years, Evaluation
             Survey)

            I don’t care what people think. I might buy the condoms for contraception. (Male, 38
             years, Evaluation Survey)

            When we go to buy condoms the seller wants to think something, it is their right. Many
             times we have the need to prevent pregnancy, who knows, who knows the truth? (Male,
             38 years, Evaluation Survey)

Of those people that did purchase condoms, the pharmacy was the most common outlet.

     Alcohol

Alcohol is an inherent part of seafarer identity. During recreation periods the seafarers visit bia om bars.
These establishments provide alcohol and sexual services. Many seafarers and their partners attributed
alcohol to men’s non-use of condoms as when they are drunk men seem to ‘forget’ to use condoms.
Drinking is a group activity and men pressure each other to drink copious amounts as proof of one’s
masculinity. Drinking often proceeds to visiting sex workers, spurred on by peer pressure and the desire to
demonstrate manliness.

            Ten men who have the habit of drinking are all the same. When they get dead drunk,
             everything escapes from their minds. When they encounter sex workers, they will get
             crazy then tease each other, then have sex with them to satisfy their desire. (Female, 37
             years, Baseline Survey)

            Generally speaking, seafarers always remind each other to use condoms when having
             sex with irregular partners. Most of the infected cases happen when seafarers get
             drunk out of their wits. They become too drunk to remember the use of condoms.
             (Male, Baseline Survey)

            When they are bloody drunk they forget to wear condoms and after having sex they get
             syphilis and gonorrhoea. (Male, 26 years, Evaluation Survey)

            I think it’s true when a man said he forgot to use a condom because of being drunk.
             (Female, 26 years, Evaluation Survey)

     Decision-Making

Men’s general reluctance to use condoms is apparent in condom negotiation within the husband-wife
relationship. Decision-making within the marital relationship lies with the men and therefore men have the
power to refuse to wear a condom in sexual relations with their wife, more so as condoms are a male form
of contraception/prevention.

            It’s me who makes the decision. I am putting condoms on. (Male, 38 years, Baseline
             Survey)

            The fact is that they [men] refuse to use condoms. I have talked to him about it but he
             refused. (Female, FGD, Baseline Survey)

                                                                                                         23
In the baseline survey 66.7% of seafarers reported that they decided on condom use during their last
sexual encounter whilst 85.7% of women reported that the couple made the decision together.

After the training, women seemed to have a stronger role in successfully negotiating condom use. The
following graph of pre and post training condom negotiation illustrates changes towards more open
communication between the husband and wife.


                                             Change in the percentage of seafarers and their partners
                                                   talking with their partners about condoms


                                      78.5                                     79

                 80


                 70


                 60


                 50                                                                                        Pre-Training
    Percentage




                 40                                                                                        Post-Training

                 30                                 20
                                                                                          11.8
                 20


                 10


                     0
                                    Seafarers                                Partners




 Women seemed to display more assertiveness and conviction in persuading their husbands to use
condoms fuelled by a greater understanding of the risks.

                        I will be very angry if she appears to not trust me. However if she forces me to wear
                         condoms what on earth can I do but follow her request. (Male, 33 years, Evaluation
                         Survey)
                        He refused at first but accepted later after finding out that I was right. (Female, 50 years,
                         Evaluation Survey)

However, husbands may not always accept this new-found assertiveness. Previously husbands simply
refused to use condoms and women were powerless to refuse sex without a condom. Power relations
within the marital relationship remained an issue, even for women who felt they could successfully
negotiate condom use. This was obvious through one woman’s comments about potential violence from
her husband.

                        I think I might ask him to use condoms again and again. If he beats me I will use a stick
                         to protect myself. (Female, 28 years, Evaluation Survey)

The evaluation also presented the issue of condom negotiation for men. Men who attended the training
experienced difficulties convincing their wives to use condoms. The women were reluctant to use condoms
as they suspected their husbands of being unfaithful and by not using condoms it is assumed that they can
maintain a level of ‘trust’ within the marital relationship. The disparity in knowledge, from one partner

                                                                                                                      24
attending training and the other not, created problems within the family and in one case it seems the
husband was unable to convince his wife and decided to relent in order to maintain family happiness.

            My wife didn’t want to but I do [want to use condoms]. She thought there was
             something wrong if I suggested using condoms and wondered why I didn’t ask to use
             them earlier. For example she would think I wasn’t faithful to her if I asked to use
             condoms all of a sudden… I asked to use condoms for contraception but she refused
             again saying she would take pills for contraception. So I decided to not use condoms
             to please her and keep peace in my family (Male, 38 years, Evaluation Survey)

            I reasoned with her, trying to win her sympathy that we should use condoms to protect
             ourselves because I don’t feel secure after having sex with another woman…I tried to
             convince my wife and she agrees at last. (Male, 33 years, Evaluation Survey)

     Lack of trust

Condoms are strongly associated with sex workers and promiscuous sexuality. There is a strong
perception that condoms should only be used with sex workers (who are seen as the transmitters) and
therefore are associated with unfaithfulness and immorality. Fifty percent of seafarers (and 38.7% of their
partners) agreed that it is only necessary to use a condom with sex workers. This posed difficulties in
condom negotiation between husbands and wives.

            Thus I negotiated with him to use condoms. He did not agree with me at first, saying
             that only those who have sex with female sex workers must wear condoms and that we
             husband and wife should not use it during sex. He really hates it. (Female, FGD,
             Baseline Survey)

            For instance, I ask him to wear condoms. He not only straightly refuses to wear
             [condoms] but also becomes nonsensically jealous, saying that I might have done
             something wrong –if not, why suddenly asking for using condoms. (Female, FGD,
             Baseline Survey)

            I told him to use condoms but he refused saying he was not involved in any illicit
             sexual intercourse. He even emphasised that using condoms will cause an
             inflammation in the woman’s uterus area. (Female, Baseline Survey)

Therefore condom use within the marital relationship is indicative of a lack of trust within the couple which
inhibits women from initiating discussions on condoms with their husbands.

            If I suspect him to do anything wrong, I will initiate a discussion on the use of
             condoms. But I have always trusted him, how can I talk with him about that. (Female,
             37 years, Baseline Survey)

            First of all, husbands and wives should trust each other. Those who have multiple
             relationships at the same time or have sex with sex workers fear getting infected. That
             is the reason they have to use condoms. We, my husband and myself, always trust
             each other. Therefore we will not use this method. (Female, 33 years, Baseline Survey)

            I think to love is to trust. Thus I haven’t mentioned anything in front of him. (Female,
             FDG, Baseline Survey)


                                                                                                          25
An emphasis on the husband and wife having a monogamous, faithful relationship was apparent in the
evaluation study. This was seen as the most effective way of preventing infection.

           If the husband and wife are faithful they cannot get infected. (Female, 41 years,
            Evaluation Study)

           There is no risk if we are faithful to the other spouse (Male, 38 years, Evaluation
            Survey)

However the issue of trust was not strongly associated with faithfulness thus suggesting that women still
didn’t trust their husbands. This was evidenced by the need for prevention techniques in addition to a
faithful relationship.

           Although my wife believes me [trusts he is faithful], we still feel the need for prevention.
            (Male, 38 years, Evaluation Survey)

     Gender Roles

Women’s lack of control over their husband’s behaviour, their reluctance to talk about condoms with their
husband and their husband’s refusal to wear condoms is further expounded by the women’s inability to
refuse sex, even though they suspect that they might be at risk of infection.

           Frankly, to be husband and wife I cannot refuse what he wants. (Female, FDG, Baseline
            Survey)

           No, I won’t. How can I refuse him because we are husband and wife. I will run the risk
            to attend to every desire, but deeply in my heart, I am so frightened, but I tell myself
            that nothing will happen. (Female, 26 years, Baseline Survey)

Only one woman expressed strong feelings of being upset with her husband’s unfaithfulness even though
93.5% of the women in the baseline survey felt that it is unacceptable for men to visit sex workers.

           The husband did not keep the faithfulness. Coming back, asking for sex. I don’t agree
            with him. (Female, FGD, Baseline Survey)

But for other women this was not a measure that they were confident in securing.

           I strongly disagree with having sex with him. Or at least I request him to use condoms
            before any sexual intercourse. (Female, 38 years, Baseline Survey)

Women in the evaluation experienced similar issues but their power to protect themselves (mainly through
using condoms) appeared to be greater.

           If he does not want to use it [condom], I will refuse to have sex with him. (Female, 41
            years, Evaluation Survey)

           I don’t think my husband will doubt me. I keep on convincing him [to use condoms].
            He will accept if he loves me. (Female, 23 years, Evaluation Survey)

There was a greater acceptance of men’s promiscuity and a focus on preventative measures. Women
accepted that they were unable to control men’s behaviours and that men were likely to have extramarital
sexual relations. Emphasis on prevention within the marital relationship and within extramarital
                                                                                                      26
relationships sought to protect all of those involved. Rather than attempting to change her husband’s
behaviour, one woman had even used her husband’s extramarital affairs to her ‘advantage’.

           If he keeps asking for sex, I have no choice but to give him money so that he can go out
            and find sex workers. But he certainly must use condoms. (Female, 28 years,
            Evaluation Survey)

Another woman bought condoms for her husband’s extramarital affairs for her own protection. In this way
the women were taking the initiative in prevention.

           When he makes long trip at sea, I buy condoms for him. I am afraid of the time he is
            very happy with wine and cannot master himself. (Female, 38 years, Evaluation Survey)

However, men expressed reliance on women to take responsibility for prevention. According to the men,
women (wives and other partners) were responsible for reminding men to use condoms. Men still
maintained power over women and used this to shirk their responsibility for condom use.

           For example, in my family I talked with my wife about the risks of infection. In addition I
            sometimes have extramarital relations. But if I forget it [condom], my wife reminds me
            or my sweetheart has the duty to remind me of this. It is almost the norm at the
            moment in the community. (Male, 42 years, Evaluation Survey)

           [When] men are drunk, women are responsible for reminding them [to use condoms].
            (Female, 41 years, Evaluation Survey)

           …the current situation in the islands is terrible and my wife has to remind me. Yes she
            gives me advice like that, for example if you have sex with someone you should use
            condoms. (Male, 26 years, Evaluation Survey)

Misconceptions

Misconceptions of prevention were apparent prior to training and largely stemmed from lack of knowledge
concerning transmission methods.

     IUD

Although 67.7% of women and 64.4% of seafarers know that oral contraceptives or the IUD do not protect
from HIV, there were still a substantial number of people who believed otherwise.

           I had used an IUD therefore I don’t think it necessary to use condoms (Female, 38
            years, Baseline Survey)

     Washing

The survey found that 71% of women and 64.4% of men knew that washing the genital area after sex was
not a preventative measure but it appears that washing before sex is a misconception.

           Whenever he came back asking for sex, I requested him to have a wash before any
            sexual intercourse (Female, 38 years, Baseline Survey)

     Antibiotics

                                                                                                    27
The myth that antibiotics prior to sex will protect from HIV infection was recognised as such by 53.2% of
women and 57.8% of men.

     Manicure

The risk of HIV/AIDS transmission via a manicure is extremely low and prevention methods as suggested
below indicate perceptions of inflated risk.

            As far as women are concerned, if we often have a manicure, we should then buy
             instruments for our own use. (Female, FGD, Baseline Survey

     Condoms

Ideas that condoms were detrimental to women’s health were often purported by husband’s as a strategy
towards non-use. However, women themselves also adopted these misconceptions.

            We women will lose weight when using condoms, won’t we? (Female, FGD, Baseline
             Survey)

The post-training misconceptions of prevention were limited. However, ethical issues concerning
prevention were raised as a result of increased knowledge about HIV/AIDS.

            It is advisable that mothers should not get pregnant if they are aware that they have got
             infected with HIV. If such a matter happens they should not abort their babies in
             embryo. When it comes time for delivery, they should experience a labour operation.
             After their babies are coming to the world they should not be breastfed as other normal
             babies. (Male, 33 years, Evaluation Survey)

The above decisions are plagued with moral and ethical dilemmas. For these issues to be raised indicates
an adequate understanding of knowledge and the need for further exploration into the impact of AIDS. In
this sense it appears that the participants have advanced and developed an understanding of basic issues
into complex ethical issues that are still being debated internationally. Debate about these issues in a
Vietnamese cultural context is necessary to successfully understand the implications.



Symptoms
Respondents distinguished between symptoms of STDs and AIDS. There were differences in responses
by men and women highlighting gender differences in knowledge of STDs and AIDS. After training,
symptoms were more clearly defined and the wider impact of HIV/AIDS was considered.

     STDs

Generally men were more educated about STDs than women perhaps due to 10% of men reporting having
had a STD in the last 12 months compared to 3% of women. Participants also acknowledged that STDs
were more common among men than women.

            …infected males will notice a chilliness then suffer from a high fever. Some men will
             make the mistake of thinking they catch a cold. But it will actually be the symptoms of
             gonorrhoea. (Female, 26 years, Baseline Survey)


                                                                                                      28
The most commonly reported symptoms of STDs included pus from the infected area, burning during
urinating and soreness. These symptoms were also reported during the evaluation survey.

                    It is said that when a man becomes infected with gonorrhoea, he will notice firstly a
                     burning sensation when urinating from his penis, later he will see pus discharging from
                     his penis. (Female, 38 years, Baseline Survey)

                    When a person catches gonorrhoea, he may feel cold or hot, then he may notice pus
                     coming from infected parts. If the infected person is not cured effectively and
                     promptly, the inner infected parts will turn into ulcer and cancer or grow up into
                     inflammation. Do you think I am right? (Female, 26 years, Baseline Survey)

                    His infected area got sore and grew pus. If it happened previously I may think of the
                     case of gonorrhoea, syphilis or any venereal disease. But now there exists so-called
                     AIDS. (Male, Baseline Survey)

                    It has symptoms such as abrasions, burning urination, pain in genital parts and itches
                     for men. (Female, 50 years, Evaluation Survey)

During the baseline survey 61% of men were aware that it’s possible to catch more than one STD at the
same time, but 51.6% of the women reported that they didn’t know if this was possible.

         AIDS

Awareness of the symptoms of AIDS was generally vague prior to the training. Apart from general poor
health, weight loss was identified as a major symptom of AIDS.

                    Once such a disease has developed, the infected people will become thin and weak. He
                     is getting to lose his weight until the death eventually comes. (Female, 26 years,
                     Baseline Survey)

                    He loses weight. He looks so terrible that I dare not see. He had no gaping wounds but
                     he is getting to lose weight. (Female, 40 years, Baseline Survey)

                    I notice one of the symptoms is that our health status will become more and more
                     weak. (Female, FGD, Baseline Survey)

Post training evaluation revealed much clearer conceptions of AIDS symptoms including initial symptoms of
HIV and the development into full-blown AIDS.

                    The symptoms of HIV are continuous diarrhoea and fever. (Male, 23 years, Evaluation
                     Survey)
...................................................... In the initial stages the patient can feel cold or get a serious flu or bad cough. (Female, 28 years, Evaluation Survey)
Seafarers’ partners (64.5%) were more aware than the seafarers (56.7%) that young, healthy people can
transmit HIV. This finding is alarming as the men reported visiting young, beautiful sex workers without
realising the risk. Gradually, however people were beginning to understand the lack of overt symptoms.

                    Maybe she looks healthy by appearance but get infected. Furthermore the sickness
                     takes a long time to show up all serious symptoms; if she is just exposed to HIV
                     infection, it is very difficult for us to pinpoint any particular symptoms. (Male, 20 years,
                     Baseline Survey)

                                                                                                                                                                            29
After the training most people clearly understood that HIV infection is not visible through one’s appearance.
The following graph illustrates the changes from pre to post training in reference to this fact of HIV/AIDS.


                       Positive change in repsonse to 'You will certainly not get infected with HIV/AIDS
                              if having sex with anyone young and pretty (pre and post training)


                                      43.3

                  45
                                                                               35.5
                  40


                  35


                  30
     Percentage




                  25                                                                                       Prior to Training
                                                                                                           Post Training
                  20


                  15
                                                                                           6.7
                  10
                                                   1.9
                   5


                   0
                                    Seafarers                                Partners




The discussion of symptoms in the evaluation study progressed to reveal a more complex understanding of
the effects of STDs and HIV/AIDS. Participants commonly recognised the wider health, social and
economic effects of infections and the implications and consequences for the individual, the family and the
community.

                      Influences on physical and mental health of each member of the family, on financial
                       status and reproduction and a high risk of infertility. (Female, 50 years, Evaluation
                       Survey)

                      Generally speaking, STDs effects our health, deteriorates the body, economy, family
                       and community. (Female, 50 years, Evaluation Survey)

                      Moreover, when we get ill we cannot work and spend more money on medicine while
                       earning nothing. (Female, 28 years, Evaluation Survey)

A fear that infections in parents could spark complications in their children was a concern of those in the
evaluation study but absent in the baseline survey. Evidence suggests that children born with HIV/AIDS
can suffer from neurological problems such as cerebral palsy or mental retardation but some participants
exaggerated the effects.

                      Malformation can happen to our children such as the cases of harelips, one eyed or
                       disabled people. I cannot predict what will happen. (Male, 33 years, Evaluation Survey)

                      I have told you that we should get rid of the disease. If not, it will negatively affect our
                       children. The children might get scabies on their heads. (Male, 38 years, Evaluation
                       Survey)

Treatment
                                                                                                                           30
AIDS was perceived as more serious than STDs during both the baseline and evaluation, largely due to the
lack of treatment available. Although 77.4% of women and 67.8% of men knew that treatment of an STD is
not immunisation against future infection before the training, STDs were less feared than AIDS as they
could be cured.

            AIDS is much more different from that disease. STDs is easier to cure, AIDS is much
             more difficult to treat. (Female, FGD, Baseline Survey)

            I heard them [seafarers] saying that they don’t care about such a disease [STDs]. One
             injection will help. They just fear of being infected with AIDS. (Male, 25 years, Baseline
             Survey)

            HIV is more serious because there is no specific cure. Contrarily, STDs can be cured.
             (Female, 28 years, Evaluation Survey)

            You’re asking about their awareness? Well, it means nothing once the sex need
             comes. Only AIDS can make them have a second thought. I think STDs doesn’t matter
             to them. (Male, 38 years, Evaluation Survey)

For some, AIDS was equated with death. Treatment options were negligible and securing a quality of life
for PLWAs was not considered.

            I will die. If I am infected with AIDS, it means death comes. Neither a cure nor
             treatment for AIDS has been found so far. (Male, 25 years, Baseline Survey)

            Those who are succumbed to AIDS will certainly die. What else can they do? (Male, 25
             years, Baseline Survey)

            No disease is more fatal than AIDS. (Female, FDG, Baseline Survey)

This attitude could result from the belief that there are no counselling or treatment services in the province
(53.3% men and 41.9% women). Furthermore 56.7% of men believe that it is pointless for a person with
HIV/AIDS to visit a health centre, as they cannot provide any assistance whereas only 24.4% of their
partners hold the same view.

In the evaluation there was also an emphasis on AIDS as incurable. This resulted in the feeling that there
was no hope for PLWAs and that life with AIDS was meaningless.

            Generally speaking, getting infected with AIDS means an end to life and life is
             meaningless. (Male, 26 years, Evaluation Survey)

            It makes human beings lose the meaning of life, lose labour capacity, little by little they
             will die. (Male, 26 years, Evaluation Survey)

This feeling of hopelessness was considered a serious issue for PLWAs and a few people in the evaluation
acknowledged the need for psychological treatment. There was also a feeling of the community
responsibility to support PLWAs and to assist them in gaining quality of life. Divergence from the
perception that life for PLWAs is worthless and meaningless indicates a change in attitude towards
treatment and care options and highlights a greater acceptance of PLWAs in the community.


                                                                                                           31
                      When they get this disease they will get a mental breakdown, they fear that those living
                       around them will avoid them. When we have time we should console them. (Female, 41
                       years, Evaluation Survey)

                      I advise them to take pills, not to think of suicide. (Female, 38 years, Evaluation Survey)

                      I still console my friend and I know a little about this disease HIV. I advise her to
                       continue working during the remaining time in her life, something useful to the society
                       and family. (Male, 23 years, Evaluation Survey)

            Misconceptions

Although 72.2% of men and 80.6% of women knew that HIV/AIDS cannot be cured, there was still
uncertainty.

                      It is said that these diseases [STDs] are likely to be treated. But AIDS is unlikely to
                       cure, isn’t it? (Female, 37 years, Baseline Survey)

                      Recently my brother returned from Saigon saying that there has been some specific
                       medicine to treat AIDS…I have heard about a specific cure but I am also afraid.
                       (Female, FGD, Baseline Survey)

The evaluation demonstrated substantial improvements in recognising that HIV/AIDS is not curable,
however there were still a small group who believed otherwise.


                       Changes in the percentage of seafarers and their parnters who beleive HIV/AIDS is curable,
                                                         pre and post training



                                     27.8
                  30



                  25

                                                                           18.1
                  20
     Percentage




                                                                                                                Prior to Training
                  15                                                                                            Post Training


                                                5.7
                  10

                                                                                       3.3
                   5



                   0
                                   Seafarers                              Partners


Additionally, prior to training 62.2% of seafarers didn’t know if a vaccine for HIV was available and 12.2%
thought it existed, whereas 50% of women didn’t know or thought it existed.

During the baseline, others believed that early diagnosis could enable HIV/AIDS to be cured.
Misconceptions concerning the development of HIV/AIDS has perhaps attributed to the belief that early
detection can enable complete recovery.


                                                                                                                                    32
            But AIDS in earlier stages can be curable. If we discover the illness right away, we can
             [cure it]. (Female, FGD, Baseline Survey)

            For example, skin and venereal diseases or some inflammation symptoms can be
             curable. If we discover such diseases just as early as when they just catch us, we can
             be cured. If they develop into HIV, it will be more serious. Then we may be lying,
             waiting for death. (Female, 33 years, Baseline Survey)

     Treatment Sources

Seafarers reported seeking treatment for STDs from two main sources, Western health services and
traditional healers.

            I have a lot of friends who follow the sea. They told me they had sex with prostitutes
             and got infected. Some of them bought medicine. Some others bought Chinese herbs.
             (Male, 38 years, Baseline Survey)

     Pharmacies, Private Clinics and Hospitals

Pharmacies proved to be the most popular health service provider for STDs. Public hospitals were rarely
used and although the standard of treatment from private doctors was acknowledged, the expense was an
impediment.

Pharmacies provided treatment for STDs at a reasonable cost. Seafarers, in particular, were not inclined to
spend much money on their health and so pharmacies provided cheap treatment that was easy to take.

            Most of them are so poor, they’re seafarers. Firstly, they just have little money,
             secondly they just stay on land for one or two days they cannot endure long and
             appropriate treatment as requested by the doctors. Furthermore, they have less money
             to afford such a treatment. (Female, Pharmacy Seller, Baseline Survey)

            Doctors prefer using injections to pills in such cases. But the fact is that injections are
             much more expensive than pills. While a dose they buy from the pharmacy costs only
             5000 dong…In the meanwhile, going to the doctor for a few days will cost them some
             hundred thousand dong. How can they afford that? (Female, Pharmacy Seller, Baseline
             Survey)

Pharmacies and private clinics were easier to access than public hospitals due to lack of resources and
strict procedures in the hospitals.

            Few people go to the public hospital. Most of them go to the private clinic or the
             pharmacy to buy medicine. (Female, 26 years, Baseline Survey)

            It is very difficult to get access to the hospital due to procedures. (Male, 20 years,
             Baseline Survey)

            Few STDs hospitals have been established here. People often go to see some private
             doctors or some obstetrics doctors. These doctors have established their own clinics.
             (Female, 38 years, Baseline Survey)

Pharmacies and private clinics were also preferred for the level of privacy and confidentiality afforded to the
patients.
                                                                                                            33
           They would rather talk with the doctor about their illness at the private clinic than go to
            the public hospital. I can tell you for sure that few people go to the public hospital.
            They said that their illness will be kept confidential if they go to the private doctor for
            treatment. (Female, 38 years, Baseline Survey)

The severity of the illness determined the choice of health service provider and pharmacies usually
provided initial treatment.

           If their sickness is less serious, they will go to the pharmacy first….Just when the
            sickness has developed into more serious stages out of their control, they then turn to
            the doctor for treatment. (Female, Pharmacy Seller, Baseline Survey)

However, the treatment provided by the pharmacy was according to the patient’s self-diagnosis. The lack
of professional medical knowledge combined with the pharmacy’s need for profit, made this method of
treatment extremely dubious.

           It is easier to get medicine from the pharmacy. They sell us whatever medicine we ask
            for. They just don’t ask anything about our disease of which we feel ashamed. (Male,
            20 years, Baseline Survey)

The service provider at the pharmacy remarks;

           We don’t have any specific medical knowledge, just know how to handle only the case
            of simple sickness which can be cured by one or two doses of medicine. As a seller, I
            just try to please our clients. If I refuse to sell medicine to them, they will go to another
            pharmacy. (Female, Pharmacy Seller, Baseline Survey)

           They just come and ask me to buy any specific medicine to treat such a sickness and
            mention nothing else. (Female, Pharmacy Seller, Baseline Survey)

The participants in the evaluation study recognised that self-diagnosis and treatment at the pharmacy was
not the best option.

           Seafarers often use the same prescription to treat themselves whenever they get
            infected. I don’t think it’s right because each disease has its own treatment and
            prescription. (Male, 33 years, Evaluation Survey)

They recognised the availability of greater quality of care at the health centres (including counselling
services), however previous impediments such as expense and confidentiality were not mentioned. The
focus on treatment for HIV/AIDS in the evaluation compared to STDs in the baseline could explain this
difference. Most participants had little experience with AIDS treatments directly and therefore spoke
hypothetically whereas the direct experience with STDs allowed participants to relate actual practices.

           The hospital has better quality of treatment as well as good doctors. (Female, 50 years,
            Evaluation Survey)

           I think it’s best for us to go to the provincial hospital for proper treatment. Doctors are
            more experienced…Medicine is available for use. Furthermore it is not good to stay
            home to cure such diseases. (Female, 28 years, Evaluation Survey)


                                                                                                      34
           It’s better to come to the health centre and take medicine following the physician’s
            prescription. (Female, 50 years, Evaluation Survey)


           Should go to the hospital for counselling and for test to know for sure if we have AIDS
            or not. If we have got it we must follow the doctor’s advice. (Male, 23 years, Evaluation
            Survey)

     Traditional Medicine

Traditional herbs were reported as a common treatment for STDs. Traditional medicine provided a cheap
alternative to Western medicine and was easy to access.

           But most seafarers, when infected, usually go to the stores to buy Chinese herbs.
            (Male, Baseline Survey)

The use of traditional medicine appears effective with reports ranging from complete to partial recovery.
However, the effectiveness of traditional medicine is questionable given the epidemiology of STDs in which
symptoms can disappear and recur at a later stage.

           Previously a young woman who got infected through sexual contact came to see Uncle
            Hai, a traditional healer, who lived near here. She got a good recovery after his
            treatment. Since then, whenever I feel chilliness (I knew I got sick), I will then go to his
            place for treatment right away. (Female, FGD, Baseline Survey)

           My family member went to some traditional physician for treatment. He prescribed
            some medicinal herbs and wrapped the infected areas. Then the symptoms gradually
            disappeared. (Female, 33 years, Baseline Survey)

           He even purchased some traditional medicine from a traditional healer in a pagoda. I
            don’t know what to call the medicine. The treatment worked but not effectively because
            some of the symptoms have not completely gone away. (Female, 26 years, Baseline
            Survey)

           Yes I witnessed many cases in which they got infected with gonorrhoea or syphilis,
            they used western medicine but in vain. Contrarily, when they turned to traditional
            medicine their disease had gone away. (Female, 28 years, Evaluation Survey)

     Ineffective Treatment

Reports of both Western and traditional treatment as ineffective were common. Reasons for this are
numerous but it appears that a lack of understanding concerning proper medication procedures resulted in
the continuance of the disease and further transmission. The baseline survey found that 81.1% of men and
66.1% of women knew that the disappearance of STD symptoms without treatment does not indicate that
the STD is cured. (These percentages increased substantially during the evaluation to 98.1% of men and
91.7% of their partners, indicating a greater understanding of STDs). Despite this, it seems that people
who sought treatment, (traditional or Western) often ceased treatment once the symptoms disappeared.

           If they thought they had pus disease, they just went there [to the pharmacy] and asked
            for medicine regarding to pus disease. If the symptoms disappeared, they would stop
            taking the pills. (Male, 38 years, Baseline Survey)

                                                                                                       35
           They follow some Chinese traditional treatment, during this time, still remain having
            sex with their wives and subsequently transmit the disease to the latter. (Male,
            Baseline Survey)

           Because medicine is very limited, if infected, people just go into the forest searching
            for some unknown ‘medicine’ plants. If the symptoms disappear, they consider as their
            illness being cured already…(Male, Baseline Survey)

Treatment of STDs and HIV/AIDS focused on the available services. Hospitals and health centres were
recognised as providing superior treatment, however the cost and the lack of privacy in these clinics
prompted a reliance on traditional medicine and self – medication at pharmacies.

Stigma
A feeling of shame and embarrassment was associated with STDs and HIV/AIDS. People who were
infected were ashamed and had a need for confidentiality as the stigma of being infected brought
discrimination from within the community.

Shame

Generally people who were infected were highly embarrassed by their illness. This embarrassment
impedes treatment as people often delay treatment in order to maintain confidentiality. Only when the
illness is causing severe discomfort do they resort to medical treatment. This is especially dangerous with
STDs as the symptoms can disappear but this is not an indication that it is cured. Fear of rumours about
their health status made many patients reluctant to seek treatment.

           Such infected people often keep their illness in secrecy. (Female, 26 years, Baseline
            Survey)

           Most patients who come for treatment are very reserved. They come embarrassed or
            frightened at the thought that they will be stigmatised. (Male, Doctor, Baseline Survey)

           Yes, they feel ashamed. When they go to the pharmacy to buy medicine, they just
            speak in a soft voice. If there are many clients standing there, they won’t come in.
            (Female, FGD, Baseline Survey)

           In my opinion, simply speaking, when they get infected for the first time, they always
            feel afraid of the rumours. I have experienced so many cases in which the patients felt
            ashamed if their friends knew and spread the news. (Male, Hospital Staff, Baseline
            Survey)

However, this shame also extended into prevention. Men and sex workers were reportedly too
embarrassed to buy condoms thus resulting in non-use of condoms, which leads to further embarrassment
if infected.

           Men always feel ashamed buying condoms. (Female, Condom Saleswoman, Baseline
            Survey)

           They [sex workers] feel embarrassed. They don’t dare to go to the pharmacy to buy
            condoms. (Female, Condom Saleswoman, Baseline Survey)


                                                                                                        36
As mentioned earlier, after the training there was a stronger understanding that public opinion and stigma
should not influence the need for prevention. This was evident by people being less embarrassed about
purchasing condoms.

            Do not be afraid of public opinion, prevention is above all. (Female, 50 years,
             Evaluation Survey)

            We should not be ashamed when buying condoms. (Female, 28 years, Evaluation
             Survey)

Discrimination

People living with AIDS (PLWAs) were discriminated against within the community. Most discrimination was
based on fear of contracting the disease indicating a superficial level of transmission knowledge. There was
a common misconception that infected people should be isolated to avoid further transmission. A majority
of the seafarers (65.6%) believed that PLWAs should be isolated from the community, however their
partners were more evenly split with 50% agreeing with isolation and 43.6% disagreeing – the remaining
6.5% gave a neutral answer.

            Yes, if we know for sure [he is infected with AIDS] we should isolate him right
             away…There is no cure for AIDS. So we are so afraid of getting infected by him.
             (Female, 26 years, Baseline Survey)


            He should live, eat and drink separately from us…Because he carried with him the
             infection we cannot live with the person who has the virus. (Female, Condom
             Saleswoman, Baseline Survey)


            Our attitude towards them should not be different but their clothes should be left
             separately, and should be washed in their own washtub. (Female, 37 years, Baseline
             Survey)

            Surely we should avoid from drinking and eating together with them. They should eat
             at one separate place and the rest of the family to eat at another separate place from
             them. (Female, 37 years, Baseline Survey)

            If we know about that [infection status], we should isolate him from the other people.
             (Female, 26 years, Baseline Survey)

Resulting largely from a lack of knowledge, discrimination was detrimental to people rumoured to be
infected with HIV. The following situation is based on rumours, which led to the young woman being highly
stigmatised.

            I knew a young lady around 20 years old. When she gave birth to a baby, the hospital
             tested her blood and reported that she was infected with HIV. Coming back home, she
             was isolated by her neighbours. It was rumoured that she became infected with HIV
             thus nobody hired her to work. (Female, FGD, Baseline Survey)

Despite the reality, 50% of seafarers and 87.1% of their partners felt that a person would not be stigmatised
if visiting a public health centre for STD treatment, perhaps reflecting an ideal rather than actuality.

                                                                                                          37
The evaluation study showed a significant change in knowledge and hence attitudes towards
discrimination. Generally participants had a greater understanding of transmission methods and risks
which appeared to reduce discrimination. Whether these attitudes were reflected in practice is unknown.

                       I advised them not to isolate the infected people because HIV/AIDS will not transmit
                        through breath. Sitting close to them is also not a problem. Sharing the same meal or
                        wearing the same clothes are excluded from the risk of transmission ways. (Female, 28
                        years, Evaluation Survey)

                       We must tell the community about this disease, which is not transmissible through
                        daily contact, mobilise people to integrate and confide with the patient and do not
                        abandon them. (Male, 42 years, Evaluation Survey)

Significant changes in attitudes concerning isolation of PLWAs were evident in the pre and post training
surveys, demonstrating a change towards a greater acceptance of PLWAs living within the community.


                       Percentage of people who agreed or didn't know whether PLWAs should be isolated from the
                                                   community pre and post training


                                      65.6

                  70

                                                                          51.8
                  60



                  50
     Percentage




                  40                                                                                         Proir to Training
                                                                                    23.3                     Post Training
                  30                            18.9


                  20



                  10



                   0
                                    Seafarers                           Partners




Changes in attitudes towards discrimination resulted from increased knowledge about HIV/AIDS.
According to the participants in the evaluation study, improving HIV/AIDS knowledge in the community is
the key to further reducing discrimination.

                       Those who have good knowledge about HIV can understand our situation. And those
                        who do not have good knowledge about HIV, they avoid us. (Male, 23 years, Evaluation
                        Survey)

                       Because some neighbours who don’t have any knowledge about the disease will
                        isolate the patients and lead their way of thinking to sadness and suicide. …We should
                        spread information about AIDS to the neighbourhood, telling them that AIDS won’t
                        transmit through social contacts, encouraging them to keep in contact with the
                        patients. (Female, 50 years, Evaluation Survey)

Despite the change in attitude of many in the evaluation, there were still traces of uncertainty and
misconceptions that resulted in discriminatory behaviour.
                                                                                                                                 38
           We can live with infected people but it’s best to separate their belongings from ours.
            (Male, 38 years, Evaluation Survey)

The evaluation highlights progress in removing discriminatory attitudes through increased knowledge and
understanding of HIV/AIDS. Whether these attitudes translate into practices is unknown, as is the extent to
which these attitudes are ingrained. Stigma of condom use has shown changes in practice, which
suggests that changes in discriminatory attitudes may be reflected in practice.




                                                                                                        39
                                                                           Discussion

The research reveals complex relationships between the seafarers, their partners and sex workers, in
relation to HIV/AIDS/STDs transmission. Seafarers distinguish between their wives and sex workers as
two very different types of women. According to O’Harrow (1995:175), extramarital affairs in Vietnam
exceed premarital affairs suggesting that extramarital affairs are an inherent part of the Vietnamese marital
relationship. A Vietnamese saying considers wives as com (rice) and lovers as pho (noodle soup). Both
are a necessary part of the man’s diet, however the pho is more delicious than everyday rice. (Pham Van
Bich, 1999:164). This cultural acceptance of extramarital affairs has shaped the relationship between
seafarers, their partners and sex workers and has allowed a hierarchy dominated by seafarers, who place
their partners before sex workers, to become established. This hierarchy is particularly dangerous, as
women (sex workers and partners) are more vulnerable to HIV/AIDS/STDs through the threat of coerced
sex and the inability to negotiate condom use. The actions of seafarers therefore, have a direct influence
on the health of women.

Partners

Partners of seafarers are a high-risk group. The patriarchal nature of the husband-wife relationship
perpetuates gender inequality. Economic dependence on the husbands reinforces this male domination,
despite seafarers long periods away from home. In fact, this lifestyle may further reinforce male dominance
through men’s expectations of their wife when they return home after working at sea for extended periods.

Gender and power inequalities within the marital relationship increase the HIV/AIDS risk for the wives and
the children, as husbands are the main source of infection. In the baseline survey these women appeared
to be accepting of their husbands’ infidelity and struggled to successfully protect themselves from the risk
that their husbands presented. Seafarers’ sexuality is characterised by natural sexual urges and alcohol
leading to sex with sex workers and the tendency to forget condom use. Wives generally accepted these
aspects of the seafaring lifestyle. This attitude was also found among Filipino seafarer’s wives whose
tolerance of male promiscuity was seen as a reflection of their helplessness and inability to control their
husband’s behaviour (Ybanez and CARAM-Asia, 1998).                  Vietnamese partners also accepted
unfaithfulness, as they were unable to control their husband’s behaviour, however for these women the risk
went one step further in that they were unable to negotiate condom use and were often unable to refuse
sex. According to Pham Van Bich (1999:159);

        Vietnamese people take it for granted that it is a wife’s duty to satisfy her husbands sexual need
        whenever he wants, no matter whether she is willing or not.

After the training there was a significant change in the attitude of these women. Although still accepting of
their husband’s extramarital affairs there was more openness and less denial about their husband’s
behaviour. This attitude empowered women to take prevention into their own hands and to become vigilant
about condom use. The case of the woman who reported buying condoms for her husband’s extramarital
affairs, highlights the assertiveness of women in protecting themselves through accepting the reality of their
husband’s behaviour, the problem of AIDS and the use of condoms as the best form of prevention.
However, the women were unable to stop their husbands having extramarital affairs and condom use
became the ‘duty’ of women. In the evaluation a community attitude emerged charging women with the
responsibility to remind men to use condoms. These factors demonstrate that the men retain power and
control within the marital relationship.


                                                                                                           40
The concept of trust between husband and wife was transformed by the training. Pre-training trust was
understood as women trusting their husbands unquestionably and relying on them for prevention. Women
lacked the assertiveness to speak to their husband about sexual issues and speaking about extramarital
affairs was often taken as an accusation of promiscuity. The use of condoms within the marital relationship
created suspicion as to the faithfulness of the partners (usually the husband) and consequently raised the
issue of trust. Condoms were considered symbolic of a ‘lack of trust’ between the husband and wife. Post-
training trust meant husbands and wives should trust each other to be faithful and should trust each other
to use condoms (even within the marital relationship). The saying ‘prevention is better than cure’ was
employed to overcome issues related to trust.

Generally, seafarers did not like using condoms. Although there were many reasons for seafarers’ non-
use, including discomfort and excessive alcohol consumption, most of the other reasons concerned gender
and power relations between the seafarer and his partner. The main reason for non-use of condoms was
the strong association between condoms and sex with sex workers. As sex workers were seen as the
transmitters, men and women believed that it was more important to use condoms in these relationships in
which sex workers cannot be ‘trusted’ to be infection free.

The situation is further expounded by gender roles. Within the marital relationship the men held power and
were the decision-makers. Hence it was the men’s decision to wear or not to wear condoms and if they
chose not to wear condoms they had the power to convince their wife to have sexual relations. Family
planning studies have illustrated men’s role in reproductive health. Men tend to make family planning
decisions, including contraceptive choice, number of children and birth-spacing, yet women have the
responsibility for implementing these decisions even at the expense of their health (Pham Van Bich,
1999:67). This shows that men have control over the female contraception methods and it is assumed that
men would have greater influence over a male method such as the condom.

Previously women (partners and sex workers) were the ones convincing men to use condoms. As
condoms are a male method often disliked by men, women are in the difficult position of being dependent
on men for safety. This was the case for many women in the study, however during the evaluation a role
reversal appeared. Men who attended the training were in the position of convincing their wives to use
condoms. Surprisingly, this proved to be a difficult task for the men with one man unable to persuade his
wife. This suggests that men are taking responsibility for their reproductive health and are willing to change
their behaviours, however they need further support to do so. It also suggests a more even power balance
within the husband-wife relationship in that both men and women can experience difficulties in condom
negotiation.

Sex Workers

The interaction between seafarers and sex workers intersects two mobile populations. Both the sex
workers and the seafarers travel to different islands and to Cambodia. The liaising of sex workers with
seafarers, long distance truck drivers and other migratory labourers has created a high risk situation in
these Cambodian border provinces. Mobility increases the risks of HIV/AIDS for seafarers as the distance
from home can increase peer pressure and attitudes and behaviours may change (Chantavanich,
2000:102). These factors coupled with the need for emotional support harness the establishment of the sex
industry. In response to this demand, sex workers travel within the region to maintain employment and to
avoid arrest. This combination of multiple partners and multiple locations increases the risk of transmission
whilst decreasing access to adequate health services and treatment.

From an intervention perspective, this mobility also increases the difficulties of accurately targeting these
populations. Sex workers and other sex partners are particularly difficult to access due to the illegal nature
of their work, which tends to push them further underground. Conceptually, prostitution is considered
immoral and offensive to the family and community (Truong, 1990:86). In Vietnam, the Social Evils policy
                                                                                                           41
classifies prostitution along with drug use and gambling as an ‘evil’ which needs to be abolished. This
ideology places blame on the sex workers (ignoring the client) making it increasingly difficult to identify sex
workers who tend to maintain a low profile to avoid arrest.

Sex workers are particularly vulnerable to HIV/AIDS/STDs. Unequal power and gender relations with
clients, coupled with marginalisation from the community, severely increase the risks for sex workers in
relation to HIV/AIDS and STDs. Sex workers are not highly regarded by seafarers thus making condom
negotiation difficult. Threats of violence and abuse further mar the situation of sex workers. The illegal
status of sex workers makes them dependent on others (clients, pimps etc) as they cannot turn to the
authorities. Due to their reputation within the community as vectors of disease, it appears that some men
are vigilant about using condoms with sex workers whereas for others, payment for sex necessitates non-
use of condoms. Sex workers, it seems, often lack the power to determine condom use with clients and
hence lack the power to control their reproductive health.

Community

The perceived differences between STDs and HIV/AIDS reflect experience.
Both men and women had personal experience or knew people who had been infected with STDs. Men’s
knowledge of STDs during the baseline was greater than the women’s, perhaps reflecting greater exposure
to STDs. Limited knowledge about HIV/AIDS and an emphasis on the inability to cure AIDS, led to the
perception that HIV/AIDS is more serious than STDs.


Treatment for STDs was easily obtained at pharmacies or though traditional healers, reinforcing the
seriousness and lack of treatment options for HIV/AIDS. This fatalistic emphasis on HIV/AIDS has
overshadowed factual information on the disease and generated fear. Even after training there was a
perception that once infected with AIDS life is meaningless and worthless. Consequently, people living with
AIDS within the community were discriminated against due to these misconceptions.

Discriminatory attitudes towards PLWAs stemmed largely from a lack of understanding about HIV/AIDS
transmission. Fear of transmission prompted responses favouring isolation of PLWAs during the baseline
survey. During the evaluation, knowledge of transmission increased and attitudes towards PLWAs
changed. The need for acceptance and support was acknowledged and people understood the importance
of encouraging PLWAs to maintain a quality of life. Knowledge was seen as the key to reducing
discriminatory attitudes within the community.

The stigma of being infected brings shame as STDs are symbolic of immoral behaviour. This shame can
hinder treatment-seeking behaviour causing the infection to remain clandestine. During the baseline
survey, delaying treatment for STDs was commonly reported. Restrictions on time and money and
embarrassment of being infected caused seafarers to delay treatment until it was considered too severe to
ignore. As the symptoms of STDs can disappear and reappear later, at times treatment was neglected.
The evaluation emphasised the seriousness of STDs in causing illness and infertility and even death and
encouraged seafarers to seek appropriate treatment.

Shame also influences condom purchasing. Buying condoms for contraception (rather than STD
prevention) was seen as a plausible reason and a way to avoid shame. A strong family planning campaign
throughout Vietnam has created a favourable response to contraception use, however traditionally
condoms (a supply method) were not the method of choice promoted by the campaign (Goodkind and
Phan Thuc Anh, 1997:174). Although, condoms are currently promoted, strong public opinion remains.
Acknowledgement that prevention and treatment are more important than public opinion was widely
recorded in the evaluation, but the extent to which this still affects practices is unknown.

                                                                                                            42
Confidentiality, regarded as one of the most important requirements, was lacking in the health services.
People complained that public hospitals could not guarantee confidentiality and the hospital was cited as a
source of rumours identifying infected individuals. This lack of respect from qualified health professionals
initiated a reliance on self-diagnosis. It was common for seafarers to consult pharmacy staff, with
extremely limited medical knowledge, or traditional healers for treatment, as these establishments were
seen to provide confidentiality. The inadequacies of the health system are seriously detrimental as they
further suppress disease and prevent effective treatment. Although after the workshop there was
recognition that health centres and hospitals provided quality medical treatment, the impediments to this
treatment (money, time and confidentiality) remain.

The evaluation demonstrated that participants had a much clearer understanding of HIV/AIDS and this
translated into participants considering the broader implications HIV/AIDS. This holistic approach to
understanding HIV/AIDS has encompassed wider consequences of the disease, which are likely to become
important to the community such as ethical issues, legal issues and social and economic implications for
the family and community of the infected person. Knowledge of HIV/AIDS has evolved from pre-training
to post-training, indicating an ability to apply understanding to the individual, community and the global
level.




                                                                                                         43
                                                                        Conclusion

The lack of condom use in both men and women was one of the most alarming findings in the baseline
study. Seafarers’ masculinity was a dominant feature of the seafaring lifestyle. Visiting sex workers and
irregular partners was inherent in maintaining one’s manliness. Wives of seafarers appeared to accept this
as a part of seafaring culture, but often denied their husband’s involvement. These wives adamantly
claimed that they trusted their husbands completely, to the extent that they would not use condoms within
the marital relationship. Unfortunately, some women were infected by their husbands.

Raising the topic of condom use within the marital relationship brought suspicion and tension. Men often
interpreted this as their wives not trusting them and became angry or accused the wife of having illicit
relationships. Difficulties in condom negotiation meant women reverted to simply trusting their husbands,
as they were powerless to change their behaviour. The women’s inability to demand their own safety in
sexual relations with their husband, and their lack of control over their husband’s behaviour, meant women
had limited means of controlling their level of risk.

The combination of a husband who does not understand the dangers and a wife who is aware of the risk
but cannot prevent it, created a community in need of intervention.
The intervention strategy involved a HIV/AIDS contest, IEC material including booklets and billboard
posters, a training workshop for STD service providers and communication sessions for seafarers and their
partners.

A change in knowledge and attitudes was noticeable after the training. Respondents had a more
comprehensive understanding of HIV/AIDS transmission and prevention methods. In particular there was
recognition of the importance of condoms in AIDS prevention. Women realised the repercussions of failing
to use condoms and were less trusting of their husbands. They became vigilant in condom use and more
assertive in condom negotiation through increased knowledge. However, they also seemed to become
responsible for reminding men to use condoms.

Improvements in knowledge led to a reduction in discriminatory attitudes. An understanding of
transmission, in particular, facilitated attitudes of acceptance of PLWAs in the community. Although these
attitudes were evident, whether they translate into practices is unknown at this stage. A basic grasp of
HIV/AIDS issues evolved into a need to discuss the wider implications of HIV/AIDS including ethical
dilemmas and the impact of the disease on the community and the economy.

The project has fulfilled a need for HIV/AIDS education in Kien Giang province. In order to reduce the
rampant spread of HIV in the community and within the Mekong area, intervention strategies have been
focused on education with the desired result being attitudinal and behavioural changes. The success of the
educational intervention in attitudinal changes is obvious however behaviour change has not yet been
recorded. The final point is whether the knowledge will be retained and result in attitude and behaviour
changes.




                                                                                                       44
                                                  Recommendations

The following recommendations are suggested to increase and sustain the impact of the project.

   Encourage male responsibility in condom use
       Encourage men to take responsibility for using condoms with both their wives and other sex
       partners, including sex workers. Strongly discourage associations of condoms with unfaithfulness.

   Include couples in training
        To increase the impact of the training and to limit power discrepancies amongst couples, both the
        husband and wife should be included in training. Research has shown that reproductive health
        decisions made jointly by both partners are more likely to be implemented (Ndong and Finger,
        1998). In the Vietnam context, this may include separate training for husbands and wives due to
        the sensitivity of talking about sex.

   Include sex workers, other sex partners in training
        Sex workers and other sex partners should receive training to encourage them and their partners
        to practice safer sex. Promoting assertiveness in sex workers is a positive step towards equalising
        power relations between the sex worker and the client and improving perceptions of sex workers
        as ‘bad’ women.

   Educate health professionals on ethical issues of AIDS, particularly about confidentiality.
       Conduct training that examines the ethical issues associated with HIV/AIDS and in particular the
       importance of patient privacy and confidentiality, future implications of HIV/AIDS to the community
       and exploring difficult issues appropriate to health professionals. Encouraging health professionals
       to recognise their own personal values and biases will also improve the services provided.

   Encourage pharmacies to recommend qualified medical treatment for clients
       Pharmacy service providers should be made aware of the dangers of self-diagnosis. They should
       recommend that the patient seek professional medical advice and encourage patients to present
       prescriptions from doctors.

   Accessibility of condoms at point of need – encourage purchase of condoms in advance.
       Seafarers need access to condoms at places where sexual services are negotiated such as bia om
       bars. Access to condoms on the islands may be restricted and so seafarers should be encouraged
       to purchase condoms in advance. Additionally, within the marital relationship, condoms are often
       not available at point of need (night-time) as pharmacies close at 10pm. Couples should be
       encouraged to purchase condoms in advance.

   Support men and women in condom negotiation, assertiveness training
       Men as well as women should be supported in assertiveness training and condom negotiation.
       Although women are most often vulnerable when negotiating with men due to condoms being a
       male method, men holding more decision-making power than women and the physical threat of
       violence, men also experience difficulties negotiating with women and they should be supported in
       this endeavour.


   Encourage more media discussion about the ethical issues of HIV/AIDS
                                                                                                        45
        Newspapers and radios should be encouraged to debate ethical issues associated with HIV/AIDS
        to educate the community about the various points of views that can be argued.

   Reinforce current messages using a variety of outlets, sites and methods – including IEC
    materials on board the boats and on islands
       In areas where condoms have been promoted through social marketing campaigns, an increase in
       condom use has been substantial (Ndong and Finger, 1998). Messages promoted in the training,
       including the importance of condoms and knowledge about HIV/AIDS, should be reinforced in
       different geographical areas, a variety of outlets including bia om bars, pharmacies and restaurants
       and should incorporate a variety of methods such as posters, leaflets, newspaper articles, videos,
       books etc.




                                                                                                        46
                                 References
Cambodian Seafarers Research Team. 1998. Rapid assessment of seafarer vulnerability to HIV/AIDS and
drug abuse. Country Report for presentation at the national meeting.

CARE International in Cambodia. 2000. Sea and Shore: an exploration of the life, health and sexuality of
Koh Kong’s fishermen. Phnom Penh. CARE International in Cambodia.

Chantavanich, S. 2000. Mobility and HIV/AIDS in the greater Mekong subregion.
       Chukalongkorn University: Bangkok.

Chung A. (Ed). 2000. HIV/AIDS country profiles. Hanoi: Vietnam’s National
       HIV/AIDS Program.

Entz, A.T., Ruffolo, V.P., Chinveschakitvanich, V., Soskolne, V. and van
        Griensven, G.J.P. 2000. HIV-1 prevalence, HIV-1 subtypes and risk factors among fishermen in the
        Gulf of Thailand and the Andaman Sea. AIDS, 14(8): 1027-1034.

Fabri, M. 1996. Population dimensions of world fishery issues. FAO:
        http://www.fao.org.sd/wpdirect/wpan0009.htm

Fishermen fearful of being snared by increasing piracy on the high seas.
       2001. Vietnam News, XI (3651), 16 October: 5.

Goodkind, D. and Phan Thuc Anh. 1997. Reasons for rising condom use in Vietnam.
       International Family Planning Perspectives, 23(4):173-178.

Komonbut, R. 1995. Thai fishermen and their local contacts in Irian Jaya – an
      assessment on issues related to the spread of HIV/AIDS in Merauke. Merauke: PATH Indonesia.

Ndong, I. and Finger, W.R. 1998. Introduction: male responsibility for
        reproductive health. Network, 18(3): http://www.fhi.org/en/fp/fppubs/network/v18-3/nt1831.html

O’Harrow, S. 1995. Vietnamese women and Confucianism: creating spaces from
       patriarchy. In Karim, I (ed). Male and female in developing Southeast Asia. Oxford: Berg.

Pham Van Bich. 1999. The Vietnamese family in change: the case of the Red River delta.
      Richmond: Curzon.

Son Thanh Nguyen. 2000. Background information on HIV/AIDS in Vietnam.
       Emory University, School of Medicine: http://www.sph.emory.edu/AITRP/vietnam.html

Truong Thanh Dam. 1990. Sex money and morality: the political economy of prostitution and tourism in
Southeast Asia. London: Zed.

Ybanez, R. and CARAM-Asia. 1998. HIV vulnerability of wives of seafarers: a case
       study. http:// caramasia.gn.apc.org/Ritchie_seafarers_vul.htm



                                                                                                         47

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:42
posted:8/8/2011
language:English
pages:47