This article was downloaded by: [Northeastern University] On: 04 January 2015, At: 10:52 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20 Recreating Kinship: Coping Options of HIV+ AIDS Widows in Vietnam a b c Pauline Oosterhoff , Nguyen Thu Anh , Pham Ngoc Yen , Pamela d Wright & Anita Hardon e a Pauline Oosterhoff Medical Committee Netherlands , Hanoi , Vietnam b Hanoi Medical University , Hanoi , Vietnam c Hanoi National University , Hanoi , Vietnam d Medical Committee Netherlands Vietnam , Hanoi , Vietnam e Amsterdam School for Social Research , Amsterdam , The Netherlands Published online: 07 Dec 2009 To cite this article: Pauline Oosterhoff , Nguyen Thu Anh , Pham Ngoc Yen , Pamela Wright & Anita Hardon (2009) Recreating Kinship: Coping Options of HIV+ AIDS Widows in Vietnam, Health Care for Women International, 31:1, 17-36, DOI: 10.1080/07399330903133424 To link to this article: http://dx.doi.org/10.1080/07399330903133424 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content This article may be used for research, teaching, and private study purposes Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden Terms & Downloaded by [Northeastern University] at 10:52 04 January 2015 Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions Health Care for Women International, 31:17–36, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399330903133424 Recreating Kinship: Coping Options of HIV+ AIDS Widows in Vietnam PAULINE OOSTERHOFF Pauline Oosterhoff Medical Committee Netherlands, Hanoi, Vietnam Downloaded by [Northeastern University] at 10:52 04 January 2015 NGUYEN THU ANH Hanoi Medical University, Hanoi, Vietnam PHAM NGOC YEN Hanoi National University, Hanoi, Vietnam PAMELA WRIGHT Medical Committee Netherlands Vietnam, Hanoi, Vietnam ANITA HARDON Amsterdam School for Social Research, Amsterdam, The Netherlands In this retrospective study we explore the life trajectory of Vietnamese HIV-positive AIDS widows over a period years after their husbands’ deaths in a patrilinear and patrilocal setting where HIV is stigmatized Some options, such as widows living with their eldest son, are not available to young HIV-positive widows, but the women in our study furthered their own interest by joining support groups, looking for new partners, and strengthening relations with their own family Most women who returned to live with their family found a new intimate relationship through support groups for HIV-positive persons In this article we aim to make a practice contribution by examining the empowerment of HIV-positive women, including AIDS widows, through various means, including their membership in support groups Challenges in preventing and mitigating the effects of HIV/AIDS are shaped and influenced by cultural norms and values that enforce or reinforce existing gender inequalities In many Asian countries, widows are discriminated against and even blamed for their husbands’ deaths For instance, Indian widows may Received 27 September 2007; accepted 22 June 2009 Address correspondence to Pauline Oosterhoff, Amsterdamseweg 32, Ede 6712 GJ, The Netherlands E-mail: pauline oosterhoff@yahoo.com 17 Downloaded by [Northeastern University] at 10:52 04 January 2015 18 P Oosterhoff et al no longer be expected to commit sati, but many still are forced out of their in-laws’ homes and live on charity Studies in African countries have shown that in addition to their vulnerability related to widowhood, women whose partners die of AIDS often face social rejection related to the disease (Human Rights Watch, 2002, 2003; International Center for Research on Women, 2005) In countries like Kenya, where the HIV/AIDS pandemic has hit hardest, thousands of women face destitution because they lack the right to inherit property upon their husbands’ deaths (Sweetman, 2006) Traditions common in several African countries, such as widows marrying their dead husband’s brother, that might have benefited widows in the past by assuring them a home, may now contribute to the spread of the epidemic The negative impact of stigma against HIV-infected persons on public health efforts to slow the epidemic has been documented (Brown, Trujillo, & Macintyre, 2001; Gerbert, Maguire, Bleecker, Coates, & McPhee, 1991; Herek & Glunt, 1988; Malcolm et al., 1998) Health-related stigma involves social disqualification of individuals and populations identified with a particular health problem, such as HIV infection (Weiss, Ramakrishna, & Somma, 2006) Women and men may experience HIV-related stigma differently, however; in some contexts women may be blamed more than men (Paxton et al., 2005; Voluntary Services Overseas-Regional AIDS Initiative of Southern Africa (VSO-RAISA), 2005) Several authors divide stigma into felt or perceived stigma and enacted stigma (Jacoby, 1994; Malcolm et al., 1998; Scrambler, 1998) Felt stigma refers to real or imagined fear of societal attitudes and potential discrimination arising from an undesirable attribute, disease (such as epilepsy or HIV), or association with a particular group Enacted stigma refers to the acts of discrimination Individuals who enact stigmatizing or discriminatory behavior are referred to as the perpetrators of stigma and discrimination, whereas infected and affected persons are the targets (Herek & Capitanio, 1998) Others consider HIV stigma as part of a larger process that works to produce and reproduce power relations, in which the HIV-related stigma reinforces existing social inequalities, such as gender inequalities (Parker & Aggleton, 2003; Parker, Aggleton, Attawell, Pulerwitz, & Brown, 2002) Many such norm-related cultural restrictions come into play in the response to and effects of the HIV epidemic in Vietnam The national prevalence of HIV in Vietnam is comparatively low, at an estimated 0.5% in 2005, and concentrated predominantly among young male intravenous drug users (IDUs) in urban areas, at borders, and in seaports (Ministry of Health [MOH], 2006b) Currently young adults between the ages of 20 and 29 account for 50.5% of all reported HIV infections (Tran Hien, 2007) Reported HIV prevalence rates among young male IDU range between 25% and 70% (Hien et al., 2001; Hien, Giang, Binh, & Wolffers, 2000; MOH, 2006a; Tung et al., 2001) The Vietnamese state’s response to the HIV epidemic has been structured by national social policies implemented in the context of the national Downloaded by [Northeastern University] at 10:52 04 January 2015 Recreating Kinship 19 “renovation” policy, or Doi Moi, which began in 1986, shortly before HIV appeared in Vietnam The state has promoted a modernizing vision of a happy, rich, and cultured family with two children Economic growth and poverty alleviation in Vietnam have been considered impressive, and population growth has slowed The gender effects of changing public expenditures, however, such as privatization of state companies and the introduction of direct and indirect taxes, appear not to have been measured systematically (Akram-Lodhi, 2002) Several authors have argued that gender inequities are increasing under Doi Moi (Bousquet & Taylor, 2005; Werner & Belanger, 2002) An increased use of drugs and spread of HIV/AIDS also is reported to be correlated with Doi Moi (Werner & Belanger, 2002) A not insignificant proportion of male IDUs worked in mining, construction, or trucking, putting them at risk of drug addiction and contracting HIV (Tran Hien, 2002) With the advent of Doi Moi, men encountered many opportunities for extramarital sex (Phinney, 2005) The wives or girlfriends of these men are now becoming infected While antiretroviral (ARV) drugs are increasingly available in Vietnam, not all patients who need these drugs have access to them, often for financial reasons (MOH, 2006c) The number of patient and self-help groups has grown dramatically in the last years (Center for Strategic and International Studies [CSIS], 2006), but the number of AIDS deaths in Vietnam is still rising, leaving more AIDS widows behind, often young women According to Confucian doctrine, the status of a Vietnamese woman during different stages of her life is closely linked to her role in providing children, preferably male (Marr, 1984) One practical reason for son preference is that sons should take care of their mothers when their mothers’ husbands die Some Confucian ideas about women, kinship, and marriage, such as polygamy and the property of widows, have been banned by newer laws, such as the 1959 Law on Marriage and the Family A marriage between a widow and a man who was not married before, however is frowned upon; a popular expression says that a widow is “a very bad dish.”2 Research has Clauses and in the Law on Marriage and Family in 1959 protect widows: Clause clarifies that to be in mourning is not an obstacle for getting remarried Clause gives widows rights to remarry and guarantee their rights to children and property These rights are reaffirmed by more recent decrees such as decree 32/2002/ND-CP (March 27, 2002) "Trai tơ trai tơ Đi đâu mà vội mà vơ nạ dòng Nạ dòng lấy trai tơ Đêm nằm hí hửng Ngơ vàng Trai tơ vớ phải nạ dòng Như nước mắm thối chấm lòng lợn thiu" “Hey, unmarried man Why you go so fast, to catch that married old woman Married old women who can get married with that unmarried man Beside herself with joy at nights as if catching the gold Unmarried man who get married with married old woman Like rotten fish sauce with putrid puddings.” Downloaded by [Northeastern University] at 10:52 04 January 2015 20 P Oosterhoff et al shown that son preference is still widespread in Vietnam, possibly on par with Bangladesh and China (Belanger, 2002; Haughton & Haughton, 1995) As the guardian of the family’s respectability and the enforcer of its moral standards, Vietnamese women have both status and responsibility Women’s health suffers from the burden of many responsibilities, however, including family planning (Gammeltoft, 1999) The ideal of the happy family, endorsed by the large Women’s Union, places the burden for population control on married women (Nguyen-Vo Thu-Huong, 1998), who feel obligated to have sex within their marriage (Phan, 2004) A woman infected with HIV is considered to have brought shame to the household, for which she may be blamed more than a man (Khuat, Nguyen, & Ogden, 2004) In the Vietnamese patrilinear and patrilocal context, one might assume that HIV-negative AIDS widows, like AIDS widows in other countries, are vulnerable, and occupy a very low position in the household and in their communities In addition to being women, they are also widows, and they have a stigmatizing health problem that requires expensive life-long treatment It is easy to imagine, therefore, that HIV-positive AIDS widows are at the point of emotional, economic, and medical collapse Furthermore, because the AIDS epidemic in Vietnam is associated with heroin addiction, AIDS widows already belong to a subset of the Vietnamese population for whom the official vision of the “happy” family is unattainable For married Vietnamese women in a marginalized social sector, with low status and limited options, the issue of the transition to AIDS “widow” status may be more complicated than at first it seems Vietnamese AIDS widows might differ from other Vietnamese widows because they tend to be young women with serious health problems, but they also have resources such as support groups that other Vietnamese widows not have Furthermore, Vietnamese society is changing, and Confucian social roles may not be fixed In this retrospective study we explored the life trajectory of HIV-positive AIDS widows after their husbands’ deaths in a patrilinear and patrilocal setting where HIV is stigmatized because of its association with drugs and sex work but where support groups for HIV-positive persons are available Following the lives of these women over years revealed HIV-positive AIDS widows’ actual experiences of and opportunities for starting a new life Given the patrilinear and patrilocal culture, where they live when their husbands die? Does having a son influence their options? How women use existing kinship networks and new support groups to cope with the double stigma of being a widow and being HIV-positive? Respondents and Methods For this explorative study we collected qualitative data in the urban areas of Hanoi and Thai Nguyen City and in Dai Tu District, a rural mining area Downloaded by [Northeastern University] at 10:52 04 January 2015 Recreating Kinship 21 in Thai Nguyen province, all in Northern Vietnam All areas have relatively high HIV prevalence rates for Vietnam, concentrated among IDUs We interviewed a convenience sample of 24 widows, all infected with HIV, recruited from six support groups, four of which are under the umbrella of the Vietnam Women’s Union (“Sympathy Clubs”) or the Vietnam Red Cross (“Sunflower and Cactus Blossom Support Groups”), and two of which are independent groups (the “Bright Futures”) Of these 24 women, 17 were in Hanoi, where they had joined support groups to access support services unavailable in their own province All the groups meet weekly or biweekly to provide psychosocial support to members and to assist them in accessing medical treatment Of the seven widows interviewed in Thai Nguyen, two were from rural areas and had come to the city for work and for AIDS-related services When we first met these 24 women, 19 had just joined a support group within the previous months We met 18 of them on their first visit to the group Six others had already had been in one of the Bright Futures or Women’s Union Sympathy Club groups for a longer time, but all for less than months The interviews took place at the support group offices after the women had signed consent forms We used semistructured questionnaires to ask about HIV, child desire, lineage, care and support for the women, and their health In 16 cases, we also interviewed the women’s family members, in-laws, and boyfriends The remaining eight women proposed no new partners or family members willing or living close enough to be interviewed Participant observation of the programs in which the widows were enrolled was conducted weekly for year at the Provincial Women’s Union in Thai Nguyen, and for years at the District Red Cross in Hanoi Observation included interactions in support group meetings, with health care providers, household visits, and the counseling available through the support groups In three cases, we knew the women while their husbands were still alive and witnessed their last months together The bias of the sample is that all the women interviewed were active, in the sense that they had sought the help of a support group for treatment and care All but one woman were ethnic Kinh, the largest cultural group in Vietnam; the women studied had diverse social and economic backgrounds and were still young when they lost their husbands Eighteen women were 20 to 30 years old, four between 30 and 40 years old, and one in her early forties Six had a history of sex work or IDU; most were probably infected by their husbands or former boyfriends, all but one of whom had a history of IDU Only one woman was fully illiterate The researchers also interviewed social and health service providers who work on drug addiction and HIV/AIDS Their names have been changed to protect their privacy 22 P Oosterhoff et al RESULTS Downloaded by [Northeastern University] at 10:52 04 January 2015 Family Situation for Women Married to HIV+ Men Prior to Widowhood To understand what happens to HIV-positive women after their husbands die of AIDS, we need a clearer picture of gender and power relations in the households when the husbands were alive The family situations of the women in this study had been dominated, often for years, by the illicit drug addiction in their husbands’ households Few women had independent sources of income Before widowhood four women were employed outside the family, all in the private sector Three described themselves as unemployed Three owned and managed small businesses located in their in-laws’ houses, and two assisted their own families with a business The 12 others described their work as assisting their in-laws in household work, small business, or farming Most widows had not been aware of their husbands’ addictions when they married; 18 of the 24 had found out after marriage that their husband was an active drug user Women learned about their husbands’ HIV-positive status either because he became ill or during antenatal care (ANC), and they had to support their husband until his death Mai, for example, was born and raised in the south of the country, and came to Hanoi to live with the in-laws of her husband without being warned of her husband’s addiction During ANC, she tested HIV positive The situation in her in-laws’ household was physically and emotionally abusive, and she wanted to escape When she was elected leader of a support group, she used her stipend to move in with a lover in another district, switched off her cell phone, and asked the support group and its related project to explain her actions to her husband and his family For days her husband sat on his scooter in front of the support group’s office, hoping for her return She left her lover and came back to her in-laws, taking out a loan to establish a scooter-washing business, hoping that capital assets and a job for her husband would improve the situation, but her husband used the money she earned, and beat her—with the approval of his mother: When my husband fell ill with AIDS, I had to earn money to cover the hospital fees for my husband, other expenses for our daughter and for myself But the hospital could not save him His liver could not manage the ARVs (HIV-positive woman, 24 years old, Hanoi) In eight cases there were other drug users in the family: brothers, uncles, or fathers living in the household, in prison, or in a rehabilitation center for drug users Women like Mai tried to change their situation, but they reported feeling socially stigmatized in the neighborhood because of both illicit drug use and HIV infection in the family All reported that women—mothers, Recreating Kinship 23 Downloaded by [Northeastern University] at 10:52 04 January 2015 sisters, wives, grandmothers, and aunts—contribute to buying drugs for the addicted men in a household, trying to keep them at home and to save family “face.” When this does not work, women will pay for rehabilitation; husbands of 10 of the women had been in a state rehabilitation center for drug users Interviews and observations revealed that as long as the drugusing husband was alive, an important part of the women’s lives revolved around catering to his many needs Some women reported feeling guilty about spoiling their husbands, sons, or grandsons by buying them what they wanted, including their drugs Others argued that a loving mother or wife has the duty to whatever is needed to keep the addict from committing crimes and causing tensions in the household: It is not fair to say that I spoiled my son I kept him off the streets and in our house, so that he did not have to go out and steal (54-year-old mother of male HIV-positive man, Hanoi) Either way, women make sacrifices for the male addicts in the family, and new wives of addicted husbands are expected to share the burden Quy, for example, lived with her in-laws after her husband’s death Her husband was the eldest son of the family, had started using drugs after their marriage, and was addicted for years: His mother usually paid for his drugs, but he also beat me to get money for his habit My husband had TB but he refused to go for treatment I had to buy him drugs; when he was high, I could persuade him to go to the TB hospital to prevent his infecting our son He had resistant TB and already had AIDS I spent all my money on his treatment to try to keep him alive (32-year-old infected widow, Hanoi) Addiction experts who were interviewed considered the family not just as part of the solution to drug abuse, but also as part of the addiction problem: It is the family that has learned to accept paying for the drug addiction, and addicts know exactly what to say to which member to get what they want In this way, families enable the addictive behavior (Psychiatrist specialized in addiction, national level hospital, Hanoi) Partly because of the difficulties of living with an IDU, not all of the women were living with their in-laws at the time they were widowed In two cases widows had not lived with their husband at their in-laws’ home, but both had lived with the wife’s family, because the in-laws rejected their drug-using HIV-positive son In one case, the family was very wealthy and did not want the son to damage the family image and thereby the family business They paid for his drugs as long as he was out of the house In the 24 P Oosterhoff et al other case, the family was too poor to finance their son’s expensive addiction at home Options for the Widows Downloaded by [Northeastern University] at 10:52 04 January 2015 When the women are widowed, they may have to make decisions about where they will live All were HIV positive when we met them; most not want to want to be a burden or an embarrassment to their elderly parents and other relatives: I have a younger brother and sister who are not married yet We live in a rural area If I move back to my parents,’ my siblings might have more difficulty marrying if somebody finds out that I am an HIV-positive widow.” (HIV-positive widow, 26 years old, Hanoi) The women want to be in a stable family situation; most actively look for male companionship: I want somebody to share my life with, with a good job and a place to stay It’s easy to meet men if you look for them, but it is difficult to find a good one, especially when you are HIV infected (Widowed mother, 26 years old, Hanoi) Because of their health issues, HIV-positive widows need to live near urban areas to access specialized medical care and support The cost of living in Hanoi and Thai Nguyen city was too high for most singles, whether HIV-positive or not, and most of these women worked in family businesses belonging to their in-laws Without family, HIV-positive widows need to find other sources of support A woman who leaves her in-laws might be able to count on the support of her own family, but when her own family lives far away, is not able to help, or is not willing to help her because of HIV-related stigma, she might have to rely on the favors of strangers, especially males One 24-year-old widow living in Hanoi described, “I never have enough money Luckily, my boyfriend supported me, but he left me and I have to it all by myself I hope to meet another man.” Staying With the In-Laws One practical reason why Vietnamese women prefer sons is that they expect that the sons will care for them when they are old, widowed, or both Only four of the 17 women who had either only daughters or whose sons were not responsible for the family lineage stayed with their in-laws In contrast, three of the four women who had a son responsible for the lineage stayed with their in-laws The numbers are small, but it seems that lineage can play a role in the options for a widow; those with a lineage-bearing son who lived 25 Recreating Kinship N = 21 women* responsible for lineage women with sons (1 twin) Downloaded by [Northeastern University] at 10:52 04 January 2015 sons alive 12 not responsible for lineage daughters dead** in-laws departed sons sons alive in-laws departed in-laws departed girls girls alive dead** in-laws departed * We interviewed 24 widows Two couples always had lived with the wife’s family One widow miscarried her child in a late stage of her pregnancy ** These children died because of HIV before the mother left the house of her in-laws FIGURE Sex of child and continuing to live with in-laws after death of husband with their in-laws before the death of the husband are more likely to be able to stay on This does not mean that they are satisfied with the situation One widow did not want to live and raise her son with her own family because of their criminal behavior and drug use She met another man whom she married, and she left her son with his grandparents Two others were rejected by their families, who were unwilling or unable to take care of them: Now I live with my mother-in-law and my twin sons, but we not have a good relationship She said she will raise and feed her grandsons I have to earn for myself My four older sisters are all married, but they cannot support me My parents are old My father is afraid that if the mosquitoes bite me, and then bite other people, that they will become infected (31-year-old HIV-positive widow, Hanoi) Living Alone Living alone is an option in many countries, but not an easy one in the social context of Vietnam Single HIV-positive widowed women encounter stigma related both to the disease and to being a young widow living alone Living alone is not only financially difficult but also makes women even more vulnerable Six of the 24 women lived without a man or a family Two of these women had debts because they borrowed money for a business 26 P Oosterhoff et al Downloaded by [Northeastern University] at 10:52 04 January 2015 and lost their businesses to their in-laws after their husbands died Five had rented a room, and one slept on a bench in a food shop The five women who rented rooms all received financial support from married men or IDU men to supplement their income Three reportedly had their rent paid by married men, probably HIV-negative, whom they met outside the networks of HIV-infected persons and groups They said they wanted a respectful and reliable man with a good social position, and that they use condoms to prevent transmission of HIV These women also said that convincing a man to wear a condom is quite difficult They feared that their lovers would leave them if they learn that they are infected Without disclosing their status, their lovers wonder why they need to use a condom: He’s married and lives abroad most of the year with his wife and family I need him I’m so afraid to lose him if he knows my status We have sex with a condom sometimes He prefers without, so I tell him he should be careful I ask him not to just trust anybody, even me But he just smiles (HIV-positive widow, 26 years old, Hanoi) All widows who lived alone had left their child with their own parents or their in-laws because they could not afford to support them even if they had employment As one 41-year-old HIV-positive widow in Thai Nguyen described, “I had to leave my daughter with my mother so that I can work in town I miss her so much, but it is better for her.” Living With Own Families Six women had been at their in-laws’ homes but returned to live with their own families after their husbands’ deaths, while two already had lived with their spouses at their own parents’ houses The six women who returned all described being pressed to leave by their in-laws and attracted by the more supportive environment in their own family Two former female drug users reported feeling unable to make a living in the household of their in-laws because nobody trusted them, while they could live with their own families with their children and work in the family business From the different stories, a picture emerges of emotional neglect by their in-laws, which preceded women’s decisions to return to their own families Uyen’s case illustrates the isolation of women after their husbands’ deaths Uyen said that she loved her husband in spite of his addiction They lived with his family, and they had a son When her son was two-and-a-half years old, both he and her husband became ill with AIDS Within a month, she lost both of them She was mourning their deaths, but her in-laws did not talk to her and made her sleep on a different floor of the house She described what happened next: Recreating Kinship 27 I moved back in with my family because I could not call my parentsin-law for help when I was sick, because I am just a daughter-in-law If I fell down in that house, no one would know My mother told me it served no purpose to stay with my in-laws Therefore, I went back to my family (HIV-positive widow, lost boy child, 26 years old, Hanoi) Downloaded by [Northeastern University] at 10:52 04 January 2015 After some months of care by her mother and sister, Uyen joined a support group where she met her new boyfriend Duc, former IDU who is also HIV-positive and who wants to marry her Uyen works as a peer educator and helps her own family with household work Duc and Uyen hope to live by themselves and to have children Recreating Kinships Seven of the eight women who lived with their parents had found new male partners, all of whom were former IDUs In five cases, these men had not used hard drugs for more than a year, suggesting that they had strong motivation to stay clean Because of the predominantly male HIV epidemic in Vietnam, it is relatively easy for a young HIV-positive woman to find a new partner at one of the mixed-gender HIV support groups Most members are male former or active drug users who would encounter difficulties in finding a partner who is not already HIV-positive HIV-positive men, who also live in difficult circumstances, are looking for partners, preferably HIVpositive women with whom they can live positively None of the women wanted to marry an active drug addict again, having lived with one already They all had some income, mostly through an existing family business, and four women received stipends for their work as peer educators Both the men and women in these couples wanted to share their lives, but none lived as a traditional family with the woman moving in with her in-laws At the time we met them, the men and women each were staying with their own families, as the following cases illustrate Lam, an unmarried HIV-positive man, is the boyfriend of HIV-positive widow Nguyet Lam is former miner, currently unemployed and living with his grandmother He became a drug user while working in abandoned mines, leading a group of others digging illegally for gold They shared drugs and needles to keep working Never married, he found Nguyet through an HIVpositive support group in Thai Nguyen: We are a group of lonely men We love it when a new female member comes and joins us All the men in our HIV support group want to find love and have a family I was one of the lucky men who found a woman who wants to marry me Downloaded by [Northeastern University] at 10:52 04 January 2015 28 P Oosterhoff et al Nguyet lives with her small daughter at her own mother’s house, where she makes an adequate living raising chickens Nguyet knows about Lam’s past but she is ready for a new relationship The couple’s families approve of their relationship, but they not know if they will live together after they marry, because Nguyet’s daughter and her business also need her In Nguyet’s words, “I really want to marry again and have another child with my new boyfriend He has had an unhappy life, as his mother died young I want him and his grandmother to have a baby to hold.” None of the families reportedly protested against this unusual arrangement, in which widows with children stay with their own families while having a relationship with a new man; on the contrary, they seemed relieved Linh, a widowed mother with a young daughter, also met her current boyfriend Dung, a former miner, in a support group for HIV-positive persons She wants to raise her daughter in the stable environment of her own family, who are happy that she has a relationship with a man who loves her Her boyfriend’s mother, a war widow, is happy about the support her son is receiving: He joined a support group where he met his new wife a year ago At first I was worried that if they cannot practice family planning, they probably will have children I not want to have HIV-positive grandchildren But if it is just because they love each other, then I agree with their choice I know my daughter-in-law’s status and I love her as my daughter She is very kind and she can change my son for the better He has not used drugs for a year She is very strict Her first husband was a drug user but she is not Her daughter is a good girl If they are happy, I am happy Linh and Dung both volunteer in support groups Dung supports her practically and emotionally, and he is proud of and grateful to her: “I am who I am because of her She gives me strength.” Only one widow, herself a recovering IDU who returned to her own family, stopped looking for love and protection from men outside her family Her father is a member of parliament She has a stable and intimate relationship with a woman, also an HIV-positive former IDU She joined a support group and became a leader because of her good education, energy, and people skills: Now I want to spend my life fighting drugs and helping other female addicts I want my family to be proud of me, and I want to show them that even though I used drugs and became infected, I can still be useful (32-year-old HIV-positive widow with a son) Recreating Kinship 29 Downloaded by [Northeastern University] at 10:52 04 January 2015 Living With the Double Stigma of HIV and Widowhood We interviewed 19 newcomers at their support group At first, all women reported very low self-esteem and feelings of isolation, helplessness, and misunderstanding They looked ill, poorly dressed, and neglected Even just asking how they were could start tears flowing They said that they had sacrificed care for themselves by remaining silent about their HIV status They had no plans for the future The most serious acts of stigma also were reported during these first encounters Being in a group enabled them to tolerate the double stigma of HIV and widowhood and to regain confidence in themselves and in others For example, during the first interview with Anh Thu, a widow in Thai Nguyen, she described felt and enacted stigma: I feel sick and weak I came to the group for help I could not stay with my in-laws, because my mother-in-law sold the land where I used to live I used to cook at village parties, and people used to help me with the rice harvest Now that my husband has died of AIDS and they suspect that I am infected, nobody wants to work with me anymore After some months, however, her perception of her situation had become more optimistic: I can share my feelings with others in the group Some are in worse situations than I am They have nobody, but I have my daughter and my mother I now see that my mother-in-law is in a very difficult situation herself, having three addicted, HIV-positive sons Two years later, she was running a food shop and had become an active, cheerful member of the group, doing outreach to rural women like herself Another example is Tuyet, who had just returned to live with her own family with her 3-year-old daughter She reported that after her husband’s death her family-in-law made her feel invisible: My family-in-law sees me as a nobody My child could not play with other children I felt isolated and lonely, so I came home and now live off my family’s kindness I not have a future plan I want to give my child away, because I cannot care for her A few months later, however, she had made friends through the support group who helped her to get medical care She gained weight, started to work at the market selling various goods, and had become more optimistic, commenting, “I am lucky I have medicines; I feel much better I am very busy with my business and can care for my child without my 30 P Oosterhoff et al Downloaded by [Northeastern University] at 10:52 04 January 2015 backward rural in-laws I don’t believe in fate I believe in taking care of my daughter.” When we met Hong, a recovering drug user, she was pregnant and had just married the father of her child, also a former drug user It was difficult to convince his family to accept the marriage and let her move in with them at first; they thought she was not a good match, but her husband subsequently relapsed and died of AIDS and she moved back to her own family with her daughter after his death She described her situation: I feel sad for my husband, but I am relieved to escape my in-laws’ criticism I don’t need a man or in-laws who not accept me I am a widow and HIV-positive, but I feel pretty good I work hard and stay clean I run a business now with my mother at our house I help members in the group who need and deserve my help All widows in the different groups emphasized that the groups had helped them to overcome low self-esteem and lack of confidence related to being an HIV-positive infected person and a widow, and that this was very important to their ability to start new lives As one widow in Thai Nguyen described, “Talking to others and learning from their experiences has really helped me and given me hope My partner, whom I met through the group, had the same experience and this has made our love stronger.” Discussion With women increasingly infected and affected by HIV/AIDS, there is a global feminization of HIV/AIDS (Dworkin & Ehrhardt, 2007; UNAIDS & WHO, 2006) In the Vietnamese context, with a drug-driven HIV epidemic concentrated among males, the options and lives of their wives are shaped not only by HIV infection, but also by the illicit drug epidemic Both the HIV and illicit drug epidemics have been linked to the national “renovation” policy, or Doi Moi, which began in 1986 These women’s husbands had jobs, but usually in environments like mining that create opportunities for illegal drug use Whether or not male addicts worked, their female partners reported cofinancing their drug habits in order to keep them at home and off the street When the women were married, the burden of drug abuse and care for HIV-infected men added to the care and support tasks that weigh on many Vietnamese women in the current context of change The widows described how, when their husbands were alive, the women of different generations in the household rarely combined forces except to support the needs of the male drug users, reinforcing their roles as mothers/caretakers, depleting them financially, and perpetuating broader existing gender inequalities Only four women had jobs outside the family before they were widowed and these were all in the private sector, which has worse terms and conditions for Downloaded by [Northeastern University] at 10:52 04 January 2015 Recreating Kinship 31 women than the public sector (Akram-Lodhi, 2002) The rest worked in the informal sector, in family businesses usually located at their in-laws’ houses These women resist their subjection, but they seem unable to change their situation at their in-laws’ houses by themselves, not only because of patriarchal and patrilocal cultural norms but also because of economic constraints, the criminalization of drug use, and HIV-related stigma A study on HIV-related stigma in Vietnam found that the most important causes were people’s fear of casual transmission and moral judgments and assumptions about lifestyles (Khuat, Nguyen, & Ogden, 2004) This was confirmed in the study Some widows reported enacted HIV-related stigma related to fear of transmission, which resulted in their being required to live in a separate room or eat alone, while other discriminatory behavior was related to views on their supposed immoral behavior Social disqualification of individuals who are identified with health problems is a characteristic of health-related stigma (Weiss et al., 2006) The widows who ended up living alone apparently had disqualified themselves socially They felt they could not burden their parents or siblings and bring shame to the house They did not feel welcome in their in-laws’ homes, partly because of their HIV status In some countries, it is not uncommon for women to live alone with children In Vietnam, living alone is financially difficult; the state promotes “happy families,” discouraging women from living alone (Phinney, 2003) The AIDS widows in this study did not want to live alone, perhaps because women of their age who live alone could be suspected of being HIV infected, using drugs, or doing sex work Such suspicions and can be related to Vietnam’s rapid economic modernization and the concomitant commoditization of sexual services by women, whereby often women from the countryside migrate to urban areas and sell sex (Earl, 2004; Nguyen-Vo Thu Huong, 2002; Walters, 2004) The HIV-related stigma the women want to avoid may be part of a process of social exclusion and reinforcement of existing social inequalities, such as gender inequalities (Parker & Aggleton, 2003; Parker, Aggleton, Attawell, Pulerwitz, & Brown, 2002) Son preference seems to play a role in the options of widows The children of these women are too young to care for their mothers Widows with a son who holds the family lineage, however, may be more likely to have the option of staying with their in-laws On the other hand, widows who stay with their in-laws often not feel part of a family, which is what they want—whether they stay with their in-laws, their own family, or alone Feminist authors have suggested that lack of self-esteem can lead to behavior that continues to marginalize and disempower women (Malhotra, Schuler, & Boender, 2002; Schrijvers, 1985) A study in India found that the actual stigma experienced by those infected with HIV was much less than the stigma HIV-positive people fear they will experience, that is, perceived stigma (Thomas et al., 2005) HIV-infected persons’ negative perceptions Downloaded by [Northeastern University] at 10:52 04 January 2015 32 P Oosterhoff et al of themselves might thus be as significant a problem as others’ negative perceptions of them Low self-esteem can change over time, and our findings suggest that widows’ negative perceptions of themselves changed as they became members of a support group Men and women reported strong emotional benefits and the release of emotional pressure by sharing their status openly in a peer group This effect might be what has been labeled as the paradox of coming out openly as an HIV-positive person: by facing AIDS-related stigma, one finds psychological release—liberation from the burdens of secrecy and shame (Paxton, 2002) Studies in other countries have shown that many people who are aware of their HIV status change their behavior to diminish the risk of infecting other people (Cleary et al., 1991; Colfax et al., 2002; Otten, Zaidi, Wroten, Witte, & Peterman, 1993) Several women in our group failed to undertake such protective behavior toward others Looking at the social pressures brought to bear on them partially explains their behavior These women are economically vulnerable and receive financial support for sexual favors from various men, which they are afraid of losing if they disclose their HIV-positive status They might be called sex workers but not see themselves that way They emphasize that they feel emotionally close to their boyfriends Almost all women look for infected partners in HIV-positive support groups This confirms findings in studies in the United States showing that HIV-positive people are unlikely to choose a partner with opposite HIV status (Wiktor et al., 1990) The evidence is that there are no linear connections between the different spheres of life in which women are (dis)empowered; greater economic freedom for example does not always equate greater reproductive freedom (Beegle, Frankenberg, & Thomas, 2001; Hashemi, Syed, Schuler, & Riley, 1996; Kabeer, 2001; Kishor, 2000) The HIV-positive AIDS widows in our study illustrate some of the complexities of (dis)empowerment Almost all were probably infected by their husband, which suggests that they were not able to protect their health, including their reproductive health They lacked individual economic autonomy when they lived with their in-laws Moreover, the women who had made investments in the business of their in-laws lost the business when they moved out after their husband’s death Because of the demographics of the epidemic and the increasing number of support groups, however, women have access to new networks The networks help women and men to learn about their disease and to encounter peers The widows who left their in-laws and returned to their own families could earn and keep income from their own families’ businesses Because of their work as peer educators, some women received stipends that are not available to poor women who are HIV-negative The groups also help HIV-positive women find HIV-positive male partners HIV-positive widows reported no fear of being discriminated against by HIV-positive men; their HIV status actually connected them A third of Downloaded by [Northeastern University] at 10:52 04 January 2015 Recreating Kinship 33 them could have an intimate relationship while remaining with their own family, with or without their children The women who lived with their own families reported feeling released from at least some of the stress of living in the households of their in-laws For some women, HIV, as devastating as its impact on their health has been, has turned out to have a few modest social benefits Their husbands’ deaths freed them from the problems of living with an HIV-positive drug user, and often also of living in the household of his family The widows who returned to their own families had the option of seeking a new partner, although almost all also were recovering drug users It is possible that these new partners will relapse and that the widows will be in the same situation as in their first marriage, but most of the men had been clean for more than a year when they met the women For the time being, these women have established new living arrangements, in which they have an intimate relationship with a man and a stable environment for themselves and their children in their own family REFERENCES Akram-Lodhi, H (2002) All decisions are top-down: Engendering public expenditure in Vietnam Feminist Economics, 8(3), 1–19 Beegle, K., Frankenberg, E., & Thomas, D (2001) Bargaining power within couples and use of prenatal and delivery care in Indonesia Studies in Family Planning, 32, 130–146 Belanger, D (2002) Son preference in a rural village in North Vietnam Studies in Family Planning, 33, 321–334 Bousquet, G., & Taylor, G (2005) Le Viet Nam au feminin [Vietnam: Women’s realities.] Paris: Les Indes Savants Brown, L., Trujillo, L., & Macintyre, K (2001) Interventions to reduce HIV/AIDS stigma: What have we learned? New York: Guilford Press Cleary, P D., Devanter, N V., Rogers, T F., Singer, E., Shipton-Levy, R., Steilen, M., et al (1991) Behavior changes after notification of HIV infection American Journal of Public Health, 81, 1586–1590 Colfax, G N., Buchbinder, S P., Cornelisse, P G A., Vittinghoff, E., Mayer, K., & Celum, C (2002) Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion AIDS 16, 1529– 1535 Center for Strategic and International Studies (CSIS) (2006) HIV/AIDS in Vietnam Hanoi: Author Dworkin, S L., & Ehrhardt, A A (2007) Going beyond “ABC” to include “GEM”: Critical reflections on progress in the HIV/AIDS epidemic American Journal of Public Health, 97, 13–18 Earl, C (2004) Leisure and social mobility in Ho Chi Minh City In P Taylor (Ed.), Social inequality in Vietnam and the challenges to reform Singapore: Institute of Southeast Asian Studies Downloaded by [Northeastern University] at 10:52 04 January 2015 34 P Oosterhoff et al Gammeltoft, T (1999) Women’s bodies, women’s worries: Health and family planning in a Vietnamese rural commune Richmond: Curzon Press Gerbert, B., Maguire, B T., Bleecker, T., Coates, T J., & McPhee, S J (1991) Primary care physicians and AIDS: Attitudinal and structural barriers to care Journal of American Medicine Association, 266, 2837–2842 Hashemi, Syed, M., Schuler, S R., & Riley, A.P (1996) Rural credit programs and women’s empowerment in Bangladesh World Development, 24, 635– 653 Haughton, D., & Haughton, J (1995) Son preference in Vietnam Studies in Family Planning, 26, 325–338 Herek, G M., & Capitanio, G P (1998) Symbolic prejudice or fear of infection? A functional analysis of AIDS-related stigma among heterosexual adults Basic and Applied Social Psychology, Health & Medicine, 20, 230–241 Herek, G M., & Glunt, E K (1988) An epidemic of stigma: Public reactions to AIDS American Psychology, 43, 886–892 Hien, N T., Giang, L T., Binh, P N., Deville, W., van Ameijden E.J.C., & Wolffers, I (2001) Risk factors of HIV infection and needle sharing among injecting drug users in Ho Chi Minh City, Vietnam Journal of Substance Abuse, 13, 45–58 Hien, N T, Giang, L T., Binh, P N., & Wolffers, I (2000) The social context of HIV risk behavior by drug injectors in Ho Chi Minh City, Vietnam AIDS Care, 12, 483–495 Human Rights Watch (2002) Double standards: Women’s property rights violations in Kenya New York: Author Human Rights Watch (2003) Policy paralysis: A call for action on HIV/AIDS-related human rights abuses against women and girls in Africa New York: Author International Center for Research on Women (ICRW) (2005) Women’s property and inheritance rights in the context of HIV/AIDS: Report on South Asia (Draft) Washington, DC: Author Jacoby, A (1994) Felt versus enacted stigma: A concept revisited Evidence from a study of people with epilepsy in remission Social Science and Medicine, 38, 269–274 Kabeer, N (2001) Reflections on the measurement of women’s empowerment Stockholm: Novum Grafiska AB Khuat, T H., Nguyen, T V A., & Ogden, J (2004) Understanding HIV and AIDSrelated stigma and discrimination Hanoi: ISDS Kishor, S (2000) Empowerment of women in Egypt and links to the survival and health of their infants In H Presser & G Sen (Eds.), Women’s empowerment and demographic processes: Moving beyond Cairo New York: Oxford University Press Malcolm, A., Aggleton, P., Bronfman, M., Galvao, J., Mane, P., & Verrall, S (1998) HIV-related stigmatisation and discrimination: Its forms and contexts Critical Public Health, 8, 347–370 Malhotra, A., Schuler, S R., & Boender, C (2002) Measuring women’s empowerment as a variable in international development Background paper prepared for the World Bank workshop on poverty and gender Washington, DC: New Perspectives Marr, D (1984) Vietnamese tradition on trial 1920–1945 (Reprint edition) Berkeley: University of California Press Downloaded by [Northeastern University] at 10:52 04 January 2015 Recreating Kinship 35 Ministry of Health (MOH) (2006a) Decision 214/2006/QD-TTg Approval for the proposal “Manage vocational training and job advocacy for ex drug users in Hanoi” Hanoi: Author Ministry of Health (MOH) (2006b) Five-year review workshop on HIV/AIDS prevention and control in 2001–2005 and action plan for 2006–2010 (149/BC-BYT) Hanoi: Author Ministry of Health (MOH) (2006c) Report scaling up towards universal access to HIV/AIDS prevention, treatment, care and support in Viet Nam Hanoi: Author Nguyen-Vo Thu Huong (2002) Governing sex: Medicine and governmental intervention in prostitution In J Werner & D Belanger (Eds.), Gender, household, state: Doi Moi in Viet Nam Ithaca, NY: Southeast Asia Program Publications Nguyen-Vo Thu Huong (1998) Governing the social: Prostitution and liberal governance in Vietnam during mercerisation Irvine, CA: University of California Press Otten, M W., Zaidi, J A A., Wroten, J E., Witte, J J., & Peterman, T (1993) Changes in sexually transmitted disease rates after HIV testing and post-test counselling, Miami, 1988 to 1989 American Journal of Public Health, 83, 529–533 Parker, R., & Aggleton, P (2003) HIV and AIDS-related stigma and discrimination: A conceptual framework and implications for action Social Science & Medicine, 57, 15–24 Parker, R., Aggleton, P., Attawell, K., Pulerwitz, J., & Brown, L (2002) HIV/AIDSrelated stigma and discrimination: A conceptual framework and an agenda for action Washington, DC: Horizons/Population Council Paxton, S (2002) The paradox of public HIV disclosure AIDS Care, 14, 559–567 Paxton, S., Gonzales, G., Uppakaew, K., Abraham, K K., Okta, S., Green, C., et al (2005) AIDS-related discrimination in Asia AIDS Care, 17, 413–424 Phan, H T T (2004) Sexual coercion within marriage: A qualitative study in a rural area of Quang Tri, Vietnam Amsterdam: University of Amsterdam Phinney, H M (2003) Asking for a child: The refashioning of reproductive space in post-war northern Vietnam The Asia Pacific Journal of Anthropology, 16, 215–230 Phinney, H M (2005, December) Rice is essential but tiresome, you should get some noodles: The political economy of married women’s HIV risk in Ha Noi, Viet Nam Department of Anthropology University of Washington Paper presented at American Public Health Association 133rd Annual Meeting & Exposition Philadelphia, PA Schrijvers, J (1985) Mothers for life: Motherhood and marginalisation in the North central province of Sri Lanka Eburon: Delft Scrambler, G (1998) Stigma and disease: Changing paradigms Lancet, 352(9133), 1054–1055 Sweetman, C (2006) How title deeds make sex safer: Women’s property rights in an era of HIV Oxford, UK: Oxfam Thomas, B E., Rehman, F., Suryanarayanan, D., Josephine, K., Dilip, M., Dorairaj, V S., et al (2005) How stigmatizing is stigma in the life of people living with HIV: A study on HIV positive individuals from Chennai, South India AIDS Care, 17, 795–801 Downloaded by [Northeastern University] at 10:52 04 January 2015 36 P Oosterhoff et al Tran Hien, N T (2002) Epidemiology of HIV/AIDS in Vietnam Amsterdam: Vrije Universiteit Tran Hien, N T (2007) Situation of HIV/AIDS/STI surveillance in Vietnam Paper presented at the National conference on HIV/AIDS M&E, Hanoi Tung, N D., Tuan, N A., Hien, N T., Hoang, T V., Thang, B D., Chung, A K T., et al (2001) Behavioural survey in Vietnam 2000 Hanoi: NASB/FHI UNAIDS & WHO (2006) AIDS epidemic update Geneva: Author Voluntary Services Overseas-Regional AIDS Initiative of Southern Africa (VSORAISA) (2005) “You don’t belong here”: Fear, blame and shame around HIV & AIDS Proceedings of VSO-RAISA Regional Conference, Pretoria, South Africa Walters, I (2004) Dutiful daughters and temporary wives: Economic dependency on commercial sex in Vietnam In E Miccolier (Ed.), The social construction of sexuality and sexual risk in a time of AIDS (pp 76–97) London: Routledge Curzon Weiss, M G., Ramakrishna, J., & Somma, D (2006) Health-related stigma: Rethinking concepts and interventions Psychology, Health & Medicine, 11, 277–287 Werner, J., & Belanger, D (2002) Gender, household, state: Doi Moi in Viet Nam New York: Cornell University Southeast Asia Program Publications Wiktor, S J., Biggar, R J., Melgye, M., Ebbesen, P., Colclough, G., Di Gioia, R., et al (1990) Effect of knowledge of human immunodeficiency virus infection status on sexual activity among homosexual men Journal of Acquired Immune Deficiency Syndrome, 3, 62–68 ... ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399330903133424 Recreating Kinship: Coping Options of HIV+ AIDS Widows in Vietnam PAULINE OOSTERHOFF Pauline Oosterhoff Medical Committee... leaving more AIDS widows behind, often young women According to Confucian doctrine, the status of a Vietnamese woman during different stages of her life is closely linked to her role in providing... refers to the acts of discrimination Individuals who enact stigmatizing or discriminatory behavior are referred to as the perpetrators of stigma and discrimination, whereas infected and affected