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b Hanoi Medical University , Hanoi , Vietnamc

Hanoi National University , Hanoi , Vietnamd

Medical Committee Netherlands Vietnam , Hanoi , Vietname

Amsterdam School for Social Research , Amsterdam , TheNetherlands

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 forWomen International, 31:1, 17-36, DOI: 10.1080/07399330903133424

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Copyright © Taylor & Francis Group, LLC

ISSN: 0739-9332 print / 1096-4665 online

DOI: 10.1080/07399330903133424

Recreating Kinship: Coping Options

PAULINE OOSTERHOFF

Pauline Oosterhoff Medical Committee Netherlands, Hanoi, Vietnam

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 2 years after their husbands’ deaths in a patrilinear and patrilocal setting where HIV is stigma- tized 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, look- ing 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 theempowerment of HIV-positive women, including AIDS widows, throughvarious means, including their membership in support groups Challenges

in preventing and mitigating the effects of HIV/AIDS are shaped and enced by cultural norms and values that enforce or reinforce existing genderinequalities In many Asian countries, widows are discriminated against andeven blamed for their husbands’ deaths For instance, Indian widows may

influ-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

no longer be expected to commit sati, but many still are forced out oftheir in-laws’ homes and live on charity Studies in African countries haveshown that in addition to their vulnerability related to widowhood, womenwhose partners die of AIDS often face social rejection related to the disease(Human Rights Watch, 2002, 2003; International Center for Research onWomen, 2005) In countries like Kenya, where the HIV/AIDS pandemic hashit hardest, thousands of women face destitution because they lack the right

to inherit property upon their husbands’ deaths (Sweetman, 2006) Traditionscommon in several African countries, such as widows marrying their deadhusband’s brother, that might have benefited widows in the past by assuringthem a home, may now contribute to the spread of the epidemic

The negative impact of stigma against HIV-infected persons on publichealth 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 socialdisqualification of individuals and populations identified with a particularhealth 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 discriminationarising from an undesirable attribute, disease (such as epilepsy or HIV),

or association with a particular group Enacted stigma refers to the acts ofdiscrimination Individuals who enact stigmatizing or discriminatory behaviorare referred to as the perpetrators of stigma and discrimination, whereasinfected and affected persons are the targets (Herek & Capitanio, 1998).Others consider HIV stigma as part of a larger process that works to produceand reproduce power relations, in which the HIV-related stigma reinforcesexisting 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 sponse to and effects of the HIV epidemic in Vietnam The national preva-lence 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 for50.5% of all reported HIV infections (Tran Hien, 2007) Reported HIV preva-lence 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 struc-tured by national social policies implemented in the context of the national

“renovation” policy, or Doi Moi, which began in 1986, shortly before HIV

appeared in Vietnam The state has promoted a modernizing vision of ahappy, rich, and cultured family with two children Economic growth andpoverty alleviation in Vietnam have been considered impressive, and popula-tion growth has slowed The gender effects of changing public expenditures,however, such as privatization of state companies and the introduction ofdirect 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, puttingthem 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 ing infected While antiretroviral (ARV) drugs are increasingly available inVietnam, not all patients who need these drugs have access to them, oftenfor financial reasons (MOH, 2006c) The number of patient and self-helpgroups has grown dramatically in the last 3 years (Center for Strategic andInternational Studies [CSIS], 2006), but the number of AIDS deaths in Vietnam

becom-is still rbecom-ising, leaving more AIDS widows behind, often young women.According to Confucian doctrine, the status of a Vietnamese womanduring different stages of her life is closely linked to her role in providingchildren, preferably male (Marr, 1984) One practical reason for son pref-erence 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 newerlaws, such as the 1959 Law on Marriage and the Family.1A 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

1

Clauses 7 and 8 in the Law on Marriage and Family in 1959 protect widows: Clause

7 clarifies that to be in mourning is not an obstacle for getting remarried Clause 8 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).

2

"Trai tơ ơi hỡi trai tơ

Đi đâu mà vội mà vơ nạ dòng

Nạ dòng lấy được trai tơ Đêm nằm hí hửng như Ngô được vàng Trai tơ vớ phải nạ dòng

Như nước mắm thối chấm lòng lợn thiu"

“Hey, unmarried man Why do 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.”

shown that son preference is still widespread in Vietnam, possibly on parwith Bangladesh and China (Belanger, 2002; Haughton & Haughton, 1995).

As the guardian of the family’s respectability and the enforcer of itsmoral 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 fam-ily, endorsed by the large Women’s Union, places the burden for populationcontrol on married women (Nguyen-Vo Thu-Huong, 1998), who feel obli-gated to have sex within their marriage (Phan, 2004) A woman infected withHIV is considered to have brought shame to the household, for which shemay be blamed more than a man (Khuat, Nguyen, & Ogden, 2004)

In the Vietnamese patrilinear and patrilocal context, one might assumethat HIV-negative AIDS widows, like AIDS widows in other countries, arevulnerable, and occupy a very low position in the household and in theircommunities In addition to being women, they are also widows, and theyhave a stigmatizing health problem that requires expensive life-long treat-ment 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 forwhom the official vision of the “happy” family is unattainable For marriedVietnamese women in a marginalized social sector, with low status and lim-ited options, the issue of the transition to AIDS “widow” status may be morecomplicated than at first it seems Vietnamese AIDS widows might differ fromother Vietnamese widows because they tend to be young women with seri-ous health problems, but they also have resources such as support groupsthat other Vietnamese widows do 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-positiveAIDS widows after their husbands’ deaths in a patrilinear and patrilocalsetting where HIV is stigmatized because of its association with drugs andsex work but where support groups for HIV-positive persons are available.Following the lives of these women over 2 years revealed HIV-positive AIDSwidows’ actual experiences of and opportunities for starting a new life Giventhe patrilinear and patrilocal culture, where do they live when their husbandsdie? Does having a son influence their options? How do women use existingkinship 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

in Thai Nguyen province, all in Northern Vietnam All areas have relativelyhigh HIV prevalence rates for Vietnam, concentrated among IDUs.

We interviewed a convenience sample of 24 widows, all infected withHIV, 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 areindependent groups (the “Bright Futures”) Of these 24 women, 17 were

in Hanoi, where they had joined support groups to access support servicesunavailable in their own province All the groups meet weekly or biweekly

to provide psychosocial support to members and to assist them in accessingmedical treatment Of the seven widows interviewed in Thai Nguyen, twowere from rural areas and had come to the city for work and for AIDS-relatedservices

When we first met these 24 women, 19 had just joined a support groupwithin the previous 2 months We met 18 of them on their first visit tothe 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 forless than 6 months The interviews took place at the support group officesafter the women had signed consent forms We used semistructured ques-tionnaires to ask about HIV, child desire, lineage, care and support for thewomen, and their health In 16 cases, we also interviewed the women’s fam-ily members, in-laws, and boyfriends The remaining eight women proposed

no new partners or family members willing or living close enough to beinterviewed

Participant observation of the programs in which the widows were rolled was conducted weekly for 1 year at the Provincial Women’s Union inThai Nguyen, and for 2 years at the District Red Cross in Hanoi Observationincluded interactions in support group meetings, with health care providers,household visits, and the counseling available through the support groups

en-In three cases, we knew the women while their husbands were still aliveand witnessed their last months together The bias of the sample is that allthe women interviewed were active, in the sense that they had sought thehelp of a support group for treatment and care

All but one woman were ethnic Kinh, the largest cultural group inVietnam; the women studied had diverse social and economic backgroundsand 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 earlyforties 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 providerswho work on drug addiction and HIV/AIDS Their names have been changed

to protect their privacy

RESULTSFamily Situation for Women Married to HIV+

Men Prior to Widowhood

To understand what happens to HIV-positive women after their husbandsdie of AIDS, we need a clearer picture of gender and power relations in thehouseholds 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 fourwomen were employed outside the family, all in the private sector Threedescribed themselves as unemployed Three owned and managed small busi-nesses located in their in-laws’ houses, and two assisted their own familieswith a business The 12 others described their work as assisting their in-laws

in household work, small business, or farming Most widows had not beenaware of their husbands’ addictions when they married; 18 of the 24 hadfound out after marriage that their husband was an active drug user Womenlearned about their husbands’ HIV-positive status either because he becameill or during antenatal care (ANC), and they had to support their husbanduntil 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 beingwarned of her husband’s addiction During ANC, she tested HIV positive Thesituation 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, switchedoff her cell phone, and asked the support group and its related project toexplain her actions to her husband and his family For days her husbandsat on his scooter in front of the support group’s office, hoping for herreturn She left her lover and came back to her in-laws, taking out a loan toestablish a scooter-washing business, hoping that capital assets and a job forher husband would improve the situation, but her husband used the moneyshe 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 fordrug users Women like Mai tried to change their situation, but they reportedfeeling socially stigmatized in the neighborhood because of both illicit druguse and HIV infection in the family All reported that women—mothers,

sisters, wives, grandmothers, and aunts—contribute to buying drugs for theaddicted men in a household, trying to keep them at home and to savefamily “face.” When this does not work, women will pay for rehabilitation;husbands of 10 of the women had been in a state rehabilitation center fordrug users Interviews and observations revealed that as long as the drug-using husband was alive, an important part of the women’s lives revolvedaround catering to his many needs Some women reported feeling guiltyabout spoiling their husbands, sons, or grandsons by buying them what theywanted, including their drugs Others argued that a loving mother or wifehas the duty to do whatever is needed to keep the addict from committingcrimes 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 husbandwas the eldest son of the family, had started using drugs after their marriage,and was addicted for 8 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 addictionproblem:

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 thewomen were living with their in-laws at the time they were widowed Intwo 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 theirdrug-using HIV-positive son In one case, the family was very wealthy anddid not want the son to damage the family image and thereby the familybusiness They paid for his drugs as long as he was out of the house In the

other case, the family was too poor to finance their son’s expensive addiction

at home

Options for the Widows

When the women are widowed, they may have to make decisions aboutwhere they will live All were HIV positive when we met them; most do notwant to want to be a burden or an embarrassment to their elderly parentsand 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 lookfor 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 urbanareas to access specialized medical care and support The cost of living

in Hanoi and Thai Nguyen city was too high for most singles, whetherHIV-positive or not, and most of these women worked in family businessesbelonging to their in-laws Without family, HIV-positive widows need to findother sources of support A woman who leaves her in-laws might be able tocount on the support of her own family, but when her own family lives faraway, is not able to help, or is not willing to help her because of HIV-relatedstigma, she might have to rely on the favors of strangers, especially males.One 24-year-old widow living in Hanoi described, “I never have enoughmoney Luckily, my boyfriend supported me, but he left me and I have to

do 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 expectthat the sons will care for them when they are old, widowed, or both Onlyfour of the 17 women who had either only daughters or whose sons werenot 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 stayedwith 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

N = 21 women*

9 responsible for lineage 12 not responsible for lineage

4 women with 5 sons (1 twin) 5 daughters 5 sons 7 girls

4 sons alive 1 dead** 5 sons alive 6 girls alive 1 dead**

3 in-laws 1 departed 1 in-laws 4 departed 2 in-laws 3 departed 1 in-laws 6 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 1 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 familybecause of their criminal behavior and drug use She met another man whomshe married, and she left her son with his grandparents Two others wererejected by their families, who were unwilling or unable to take care ofthem:

Now I live with my mother-in-law and my twin sons, but we do 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 thesocial context of Vietnam Single HIV-positive widowed women encounterstigma related both to the disease and to being a young widow living alone.Living alone is not only financially difficult but also makes women evenmore 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