DSpace at VNU: Recreating Kinship: Coping Options of HIV+ AIDS Widows in Vietnam

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:
/>
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: />
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 />

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 2 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
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 3 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
1
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

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.”


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 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-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 2 years revealed HIV-positive AIDS
widows’ actual experiences of and opportunities for starting a new life. Given
the patrilinear and patrilocal culture, where do they live when their husbands
die? Does having a son influence their options? How do 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 2 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 6 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 1 year at the Provincial Women’s Union in
Thai Nguyen, and for 2 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 do 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 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 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 do 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
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 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*

9 responsible for lineage

4 women with 5 sons (1 twin)

Downloaded by [Northeastern University] at 10:52 04 January 2015

4 sons alive

12 not responsible for lineage

5 daughters

1 dead**

3 in-laws 1 departed

5 sons

5 sons alive

1 in-laws 4 departed

2 in-laws 3 departed

7 girls

6 girls alive 1 dead**

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 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 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 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 do 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 do 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 do 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 do 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 do 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 do 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.