SHAPC

RESEARCH REPORT

MSM sex-workers in Hanoi: High risk behaviors and barriers to HIV prevention

1
 Hanoi, September 2010

Abbreviations
AIDS Acquired Immune Deficiency Syndrome
HIV Virus HIV
STDs Sexually transmitted diseases
MSM Men who have sex with men
RP Reproductive Health
STI Sexually transmitted infection
VCT HIV Voluntary Counseling and Testing
EEs Entertainment Establishments

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Contents
I. Introduction ........................................................................................................4
1.1. Objective of the research ................................................................................5
1.2. Research methodology ...............................................................................5
II. Characteristics of samples in the study ..............................................................9
III. Knowledge on HIV/STIs and disease prevention measures ..........................10
3.1. Knowledge on HIV/AIDS ........................................................................10
3.2. HIV Testing ..............................................................................................16
3.3. Sexually transmitted diseases (STDs) ......................................................18
IV. HIV/STD infection risk behaviours and prevention behaviours ....................18
4.1. Sex partner number, frequency and forms of sex work/activity ..............18
4.2. Purposes of sex work................................................................................23
4.3. Use of condoms and lubricants ................................................................30
4.4. Alcohol and drug use................................................................................37
V. Working for the establishment owner ..............................................................39
VI. Participating in club activities or using reproductive health counseling/VCT
services .....................................................................................................................43
VII. Barriers encountered by MSWs in HIV/AIDS prevention and control ......48
7.1. Barriers as a result from lack of understanding .......................................48
7.2. Barriers stemming from value perception of sexual activities ................49
7.3. Barriers stemming from situational context .............................................49
7.4. Barriers due to power unbalance in sexual relationship ..........................50
7.5. Barriers due to the nature of male sex work ............................................51
7.6. Barriers caused by self complex and self stigma of MSWs.....................52
VIII. Conclusions and recommendations .............................................................54

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I. Introduction

“MSM” is an issue faced by many nations in the world (USAIDS 2006). This
global issue (UNAIDS 2006) requires the joint effort of the whole society. In
Vietnam, recently MSM has attracted the attention of researchers, practitioners in
the field of reproductive health and HIV prevention and policy makers.

There is a number of scientists who implemented projects and research reports

about MSM focusing on characteristics, reality, and risks of HIV/AIDS infection
or social stigma toward MSM (Colby 2003; Colby, Nghia Huu Cao, and
Doussantousse 2004; Vũ Mạnh Lợi, Trần Thị Nga, and colleagues, 2009).
However, MSM sex work is still new and has not gotten much attention. There are
a few studies mentioning this social group and research findings are often
discussed in workshop but have not been widely publicized.

Based on experience in implementing the project “Male sexual health

interventions in Hanoi” funded by USAID/FHI and the research project “MSM in
Vietnam – Social Stigma and Consequences” funded by Ford Foundation,
STDs/HIV/AIDS Prevention Center (SHAPC) recognizes that MSM are facing
difficulties such as stigma from the family and the community, hinderences to the
practice of MSM rights and access to healthcare, education, employment, and
entertainment services. Despite the MSM prevention activities in place and
existing friendly/VCT service network in Hanoi, MSM often find them hard to
access these services, especially MSM sex workers. This contains potentially high
risks of HIV/AIDS infection for their partners and the community.

Supported by the funds from AmfAR, SHAPC implemented the research project
“MSM sex workers in Hanoi - High risks and barriers to HIV prevention” with the
purpose of providing the general reality of MSM sex workers and barriers to

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HIV/STIs prevention and at the same time making recommendations to
organizations involved in HIV/AIDS prevention for their better interventions in
HIV prevention for MSM sex workers.

1.1. Objective of the research

 Describe the reality of MSM sex workers: social characteristics,

understanding about HIV/STD
 Explore the high risk behaviors among MSM sex workers in Hanoi
 Explore the barriers towards MSM sex workers in HIV prevention
 Define the needs of MSM sex workers in Hanoi in HIV prevention
 Propose the intervention solutions to enhance the resources and access
opportunity for MSM to HIV/STIs prevention, thus reducing STIs/HIV
infection among MSM and in the community.

1.2. Research methodology

The research team combines the qualitative method (in-depth interview) with
quantitative questionnaires and observation.

Sampling method

Commercial sex work in general and MSM sex work in particular are not accepted
legally and ethically. Therefore, it is very difficult to contact male sex
sellers/buyers. Due to the sensitivity of this topic, the research team selected the
sampling method “snowball”. Through members of the MSM club called Hai Dang
(Lighthouse) Club as guiders Many of them used to be sex workers so convincing
them to lead the way will make it easier for the study.

The method of sampling does not represent all MSM sex workers and the EEs with
MSM involved in commercial sex activity. This limitation will be discussed further
below. The final research sample included 150 MSM sex workers who were
interviewed by quantitative questionnaires, 24 in-depth interviews with 9 MSM
sex workers, 3 clients of MSM sex workers, 5 doctors of VCT/STIs services and 7
with Ees with MSM sex work.

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Interview by questionnaire

The research team collected data based on questionnaires. This questionnaire was
developed with the contribution of MSM and tested before formal information
collection.

The research team used questionnaires for 150 MSM sex workers in Hanoi with
the purpose of exploring the status of MSM sex workers in Hanoi, and high risk
behaviors that can spread HIV/AIDS and STDs and at the same time seeking to
understand the needs and barriers to HIV prevention among MSM sex workers
when accessing HIV/AIDS prevention services.

In-depth interview and observation

This method was applied to MSM sex workers, MSM peer educators, MSM sex
workers’ clients, VCT/STIs service providers and EEs’ owners. All the in-depth
interview sessions took place in private places to ensure privacy and at a
convenient time for interviewees. For 24 in-depth interviews for target groups, we
collected abundant information that can help to recognize and assess the reality of
MSM sex workers as well as high risk behaviors and barriers to HIV prevention in
this group.

Observation method

The observation method was applied for in-depth interviews and quantitative
information collection at the research sites and it proved highly effective. Attitudes
and reflexion of MSM sex workers, clients of sex workers, and EE- and VCT/STI
service owners in the interview were observed to help the investigators collect the
data and at the same time estimate degree of reliability and ways of using
necessary information.

1.3 Advantages and disadvantages in information collection

The research was implemented from late March to early May 2010. It was very
difficult to contact and organize meetings with MSM sex workers for questionnaire

6
and in-depth interviews. Due to the sensitivity, some of MSM sex workers were
afraid or tried to hide their status after introduced about the project. Peer educators
of the research team in the MSM clubs made great efforts to convince and arrange
interviews.

The timing to meet research targets is rather difficult. MSM sex workers often
work from late afternoon to late night. Therefore, to reach them, researchers and
investigators often have to make several visits or wait until they are free or they are
available at very late night to make appointments.

Due to being controlled by the EE owner, MSM working at Ees are rarely free to
be approached by researchers and the information provided by them trickled.

The outreach points of MSM sex workers often are parks, around Hoan Kiem
Lake, Hale Lake, massage parlors and guest houses. These places are hot spots so
that it is quite difficult to collect information.

Another difficulty is terminology. Some of terms such as sexual intercourse, sex

work and brothels are sensitive to MSM. At the same time, MSM often use lots of
“slang” to infer their action that only MSM themselves can understand. Thanks to
active support of peer educators in MSM clubs, the difficulties in slang have been
overcome through investigator training and test interviewing before finalizing the
research toolkit.

The research team has drawn some experience in collecting information from
MSM sex workers as follows:

 Count on the active support of peer educators to reach MSM sex workers;

 Adopt anonymity in the research to get the confidence of MSM sex workers
involved;

 Create mutual trust by making friends, and starting conversations in open

and sharing spirit with MSM buyers/sellers before putting questions.

 Interview about the general situation of MSM sex workers and

understanding about MSM first to win mutual trust and openness before
inching on to interview about their private life.

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  Express the question simply without any implication of criticism or praise,
approval or disapproval; use the terms that MSM often use; and avoid
sensitive words that can affect research’s results.

1.4 Research’s limitations

The research’s objective is to explore the real situation of commercial sex work
and high risk behaviors that spread HIV/STIs and barriers to HIV prevention faced
by MSM sex workers. However, as this topic is very sensitive so it is difficult to
collect information from target groups. For example, for the high risk behaviors
such as drug abuse and sex violence, MSM rarely share their opinions. Especially,
MSM often conceal or avoid STDs or HIV problems. For these problems, research
results probably have not reflected all real situations.

In this research, the research team mentions the targets who are owners of EEs
such as guest houses, brothels, bars, karaoke lounges, and massage parlors. Some
of these EE’s owners have known about the project “Male sexual health
interventions in Hanoi” implemented by SHAPC. Therefore, have been equipped
with knowledge about HIV and STDs prevention. Thus, their opinion may not
represent for the EE owners in the country as a whole. For many times, project PEs
approached them to provide condoms, lubricants and communications materials.
This led to their positive attitudes.

Another limitation of the research is the representation of research samples. As we

stated in the sampling part, this is a research study with small-scale sampling. The
targeted sampling method does not represent for all MSM sex workers and EEs
with MSM sex workers. Most of participants in this research sampling had been
approached by PEs to provide condoms, lubricants and communications materials
so they propably have better understanding about MSM club activities and thus
they are more knowledgeable about HIV/STD prevention, counseling services and
health care than other MSM sex workers. The research results, therefore, can be
biased in a way that it reflects the understanding of MSM sex workers who have
better knowledge about HIV/STD prevention than those average MSM who are
practicing commercial sex work. In other words, in reality, average MSM sex
workers can have more difficulties and obstacles than it is shown in the research’s
results. Additionally, the research site is only one city which cannot represent for a

8
region or a country. The selection of research areas, though having taken into
account the general situation, remains a deliberate choice, so the results only
reflect the situation in that area. For those research studies on the sensitive subject
of MSM sex workers, a topic that many MSM do not want to talk about and show
up to participate in the research. As a result, the limitations of the sampling are
unavoidable. In spite of above limitations, the research results also show us an
overview picture of the current status of MSM sex workers in Hanoi, high risk
behaviors and barriers to HIV prevention. The important thing is that the results of
this study raise many issues as a basis for further studies to explore deeper into the
life of this particular social group.

II. Characteristics of samples in the study

The study took samples of 150 males aged between 17 and 38, of whom those aged
under 25 years account for 62% and those males aged between 25-38 years, 38%.
93 assume that they are males with heterosexual orientation (62%); 46 with
homosexual orientation (30.7%), 8 with bisexual orientation and 3, transgendered
males.

In the study sample, there are 36 whose education level is either primary or
secondary (accounting for 24%), 89 with education level of high school
(accounting for 59.3%), and 25 now pursuing or having graduated from university
(accounting for 16.7%). Almost all respondents are single who have no currently
stable relationship with any partner (79.3%) or who are living in spouse-like
relationship with the female (6.7%) or the male (7.3%). There are only 7
respondents who are married (4.7%) and 3 who have divorced (2%).

The majority of respondents registered their residence in other provinces (102,

accounting for 68%). Those people moved to Hanoi to live due to different reasons
but most of them migrated to Ha Noi for employment (90.2%), or study (32.4%).
Many respondents said that they moved to Hanoi in order to avoid stigma (19.6%)
or seek a sex partner (31.4%). Nearly half of them (47.1%) have lived in Hanoi for
more than 3 years; 38.2% in Hanoi from 1-3 years, and only 14.7% of them have
lived in Hanoi for less than 1 year.

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Among 150 in the sample, 32 (21.3%) said that their current household living
condition in comparison with other households in the same living quarter is poor;
91 (60.7%) average and 27 (18%) better-off.

Qualitative interviews also show that MSM sellers/buyers are from different
backgrounds, social groups, and age ranges. One owner of the guest house visited
by many MSMs said as follows:

Overall, each one has a certain social position. Some work in the court
house.,others are directors and teachers. By labor distribution and level of
education and knowledge, they are in a wide range of social positions. Many
MSM are in the 30s, a mature age. Some are rich, others are average and
there are also people with little money visiting us once in a month only.

A guest house owner

Thus, the interviewed MSWs come from a population which is relatively

diversified, consisting of people from different social groups, age groups, sexual
orientations, family circumstances and status.

III. Knowledge on HIV/STIs and disease prevention measures

3.1. Knowledge on HIV/AIDS

Generally, respondents have ever heard about HIV/AIDS, mainly from the period
of 2000 up to present. Table 3.1.1 shows a high proportion of respondents with the
understanding that either making love with women or having anal sex with men
without condom use, sharing needles, or unsafe blood transfusion can lead to
infection of HIV. There is also a relatively high percentage of respondents who
assumed that HIV can be transmitted by sharing razor (68.5%), or having oral sex
with either men or women without condom use (41.6%), sharing toothpick/oral
care devices with HIV infected people (44.3%), or mother to child HIV
transmission during pregnancy (70.5%). A small proportion of respondents
assumed that HIV can be transmitted through other interpersonal communication
behaviours such as kissing (0.7%), hand shaking (2%), joining a meal or sharing
dishes with HIV infected people (6%), making love with women using a condom
(4%), or mosquito bites (7.4%).

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For those comments, no considerable difference is found among people of different
age groups, or between MSM and non-MSM groups. It is worth noting that the
study sample is rather small (n=150) with ages ranging from 17 to 38, so stastical
difference in age is hard to notice. Qualitative interviews suggest that younger
people, especially those who are studying at school or new school leavers often
have very limited knowledge on reproductive health, HIV/AIDS, and STIs/STDs.

Box 3.1.1. Young people lack knowledge

I gave counseling to some clients. Recently, two of them were infected by STDs
(genital wards in anus). They are all young and fell miserable after finding out
being HIV positive. One is in year 11 and the other is about 19-20 years old
The 11th-grade boy came here with his parents. The parents had never dreamed
that the kid had sex—he was just a small boy. Then the boy said that he had sex
with men as the result of information obtained on the Internet. The boy had had sex
with men for about 1-2 years already. The parents were shocked.

A month ago another boy, 20 years old, came here. He said that he love men and
did not think this could lead to HIV. He seriously lacks knowledge about HIV but
has male homesexual intercourse. Thus, he is more vunerable to HIV.

Most of those who come here for treatment are teenagers or in their 20s;
there are no older people.

In- depth interview, doctor from a VCT

Those people who have higher levels of education show their better understanding
than those who have lower levels of education. For instance, only 72.2% of those
who have education level of secondary school assumed that having sex with
women without condom use may cause HIV infection while this proportion for

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those who are at education level of high school accounts for 86.4%, and those who
have education level of unviversity/college account for 100%. The corresponding
proportions for having annal sex with men without condom use are 88.9% among
those who have secondary school education level and lower, 97.7% among those
who have high school education level, and 100% among those who have
university/college education level. People with higher education levels also have
more considerate attitude for such behaviours as sharing razor, having oral sex
with either women or men without condom use, or sharing toothpick/oral care
devices with HIV infected people. Those who have high education level account
for a substantially higher proportion than those people with lower education level
in saying that those behaviours may lead to HIV infection. Disparities in
understanding HIV transmission routes by education level are stastically
significant (Chi square < 0.05).

Table 3.1.1. Percentage of comments assuming that the said behaviours may
cause HIV infection.

Behaviour % in
agreement
Kissing 0.7
Hand shakes 2
Joining a meal or using or sharing discs with HIV inffected people 6
Sharing a razor 68.5
Having sex with women with condom use 4
Having sex with women without condom use 85.2
Having anal sex with men without condom use 96
Having oral sex with men or women without condom use 41.6
Sharing a needle 86.6
Sharing a toothpick/oral care devices with HIV infected people 44.3
Mother to child transmission during pregnancy 70.5
Mosquito bites 7.4
Unsafe blood transfusion 83.2
Number of respondents 149

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Overall, there is no significant difference among comments of heterosexual,
homosexual, bisexual, or transgendered respondents in answering the above
mentioned in Table 3.1.1. There is single substantial statistical difference (Chi
square = 0.049 < 0.05) in saying that having anal sex with men without condom
use can cause HIV infection. 100% homosexual, transgendered or heterosexual
respondents say so while only 93.5% of the bisexual respondents agree with this.
The difference among comments above between drug users and non-drug users is
reflected in the saying that HIV can be infected by having sex with women without
condom use and sharing toothpick/oral care devices with HIV-infected people
(27.8% drug users v.s. 49.6% non-drug users).
All respondents have ever heard sexually transmitted diseases (STDs), but
differences are found with their understanding of specific types of diseases. Figure
3.1.1 shows the percentage of those who agreed that the mentioned diseases are
STDs. It is possible to see that respondents are knowledgeable on gonorrhea,
syphilis or HIV which are STDs. A considerable percentage of respondents also
know that Hepatitis B/C or genital warts are STDs. However, there is a relatively
low percentage of respondents who know about trichomoniasis or Chlamydia
which are also STDs.

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 Chart 3.1.1. Percent of opinions that the given disease
is a STD (N=149)
120

97.3 97.3
100
89.3

80 73.8
62.4
%

60
41.6
40
28.2

20
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Similar to understanding of HIV transmission routes, those who have higher

education levels seem to be more knowledgeable about other STDs (see Figure
3.1.2).

14
 Chart 3.1.2. Percent of opinions that the given disease is a STD by
education of respondent
120

98.9100
100 95.5 96
91.7
88
84 83
80
68.2 69.4 68
%

60

41.7 44.3
40 33.3 33 32

20 16.7
13.9

0
Hepatitis Gonorrhoea Syphilis Condyloma Trichomonas Chlamydia
B/C Acuminatum vaginalis

THCS- (N=36) THPT (N=88) CD DH+ (N=25)

There is no significant difference in understanding STDs among heterosexuals,

homosexuals, bisexuals and transgenders as well as between drug users and non-
drug users.
About 81% of respondents believed that condom use prevents both HIV and other
STDs while 15.6% of them said that condom use avoids HIV infection but not
STDs. Only one respondent (0.7%) thought that condom can help prevent STDs
but not HIV, and 2.7% (4 respondents) reckoned that it is impossible to avoid HIV
and STDs. As far as the use of lubricants is concerned, 82.6% of respondents
assumed that lubricants cannot avoid HIV or STDs.
In response to the question: “whether the HIV infected couple need to use condoms
during sexual encounters or not”, the “Yes” accounted for only 55.7% and “No”
16.1% while 28.2% gave neither “Yes” nor “No” answer. This shows a considerable
percentage of repondents having poor awareness of HIV surinfection.
Thus, general knowledge on HIV and STDs of MSM sex workers in the study
sample is only at a basic level about transmission routes and some common STDs.

15
Those people who have higher education levels often have better undestanding.
There is still a considerable proportion of respondents who have poor awareness or
do not know about potential risks of HIV infection such as sharing a razor, unsafe
oral sex, sharing a toothpick/oral care devices, or mother to child HIV transmission,
and also a substantial proportion of respondents having no idea of trichomoniasis or
Chlamydia. Nearly half of respondents were not aware of HIV surinfection when
both HIV infected partners have sex without condom use. This suggests that
communication for awareness raising among MSW group is of utmost importance to
help them and their partners with HIV and STD prevention.
The majority of respondents claimed that they got information on HIV or STDs
from school (49.7%), the mass media (82.6%), HIV/STD care and testing services
at district or subdistrict health care facilities (35.6%), communicators from HIV
prevention projects (73.2%), MSM clubs (71.8%), friends (43.6%), or sex clients
(32.9%).
About 55.7% of respondents thought that they are more or less at risk of HIV
infection. Specifically, 10.7% of them claimed that they are not at risk of HIV
infection while 33.6% did not know how to assess their own risk of getting
infection.
Most of respondents were very concerned about the HIV infection status of their
sex clients. They show this concern by different ways, from judging the
appearance and then guessing if their clients are infected with HIV or not,
discussing favorite methods of love making in order to assess the risk, or directly
asking questions and exchanging ideas with clients about this issue. Generally
speaking, many people admited that it is difficult to know about the truth of their
clients’ HIV status. But some people do not care about it as they always use a
condom or since they need money or think that being an MSW, they should adopt
adventure.

3.2. HIV Testing

There are 118 respondents (78.7%) who have ever got HIV testing. Almost all
those people have got HIV tests since 2005 until now (only 16.9% of them got
HIV testing before 2005), and the percentage of HIV testing people increases year
after year (tested people in 2009 accounts for 24.6% of the total number of people
who have ever tested, and 19.5% in 2008, 11.9% in 2007, 8.5% in 2006, and 6.8%
in 2005). There is no significant difference in having ever conducted an HIV test

16
among MSWs who heterosexuals, homosexuals, bisexuals or transgenders as well
as among drug users and non-drug users.
Among those respondents who have got involved in HIV testing, 49.2% got their
first tests at polyclinics or public hospitals, 9.3% at VCT clinics under different
projects and 33.9% with unknown location of testing. A few people got their tests
with private doctors (4 respondents), in prison (1 respondent), or at a drug
rehabilitation center (3 respondents).
Within 6 months prior to this study, 93 repondents have got involved in HIV
testing (accounting for 78.8% of the total number of people getting HIV tests).
Among them, there are 2 people positive to the test, 84 negative to the test, and 7
people who have not been notified about their HIV status. In the most recent
testing within 6 months prior to this study, around half of them (46 people
accounting for 49.5%) assumed that the doctor knows that they are MSM, MSW or
drug users. However, the majority of those people said that the doctors have
friendly behaviour or normal treatment to them. Only 4 respondents have the
feeling that they show unfriendly attitude and the other 2 respondents said the
doctor dislikes them. Almost all people getting HIV tests in the past 6 months
were given discussion by the doctor on the test results (93.5%), HIV prevention
measures (94.6%), what to do upon being given test results (90.3%), and referral to
places where tested people can get help (71%). However, the doctors tend to have
less discussion with those people involved in HIV testing who are MSM and sex
workers. Only 38.7% of those people having been tested in the last 6 months said
that they are in discussion with the doctor on this topic.
In-depth interviews show progress made in HIV testing service in terms of attitude
of service providers, quality of counseling and testing service.
I had HIV test twice. The first time was in 1997. Last year I had the second test.
Both were negative. The first time it was in a hospital. The test last year was in a
day-care center. In the past it was very unpleasant. Then there were not many HIV
clinics as there are now. I had to cover my face to go there then. Now it is much
easier. No problem. The test last year was quite relaxing, not terrible as it was in
the past. Back then there were a few HIV clinics for choice and people thought that
HIV was something terrible, there were not many pieces of information about it as
it is now. You had to wait for a longer time for the result, and doctors did not

17
provide counseling as they often do today. Now testing staff are friendlier. In the
past I had to pay for the test. The test last year was free.

An MSM sex worker

3.3. Sexually transmitted diseases (STDs)

Of the total of 150 respondents, only 18 people (12%) informed that in the past 6
months they had genital or anal ulcer, wart or discharge. Four of them visited
public health facilities, 3 people to private clinics, 10 people to pharmacies for self-
medication, 9 people to project-supported clinics, and 5 people had home-based
treatment (possibly with self-medication). Generally, they were satisfied with the
above mentioned health facilities and considered those services as
“average/moderate”. Only one person expressed “disatisfaction” with the service
provided by project-supported clinics.
Among 18 people having genital or rectal ulcer, wart or discharge in the past 6
months, 9 people have told their loving partners about disease status but only one
person disclosed it to regular sex clients and one person to irregular sex clients. As
many as 8 people used a condom when having sex with consensual/loving partners,
10 people with condom use when having sex regular sex clients, and 9 people with
condom use when having sex with irregular sex clients. Thus, there are still a
number of people having sex without condom use while they are suffering from
STDs.

IV. HIV/STD infection risk behaviours and prevention behaviours

4.1. Sex partner number, frequency and forms of sex work/activity

Among 150 MSW repondents who are male sex workers, 146 (97.3%) still remain
with sex work. Only 4 repondents claimed that they have quit sex work recently
(from December 2009). During 6 months prior to the study, almost all respondents
sold sex to men (81.3%). Only 18.7% of them told that they sold sex to both men
and women during 6 months before the study.

Within 6 months prior to the study, generally each MSW sold sex for 5 times to
“lovers” who were men on average (for 90 respondents who have “male lovers”),
10 times to irregular male sex clients, and 6 times to regular male sex clients. For

18
those respondents who have sold sex to women (29 people), apart from selling sex
to men as mentioned above, they sold sex for 3 times on average to “female
lovers”, (for 26 people who have "female lovers"), 3 times to irregular female
clients, and 5 times to regular female clients. Thus, on average, each respondent
who sold sex to men engaged in 21 sex episodes per month, and each respondent
who sold sex to both men and women engaged in 32 sex episodes. In general, sex
work is conducted all the year round.

MSWs were found to have multiple sex partners in the last 6 months (Figure
4.1.1). The majority of MSWs had more than 10 sex partners in the last 6 months
and especially, more than 40% had over 20 clients in the last 6 months. In the
study, there is a fewer number of female clients for people who sold sex to both
males and females. Most had more than 5 female sex clients and up to 31% had 10
female sex clients in the 6 months prior to the study.

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 Chart 4.1.1. Percent of MSM sex workers having given
number of sexual partners in 6 months prior to the
survey
100%
6
10.3
90%
3.4
17.3
80%
17.2

70%
19.3

60% Don't know/Not remember

More than 30
50% 21-30 partners
51.7 11-20 partners
40%
5-10 partners
42
Less than 5
30%

20%

10% 11.3 17.2

4
0%
Male partner (N=150) Female partner (N=29)

About 26.7% (45 respondents) informed that they had sex with multiple clients
simultaneously in the last 6 months. Most of them had sex with men at the same
time (40 respondents). Only 1 respondent reported that he had sex with multiple
females at the same time and 4 respondents reported that they had sex with men
and women simultaneously. Among those 45 people having sex with multiple
people at the same time in the last 6 months, 35 people stated that they did it for 1
or 2 times while 8 people did for 2 to 5 times and 2 people did it for more than 10
times.

Regarding the role of partners during sex, 33.3% of respondents stated that they
mainly played the role of “giver/insertive” and 57.3% of them played, more or less,

20
both the “giver/insertive” and “receiver/receptive” roles, and only 9.3% reported
that they were always in the role of “receiver/receptive”.

MSWs seem to have more power in decision making in having sex with their
consensual partners or regular sex clients (Figure 4.1.2), and they have the least
power in making decision when selling sex to irregular sex clients. Figure 4.1.2
shows that 52.8% of respondents proved to be the decision makers in sexual
encounters with loving/consensual partners, but only 20.7% of respondents had
such power with regular sex clients and 20.8% with irregular sex clients. The
highest percentage of both parties “receiver” and “giver” making decision for sex
methods is reached when MSWs sell sex to regular sex clients (52.7%). It is
possible that the frequency of their sex selling and buying makes it easier for them
to get a consensus on the sex methods. The percentage of sex clients giving
decisions on sex methods is the highest when sex is sold to irregular sex clients
(47.7%) and the lowest when having sex with the loving partners (16.3%).

Chart 4.1.2. Who decided the way of sexual

activities? (%)
100%

16.3
26.7
80%
47.7

30.9

60%

My partner
52.7
Both
40%
31.5 I myself

52.8
20%

20.7 20.8

0%
with lover (N=123) with regular partner with casual partner
(N=150) (N=149)

21
As reported by some MSWs, in the last 6 months prior to the study, sex was
performed together with other violent acts such as clawing, pinching, beating,
roping, hanging, and scolding. The percentage of those having sex together with
violence is higher when they sell sex to the clients, both regular and irregular sex
clients. While 18.8% of MSWs stated that they had such acts in making love with
partners, 28.2% of them had these acts with regular sex clients and 28.9% with
irregular sex clients.

Of those who had sex with violent acts in the last 6 months, the frequency of
violence is found the highest in performing sex with the loving partners, then with
regular sex clients and the lowest with irregular sex clients (Figure 4.1.3). The
greater intimacy seems to make violence more frequent.

It should be noted that with the frequency of sex mentioned above, each
respondent sold sex for 30 times to “loving/consensual partners”, 36 times to
regular sex clients and 60 times to irregular sex clients on the average in the last 6
months. Therefore, the incidence of violent sex with irregular clients as shown in
Figure 4.1.3 was twofold that of having sex with partners or almost twofold that of
having sex with irregular sex clients. Specifically, 65.1% of respondents had 1 to 5
times of violent sex within 60 sex encounters with irregular sex clients. This
frequency is less in comparison with 37% of respondents having 1-5 times of
violent sex within 30 times of giving sex to the loving partners. If the factor of
frequency of sex is included in the last 6 months, violent sex with irregular clients
is much less than violent sex performed with the loving partner or regular sex
clients.

22
 Chart 4.1.3. How often sexual activities are
accompanied by violence? (% among those with
violence in sexual activities)
100% 2.3
11.1 9.8

80% 32.6

36.6

51.9
60%

More than 10 times

6-10 times
40%
1-5 times
65.1
53.7
20% 37

0%
with lover (N=123) with regular with casual
partner (N=150) partner (N=149)

4.2. Purposes of sex work

Most MSWs who are respondents reported that they sell sex to men in order to
earn money (96%, see Figure 4.2.1). Around 1/3 of them said they have sex with
men to satisfy their sexual desire or get money for gambling. Only 15.3% said that
they do the sex work for earning money to buy drugs.

Regarding having sex with females (practiced by only 29 out of 150 respondents),
most of respondents had sex with females for sexual satisfaction (86.2%, see
Figure 4.1). More or less than 2/3 of respondents had sex with women for money
(69%) or getting money for gambling purposes (58.6%). About 1/3 of respondents
had sex with women in order to get drugs (31%).

23
Generally, MSWs sold sex, regardless of men or women, mainly for money. Other
purposes of this practice are subsidiary. A testimony given by a gay who is a sex
client but he fails to have a long-term relationship with a MSW reflects that fact.

I love a man openly. I only want to be his wife. He was an MSW, and the love
affair lasted for one year. Just only one year. I was very disappointed because
MSW only wants money, and wants me to buy this and that item, I was able not do
it.He is an MSW, I have to afford him then he will afford me. Many nights, I was
thinking that he eventually has to get married and has children while I do not have
money. I can not afford him then he leaves me, love is just illusion.

A male customer of MSM sex worker

Although the majority of MSWs practice sex sale for the main purpose of getting
money, there are still MSWs who do it not for such a main purpose but for
satisfying sexual desire with men. An MSW (calling himself as “sister”) reported
his experience when starting his sex trade as follows:

Money is not the main thing to sell sex. The main thing is the need of love. I
desperately need love. In childhood, I lived a close way of life, suppressing
aspirations, not revealing myself, feeling hard. Now we work (as sex workers) for
money OK, not for money also OK. Selling sex means only having sex with him,
nothing bad. If I do not sell sex, I still go out with MSM sex workers then I have to
spend money. Thus, I sell sex then I can have both. Little money is totally OK.

Such people are MSWs when they receive sex clients, but they are also the sex
clients buying sex when they have sexual desire. The same MSW expressed
himself as follows:

“I like young man aged 20-22. I don’t like old ones. I like young, clean, handsome
guys. Employment, background, and qualification are not important to me as they
do not live with me until the end of life, just make love. I pay money then forget. If I

24
like then we meet again, otherwise… I don’t care about their private life. If I have
money, then I will spend it on men.”

There are people who get involved in sex work for money to use drugs. Those
people often sell sex after they got addicted to drugs.

“I used to be a post-graduate in banking. In 1998, I was arrested for appropriating

assets of others. Then I was expelled and imprisioned. After I was released, I used
drug and got addicted. To have money for my drug, I began selling sex. In 2003, I
had to follow compulsory detoxification for 1 year; at that time I knew that I am
HIV positive.”

Income gained from male sex work is rather high. For the most recent sex selling
to male sex clients, an MSW got 388,000 VND on the average; and to female sex
clients, an MSW got 539,310 VND. Most respondents said that such money gained
from one sex session/episode was the average level that they often obtain, and
there is not much difference between the most recent sex selling session to
compare with other sessions. Thus, if an MSW can have 21 sessions of sex selling
to men per month as mentioned above, he earns more than 8 million VND/month
by selling sex, on the average. This is a relatively attractive income level and it is
hard to find any other unskilled jobs to compete with it. This shows that advocacy
for not getting involved in sex work seems not to be a simple thing to do.

Box 4.2.1. Income from sex work

Q: What is your monthly income from selling sex?

A: I don’t remember exactly. Each day I need VND 300,000 for drug. I
think each month I earn about VND 15 to 20 million.

An MSM sex worker

25
 Chart 4.2.1. Reasons for selling sex
120

100 96

86.2

80
69

58.6
%

60

40 36 36.7
31

20 15.3

3.3
0
Because of sexual Need money Need money for Need money for Other reasons
needs drug gambling

Male partner (N=150) Female partner (N=29)

In some establishments where sex work services are available such as massage
parlors, the owner is interested in massage service fee only while the sex service in
his establishment is ignored by him/her. Money gained from sex work will be
completely based on the negotiation between the MSW and the sex client. In those
establishments, apart from money gained by selling sex, fee from massage service
is a source of supplementary income.

“We divide the profit 50/50. For example: one client pays 60,000 VND so I will get
30,000 VND and my employee gets 30.000 VND. If they go to hotel or to the
client’s place, I have to collect transportation fee from the client and only take
20,000 VND from the employee because I do not have to pay for power cost.”

An owner of massage parlour

26
Figure 4.2.2 shows the purposes of spending money gained from sex work by
MSWs. Generally, it is possible to see the expenditure structure which reflects
essential needs of living. Respondents spent their money from sex work for meals,
house rental, clothing, belongings, and recreation. Some MSWs spent money on
health care, education, and paying debt (not everyone needs to do this because not
everyone got diseases in the 6 months prior to the study or involved in education or
in debt). It is worth noting that 42.7% of MSWs spent money on gambling which
seems to be a common activity among MSWs. About 14.7% of them spent money
to buy drugs/heroine, 12% spending money on job application, and especially
5.3% (8 respondents) do sex work in order to get money for their gender
transformation.

Chart 4.2.2. For what did you spend money earned from
selling sex? (%)
Paying cost for changing sex 5.3
Gambling 42.7
Finding job/doing business 12
Taking care of lover 26
Buying drug or heroin 14.7
Entertainment 77.3
Education 20
Paying debts 39.3
Helping family 34
Buying personal items 58.7
Health care 20.7
Buying dresses 90.7
Housing payment 56
Food 92.7

0 10 20 30 40 50 60 70 80 90 100

Around 70% of respondents said that sex work is not the only way for them to earn
money and 30% respondents explained that they have no choice to do sex work to
earn money. Among those respondents who used to earn money by other ways, the
majority involved in sex work rather than earning money by other ways say other

27
ways do not bring much money to them (78.1%) or bring them more hardship
(72.4%). With the high income level from sex work as mentioned above, it is very
difficult to find other jobs with similar level of income. Other reasons have been
cited such as more dangerous jobs (41.9%), not bringing the interests to them
(32.4%), and being looked down upon (14.3%), and 34.3% of respondents selected
sex work because they got used to get money from sex work.

Guest houses are the venues where most MSWs in the study sample performed sex
work. About 60% of those men had sex with men and 62% of them had sex with
women in the guest houses. Another type of venue where sex work is reported by
20% of respondents is the brothel/"động". The remaining of respondents provided
service in such venues as Karaoke bars or massage parlors, discotheques, saunas
(5.3%), parks (2.7%), less busy places (1.3%), sex client’s home (8% with men and
6.9% with women), sex seller’s home or the rental home of the sex seller (1% with
men, and 31% with women).

Despite the attractive income level from sex work, MSWs have fears as well.
Figure 4.2.3 shows their most concerns which are HIV infection and STDs, being
known by their family members or loved ones, and being stigmatized by society.
All those fears are mentioned by more than half of respondents. Other considerable
fears include being arrested by the police, harm to health, being left by the partner,
or damage to family happiness. Only 3.3% of respondents said that they have
nothing to worry about. The fears presented in Figure 4.2.3 are important ones for
an adult, but those fears are not strong enough to suppress the attraction of high
income from sex work as mentioned above.

28
 Chart 4.2.3. While selling sex, what concern you
most? (%)

Concern about harms for family integrity 24.7

Afraid of losing job 12

Afraid of being deserted by lover 32

Afraid of social discrimination 58.7

Afraid that family would know 74

Afraid of being arrested by police 48

Concern about health 41.3

Fear of HIV 90

Fear of STDs 72.7

0 20 40 60 80 100

MSWs are also very concerned about their own health (Figure 4.2.1). About 22.1%
of respondents who are MSWs reported that they often visit health clinics while
50.3% of them said they sometimes have health check-up, seek information on
HIV and STDs prevention, and STDs, and 46.3% self explore information on HIV
& STD counseling and testing centers, and 61.7% have ever had STI consultation
and got blood drawn for HIV testing. Only 18.2% are not concerned with their own
health status while getting involved in the above activities.

Table 4.2.1. Percentage of people doing the following activities

% involved
Have frequent medical checkup 22.1
Have occasional health checkup 50.3
Self explore information on HIV and STDs prevention 50.3
Self explore information on HIV and STDs counseling and 46.3
testing centres

29
Have had STI examination and had blood drawn for HIV testing 61.7
Never concern about health status 18.2
Total respondents 149

4.3. Use of condoms and lubricants

Attention should be paid to the low percentage of respondents who said that they
have regular condom use during sex, especially having sex with loving partners,
new clients with good appearance or regular clients. The percentage of those who
had consistent condom use is also higher with those clients whose appearance is
unhealthy-looking, reaching around 50% (Figure 4.3.1). For all types of clients or
partners, only 11 respondents (accounting for 7.3%) had consistent use of condom
when having sex with men in the last 6 months regardless who the clients were,
and only one person who had consistent condom use with women regardless they
are acquainted or not. The rest are other cases such as MSWs selling sex without
condom use, or having inconsistent use of condom. There is no sufficient
difference between MSWs working for the brothels or those who do not in the use
of condom. This shows that MSWs have higher risks of HIV infection or other
STDs. For those who use condoms, the main reason for such a practice is for
avoidance of STDs or for contraception during sex with women.

30
 Chart 4.3.1. Percent of respondents who always use condom during
the last 6 months
60

50.7
50

41.4
40
%

30 27.3
24.7
20.7
20 17.2

10 10.3
10

0
with lover with clean-looking with unhealthy-looking with regular customer
customer customer

Male partner Female partner

For those who do not use condoms, their main reasons are client’s requirement of
not using condoms (67.2%), no proactive preparation (53%), no access to condoms
(42.5%), assumption of both being free from STDs (38.1%), lack of knowledge on
HIV/STDs (31.3%) and fear of reduction in sensation (23.9%). The less important
reasons which have been raised include no need to use condom with anal sex,
allergy with condom, lack of knowledge of condom’s benefits, both people being
HIV positive, and “giving revenge to life” (Figure 4.3.2).

Those figures show that many MSWs lack negotiation skills on condom use with
clients or partners, or forget to bring condoms along or meet difficulty in getting
condoms (buying with money or free of charge), and lack of comprehensive
knowledge on HIV infection and surinfection so that they can protect by
themselves the health of him/herself as well as the partner effectively. Intervention
activities to help raise the awareness and capability for HIV prevention for MSWs
should bring into account those contents.

31
 Chart 4.3.2. Percent of respondents with reasons for not using
condom (N=139)
Practice oral sex 14.2

Lack knowledge of HIV/STDs 31.3

Want others to suffer 1.5

Do not like condom 9.7

Allergic with condom 14.9

Not clear effects of condom 6.7

Both are HIV positive 1.5

Know that both are healthy 38.1

Customer requested not using condom 67.2

Fear of reducing satisfaction 23.9

Cannot obtain condom 42.5

Not prepare it beforehand 53

Figure 4.3.3 shows the person who is often dominantly in giving decisions on
condom use in sex. Here, we see a slightly different picture in comparison with
making decisions on sex methods mentioned earlier. For having sex with the
loving partner, basically, the extent to which MSWs give decisions on condom use
is similar to that extent in giving decisions on sex methods (both with 52.8%), but
the percentage of MSWs mutually giving decisions on condom use reduces
considerably (from 30.9% on mutually giving decisions on sex methods down to
19.4% on mutually giving decisions on condom use), and the percentage of "loving
partner" dominantly giving decisions increases correspondingly from 16.3% for
sex method decision to 27.8% for condom use decision.

For regular sex clients, the percentage of MSWs as well as percentage of clients
dominantly giving decisions on condom use increase substantially while the
percentage of mutual giving decisions reduces more than half (from 52.7% of
mutual giving decisions on sex methods to 23.3% of mutual giving decisions on
condom use). The percentage of clients dominantly giving decisions increases from
26.7% on sex methods to 42.2% on condom use, which is nearly double, while the

32
percentage of MSWs with dominant decision making increases from 20.7% on sex
methods to 31.5% on condom use, that is, around 1.5 times higher.

For irregular sex clients, the percentage of MSWs dominantly giving decisions
increases from 20.8% on sex methods to 42.8% on condom use while the
percentage of mutually giving decisions as well as client dominantly giving
decisions reduce considerably (see Figures 4.1.2 and 4.3.3). Thus, we can see that
there seems to be bargaining in condom use after a decision on sex methods is
made. MSWs seem to have more power in bargaining with irregular clients than
regular clients. If MSW’s dominant and mutual decision making is taken taking
into consideration , MSWs have more power in giving decisions on condom use
than on sex method decisions for irregular clients, but they have less power in
condom use decision making than sex method decision making for loving partners
or regular clients. For all cases, it seems that MSWs are more considerate to
condom use than sex methods, reflected by their dominance in making decisions
on condom use. If it is true, this is a favorable condition for programs to support
MSWs with condom use and improving their skills and knowledge of negotiation
with partners in condom use.

Qualitative interviews show that sex clients have more power in negotiating for
condom use. If they are aware of the danger for not using condoms and want to use
condoms, they are able to urge SWs to use condoms.

If they did not agree to use condoms I would not buy sex because HIV will not
avoid anyone. I should take care of myself. I pay them and they have to meet my
needs. If not, I will not buy; I can find another sex worker. If I do not take care of
myself, I could die.

An MSM customer (who addresses himself as “sister”)

However, it is not necessary that MSWs are always successful in giving decisions.
In many cases, they have to follow the requirements from sex clients.

Box 4.3.1. Decision on condom use

33
 Q: Have you ever used condoms?
A: Yes but not very frequently
A: Do you use lubricants?
A: Yes but not very frequently
Q: When do you use them?
A: Whenever a client needs
Q: What about you?
A: Actually, some times I decide to use but not very frequently
A male sex worker

Chart 4.3.3. Who decided to use condom or not? (%)

100%

27.8
33.8
80%
45.2

19.4
60%
23.4
My partner

23.3 Both
40%
I myself

52.8
20% 42.8
31.5

0%
with lover (N=108) with regular customer with casual customer
(N=146) (N=145)

34
For lubricant use, only 20% of respondents often use lubricants in having sex with
men and only one out of 29 respondents having sex with women often use
lubricants frequently. Most of the other people use lubricants irregularly and only
10 people (6.7%) do not use lubricants at all when having sex with men. The
percentage of not using lubricants in having sex with women is much higher – 15
out of 29 respondents having sex with women in the 6 months prior to the study
(51.7%). The purpose for lubricant use is to avoid pain (55.7% of lubricant users)
or STDs (24.3%). Non-lubricant users or non-regular lubricant users stated their
reasons such as no preparation in advance (60.5%), non-availability of lubricants
(62.2%), or being required of not using by the client (47.1%).

The above figures regarding lubricant use reflect similar issues in condom use.
Many MSWs reveal their absence of negotiation skills with partners and lack of
understanding in using protective tools for health, avoiding skin tear, scratches and
thus reducing other STDs by using lubricants in sex, especially having sex with
men.

Figure 4.3.4 shows the sources of supply of condoms or lubricants for MSWs in
the sample. Many MSWs get access to free supplies of condoms or lubricants from
peer educators, centers for counseling on love, marriage, family affairs, or centers
for reproductive health or HIV/AIDS counseling, STI/STD clinics, VCTs, and
public health facilities. Sexual partners are an important source of condom or
lubricant supply. For those working in brothels, the owner provides free condoms
to them. MSWs buy condoms mainly at shops, supermarkets or pharmacies. Thus,
access to supply of condoms or lubricants does not pose a big problem. However,
the modest rate of condom and lubricant use and the inconsistent frequency of use
show challenges in condom and lubricant use.

35
 Chart 4.3.4. What are sources for condom or jelly? (%)

Peers 85.5
0.7
Counseling centers for love, marriage & 26.9
family 0.7

Counseling centers for RH and HIV/AIDS 45.8

0.7
Clinic for HIV voluntary counseling and 52.4
testing 0

Private health facility 8.3

1.4

Public health facility 30.3

1.4 Free

26.9 Buy
Sex partner 4.9

Brothel owner 13.8

0.7

Drug store 0.7

67.4

Shop/supermarket 0
34.7

Market 0.7
1.4

0 10 20 30 40 50 60 70 80 90

Owners of guest houses and brothels where MSWs often visit are also the
important source of condom supply. Though only 13.8% of respondents in Figure
4.3.4 said that the owner can be a source of condom or lubricant supply,
interviewing some owners of guest houses and brothels reveals that they are aware
of their client’s sex behaviors and provide condoms or lubricants, especially those
guest houses and brothels having relations with clubs supported by HIV/AIDS
prevention projects, such as “Hải Đăng – Lighthouse”, “Vì ngày mai tươi sáng –
For a Bright Future”, “Niềm tin xanh – Green Belief”, “Khát vọng sống – Life
Aspiration”, or “Thông Xanh – Green Pine”.

There are plenty of condoms here. Anyone can ask for it, no problem. Before we
put it in the telephone box, now we keep it with reception. Those who come here
(for sex) do not hesitate to call down to reception and we bring for them. Before we

36
put in the telephone box and visitors from provinces may think that it is bad, they
do not think that it is normal and necessary to do. Condoms or lubricants that we
have all come from the project of Hai Dang and other projects, such as For a
Brighter Future, Green Belief, Green Pine, and Living Aspiration. The projects
often organize meetings here too.

An owner of a guest house

4.4. Alcohol and drug use

About 18.1% of respondents reported that they often used alcohol when having
sex; 45% of respondents said they rarely used alcohol during sex, and 36.9% said
they have never used it when having sex. Alcoholic users, during sex, had lower
rate of condom use than the non-users (Figure 4.4.1). This finding is consistent
with the qualitative data.

“Poor students often do not drink alcohol, they are so gentle. Before making love
they ask about a condom then use it while the old alcoholic do not care about this.
They also do not like to use it.”

A male client of MSM sex worker

Alcoholics make love together and do not care about the consequences. The clients
I often meet by day do not go to the discotheque but they contact by telephone, they
often have condoms and lubricants.

An MSM sex worker

37
 Chart 4.4.1. Percent of respondents who always use condom
and degree of using alcohol while having sex (often, rarely,
never drink)
45
40
40
34.5
35

30

25 22.4
%

20.9
20 18.2

15
11.1 11.1
10
3.7 4.5
5

0
with lover with regular customer with new healthy-looking
customer

Often Rarely Never

Among 150 respondents who are MSWs, 36 are drug users (accounting for 24%).
There are reasons leading to drug use. Most of drug users reported that they use
drugs because of being invited by friends (94.4%), easing tension (75%) or being
self interested in drug use (63.9%). It worths noting that 1/3 of drug users
confessed that to some extent they were tempted by partners or sex clients, and
19.4% of them used drugs upon being requested by sex clients. Those reasons
together with the assumption that drugs make them healthy to receive multiple
clients (27.8%) are directly related to male sex work. In other words, male sex
work has created more pressure for sex workers who use drugs.

Table 4.4.1. Reasons leading to drug use (%)

%
Being tempted by friends 94.4
Being tempted by loving partners 33.3
Being tempted by clients 33.3
Assuming that drug use make them healthy to 27.8

38
receive multiple clients
Being requested by the client 19.4
Being self-interested in drug use 63.9
Using drugs to ease stress and boredom at tough 75
times
Using drugs to stay awake at night 11.1
Number of respondents 36

Out of 36 people using drugs, 7 practiced drug use with smoking, 8 with sniffing,
15 with pills by oral administration, and only 6 with injecting. They often practiced
drug use with friends (69.4%), partners (8.3%), or clients (13.9%). Only 8.3%
practiced drugs alone. On the average, each respondent use drugs once a day. This
number seems smaller as compared to the number of times for drug use found in
other studies (Vu Manh Loi, Nguyen Huu Minh, Tran Vu Hoang, Vuong Thi
Huong Thu, Roberts Broadhead, Dang Thanh Truc, Nguyen Nga My, and Doan
Kim Thang 2006). Drug sources for MSWs are mainly from self purchase (86.1%),
being given by friends (75%), by clients (41.7%), and having sex with other people
for exchange of drugs (36.1%). Clearly, drug use MSWs are involved in a network
of friends or clients who are also drug users and they help each other. Among those
injecting drug users (6 people), only 2 people said they have shared needles with
others due to lack of needles and syringes (2 people), being given by sex clients (1
person), being invited by friends to have fun (1 person), lack of money to buy new
needles and syringes (1 person), and being HIV positive and thus having no fear of
infection (1 person).

V. Working for the establishment owner

Out of 150 MSW respondents, 43 people (28.7%) have worked for the owner, and
the rest worked independently. Of the 35 drug users, only seven (19.4%) used to
work for the entertainment establishment owner. Among those have worked for the
owner are 24 working for one owner only, 13 working for 2 owners, 4 working for
3 owners, 1 working for 5 owners and 1 who cannot remember the number of
owners he has worked for. At the time of the study, only 24 people were working
for the owner, including one using drugs. Brothels where those people were

39
working are in the form of Karaoke bars or massage parlors, and saunas. At
brothels, respondents are recruited mainly for sex work.

Among 24 respondents who are working for the owners, only 8 reported that the
owner gave them explanation on infection risks of HIV or STDs and 14 said the
owner did not give any explanation. Generally, the owners are also concerned
about the health of SWs to certain extent. Six out of 24 people who are working for
the owner are allowed by the owners in having regular health check-ups, 14 people
having intermittent health check ups, 6 receiving information on HIV prevention, 9
with information about centers for counseling, HIV testing and STDs, 2 people
being given health examinations by visiting doctors, and 2 being given no concerns
at all.

Those people who are working for one owner only (23 out of 24 people) reported
that on the average, 1 brothel has 9 MSWs and there are no FSWs. Most of
respondents said that those MSWs live in the brothel, but some other ideas show
that some MSWs live at the brothel while others live in other places. Four MSWs
out of 24 people currently working for brothel owners sell sex at that venue, while
others reported that they sell sex at that venue sometimes and other times they sell
sex in other places such as brothels (5 people), guest houses (19 people),
karaoke/massage parlors (6 people), parks (1 person), deserted spaces (2 people),
sex clients’ homes (19 people), houses of other people (4 people), and inside the
car (4 people). Thus, locations for sex selling of MSWs are diversified, depending
on each client and specific circumstances.

Selecting venues for sex work is not completely based on the MSWs, but the
mutual decision making process between the MSW and a client (1 person) or
between the MSW and the owner and the client (3 people), between the owner and
clients (5 people), or decision is made by the client (5 people). Thus working for an
owner, the MSW cannot raise their voice in giving decisions on locations for
practice.

Qualitative interviews show the close management of the owner to apply on staff:

I have always to pay attention to management. If customer calls, I send employees

out. I have to monitor them. For example, if they go from 7h to 8h for one service.

40
If it is far away, I can count as it takes 1.5 hours for one service. If there is any
problem they have to call me to report. If they go to a guest house, I would record
the address, the room number, and the telephone number before sending my people
out. The same is for private house service.

An owner of a brothel which is a disguised massage parlor

Sex work often took place in the afternoon (reported by 11 respondents) or in the
evening (12 respondents). Few people performed sex work in the morning (5
respondents) or after midnight (2 respondents). Those people who are currently
working for one owner have the continuous duration of working for that owner
ranging from 1 to 15 months. The length of average time working for the owner
among those working for such owners (reported by 23 respondents) is 5 months.
As such, MSWs do not seem to work for a long-term at a brothel and they may
change their workplace after a few months.

Sex clients often visit MSWs through different ways such as contacting the owner
(23 respondents, and one did not answer this question), other middlemen (11
respondents), through telephone (17 respondents), being introduced by the co-
MSW (9 respondents), being invited by the MSW himself (2 respondents), and
being introduced/word of mouth by the sex client (14 respondents).

Thus, despite the small study sample covering only 24 respondents working for the
owner, we can see that male sex work takes place in diversified format in terms of
time, location, middlemen, and the decision maker on the venue for sex work.

Besides those brothels having agreement on sex trade as mentioned above, many
guest houses or massage parlors and karaoke bars allow clients to have sex there
without interfering them. Clients with adequate ID documents can rent the room.
In this case, the MSW and the client may reach an agreement. The owner of the
establishment has no intervention in their sexual encounters, or sex selling and
buying even though they know that the client rents the room for sex purpose. Sex
trading in Viet Nam is illegal but the police often pay attention to the heterosexual
couples renting room at a guest house for heterosexual intercourse while less

41
attention is paid to those couple of males or a group of males renting a room in the
guest house.

Customers come and have sex here, honestly speaking, sometimes I know. But it is
a sensitive issue. As long as I do not serve as a go-between, I would not fear
anything. If a man and a woman have proper personal papers (to be accepted
here) and they have sex, this is their business. If police come and find them, they
would arrest them. As for us, we register according to regulation, we are not liable
for this sex exchange. There had been many cases like this before between a man
and a woman, but not between a man and another man.

An owner of a guest house

Free condoms are provided to clients by such guest houses. The source of their free
condoms is from HIV prevention projects, and also from their external purchases
to sufficiently meet all needs of different types of customers, not only those
MSWs.

The number of condoms that projects provide for MSM is not enough. Additionally,
we do not only provide condoms for MSM but also for other groups. We always
have to buy more condoms which occupy 80% of all total number.

An owner of a guest house

It is not easy to have an in-depth study on the involvement of the guest house
owners in HIV prevention activities. Not every owner is ready to share information
on this sensitive topic, especially when such information may influence their
economic activities. However, qualitative data in this study suggest that the
involvement of owners of guest houses, massage parlors, and karaoke bars in HIV
prevention is very important and practical. The HIV prevention project, through
activities conducted by the Hai Dang (Lighthouse) club, has accessed and
convinced the involvement of some guest houses. There should be studies to

42
review preliminary experience and successes on this issue so that more owners of
guest houses and related recreational facilities can actively get involved in HIV
prevention and control among MSM in particular and in society in general.

VI. Participating in club activities or using reproductive health

counseling/VCT services
Among 149 respondents on this topic, only 21 respondents (14.1%) participated in
local MSM clubs or societies. However, up to 83.8% of non-club members
reported that they have attended communication sessions or received materials on
HIV prevention.

Almost all respondents (125 people accounting for 83.9%) disclosed the places
where they can visit to get counseling service on reproductive health, and HIV and
STD prevention (Figure 6.1). The places which are the most frequently visited by
respondents is STD clinics and VCT services, followed by public health care
facilities, reproductive health/HIV/AIDS counseling centers, counseling centers on
love/marriage/family affairs. Private health clinics or pharmacies are rarely
mentioned by respondents. It is noted that there are some STDs/VCT services
located inside public hospitals can be referred to by the respondent in the “public
health facilities” section instead of the “STDs/VCT services” section.

43
 Chart 6.1. Percent of 125 persons who know where they can
have a counseling on RH or HIV/STDs

Telephone counseling 39.2

Counseling centers for love, marriage &

32.8
family

Counseling centers for RH and HIV/AIDS 58.4

Clinic for HIV voluntary counseling and

82.4
testing

Drug store 5.6

Private health facility 17.6

Public health facility 61.6

About 65.8% of respondents told that they have taken advantage of counseling
services on HIV/STD prevention (98 out of 149 respondents for this question). In
general, among those people who have ever utilized the counseling service, only a
few people showed their dissatisfaction on certain aspects of the service. Most of
respondents commented that the service is accepted, satisfactory or very
satisfactory. The percentage of people showing their satisfaction or high
satisfaction with the counseling service is very high (see Figure 6.2).

44
 Chart 6.2. Percent among those who used counseling services
and satisfied with the aspects of services (N=98)
h. Quality of counseling 79.6
f. Service attitudes 67.3
e. Privacy and confidentiality 91.8
d. Cost of services 81.6
c. Qualification and experience of counsellor 78.6
b. Working time 76.5
a. Place 81.6

Counseling centers for reproductive health/ HIV/AIDS, love/marriage/family

affairs, STDs/VCT services,, and MSM supporting clubs play an important role in
giving encouragement and assistance to MSWs, sex clients and the homosexual
people in general to use HIV counseling and testing services (Box 1.6).

Box 6.1. Experience with VCT

I went for HIV/STI testing. I never did it before but since I knew Hai Dang 4
years ago, I always go for HIV/STI testing twice per year. The result is
good. I often go to VCT/STIs centers in Bach Mai Hospital, on No2 Truc
Bach Street, and on Nguyen Khuyen Street. Moreover, I was also tested 2
times in Hai Dang Club. I do not have to pay anything. I also introduce this
place to my gay friends. I just have to pay for motor cycle trips. I was given
conselling about HIV, safe sex, and blood testing.

45
 The staff are friendly and open. The doctor has skills, speak politely and
make appointment on time. If the clinic was larger and the doctor could
work on Saturdays and Sundays, it would be better. Gay men like me should
have safe sex and always have blood tested. We also should participate in
social activities because we can get more information, improve our
awareness and reduce the risk of infection.
A gay man and also MSW client (call himself a “sister”)

The HIV prevention projects utilize the pool of peer educators who have similar
circumstances and were trained on prevention of HIV/AIDS and communication
skills for advocating MSWs and other homosexual people to raise the awareness
on HIV, measures for HIV prevention, and how to get involved in such activities
as VCTs and community-based activities with the purpose of health protection.
This way of doing proves to be effective because the peer educators find it easier to
access MSMs and MSWs and convince their sex partners.

Those involved in MSM clubs such as Hải Đăng club (the Lighthouse) assumed
that they have good knowledge on HIV prevention. Actually, they have been given
counseling and communication materials on this topic, and free condoms and
lubricants during the course of participating in the club’s activities. That is why
MSM club members visit VCTs for HIV testing purpose rather than HIV
counseling services. A doctor working at a VCT clinic expressed as follows:

“STD-infected people coming to us by themselves or being referred to us by

the physicians sufferers tend to seek counseling or help from us. Unlike them,
those are referred by club members just come here for the purpose of HIV testing.
”

A VCT clinic doctor

Other comments show limitations of some VTCs such as the inability to ensure
confidentiality, overcrowding, and health staff’s unfriendly attitudes which make
MSMs reluctant when using the services.

46
There are people with discriminatory attitudes. To be honest, it is inconvenient if
VCT services are located among other departments in the hospitat. The space is
small and crowded. Sometimes staff shout at clients. They give results and go
without counseling. Many MSM hesitate to go there. Many of them are young and
do not understand. I think this is the most important drawback.

An MSM sex worker

For those who did not use the counseling service, many reasons have been cited
(Figure 6.3), of which it is worth noting with “fear of confronting the truth of HIV
infection”, “fear of losing clients with disclosure of information”, and the feeling
that the counseling service is not necessary (Figure 6.3). Those worries should be
dealt with in order to attract more MSWs to visit and use services available at RH
counseling and HIV/AIDS prevention centers.

Chart 6.3. If not using counseling services, what are the main
reasons?
(% among 51 respondents not using counseling services)
Afraid others would know who I am 27.5

Afraid to face HIV+ verdict 56.9

Afraid of being deserted by lover 11.8

Afraid of losing job 5.9

Afraid of losing customers if they know 47.1

Afraid of lack of confidentiality 23.5

Afraid that others will know and laugh at me 19.6

Afraid that counsellor would look down on me 29.4

Afraid of cost 23.5

No time 29.4

Lack of knowledge about HIV services 27.5

Lack of knowledge about HIV prevention 13.7

No needs 54.9

47
VII. Barriers encountered by MSWs in HIV/AIDS prevention and control
This section systematizes discussion outcomes on barriers for MSM in HIV/STD
prevention. It is noted that some barriers have been scatteredly mentioned in the
analyses above and will not be repeated in here as evidence or supportive data.
Categorization of barriers is done in a relative manner so as to make the readers
understand those barriers. In reality, those barriers have their interaction to create
an aggregated impact on behaviors of sex workers.

7.1. Barriers as a result from lack of understanding

A person may not use necessary measures for HIV prevention just simply because
of his/her inadequate understanding on reproductive health and HIV prevention.
Analysis presented in section III on “knowledge on HIV/STDs and preventive
measures” shows that the youngsters with low level of education are those people
having lower level of knowledge on reproductive health and HIV/STDs than those
who are older and have higher education levels. Lack of understanding is observed
more among male adolescents who starts their interest in sexual activities (between
15-19 years of age, see more in Box 3.1.1).

Condom use during sex is a very important measure for prevention of HIV and
STDs. However, as shown in the above analysis, the majority of sex workers either
do not use condoms or use condoms inconsistently due to different reasons. Of
those people, 1/3 do not have condom use due to poor knowledge on HIV/STDs
(31.3%), and 38.1% do not use condoms because they think both have no STDs or
have the healthy-looking appearance. Absence of condom use with the belief that
condom is not necessary for oral sex, poor knowledge of condom usefulness, both
partners being HIV positive, or “taking a revenge for life” reflects the poor
understanding of a proportion of MSMs involved in sex work.

Barriers stemming from poor knowledge of MSWs are paid most attention and
normally intervention measures provided by supportive projects focus on raising
their awareness. This activity should be promoted, but there should be
improvements on identification of and access to them for communication activities
so that high-risk group members can have the opportunity to get access to
information. Lack of understanding found among very young people shows the
huge need of education on gender, reproductive health, HIV/AIDS and STD

48
prevention for adolescents. The family, school, and social organizations working
with adolescents are the ones which can provide better knowledge to adolescents
on this topic. At the same time, it is necessary to improve quality and contents of
the messages.

7.2. Barriers stemming from value perception of sexual activities

Most MSWs sell sex for money, but some MSWs sell sex to satisfy their own
sexual desire to some extent. Those people sometimes play the role of the sex
clients. Being both the sex seller and the sex buyer increases the number of sex
partners in a certain period of time and therefore increases the risk of HIV
infection and STDs.

The perception that condom use may reduce sexual sensation is also an important
barrier which makes nearly ¼ of MSW respondents not use condoms or have
inconsistent condom use. This perception which exists among clients may lead to
absence of condom use in having sex with sex workers even though the sex
workers have knowledge and are in need of condom use but they lack successful
negotiation ability for condom use in sex. As analyzed in the above section, up to
67.2% of MSWs do not use condom because of the client’s requirement of not
using condoms during sex.

This perception is also found in other studies (SAVY 1, SAVY 2). This perception
is partly stemmed from the circulation of low quality condoms in the market or
partly due to the poor understanding of benefits of consistent condom use.
Communication on safe sex should take this into consideration.

7.3. Barriers stemming from situational context

Male sex work does not always take place as planned. In many cases, the specific
situation of sex practice can influence the use of HIV/STD prevention measures.
As mentioned above, up to 53% of MSWs do not use condoms at times due to their
lack of preparation in advance, and still 42.5% of respondents reported that they
could not get condoms at the time when sex is being performed. One person can
have consistent use of condoms, but if he misses one time of condom use during
sex, he is able to get infection. Prevention of HIV and STDs requires consistent
condom use during sex. This means that MSWs should bring along condoms, even

49
in a big number. Only bringing along condoms does not ensure the use of condoms
during sex selling, but at least this can help to make condoms available when in
need. To overcome this barrier in such a situation, it is necessary to encourage
MSWs to always bring condoms along with them, even many condoms.
Establishments where sex work may be possible, availability of condoms should be
made in convenient places in order to reduce the cases where condom is needed
but not available during sex.

Another situational factor is the use of alcohol or other stimulants prior to sex.
Using alcohol or other stimulants may reduce the ability to assess the situation for
application of safe sex behaviors, and ability to negotiate condom and lubricant
use. Alcohol and stimulants reduce the ability to assess safe sex of both drinking or
stimulant-use clients. The above analysis shows the lower percentage of condom
use among alcoholic drinkers during sex. In order to overcome this barrier, it is a
requirement for MSWs to avoid drinking alcohol or using stimulants when
performing sex work. Communication programs can deliver this message to MSWs
through communication channels which may access establishments with sex work.
But the awareness raising for clients not to drink alcohol or to use stimulants
during sex is more difficult. This should be partly conducted through the mass
media system, in general.

7.4. Barriers due to power unbalance in sexual relationship

Safe or unsafe sex is often a result of clear and frank negotiation or through the
hidden understanding on specific sex methods to be performed. In all cases, this
depends largely on negotiation skills and power correlation between the MSW and
the client. In this power correlation, the MSW often shows his weakness because
he has to make clients happy. As mentioned above, up to 67.2% of MSWs reported
that they did not use condoms at times because of requirement made by the sex
client.

Analyzing correlation between the MSW and the client in making decisions on sex
methods shows that MSWs have more power in giving decisions on sex methods
with loving partners or regular clients than with irregular clients. This shows the
fact that not all sex workers lose their will and accept risks in selling sex. What
they need seems to be the negotiation skill for protective sex methods, good

50
knowledge on health risks resulting from unsafe sex, even with loving partners and
regular clients (because those people may provide the assumption that they are not
infected with diseases), and the strong spirit to overcome attraction/temptation in
terms of money or love brought about by satisfying the clients. Those skills are
complementary to each other for a successful negotiation. For example, good
understanding can be a basis for a sensible, mutually beneficial negotiation on
condom use for both the sex seller and the sex buyer, which makes this
requirement easier to be accepted.

Sex violence is also indicative for the fact that some MSWs have unequal power
with the partner in sex work, and HIV/STD prevention, and in this case, depends
largely on knowledge and awareness on disease prevention of the partner.

Another aspect relating to power correlation in making decisions on sex methods is

the role played by the owner of establishment. In this study, there is not much
information on what role they can play in giving decisions on sex methods between
the MSW and the client, but the above analysis of the owner’s relationship shows
that MSWs in brothels do not have much power in giving decisions on
location/venue and time for their sex work and their clients. When the main
purpose of brothels is to sell sex, saving the credibility of the brothels by satisfying
clients is the concern of the owners. In case where satisfying clients requires
unsafe sex practice, the sex workers are under strong pressure in satisfying clients,
also satisfying the owners – on the other hand, protecting his sexual health presents
the risk of losing his job. This aspect shows that brothel owners should be targeted
for HIV/STD prevention program activities.

7.5. Barriers due to the nature of male sex work

As shown by the above analysis, MSWs have multiple partners, “loving partners”,
and regular and irregular sex partners, and for bisexual people the number of
partners and average number of sex encounters per month increases considerably.
The number of partners and frequency of sex practice is directly proportional to
HIV infection and STD risks. Sex work takes place all the year round, and
therefore, sex work related risks always threaten health of MSWs.

51
Another aspect that makes MSM more vulnerable to HIV infection, more difficult
to control sex behaviors or to ensure the application of STD prevention measures is
that many of them often have sex with multiple partners simultaneously (26.7%).
During multiple sex performance, the likelihood of negotiation for safe sex
methods is much more difficult, especially when the sex partner is not “the loving
partner” or regular sex client.

Reducing harm of the barrier caused by the nature of MSM can only be done by
advocating them to stop selling sex and switch to other jobs or creating appropriate
jobs for them and encouraging potential sex clients to stop buying sex. In reality, it
is very difficult to do this. However, activities on this track could be successful for
many of them. Eliminating stigma and discrimination against MSM in society can
have positive impacts, which makes som MSM avoid the trap of male sex work for
money and satisfying their own sexual desire with men. This example shows that
efforts in eliminating male sex work in reality can gain certain success in HIV/STD
prevention.

7.6. Barriers caused by self complex and self stigma of MSWs

Question on MSWs’ worries in their sex practice refers to 6 forms of self stigma
including fear of being arrested by the police, fear of being disclosed by the family
or loved ones, being abandoned by sex partners, being sacked by the employers,
and damage to family happiness. Up to 94% of respondents have one or two self
stigmas out of 6 types mentioned above. Nearly half (46.7%) of respondents have 3
or more types of self stigma.

Self stigma leads many MSWs to refusing use of counseling services for HIV/STD
prevention. Figure 6.3 shows that among those people who do not use this service,
many stated the reason of self stigmatization such as fears of disclosure, of facing
with the truth of being HIV infected, of being left by the partner, of being sacked
by the employer upon discovering their HIV status, of losing clients once the
information is leaking, of information leaking from the service provider, and of
being criticized by other people or the counseling staff. If all those types of self
stigmas are taken into consideration, the proportion of people who have self stigma
(at least one of those 8 types mentioned above) among those who do not use HIV

52
counseling services rises to 76.5%. Self stigma, as such, is clearly an important
obstacle which makes MSWs reluctant to visit VCT/STD counseling services.

Self stigma prevents MSWs from using VCT/STI counseling and health care
services promptly. They use those services only when they have health problems,
especially when it is too late (Box 3.1.1). Inferiority and complex also makes many
MSWs, upon attending HIV counseling or testing services, feel passive to ask in
detail the counseling or health staff about their health status as well as measures for
HIV prevention in order to enrich their knowledge on this issue. This explains why
there is a high rate of service utilization but understanding of many MSWs in the
study sample is still limited.

Self stigma together with the fear of receiving discrimination from health staff
could be the reason for many people suffering from STDs to avoid visiting health
facilities. As presented above, only 4 out of 18 people having ulcer, wart or
discharge in their genital organ or anus during the 6 months prior to the study
received services in public health care faculties, and 3 people received services
from private clinics. Other people bought medicines for self treatment or visited
clinics of projects where they feel secure and have no discrimination. Many of
them still continue their unsafe sexual practice without condom use. This influence
of discrimination has reduced the number of opportunities to get access to services
for MSWs and increased STD risks.

Self stigma also makes many MSWs feel less confident to negotiate safe sex with
clients, accept easily the risk of not using condoms and lubricants upon being
required by the client, which therefore leads to a higher risk of HIV/STD infection.
The percentage of those MSWs having a high level of self-stigma (from 3 to 6
types of self stigma as mentioned in the early part of this section) and having no
condom use during sex with male partners is often higher than the percentage of
those who do not use condom during sex and have a low level of self stigma
(having no sign of self-stigma or from 1 to 2 types of self stigma as mentioned in
the early part of this section1). For example, the percentage of MSWs with a high

1
Only 6% of respondents (9) did not mention any among the 6 types – a too small number to be devided into groups
for significant analysis, thus we group them with people having 1-2 types of self-stigma (53.3%), and those people
having 3-6 types of self stigma into another group (46.7%).

53
level of self-stigma and no condom use during sex with irregular sex clients having
unhealthy appearance is 58.6% while this percentage among those who have a low
level of self-stigma is 43.8%. The corresponding percentage for those who have
sex with clients with healthy appearance is 30.4% for a group with a high level of
self-stigma and 25.6% for a group with the low level of self-stigma.

Therefore, self-stigma seems to be one of the biggest obstacles which make MSWs
be in passive manner in getting access to counseling and health care services as
well preventing them from making decisions and taking actions for their self
protection. Self stigma increases risks of HIV/STD infection for MSWs and
through this increases risks for those who have unsafe sex with them. This, in turn,
can lead to bad consequences to MSWs in particular and the community in general.

VIII. Conclusions and recommendations

The MSW respondents are in a relatively diversified population, consisting of

members from different social groups, age groups, sexual orientations, family
circumstances and personal background.

Generally, MSWs’ knowledge on HIV/STDs in the sample is at a basic level

concerning transmission routes and some common STDs. Those who have higher
education levels have better understanding. There is still a considerable percentage
of respondents showing their lack of understanding or unclear understanding on
potential routes of HIV transmission such as sharing a razor, unsafe oral sex,
sharing a toothpick/oral care devices, or mother to child HIV transmission during
pregnancy. There is also a considerable percentage of respondents who do not
know STDs such as trochomiasis or Chlamydia. Nearly half of repondents are not
aware of the risk for HIV surinfection when both HIV infected partners do not use
condom during sex. This shows the strong necessity of communication for awareness
raising among MSW group to help them with HIV and STDs prevention for
themselves and for their partners.

As many as 118 respondents (78.7%) have ever attended HIV testing. The majority
of those people have had HIV testing between 2005 and now and had their first test
at polyclinics of public hospitals, or VCT clinics of different projects. Most of
respondents reported that doctors had friendly or normal treatment behaviour to

54
them. Almost all those having had HIV testing in the last 6 months received
discussion with doctors on the interpretation of test results, HIV prevention
measures, what should be done upon receiving the test results and introduction of
where they can receive assistance. However, doctors seem to have less disussion
with tested people on homosexual and MSM sex.

Almost all respondents presently continue their sex selling to men (81.3%). Only
18.7% of them reported that they sell sex to both men and women during the 6
months prior to this study. On the average, each respondent who sells sex to men
had 21 sexual episodes per month, and each respondent who sells sex to both men
and women had 32 ones. In general, sexual activities are conducted around the
year.

MSWs had multiple sex partners in the last 6 months. The majority of MSWs had
more than 10 sex partners during the last 6 months and even more than 40% of
them had over 20 sex partners in the last 6 months. More than ¼ of MSWs had sex
with multiple people at the same time. Most had sex with multiple men at the same
time. MSWs often had more power in making decisions on sex methods with
partners or regular sex clients, and they had the least power when selling sex to
irregular sex clients.

A number of MSWs expressed that sexual activities in the 6 months prior to this
study were accompanied with violent acts such as clawing, pinching, beating,
roping, hanging, and scolding. The percentage of those having sex together with
violence is higher when they sell sex to clients, both regular and irregular.

Generally, MSWs had sex, regardless with men or women, mainly for money.
Other purposes of this practice are optional. Income gained from male sex work is
rather high. On the average, an MSW can earn more than 8 million VND/month by
selling sex. This is a relatively attractive income level and it is hard to find any
other unskilled jobs to compete with it. This shows that advocacy for not getting
involved in sex work seems not to be a simple thing to do.

The expenditure structure of money gained from sex work reflects essential needs
of living illustrated by the fact that most of respondents spent their money from sex
work on meals, house rental, clothing, belongings, and recreation. Some MSWs
spend money on health care, education and paying debt.

55
Around 70% of respondents said that sex work is not the only way for them to earn
money. Among those respondents who earn money by other ways, the majority
involved in sex work rather than earning money by other ways because other ways
do not bring much money to them or bring them more hardships. With the high
income level from sex work as mentioned above, it is very difficult to find other
jobs with similar level of income.

Attention should be paid to the low percentage of respondents who said that they
have regular condom use during sex, especially having sex with partners, new
clients with healthy-looking appearance or regular clients. Many MSWs do not use
condoms or had inconsistent use of condom. Alcoholic users, during sex, have a
lower rate of condom use than the non-users. This shows that MSWs have a high
risk of HIV/STD. Many MSWs lack negotiation skills on condom use with clients
or partners, or forget to bring condoms along or meet difficulty in getting condoms
(obtained by buying or free of charge), and lack of comprehensive knowledge on
HIV infection and surinfection so that they can protect the health of him/herself as
well as the partner effectively. Intervention activities to help raise the awareness
and capability for HIV prevention for MSWs should bring into account those
contents. The above figures regarding lubricant use reflect similar issues in
condom use.

Many MSWs in this study clearly got access to free supplies of condoms or
lubricants from peer educators, centers for counseling on love, marriage, family
affairs, or centers for reproductive health or HIV/AIDS counseling, STI/STD
clinics, VCTs, and public health facilities. Partners are an important source of
condom or lubricant supply. For those working in brothels, the owner provides free
condoms to them. MSWs buy condoms mainly at shops, supermarkets or
pharmacies. Thus, access to supply of condoms or lubricants does not pose a big
problem. However, the modest rate of condom and lubricant use and the
inconsistent frequency of use show challenges in condom and lubricant use.

Among 150 respondents who are MSWs, 36 are drug users (accounting for 24%).
There are reasons leading to drug use. Most of drug users reported that they use
drugs because of being invited by friends, easing the tension or being self
interested in drug use. MSW has created more pressure for SWs using drugs
through invitation, or coercion of sex clients or partners. Drug use MSWs are

56
involved in a network of friends or clients who are also drug users and they help
each other.

Out of 150 MSW respondents, only 43 (28.7%) have worked for the owner, and
the rest work independently. Brothels where those people were working are in the
form of Karaoke bars or massage parlors, and saunas. At brothels, respondents are
recruited mainly for sex work. Generally, the owners are also concerned about the
health of SWs at to certain extent. On the average, 1 brothel has 9 MSWs and there
are no FSWs. Most MSWs live in the brothel. Sex work often takes place in the
afternoon or in the evening. Few people perform sex work in the morning or after
midnight. Sex clients often visit MSWs through different ways such as contacting
the owner, middlemen, telephoning, being introduced by the co-MSW, being
invited by the MSW himself, and being introduced/word of mouth by the sex
client. Thus, male sex work takes place in a diversified format in terms of time,
location, middlemen, and the decision maker on the venue for sex work.

Among 149 respondents on this topic, only 21 respondents (14.1%) participated in

local MSM clubs or societies. However, up to 83.8% of non-club members
reported that they have attended communication sessions or received materials on
HIV prevention.

Almost all respondents disclosed the places where they can visit to get counseling
services on reproductive health, HIV and STD prevention. The places most
frequently visited are STD clinics and VCTs, followed by public health care
facilities, reproductive health/HIV/AIDS counseling centers, and counseling
centers on love/marriage/family affairs. Private health clinics or pharmacies are
rarely mentioned by respondents. About 65.8% of respondents told that they have
taken advantage of counseling services on HIV/STD prevention. Most of
respondents commented that the service is accepted, satisfactory or very
satisfactory.

From the perspective of prevention of HIV and STDs, the analysis of MSW’s life
aspects suggested that there are 6 main types of barriers for MSWs in getting
access to services of health care, and HIV/STD prevention, including barriers
steming from lack of understanding, value perception of sexual activities,
situational context, power unbalance in sexual relationship, the nature of male sex

57
work, and self complex and self stigma of MSM. In reality, those barriers do not
have independent impacts on bahaviours and thoughts of MSWs, but in a
combination making a higher risk of HIV/STD infection for MSWs. Each type of
barriers suggests specific measures for MSW’s harm reduction and HIV/STD
intervention programs to be taken. The followings are some reccommendations
made in this direction:

Recommendations

 Awareness raising communication on reproductive health and HIV/AIDS

among MSWs is very necessary and needs to be further strengthened. A
review of communication formats that have been used is also needed in order
to improve communication effectiveness. Special attention should be paid to
the followings:
o Some potential HIV transmission routes;
o Surinfection risks when two HIV positive people having unprotected sex;
o Other STDs;
o HIV risks from having multiple sex partners and inconsistent use of
condoms and lubricants during sex;
o Violence prevention in sex;
o Health risks from alcoholic drinking or drug use during sex;
o Adequate provision of information on counseling centers to MSM;
o Communication on barriers and their possible consequences on
HIV/STD prevention for MSWs and the community.
 Communication activities to raise the awareness of reproductive health and
HIV/AIDS in male sex work among the brothel owners or those who are
potentially becoming the owners;
 Communication activities to raise the awareness and counselling skills on
homosexuality and sex work for doctors providing HIV/AIDS counseling and
testing so that they could provide more effective support to MSWs in
prevention of HIV/AIDS.
 Due to the important role of MSM clubs in improving knowledge on HIV
prevention among homosexual people, MSWs and at the same time
providing counseling services, condoms, lubricants, referring homosexual
people and MSWs to voluntary HIV testing facilities, thus contributing to

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 prevention of HIV pandemic in society, the responsible government
agencies should have appropriate mechanisms and policies to create
favorable conditions for clubs’ formulation and effective operation.
 Conducting studies on this topic on larger scale in order to clarify those issues
mentioned in this study such as barriers in ustilization of concoms and
lubricants, options for employment rather than sex work, risks resulted from
acolhol or addictive substances during sex selling, relationship between MSM
and operational activities of counseling centers, types of barriers for MSWs
HIV/STD prevention, especially barriers relating to self-stigma.

References

Colby, Donn J. 2003. HIV Knowledge and Risk Factors Among Men Who Have
Sex with Men in Ho Chi Minh City, Vietnam. Ho Chi Minh city.

Colby, Donn, Nghia Huu Cao, and Serge Doussantousse. 2004. "Mem Who Have
Sex With Men and HIV in Vietnam: A Review." AIDS Education and
Prevention 16:45-54.

UNAID. 2006. HIV and Men Who Have Sex With Men in Asia – Pacific. Geneva.

Vu Manh Loi, Nguyen Huu Minh, Tran Vu Hoang, Vuong Thi Huong Thu,
Roberts Broadhead, Dang Thanh Truc, Nguyen Nga My, and Doan Kim
Thang. 2006. “I Want to Quit But Can’t”: Drug Addiction, Networks, and
HIV Risks in Hai Phong and Cam Pha. Hanoi: Lotus Communication.
Vu Manh Loi, Tran Thi Nga, Le Thi Mong Phuong, Nguyen Thi Van, Doan Kim
Thang, Tran Quoc Tuan, Nguyen Thi Nga My, Duong Thi Kieu Lan, Le
Thanh Doan, Nguyen Quoc Huy and Nguyen Tien Dong. 2009. Men who
have sex with men in Vietnam: Stigma and social consequences. Hanoi:
SHAPC.

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