MEN WHO HAVE SEX WITH MEN AND HIV IN VIETNAM: A REVIEW

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1 COLBY, MSM AND CAO, HIV AND IN VIETNAM DOUSSANTOUSSE AIDS Education and Prevention, 16(1), 45 54, The Guilford Press MEN WHO HAVE SEX WITH MEN AND HIV IN VIETNAM: A REVIEW Donn Colby, Nghia Huu Cao, and Serge Doussantousse Men who have sex with men (MSM) in Vietnam s urban centers are increasing in numbers and visibility. Although limited to a few surveys, the available data on MSM in Vietnam show that they are at increased risk for HIV infection due to high numbers of sexual partners, high rates of unsafe sex, and inconsistent condom use. There are significant numbers of male sex workers in Vietnam and these men are also at high risk for HIV infection. The lack of data on HIV prevalence among MSM and the fact that the media and public health prevention programs ignore MSM as a population at risk leads many MSM to mistakenly believe that their risk for HIV is low. The low perception of risk, combined with inadequate knowledge, may make MSM less likely to actively protect themselves from HIV infection. More research is needed on current behavior and HIV prevalence among MSM and male sex workers in Vietnam. MSM in Vietnam s larger cities could easily be targeted for prevention using peer educators to decrease their risk for HIV infection. The situation of men who have sex with men (MSM) in Vietnam is changing rapidly. On one hand, rapid economic growth and liberalizing social attitudes in the larger cities have allowed the emergence of large and increasingly visible homosexual populations. On the other hand, homosexuality is definitely not considered normal or an acceptable lifestyle in Vietnam and the majority of homosexual men keep their sexual orientation secret. Increasing communication with the rest of the world has also allowed urban MSM in Vietnam to learn from gay rights movements in other countries. Gay foreign tourists and Viet Kieu, ethnic Vietnamese who live in Western countries and return to Vietnam to work or vacation, are commonly encountered in MSM identified venues in the larger cities. The term gay is now being adopted by many urban MSM to describe a male homosexual. Although MSM may be increasingly visible, there has been very little published research on homosexuality in Vietnam (Khuat, 1998). In fact, there had been very little published research on any aspect of sexuality in Vietnam prior to the emergence of the HIV epidemic. Therefore, most research in Vietnam that deals with sexuality and Donn Colby is with the Center for AIDS Prevention Studies, University of California, San Francisco, and the ColumbiaAsia Medical Center, Ho Chi Minh City, Vietnam. Nghia Huu Cao is with Pasteur Institute, Ho Chi Minh City, Vietnam. Serge Doussantousse is with Médècins Sans Frontieres, Vientiane, Laos. Address correspondence to Donn Colby, M.D., M.P.H., ColumbiaAsia Medical Center, 08 Alexandre de Rhodes, District 1, Ho Chi Minh City, Vietnam; donncolby@columbiaasia.com 45

2 46 COLBY, CAO, AND DOUSSANTOUSSE all of the few published studies that even mention homosexuality have focused on the relationship between sexual behavior and the risk for acquiring HIV infection. In this article we will review the current situation of MSM in Vietnam, with attention to sexual behavior and the risk of transmitting HIV infection. Where available, the information in this review comes from published studies on risk behavior, knowledge, and attitudes regarding HIV. Also cited is information from the Vietnamese media, which for most people in the country is the only available source of information about homosexuality. The media therefore influence public opinion even if, given that they are entirely state controlled, they do not necessarily represent all of the attitudes and opinions toward MSM and homosexuality present in Vietnamese society today. Media reports also give insight into the attitudes and biases of the country s political rulers, who through state censorship manage what is written and published. Our aim is to try to relate an understanding of the situation of Vietnamese MSM in relation to the HIV epidemic in the year VIETNAM: A BRIEF OVERVIEW Vietnam is located in Southeast Asia and shares land borders with Cambodia, Laos, and China. Its population in 2001 was 79 million, of which 80% was rural. The population is very young, with a median age of 23. Literacy is high at 93% (UNAIDS/WHO, Working Group on Global HIV/AIDS and STI Surveillance, 2002). In 1986, the government of Vietnam established the policy Doi Moi, or new change, which allowed increased private enterprise and foreign investment. In 1995, Vietnam normalized relations with the United States and joined the Association of South East Asian Nations (ASEAN). Economic growth has been rapid in the past few years, especially in the urban areas. Nevertheless, Vietnam remains a poor country, with a year 2000 per capita gross national product (GNP) of U.S. $404 (Asian Development Bank, 2002). Ho Chi Minh City, formerly Saigon, is the largest city in Vietnam, with a population of about 7 million. It is located in the south and is the commercial center of the country. Hanoi, with a population of about 2 million, is the capitol of Vietnam and lies in the north of the country. The distance between the two cities is more than 1,100 kilometers (700 miles). HIV IN VIETNAM The first known case of HIV infection in Vietnam was reported in 1990 (World Health Organization [WHO], 1999). The number of new HIV infections reported per year has risen dramatically from less than 2,000 per year in the early 1990s to 4,316 in 1998, 9,329 in the year 2000, and more than 15,000 in By the end of 2002, the cumulative total number of infections reached 59,200 (Vietnam Ministry of Health, 2003). Intravenous drug users (IDUs) are the largest group affected, constituting 62% of infections (Vietnam Ministry of Health, 2003). Other known high-risk groups in Vietnam are female commercial sex workers (CSWs) and patients in sexually transmitted disease (STD) clinics. Fully 35% of infections have no reported risk factor and 85% of infections occur in males. UNAIDS estimated that there were up 130,000 people living with HIV in Vietnam at the end of 2001 (UNAIDS/WHO, 2002). Sentinel surveillance for HIV in Vietnam targets six populations in 20 different provinces: patients in STD clinics, female CSWs, IDUs, tuberculosis patients, preg-

3 MSM AND HIV IN VIETNAM 47 nant women, and male military conscripts (Nguyen et al., 1999). Information on risk behavior, other than category of surveillance, is not recorded (WHO, Regional Office for the Western Pacific, 1999). MSM are not included in routine surveillance. In Ho Chi Minh City, the number of new infections identified in the city more than doubled from 1,164 in 1999 to 2,940 in the year Prevalence rates have been rising rapidly in most surveillance populations in Ho Chi Minh City and in 2002 reached 76% in IDUs, 26% in female CSWs, 8% in STD patients, 3.4% in male military recruits, and 0.9% in pregnant women (Provincial AIDS Committee of Ho Chi Minh City, 2002). In western Europe, Australia and the United States, the majority of people infected with HIV are MSM (United Nations Programme on HIV/AIDS, 2000). In Asian countries that include homosexual sex in their statistics, MSM have been found to be at increased risk for HIV infection (Chan et al., 1998). Prevalence of HIV among MSM in Cambodia in the year 2000 was 15% (Monitoring the AIDS Pandemic [MAP], 2001). Among Japanese men, homosexual sex accounts for three times as many HIV infections as heterosexual sex (MAP, 2001). Research in Thailand has shown an increased risk for HIV infection among male military recruits reporting same-sex behavior (Beyrer et al., 1995) and among male sex workers (MSWs) (Kunawararak et al., 1995). In Vietnam, sentinel surveillance does not include MSM, and behavioral surveillance surveys do not ask about same-sex behavior. Therefore, there are no data on the relative importance of homosexual sex in the overall HIV epidemic or in relation to other risk behaviors. HOMOSEXUALITY AND VIETNAMESE SOCIETY There is very little information on homosexuality in Vietnam prior to the emergence of HIV as a public health problem in the 1990s. In Vietnam there is no tradition of an accepted or historical role in society for homosexual men. This is in contrast with other Southeast Asian countries such as Thailand and Laos, where effeminate men known as kathoey have a long tradition of an accepted albeit highly stigmatized role in society (Chan et al., 1998). The most notable aspect of Vietnamese society s view on homosexuality is its lack of attention to the matter. The 1990 government plan for responding to the HIV epidemic noted that: Homosexual behaviour probably occurs in Viet Nam as in most other countries, but there are no formal meeting places or organized homosexual groups. This mode of transmission is therefore not considered to contribute significantly to an eventual spread of HIV in Viet Nam (Vietnam Ministry of Health, 1990, p. 11). In 2002, when interviewed about the HIV epidemic, the head of the communication department of the National AIDS Committee was quoted as saying, My guess is the number of homosexuals in Vietnam is only a few hundred (Tran, 2002). Even the law in Vietnam ignores homosexuality. There are no laws against homosexuality or homosexual sex in Vietnam, a fact that probably owes more to inattention rather than to any progressiveness on the part of the legal system. A common belief about MSM in Vietnam is that most are not truly homosexual but merely temporarily following a Western fashion or trend. This idea can be seen in the writings of Dr. Tran Bong Son, the most famous sexologist in Vietnam. He has written numerous books on sexuality and frequently answers questions about sexual issues in newspapers and magazines. Although his views on homosexuality are based

4 48 COLBY, CAO, AND DOUSSANTOUSSE more on his opinion than on any research or data (Dr. Tran Bong Son, personal communication, 2002), it is informative to look at what he writes because his name and books are widely known within Vietnam and have a great influence on what the general population, including medical professionals and policy makers, believe to be the truth about homosexuality in Vietnamese society. An example of Dr. Son s views can be seen in a Vietnamese language HIV prevention brochure that was published by an international nongovernmental organization (NGO) and that lists Dr. Son both as an advisor and as the author of several references (CARE International, 2001). The brochure describes two kinds of homosexual men in Vietnam: the that, or true, kind that is inherently homosexual and is very rare and the gia, or fake, kind that has been lured by fashion or experimentation into trying homosexuality and who will eventually return to a heterosexual lifestyle. The stated conclusion in the brochure is that the majority of the homosexual men in Vietnam are fake. Although there is no scientific research or facts to support this idea, it has been repeated so many times within the media and popular culture that it is now accepted as the truth in Vietnam. In a recent newspaper article about homosexuality, a physician in the Ho Chi Minh City Department of Health Education was quoted as saying that you can conclude that the majority of young homosexuals are gia. (Tien, 2002). The state-controlled media in Vietnam occasionally carry reports on homosexuality. These reports often cite facts from international research but always include statements that reveal a negative bias against homosexuals. For example, one recent magazine article stated, There is no scientific basis to conclude that homosexuality is an illness. But it is clear that these people are mentally confused (Tiep Thi & Gia Dinh, 2003). The government of Vietnam currently has a social evils campaign to crack down on prostitution and drug use, both of which are associated with HIV infection. Although one press report in 2002 stated that the Ministry of Labor, War Invalids and Social Affairs was calling for homosexuality to be labeled as a social evil (Deutsche Presse-Agentur, 2002), the government has not publicly voiced any official policy toward homosexuality or MSM. RESEARCH ON VIETNAMESE MSM AND RISK FACTORS FOR HIV Between 1993 and 2001, there were three behavioral surveys of HIV risk factors that targeted MSM in Vietnam. One other published report cited qualitative data collected during an outreach program for MSM in central Vietnam in 1996 to Results of these reports are reviewed below. In 1993 CARE International performed a survey to assess the risk of HIV among urban men and female CSWs in Ho Chi Minh City and Hanoi (CARE International, 1993). Over 1,000 people were interviewed, including a subset of 107 Vietnamese and 12 foreign MSM. Both male and female subjects were recruited from bars and other locations where CSWs were often found, which may have biased the results of the study toward more sexually active individuals. Results of the study showed that MSM had multiple sexual partners: the average number of partners in the previous 2 weeks was 3.3 for Vietnamese men and 2.6 for foreign men. The averages for Vietnamese and foreign heterosexual men were 1.9 and 1.3, respectively. More than half (55%) of the Vietnamese MSM did not know that a person infected with HIV could look and feel healthy. The majority (62%) had never

5 MSM AND HIV IN VIETNAM 49 used a condom and most (60%) felt that they could not ask their male partners to use condoms. More than one third of MSM believed that sex with men was safer than sex with women. This was attributed to the fact that public education campaigns at that time (and continuing through to the present) focused only on drug use and female prostitution as routes for transmitting HIV infection. The survey did not report any quantitative data on types of sexual behavior. Nha Trang, a popular beach resort in south central Vietnam, was the site of an outreach program directed at MSM for seven months in 1996 and 1997 (Wilson & Cawthorne, 1999). A peer educator interviewed 12 key informants and collected qualitative data on knowledge and behavior in regard to HIV. Of note, the project was not endorsed by Vietnamese officials, and the outreach worker refused to any affiliation with government agencies for fear of being identified as homosexual. Most MSM in this study had multiple sexual partners and rarely used condoms. Knowledge about HIV transmission was poor. For example, many thought that oral sex was more risky than anal sex. This was attributed to public health messages at the time stating that HIV was transmitted by body fluids but not specifying which fluids were most risky. Therefore, the wet mouth was felt to be more dangerous than the dry anus. Another misconception was that HIV could pass through intact skin. Save the Children (United Kingdom) conducted a behavioral survey of 276 MSM in Ho Chi Minh City in 1997 (St. Pierre, 1997). Subjects were recruited from public locations and through social networks using the snowball method. The author noted that MSM were easy to contact and were willing to answer detailed questions about their sexual behavior. Among the findings were that one third also had sex with women and that three quarters of those with regular partners also had sex with nonregular partners. Anal sex was commonly practiced: 64% had ever had anal sex and 42% had anal sex during their last sexual encounter. Half had never used condoms and only 29% used a condom the last time that they had sex. Commercial sex was common with 36% ever having had sex with a male or female CSWs and 29% having been paid for sex. Although the respondents self-rated their knowledge of HIV/AIDS highly, more than half did not know how to correctly prevent transmission and less than one third considered MSM to be a high-risk group. The authors concluded that their sexual behavior placed MSM at high risk for HIV and that their knowledge about HIV was not enough to protect themselves from infection. The most recent behavioral study of MSM in Vietnam occurred in 2001 and surveyed 219 MSM aged in Ho Chi Minh City about HIV risk factors and knowledge (Colby, 2003). Subjects were recruited in bars and cafes (40%), parks and streets (25%), and through social networks (20%). Most of these men considered themselves to be homosexual (66%) or bisexual (31%). Median numbers of sexual partners were two in the previous month and seven in the previous year. Most (81%) had sex with nonregular partners and half practiced anal sex with nonregular partners. Two thirds had ever used condoms, but only 40% used condoms the last time they had anal sex and only 55% used condoms the last time they had anal sex with nonregular partners. Condom use with oral sex was very rare. Although respondents felt that condoms were easy to obtain, unavailability was frequently cited as a reason for not always using them. One interesting finding was that condom use with female was consistently higher than with male across all categories of sexual partners: regular partners, nonregular partners and CSWs. As in previous studies, the author concluded

6 50 COLBY, CAO, AND DOUSSANTOUSSE that public health campaigns focusing on male-female sex may have lead many MSM to believe that male-male sex was safer. Only 30% agreed with the statement Homosexuals are at greater risk for HIV than other people in Vietnam. When those subjects who agreed with the statement were compared with the aggregate of those who disagreed or were unsure, there were statistically significant increases in use of condoms for anal sex with nonregular partners (77% vs. 47%, p =.003) and in ever having been tested for HIV (42% vs. 25%, p =.01) (D. Colby, unpublished data, 2002). Knowledge about the transmission of HIV and the ways to prevent infection was found to be fairly good. For example, more than 75% could correctly identify the bodily fluids that transmit HIV. However, only 47% knew that someone who looked and felt well could transmit HIV and only 33% knew that they could get an STD from someone without symptoms. The majority (87%) felt that they needed more information to protect themselves from HIV. Despite high rates of sexual activity and low rates of condom usage, few MSM (6%) rated their risk for becoming infected with HIV as high. Half rated their risk as none or low, and 44% were not sure of their risk. Recreational drug use was uncommon: fewer than 2% of MSM admitted to using intravenous drugs. The two surveys conducted among MSM in Ho Chi Minh City allow some comparison of behavior and attitudes over time (Colby, 2003; St. Pierre, 1997). From 1997 to 2001, many measures of behavior were relatively stable. For example, the percentages of respondents who had more than one sexual partner in the previous month (62% in 1997 and 56% in 2001), had ever had vaginal sex (27% and 30%), and had sex with nonregular partners (74% and 81%) were about the same. Some measures, however, did show change over time, suggesting at least some increased awareness of the risk for HIV among MSM in Ho Chi Minh City. For example, between 1997 and 2001, there was an increase in the percentage of MSM who agreed that homosexuals were at higher risk for HIV infection (22% and 30%), had ever been tested for HIV (11% and 30%), and had ever used a condom (51% and 67%). In Vietnam, there are limited data on the seroprevalence of HIV among MSM. A survey of 208 MSM presenting to the Pasteur Institute in Ho Chi Minh City for voluntary testing in 2000 found an HIV prevalence of 5.8% (Cao, Le, Luong, & Truong, 2002). In the same group the prevalence rates were 7% for syphilis and 27% for hepatitis B surface antigen. At the same center in 2002, 4 of 72 MSM (5.6%) tested positive for HIV (N.H. Cao, unpublished data, 2003). Results were 8.3% for syphilis and 31% for hepatitis B surface antigen. In this group none used condoms for oral sex, and of the 61 who practiced anal sex only 29 (48%) regularly used condoms. There is no program of surveillance or routine testing to follow the prevalence of HIV infection in MSM over time. The prevalence data cited here are from one center using MSM who present themselves for voluntary testing. Whether or not this small group is representative of the larger MSM population in Ho Chi Minh City is unknown. As of yet there has been no research that has tried to determine the prevalence of HIV infection in the general MSM population. MALE SEX WORKERS IN VIETNAM Research on prostitution in Vietnam has been almost exclusively concerned with female CSWs. CSWs are included in yearly HIV surveillance surveys in 20 provinces. There are numerous published reports about Vietnamese female CSWs, including risk

7 MSM AND HIV IN VIETNAM 51 behavior and HIV prevalence (Rekart, 2002). Throughout the country there are programs that use peer educators to specifically target female CSWs for HIV prevention activities. In contrast, there is very little published data about MSWs in Vietnam. And whereas female prostitution is criminalized and specifically identified by the government as a social evil to be eradicated, its male counterpart is almost completely ignored. One qualitative survey about male sex work was conducted in Hanoi in 2002 (Doussantousse, Nguyen, & Tooke, 2002). Interviewers collected data from 15 male sex workers, clients, and intermediaries. Most of the MSWs were between 18 and 25 years old and considered themselves to be heterosexual. The most common reason that they gave for engaging in sex work was because it was an easy way to make money. Only in the city center were any of the clients foreigners, and even there the majority of clients were Vietnamese. MSWs averaged about 10 clients per week. Interviewees estimated that there were about 100 MSW working in Hanoi. MSWs reported about half of their sexual encounters involved only masturbation and oral sex, but anal sex was also common. Vietnamese clients preferred not to use condoms: the majority seemed oblivious to the risk for STDS and HIV. The unavailability of suitable lubricants was also a major issue. One MSW believed that if a client does not want to use [a condom], it means he is not infected. The client knows better about his own risk. Although no quantitative data on drug use among MSWs are available, the perception of the subjects in this study was that drug use was common. Female CSWs in Hanoi are known to frequently use drugs. One survey found that 29% of incarcerated female CSWs had also injected drugs within the previous 6 months (Nguyen et al., 2002). The 2001 survey of 219 MSM in Ho Chi Minh City included a subset of 54 MSWs who had engaged in sex for money within the previous month (Colby, 2003). In this group the median number of sexual encounters was five in 1 month (range = 1-70) and the median amount of time working as an MSW was 2 years. The majority reported a wage of U.S.$7 or less per encounter. Almost all reported practicing both oral and anal sex with clients. Consistent condom use (the percentage of MSWs reporting usually or always using condoms with clients) was low for both oral sex (15%) and anal sex (42%). CONCLUSIONS The beginning of the 21st century is a time of profound economic, social, and cultural change in Vietnam. Rising incomes and increased exposure to other peoples and cultures have fostered a liberalization of social values. In the biggest cities there are growing populations of MSM that are becoming increasingly visible. However, MSM in Vietnam are still largely underground and for the most part are ignored by both the government and the rest of society. Routine surveillance for HIV does not include MSM, and behavioral surveys do not ask about same-sex behavior. Official statistics and media reports about HIV and AIDS focus only on drug use, female prostitution, and male-female sex as risk behaviors. The general misconception that there are very MSM in Vietnam and that most of these are not truly homosexual but merely following a temporary trend allows policy makers and public health officials to ignore MSM or disregard them as a small group not worthy of particular attention.

8 52 COLBY, CAO, AND DOUSSANTOUSSE The fact that HIV prevention programs and media reports about the HIV epidemic are silent about homosexuality reinforces the perception among MSM that male-male sex is not a high risk for HIV. Surveys have shown that many MSM mistakenly believe that male-male sex is safer than male-female sex. In both the 1997 and 2001 behavioral surveys, fewer than one third of MSM agreed that homosexuals have a higher risk for HIV than others, showing that MSM have a low perception of risk for both themselves and for MSM in general. Even if they are knowledgeable about the transmission and prevention of HIV and other STDS, the perception of low risk may make MSM less likely to take measures to protect themselves from infection. The association found between the belief that homosexuals have higher risk for HIV and increased condom use and HIV testing suggests that making MSM more accurately aware of their risk may motivate them to change their behavior. Surveys have found that MSM in Vietnam s large cities are easy to locate and are willing to interact with outreach workers. Peer educators who are familiar with the MSM community could easily contact large numbers of MSM and help to correct some of their mistaken beliefs about the risk of male-male sex while increasing their knowledge about how to prevent HIV prevention. Coupled with distribution of condoms and water-based lubricant, outreach programs may be able to decrease high-risk sexual behavior among MSM. All of the research about homosexuality in Vietnam has been conducted in relation to MSM and their risk for HIV infection. This research is necessary to help understand the current situation and to guide initial interventions to reduce the risk of HIV infection among MSM. However, there is a lack of research on homosexuality in Vietnam from a social sciences perspective. It is also remarkable that most of the research on this topic in Vietnam has been conducted by foreign researchers. A better understanding of the psychological and social issues that MSM in Vietnam face, with the support and leadership of Vietnamese researchers, would greatly help in designing programs that seek to change their behavior. There is also a lack of quantitative data on MSWs in Vietnam. Although numerous studies and interventions have targeted female CSWs, their male counterparts have mostly been ignored. Our experience is that MSWs are easily found in streets, parks, bars, discos, brothels, and massage establishments in both Hanoi and Ho Chi Minh City. There are no official statistics, but from our observations we estimate that the number of MSWs in Ho Chi Minh City to be at least 1,000, and estimates of 100 MSWs in Hanoi seem to us to be low. More research is needed to quantify the number of MSWs as well as to better understand their risk for HIV and how address that risk. Nevertheless, it is a fact that MSWs in Vietnam are at high risk for HIV infection. Because many MSW are heterosexual or bisexual, they also form a bridge between MSM and the female population in spreading HIV and other STDs. The fact that they are officially ignored allows MSWs to work with little fear of arrest. But it also means that there are no programs to educate them on how to protect themselves and that they will continue to ply their trade in ignorance of the risk they pose to themselves and their clients. Programs that target MSM for HIV prevention will also need to reach MSWs. These programs also need to recognize that as a distinct group within the larger MSM population, the methods used to contact and educate MSWs will need to be different than the methods used with other MSM.

9 MSM AND HIV IN VIETNAM 53 More research is also needed to determine the current prevalence of HIV infection within the overall MSM population. Repeated HIV prevalence and behavioral surveillance surveys over time can help to follow the trend of the epidemic among MSM and can also help to evaluate the effects of any future HIV prevention programs. Hanoi and Ho Chi Minh City are the two largest cities in Vietnam. They are separately geographically and are also quite culturally distinct. Information gathered in one city can help to guide research and programs in the other city, but it should not be assumed that the behavior and risk for HIV infection among MSM is the same in both cities. The best way to approach HIV prevention may be different in the two cities and will need to be guided by the local situation. Although MSM may be most easily noticed in the big cities, it should not be assumed that they do not exist in Vietnam s medium-sized cities, many of which have populations in the hundreds of thousands and several of which lie on the ocean and have sizable domestic and international tourist trades. More information is needed on MSM in these areas, which may warrant local prevention programs of their own. Although there is a need for more research and information about MSM in Vietnam, it has to be acknowledged that increased attention also carries the risk of a negative reaction. If the government takes more notice of MSM in society, there is no guarantee that its response will not be harmful with stigmatization or overt persecution rather than constructive with education and support. Within the past year the two locations in Ho Chi Minh City that most openly catered to homosexual men, one disco and one sauna, have both been closed by the government. Although the same fate befalls many nongay-identified venues in the city and the government has not released any official policy toward MSM or homosexuality, it is entirely possible that a bias against homosexuals is already showing in official actions. Increased awareness about MSM may bring a backlash of negative reaction. However, inaction also carries the almost certain risk of increased HIV infections and deaths from AIDS in the not too distant future. Although there is plenty of room for more research into the situation of MSM in Vietnam, it is already clear that significant populations of MSM exist in the major cities and that their behavior puts them at high risk for HIV infection. With their low perception of that risk, MSM currently have no reason to change their behavior. A program employing peer educators could easily reach a large number of MSM and help them to better understand their risk for acquiring HIV. With an improved comprehension of that risk, MSM in Vietnam would be better motivated and equipped to protect themselves from HIV. REFERENCES Asian Development Bank. (2002). Key indicators 2002: Population and human resource trends and challenges. Manila, Philipines: Author. Beyrer, C., Eiumtrakul, S., Celentano, D. D., Nelson, K. E., Ruckphaopunt, S., & Khamboonruang, C. (1995). Same-sex behavior, sexually transmitted diseases and HIV risks among northern Thai men. AIDS, 9, Cao, H. N., Le, V. D., Luong, T. T., & Truong, X. L. (2002, July). Knowledge, attitudes and practices on HIV/AIDS among men who had sex with men (MSM) and visited the Consultation Unit of the Pasteur Institute in Ho Chi Minh City (PIHo Chi Minh City), Vietnam. [Abstract MoPeC3447]. Paper presented at the 14th International Conference on AIDS, Barcelona, Spain.

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