Drug addiction stigma in relation to methadone maintenance treatment by different service delivery models in Vietnam

A cross-sectional survey was performed from June to August 2013 in Hanoi and Nam Dinh provinces. There were five MMT clinics involved, four of which were located at district health centres (DHC), namely Tu Liem, Ha Dong, Long Bien, and Xuan Truong, and one clinic was at Nam Dinh Provincial AIDS Center (PAC). The characteristics of study sites are listed in Table 1. We selected the two provinces in consultation with program managers at the Vietnam Authority of HIV/AIDS for a purposive comparison of an experienced setting, Hanoi, and a new setting, Nam Dinh Province. The MMT sites were primarily selected for the comparison of various service delivery models in different level of health administration. In general, drug users register at the nearest MMT clinics and these clinics provide treatment regardless of patients’ HIV status. In the organization of Vietnam’s health services delivery system, the regional polyclinic is providing primary health care for an area that combines several communes and is linked to commune health stations [25, 26]. Therefore, the criteria for enrolling drug users in selected MMT were indifferent.

Eligibility criteria for recruiting participants included: 1) taking or initiating MMT in selected sites; 2) presenting at clinics during study periods; 3) being 18 years old or above; 4) having the capacity to answer questionnaire within 20 min and 5) agreeing to participate. A convenient sampling technique was used to enroll a total of 1016 patients in this study. Patients were invited into a designated room for face-to-face interviewing. Before the interview, participants were introduced to the study and asked to provide written informed consent. The response rate was 80–90 % across sites. Interviewers were master’s students of public health at Hanoi Medical University. The students were working in HIV study and had no affiliation with the clinics in which they invited patients to participate.

A structured questionnaire was developed to use in this study. Data on socioeconomic characteristics, drug use behaviors, HIV status was interviewed. Drug use information included age at initial drug use, time since first drug injection, times of previous drug rehabilitation, and duration of MMT treatment. Health status of respondents was measured in five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) using the five-level EQ-5D (EQ-5D-5 L) instrument that has been validated and widely used in Vietnamese populations [6, 27, 28]. Responses were then recorded to the EQ-5D dimensions as either having any health problems or no problems.

It has been well-documented that the stigma against HIV and drug use in Vietnam has been fueled by both the fear of HIV infection and social values and by judgements on addiction and other risk behaviours [3, 18, 29‐32]. In some settings that contain large drug-using populations with generalized HIV epidemics, the stigma and discrimination against HIV/AIDS and addiction are intertwined [3, 33, 34]. We referred to the Substance Abuse Self-Stigma Scale by Luoma and measures of HIV-related stigma [35, 36]. In addition, we adapted the conceptual framework by Parker and Aggleton to construct the measure of drug addiction-related stigma among MMT patients [37]. We then piloted the measures in drug users and people living with HIV/AIDS. The final measure of stigma included five dimensions: (1)Blame/Judgement, (2) Shame, (3) Discrimination in various settings (work place, health care services, family, and community), (4) Disclosure of addiction or health status (including HIV-positive if seropositive), and (5) Other’s fear of HIV transmission among those patients who self-reported being HIV-positive [36]. Respondents were asked if they had experienced any of the above types of stigma within the last month. The measure, for example, included the following questions with the response options: Yes/No/Not answer.

T-test and χ2 tests were used to compare differences of characteristics among different services models. Multivariate logistic regression was employed to determine the associated factors with self-stigma, discrimination, and disclosure. In this study, a stepwise backward selection strategy was applied along with multivariate regression to have reduced models. This strategy used threshold with the log-likelihood ratio test to have predictors with p-values of < 0.1 included.

The protocol of this study was reviewed and approved by the Vietnam Authority of HIV/AIDS Control's Scientific Research Committee. Written informed consent was obtained from all participants. Patients could withdraw at any time without the influence on their current treatment.

Our findings highlight the encouraging progress in quality improvement and stigma reduction in HIV-related health care services in Vietnam. Previously, stigma was commonly reported in health care services, which reduced the access and use of health care and support services among people with HIV/AIDS [18], and was burdensome to health workers in HIV facilities [30]. In this study, just about 2 % of respondents reported experiencing any discrimination at health care services. Meanwhile, the high level of discrimination from communities against drug users is consistent with a previous qualitative analysis in Thai Nguyen Province by Rudolph et al. [31] In addition to previous studies, we found that not only socioeconomic status and history of drug rehabilitation significantly predicted stigma and discrimination among drug users taking MMT, but also other major factors included health status and the availability of comprehensive HIV/AIDS and general health care services.

In Vietnam, a DHC is the closest health care facility providing methadone medication for drug dependence treatment. In this study, patients at DHCs or regional polyclinics were less likely to be stigmatized compared to those at PAC. One study by Mukora et al. showed that patients were concerned about stigma and loss of privacy if they received treatment in decentralized clinics [38]. However, a study by Odeny et al. found that decentralized HIV-related services that were integrated into primary health care did not worsen stigma [39]. The differences in patients’ preferences and perceived stigma highlighted the importance of understanding contextual factors and stages of the epidemics in each setting. In this study, fewer patients felt ashamed or experienced discrimination at MMT clinics with other HIV-related and general health care services; nonetheless, these results may not apply to those living in rural areas.

In addition, we found that drug users taking MMT for longer periods of time felt less blamed or judged (OR = 0.98, 95 % CI = 0.97–0.99). This may be due to the effects of MMT on the improvement of health status and the reduction of risk behaviors and illegal activities, which may promote positive attitudes of family and others toward MMT patients. Previous studies have shown that MMT patients improved substantially in physical health; however, the changes in mental and social status were moderate and small, respectively [7, 40]. Participants reporting anxiety and depression were also much more likely to report feeling blamed/judged and shame. In addition, drug users who currently used drugs during MMT were more likely to suffer from discrimination than those who did not. Collectively, these results indicated the importance of maintaining MMT to reduce drug use behaviors, as well as the importance of providing comprehensive mental health care for patients.

The study also suggests that the use of MMT is preferred more than traditional drug rehabilitation in Vietnam. Less effective drug rehabilitation was significantly associated with higher stigma. Drug detoxification is available in Vietnam [6]^, but with high episodes of failure rehabilitation, patients may believe that they cannot be successfully treated, and therefore, blame themselves for relapsing. In this study, the proportion of felt stigma was lower than in other settings. This coincides with findings from previous studies that MMT helps improve social and economic status of patients and their families [5, 7, 40‐42].

Notably, the proportion of MMT patients’ felt stigma in communities was significantly higher than in families, health facilities, or workplaces. This result suggested that although participating in MMT program could reduce stigma in those latter place, stigma remained a great barrier for MMT patients trying to reenter into their community. A study conducted by Tomori et al. in Vietnam showed that even when a person successfully detoxifies from illicit drugs, they had to confront the drug-related stigmatization in their community [2]. Therefore, mass media campaigns are necessary to reduce stigma against people with HIV/AIDS and history of drug addiction in settings with large drug injection related HIV epidemics.

In this study, we also found that patients who were HIV positive or unknown status were more likely to report self-stigmatization. Literature suggests that drug users report shameful attitudes and think that HIV might be a punishment for their past [2]. On the other hand, it is noteworthy to find that people who were employed were less likely to feel self-stigmatization. Vocational training and job referrals should be considered in local planning to maximize the benefits of MMT programs.

Disclosure of status among HIV-positive people and PWID has been considered a potential method to reduce the spread of HIV/AIDS. Although the drawbacks of self-disclosure may include stigma, loss of privacy, and blame, it may help those high-risk populations to reduce HIV risk behaviors and increase access to HIV-related care, as well as being related to better adherence for those receiving treatment [18]. In present study, patients receiving MMT at DHC reported a higher percentage of disclosing their condition to spouses, relatives, health workers, and friends than patients at PAC. This association can be partially explained by the fact that in order to hide their conditions and avoid discrimination, drug users tended to receive treatment at a health center far from their hometowns [43].

People taking MMT in long duration were less likely to disclose their health status to other people. There may several reasons be for this finding. First, as we observed, with the improvement in health status due to long duration of treatment, MMT patients might feel confident about their health and therefore may think that they do not need to share their status with other people. Second, information about MMT patients’ treatment or their past may be used against them at work or in the community [44].

Most patients shared their status with their spouse (58.3 %) and parents (50.4 %), who were the closest relatives of patients. People living with a spouse also were likely to disclose. Families are a critical source of financial, physical, and emotional supports, which facilitate re-entry into the community for drug users [45]. Therefore, support from family has a central role in encouraging patients’ disclosure.

There were several implications that can be drawn from this study. First, MMT clinics should be integrated with other health services and decentralized as satellite model to provide patients with accessible and friendly health care, which in turn may reduce stigma of patients. Strategies to optimize the effectiveness of this model should be considered for the scale-up plan of MMT programs. Second, mass media campaigns in television or on the internet should be conducted to reduce stigmatization in the community for MMT patients. Third, the role of parents/spouses should be heightened to help combat difficulties encountered when patients participate in MMT treatment. Lastly, physical and mental health conditions of patients should be acknowledged and addressed.

Several limitations in this study should be under consideration. First, this cross-sectional design could not establish causal relation between stigma outcomes and MMT delivery models. In addition, a qualitative study should be conducted to understand how different models can impact on the feeling of stigma in accordance to patients’ perceptions and experiences. Second, Self-report information may be subject to recall bias. Finally, the convenient sampling technique limited the generalization of this study.

Data are available from the Authority of HIV/AIDS Control (VAAC). However, since the Government of Vietnam issued the Law on HIV/AIDS, information of HIV-affected people is confidential and cannot be shared. Requests for data on this study may be submitted to VAAC and go through a review process by the Scientific and Ethical Research Committee. The contact for requesting data use is Dr. Phan Thi Thu Huong, email huongphanmoh@gmail.com, Deputy Director in Research of the Vietnam Authority of HIV/AIDS Control, Ministry of Health, Vietnam.