Sample characteristics

As delineated in Table 1, the survey encompassed 22 participants. The median age of the participants was 23.5 years. A majority of the participants (n = 19; 86.4%) originated from rural areas, while a minority (n = 3; 13.6%) hailed from urban areas. A substantial proportion (77.3%) of the sex workers disclosed having a regular sexual partner, such as a husband or boyfriend. Over half of the participants (63.6%) reported having experienced pregnancy at least once. In terms of HIV status, 2 participants (9.1%) reported being HIV positive, while 5 (22.7%) had never undergone HIV testing.

Table 1 Demographic characteristics of FSWsQualitative findings

Figure 1 presents the key emergent themes and subthemes in the qualitative data. The results showed that the social networks of Vietnamese FSWs mainly involved three components: Workplace networks, Hometown networks, and Social institutions networks.

Fig. 1

Main components of the social network of Vietnamese female sex workers

Workplace networks

Workplace networks were composed of customer network, boss network, and colleague network. These three types of relationships could have both supportive and hindering effects on preventing high-risk HIV behaviors.

The ascendant position of customers leads to high-risk behaviors

The interactions between Vietnamese FSWs and their customers were typically characterized by a transactional, one-off nature. On average, Vietnamese FSWs catered to between four to six customers daily, with the majority being Chinese customers. Many Vietnamese FSWs would refuse to serve compatriots or drunk customers. This reluctance stemmed from the societal stigma attached to their profession, which discouraged them from disclosing personal information to Vietnamese clients. Besides, drunk customers posed a greater challenge to negotiating condom use and often exhibited disrespectful behavior during sexual activity, which can lead to the condom breaking easily. One Vietnamese FSW, when asked why she was reluctant to take on Vietnamese and drunk customers, replied:

“When Vietnamese customers come in, they tend to ask a lot of questions, which I don't like to answer. That's just how it is. I don't serve drunk customers anymore because it's too tiring and sometimes they can be argumentative and cause trouble.”(VFSW 10)

Customers occupied an ascendant position during the commercial sex act. Vietnamese FSWs often encountered communication barriers and other obstacles when negotiating with customers, which could render them feeling powerless and submissive in such transactions. This ascendaancy and submissiveness dynamic was identified as a potential barrier to the prevention of high-risk HIV behaviors. Within this context, customers frequently withheld the preparation of condoms during sexual encounters and instead made requests for additional payment in lieu of their use. Under financial pressure, Vietnamese FSWs might acquiesce to such demands, thereby exacerbating the risk of HIV transmission.

“If the customer feels uncomfortable with using a condom during oral sex, then they may not want to continue with sexual activity.”(VFSW 01)

“There was one time when there were no other customers around, and the customer offered to pay extra money to have sex without a condom, so I agreed (to have sex without condoms).”(VFSW 06).

Almost all the Vietnamese FSWs expressed a willingness to initiate condom use. However, approximately 30% of customers declined this request, and there were instances of condom removal during sexual activity or condom breakage due to rude actions. Vietnamese FSWs were often at a disadvantaged stage when negotiating with customers who refuse to comply with safe sex practices and engage in rude behavior. This dynamic increases the likelihood of Vietnamese FSWs acquiescing to customers’ requests for high-risk sexual practices, thereby making them a target group for high-risk HIV behaviors.

While some Vietnamese FSWs took proactive measures to address requests for high-risk behavior by customers, not all of these measures proved effective. For instance, some Vietnamese FSWs reported conducting visual inspections of their customers' genitals for abnormalities before engaging in oral sex. In cases where a condom is broken during sexual activity, some Vietnamese FSWs some Vietnamese FSWs were unsure of how to respond. Most would replace the condom immediately, followed by vaginal cleansing with toothpaste or cleansing agents, and the intake of contraceptives and pain medication. However, as vaginal cleansing occurred post-sex, its efficacy remained uncertain.

“I would put a new condom back on and then wash that area after it (sex activity) was over.”(VFSW 04)

“Once having sex with a customer, the condom broke, and then ejaculated inside. In addition to the use of birth control pills, I did not think of using any other drugs to prevent disease.”(VFSW 06)

The willingness of some customers to engage in high-risk sexual behavior compelled VFSWs to educate themselves about STI prevention, yet the accuracy and reliability of the knowledge couldn’t be guaranteed.

Bosses provide incomplete protection

The dependency of Vietnamese FSWs on their bosses was significant, as they often acted as intermediaries between the FSWs and their customers. In most cases, Vietnamese FSWs worked under one boss and were reluctant to be transferred to another location by the boss, as this meant a further reduction in wages and a longer distance from their homes. Additionally, the risk of provocation by the previous boss cannot be ignored.

“If we want to change bosses, we have to share the earnings not only with the new boss but also with the original boss.”(VFSW 02)

“There is a rule here. If you change the workplace, he (the original boss) will trouble you. He will get someone to beat you up. He won't give you your money, he won't let you go to work.”(VFSW 11).

“I wouldn't want to go if the boss rented me out. I am homesick and don't want to go.”(VFSW 12)

Vietnamese Female Sex Workers relied significantly on their bosses to facilitate their smuggling activities. At the same time, Vietnamese FSWs faced challenges in surviving independently in China due to language barriers. In the event of an arrest by the Public Security Bureau, the boss might assist in posting bail. This dependence on the boss further diminished the negotiating power of Vietnamese FSWs. The dependence increased the likelihood of acquiescence to the boss’s arrangements.

The precarious reliance of Vietnamese FSWs on their bosses was a concerning reality, underscored by the latter’s coercive role in their work. This situation was compounded by the illegal nature of sex work and the bosses' close ties with the local police, further reinforcing their control over the FSWs. Several Vietnamese FSWs stated:

“I don’t feel like to do that (serving the customer). But it is the boss who solicits these customers, so no matter if they are Chinese or Vietnamese, I have to take.”(VFSW 08)

“One day I could not stand the pain and I did not want to go to work, but the boss forced me to go to work anyway.”(VFSW 10)

Given the dependence and coercive role, the attitudes of bosses towards HIV-risk prevention measures were of paramount importance. However, these attitudes were often ambivalent. While safeguarding the health of Vietnamese Female Sex Workers may yield long-term benefits for bosses, excessive adherence to HIV prevention measures could potentially dissatisfy customers. Consequently, the protection provided by bosses against high-risk behaviors among Vietnamese FSWs was often incomplete.

In general, most of the bosses would provide information about HIV prevention and mandate Vietnamese FSWs to use condoms during service.

“The boss also tells us to use condoms. We have sex with customers every day, but we don't know which one has a disease. If we get infected, the money we earn is not even enough to treat the disease, so we have to use condoms to protect ourselves.”(VFSW 02)

In the pursuit of financial gain, the bosses of Vietnamese Female Sex Workers demanded the use of condoms during sexual activity, yet the condoms they provided were often of poor quality. Driven by the same profit motive, the bosses did not consistently insist on measures to prevent high-risk HIV behavior. Alarmingly, many bosses discouraged the use of condoms, particularly for FSWs engaging in sexual activity for the first time.

“Usually people don't use condoms when having sex for the first time, he (the boss) said so.”(VFSW 10)

Colleagues disseminate HIV knowledge and compete

The colleagues of Vietnamese FSWs constituted the most frequent and intimate contacts in their daily lives, although the number of colleagues could vary depending on the size of their workplace. Colleague networks, in general, provided valuable support for preventing high-risk HIV behaviors by facilitating the dissemination of knowledge related to sexually transmitted infections (STIs).

“The elder colleague had told us something, that if we had oral sex without a condom, we would get some sexually transmitted diseases in our throat and mouth. I was frightened of what she said, so I wouldn’t have oral sex without a condom later.”(VFSW 18).

However, competition among FSWs within the same workplace for economic gain may increase the likelihood of high-risk HIV behaviors.

“When the customer comes and chooses me, she (the person with scars on her face) will be unhappy and wants the customer to choose her.”(VFSW 17)

Hometown networksMutual trust to spouse or boyfriend impedes engagement in high-risk behaviors

The majority of Vietnamese FSWs maintained relationships with husbands or boyfriends in Vietnam, typically returning home every half-month to a month, during which they engaged in sexual activity with their partners. However, due to the stigma associated with sex work, many FSWs kept their occupation and even their HIV status a secret from their partners. Several Vietnamese FSWs, when asked why they went home at intervals or whether they informed their spouses or boyfriends of their work, said:

“I lied to him (the husband) that I am working in Hanoi (Vietnam).”(VFSW 10)

“No, I won’t tell anyone (if got AIDS). I will remember it alone.”(VFSW 13)

The decision to enter the sex industry was often driven by financial constraints within the family and the husband’s inability to secure sufficient income. In some cases, husbands might even encourage their wives to engage in sex work when they were unable to financially support the family.

“my husband was moved when he saw his sister earning money here. Then he asked me to come here and do the same job to earn money, and that's what happened.”(VFSW 12)

There existed a mutual trust between Vietnamese FSWs and their spouses or boyfriends, but this trust could often be accompanied by blindness, resulting in high-risk sexual behaviors.

“Oh, let me tell you something. If you still have this defence when you have sex with your husband in Vietnam, then it's not called a couple, it's called boyfriend and girlfriend. He will doubt that you don't trust him enough or don't love him enough.”(VFSW 05).

Despite this, this trust could be beneficial in preventing HIV-risk behaviors, in the form of increasing proactivity and willingness to prevent contracting and transmitting HIV to their partners.

“I would use condoms with every customer to avoid getting infected and spreading the disease back to my husband.”(VFSW 20)

However, the high-risk behaviors of their spouses, such as unsafe sex with others and drug use, can also make this trust a source of HIV transmission.

“My husband got infected (with HIV) by other women who would call my husband to play with them.”(VFSW 05)

Thus, the role of spouses or boyfriends in preventing high-risk HIV behaviors among Vietnamese FSWs was dual in nature: it can be supportive, but it can also lead to HIV transmission.

Sense of family responsibility causes hesitation to engage in high-risk behaviors

The financial necessity to support their families or to seek independence drove Vietnamese FSWs to pursue higher profits riskily. The majority of Vietnamese FSWs came from financially challenged families, and the high earning potential of sex work had made them the primary breadwinners in many households. Moreover, FSWs with strained family relationships were more likely to seek independence.

The responsibility and obligation to raise children provided moral support for Vietnamese FSWs to engage in sex work, especially for those who were divorced or single parents.

“I come here because of the difficulty of my family. I used to work harder but earn less in Vietnam, so I wanted to earn more money to support my children and the old.”(VFSW 02)

However, not all FSWs chose this work voluntarily, as some family members coerced them into engaging in commercial services to alleviate financial burdens.

“In my hometown, if the family is poor, the parents will ask the girls to come over here to do this job. It's not unusual.”(VFSW 07)

The desire for independence or a sense of familial responsibility among Vietnamese FSWs engendered a strong need for greater financial resources. This need, in turn, could tempt them to take risks in commercial sex, thereby hindering efforts to prevent HIV-risk behavior. Although they were often the main breadwinners for their families, most Vietnamese FSWs did not want their families to be aware of their occupation. They would not disclose their HIV status even if infected, fearing that such knowledge might distress their parents. This secrecy leads to a certain level of apprehension about engaging in HIV high-risk behaviors and can be a supportive factor for HIV high-risk behavior prevention.

“My mother will ask me (why I got the disease). She will be heartbroken. She will not understand why I have this disease, and she will be sad to know. Her health will not be good if she worried too much.”(VFSW 10)

The concealment of information by fellow villagers leads to high-risk behaviors

The relationship between Vietnamese FSWs and their fellow villagers was primarily driven by reciprocal economic interests. When Vietnamese FSWs were introduced to China, an intermediary fee was often charged by their fellow villagers. In an effort to protect their vested interests, some fellow villagers withholded information pertaining to the inherent risks and potential for high-risk HIV behavior associated with sex work, instead highlighting the lucrative nature of the profession. Due to the evasion of responsibility by their fellow-villagers and the self-stigma of the Vietnamese FSWs, Vietnamese FSWs were afraid of fellow-villagers revealing their work, which resulted in the loss of contact with one another after arrival in China. The interests between fellow villagers and Vietnamese FSWs, as well as the self-stigma of Vietnamese FSWs, limited Vietnamese FSWs’ access to HIV prevention knowledge and hindered their understanding of the importance of preventing high-risk HIV behavior.

Social institutions networksChinese institutions provide measures to prevent HIV high risk behaviors

In China, Vietnamese FSWs mainly interacted with Public Security Bureau and CDC. The Public Security Bureau’s legal mandate to investigate and apprehend individuals involved in prostitution and smuggling engenders a climate of fear and mistrust among the Vietnamese FSWs. Moreover, some bosses had some relationship with the Public Security Bureau, further amplifying the distrust of Vietnamese FSWs towards the institution and reinforcing the bosses' control over them. Conversely, the relationship between the Vietnamese FSWs and the CDC was characterized by trust and close cooperation, with the CDC being viewed as a supportive entity.

“I didn’t mention (the fact that I was trafficked to China) because the boss has a relationship with the public security, and I don’t trust those public security officers” (VFSW 22).

“I don't know what to do (to prevent the disease), so I hope that I could get tested. Then I just wait for you (CDC) to come and help.”(VFSW 18:)

This reliance on the CDC had given it a significant role in helping Vietnamese FSWs prevent high-risk HIV behaviors. Several Vietnamese FSWs stated:

“I also listen to what you (the CDC) say and read the materials you send out.”(VFSW 18)

The CDC played a pivotal role in the dissemination of HIV prevention information, provision of HIV testing services, and distribution of condoms, all of which were integral to supporting Vietnamese FSWs to prevent HIV-risk behaviors. However, concerns had been raised regarding the quality of the freely distributed condoms, which had been reported to rupture during commercial sex acts. This not only increased the likelihood of disease transmission but also posed a significant obstacle to the prevention of high-risk HIV behaviors among Vietnamese FSWs.

“I am afraid that the condom will break easily and then I will get HIV. The quality of this condom (from the CDC) is not good.”(VFSW 15)

The Vietnamese government disseminates knowledge about HIV

The Vietnamese government's efforts had been helpful for Vietnamese FSWs in HIV prevention, especially in terms of knowledge dissemination. Approximately half of the Vietnamese FSWs had reported that their understanding of HIV prevention was acquired during their academic years. The advocacy efforts of the Vietnamese government had not only heightened the awareness of some Vietnamese FSWs towards the practice of safe sex but had also enhanced their capacity to prevent HIV transmission during commercial sex encounters.

“Well, compared to the Hekou (China), there are billboards posted everywhere in Vietnam, like staying away from drugs to not transmit HIV or something.”(VFSW 05)

Vietnamese FSWs maintained strong affiliations with medical institutions and pharmacies within Vietnam. Most Vietnamese FSWs opted to return to Vietnam for treatment when confronted with health issues. However, due to the Vietnamese government's measures to manage HIV infection, one Vietnamese FSW stated that she would not return to Vietnam for testing if she was infected with HIV:

“The hospital won’t tell the family, but it will report to the district where I live, like the village, and the governor in my village will know that I get AIDS.”(VFSW 20)