PRB

(March 2003) In only 20 years, HIV/AIDS has developed into the most devastating epidemic the world has faced. Forty million individuals worldwide live with HIV/AIDS and millions more individuals, families, children, and communities affected by HIV/AIDS face multiple challenges.¹ Yet while many countries continue to experience increasing HIV prevalence rates, Cambodia appears to be making progress.

From the detection of its first case of HIV infection in 1991, Cambodia has faced rapidly increasing HIV/AIDS incidence and prevalence rates. HIV is the fastest growing epidemic in Asia. Strong political leadership and public response have aided in what appears to be a slowing down of the epidemic among populations at risk since 1997. A multifaceted approach, including a 100 percent condom use program and steps to counter stigma and reduce people’s vulnerability, has increased HIV/AIDS knowledge and protective behaviors resulting in decreased infection rates. Overall, the national estimated HIV prevalence among the population ages 15 to 49 has fallen from 3.3 percent in 1998 to 2.6 percent in 2002. This estimate is based on annual data collected by the national surveillance system among sex workers, police officers, tuberculosis (TB) patients, blood donors, and antenatal clinic attendees. The largest decline has occurred among direct sex workers (based in brothels), from a crude HIV prevalence rate of 42.6 percent in 1998 to 28.8 percent in 2002. There has been a smaller decline in the prevalence of HIV among pregnant women, from 3.2 percent in 1997 to 2.8 percent in 2002.² Despite the promising news, continued and vigilant support is necessary to ensure momentum and to sustain the positive changes.

Populations That Engage in High-Risk Behaviors

HIV can be transmitted from one person to another through unprotected sex; from contaminated blood transfusions and use of unsterilized injection equipment; and from an infected mother to her child in utero, during labor, or during breastfeeding. In Cambodia, the predominant mode of HIV transmission is sexual contact, primarily through heterosexual sex. While the epidemic has been primarily concentrated in groups that engage in high-risk behavior, including sex workers and their clients, police officers, and military personnel, the epidemic in Cambodia is now considered a general epidemic as HIV is spreading from those individuals to their spouses and partners.

Commercial sex work is the exchange of sex for money or other favors. In Cambodia, this exchange can be found among direct sex workers and indirect sex workers (based in bars, massage houses, or karaoke lounges). According to the 2002 HIV Sentinel Surveillance Survey (HSS), while HIV has declined among sex workers, the rates remain relatively high — 29 percent among direct sex workers and 15 percent among indirect sex workers.³

Police officers and military personnel are other groups that engages in high-risk activities: They often work far from their wives and families and visit sex workers. In 1999, nearly 10 percent of police officers in Cambodia reported buying unprotected sex during the one month preceding the Behavioral Surveillance Survey (BSS). Among military personnel, 30 percent did not consistently use condoms with sex workers during the three months before the BSS.⁴

In 1999, 43 percent of married men in rural areas and 27 percent in urban areas reported engaging in commercial sex without using condoms.⁵ This large pool of unprotected sex fuels the epidemic between sex workers and clients, between sex workers and noncommercial sex partners and spouses, and between clients and their partners and spouses. If women of reproductive age are infected, HIV can be transmitted from them to their children.

Prevention of HIV/AIDS Transmission

The most cost-effective ways to reduce the spread of HIV are through prevention and protection. Cambodia’s prevention efforts since the mid-1990s have focused largely on encouraging condom use among men when engaging in commercial sex and encouraging men to reduce their commercial sex activity. Additionally, the government launched a 100 percent condom use campaign among brothel-based sex workers in 1999 that was modeled after Thailand’s successful program.

Condom Use

Government action has led to a distinct decline in HIV prevalence among direct sex workers with a marginal decline for indirect sex workers (see Figure 1). Because brothels can be shut down if they do not comply with the 100 percent condom use policy, many brothel owners are educating their workers about HIV and insisting that they use condoms. Among police personnel, condom use with sex workers increased from 69 percent to 85 percent between 1999 and 2001.⁶ Data indicate, however, that the program still has some distance to go before reaching the 100 percent level: 22 percent of sex workers in the 2002 Report on the Global AIDS Epidemic reported that their clients did not use condoms. Moreover, despite overall decreases in HIV prevalence, some provinces continue to have prevalence rates among sex workers that are continuing at the same pace or increasing.⁷

Figure 1

Percent of Sex Workers Infected with HIV, Cambodia

Note: DSWs = Direct sex workers. IDSWs = Indirect sex workers.

Source: HIV Sentinal Surveillance Survey 2002.

Education

Education is key to prevention efforts. According to the 2000 Cambodia Demographic and Health Survey, while most women in Cambodia (95 percent) know about HIV/AIDS, only 39 percent know about other sexually transmitted infections (STIs). Lack of knowledge of STIs varies significantly by province: 29 percent of women in Prey Veaeng province are unable to identify other STIs as compared to 91 percent of women in Kampong Spueu province.⁸ Knowledge of STIs and seeking appropriate treatment have been shown to increase condom use, thereby decreasing the risk of HIV transmission.

Overall, nearly three-fourths (73 percent) of women ages 15 to 49 report knowing at least one important way to prevent HIV/AIDS. These include limiting the number of sexual partners, using condoms, and abstaining from sexual relations. Knowledge varies by residence — 86 percent of women in urban areas report knowing of at least one method to prevent HIV transmission, as compared to 71 percent of women in rural areas.⁹ Moreover, for married women, none of the above-mentioned strategies for preventing HIV infection is typically within their control. More information is needed, particularly in rural areas, to increase knowledge about preventive measures.

Voluntary Counseling and Testing

Counseling and testing are key to prevention and control of the HIV/AIDS epidemic. Individuals who know their HIV status can take appropriate action to protect others and to maintain their own health. Voluntary counseling and testing (VCT) is an approach that incorporates pretest and posttest counseling into the process of learning one’s HIV status. During the counseling session, providers give critical prevention messages in methods such as condoms and clean needles. For those infected with HIV, VCT acts as a means of outreach: It helps refer individuals for treatment of opportunistic infections and for care and support. It also imparts knowledge on how these individuals can prevent transmitting the infection to others. For those who don’t have HIV, important preventive behavior is reinforced. VCT, when anonymously recorded in health information systems, assists governments by providing information on levels of HIV, which enables them to target programs to the populations that need them.

Only 3 percent of Cambodian women report having been tested for HIV, ranging from 14 percent in Phnom Penh to 0.1 percent in Kampong Thum. Urban women are more than four times more likely to have been tested than rural women. Levels of testing also vary by education — 8 percent of women with a secondary or higher education have been tested for HIV as compared to only 1 percent of uneducated women. On average, one-quarter of untested women state they would like to be tested, ranging from 59 percent in Kampong Chhnang to 3 percent in Prey Veaeng.¹⁰

Care and Treatment for People Living With HIV/AIDS

In Cambodia, an estimated 157,500 people were living with HIV/AIDS in 2001.¹¹ Many of these individuals and their households face extreme economic, social, and psychological hardships. Families living with HIV/AIDS often exhaust their personal resources paying for inappropriate and ineffective treatment in the face of an insufficiently resourced health system. In addition, health problems can affect job performance and the ability to work. The Royal Government of Cambodia and partner nongovernmental organizations (NGOs) are providing institutional and home-based care and support services, but scaling up these programs, particularly in rural areas, remains a key challenge.

Although there is no cure for HIV/AIDS, antiretroviral drugs (ARVs) have the potential to dramatically improve the health and extend the lives of many people infected with HIV. Unfortunately, the cost and clinical care requirements of these drugs put them out of reach of the majority of Cambodians with HIV. Efforts to reduce the price of ARVs in Cambodia are part of the challenge of meeting the demand for health care for people with HIV/AIDS in ways that are effective and compassionate, as well as fair and affordable.

In Cambodia, one in five people with HIV is coinfected with TB.¹² TB is the leading cause of death in people infected with HIV as it quickens the disease progression. Since the establishment of the National Tuberculosis Program in 1994, Cambodia has achieved remarkable results in detecting and treating TB cases. It has been able to extend community-based TB therapy through the Directly Observed Treatment Short-course (DOTS) program throughout the country. Yet more work is needed to strengthen the surveillance of TB/HIV coinfections and to develop appropriate interventions to address the dual epidemics.

Prevention of Mother-to-Child Transmission

As access to treatment improves, prevention of HIV transmission from a mother to her child will also be improved. Providing ARVs to pregnant women with HIV and ensuring safe delivery procedures can reduce the risk of transmission during delivery. In the absence of such drugs, mothers need counseling on infant feeding options to reduce the risk of HIV transmission. UNAIDS recommends exclusive breastfeeding for the prevention of HIV transmission from mother to child in developing countries where infant mortality is high. While HIV can be transmitted to the baby through breast milk, the risk is reduced with exclusive breastfeeding, and the benefits against other deadly infections such as diarrhea outweigh the risks of nonexclusive breastfeeding.¹³

Policy Implications

To date, Cambodia has experienced some success in fighting HIV/AIDS. Policies such as the 100 percent condom use campaign and the integration of HIV/AIDS messages within the work of other government agencies, such as the Ministry of Defense, have helped reduce the HIV/AIDS infection rate among populations who engage in high-risk behaviors. Prevention and protection messages must continue to focus on these groups while vigilance is maintained against the spread of the epidemic to the general population. VCT for HIV/AIDS must be expanded countrywide to help fulfill the unmet need for these services, as well as to increase self-awareness of HIV/AIDS status. Efforts to assist people living with the disease and to prevent mother-to-child transmission must be part of future initiatives. Stopping the spread of HIV/AIDS will require a comprehensive and sustained strategy that focuses on prevention, education, and communication; access to condoms and other modes of protection against HIV; HIV counseling and testing; and care and support for those living with the disease.

References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global AIDS Epidemic (Geneva: UNAIDS, 2002).
2. National Center for HIV/AIDS, Dermatology, and STI (NCHADS), public dissemination of 2002 HSS data on Sept. 10, 2002, in Phnom Penh (data for HIV prevalence among ANC attendees not available for 1997); Cambodia Behavioral Surveillance Survey (BSS) 2001 (Phnom Penh: NCHADS, 2001).
3. NCHADS, HIV Sentinal Surveillance Survey (HSS) 2000 and public dissemination of HSS 2002 data on Sept. 10, 2002.
4. NCHADS, BSS 2000.
5. NCHADS, BSS 2000.
6. NCHADS, BSS 2001.
7. UNAIDS, Report on the Global AIDS Epidemic.
8. National Institute of Statistics (NIS), Directorate General for Health [Cambodia] and ORC Macro, Cambodia Demographic and Health Survey (CDHS) 2000 (Phnom Penh, Cambodia, and Calverton, MD: NIS Directorate General for Health and ORC Macro, 2001): 198.
9. NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 191.
10. NIS, Directorate General for Health [Cambodia] and ORC Macro, CDHS 2000: 197.
11. NCHADS, public dissemination of HSS 2002 data on Sept. 10, 2002.
12. World Health Organization (WHO), Global Tuberculosis Control (Geneva: WHO, 2001): 30.
13. UNAIDS, Report on the Global AIDS Epidemic.

For More Information

Please contact the Department of Planning and Health Information, Ministry of Health, #151-153, Blvd Kampuchea Krom Ave., Phnom Penh, Cambodia, E-mail: ratnary@bigpond.com.kh