HIV/AIDS in Cambodia Elliot Marseille, DrPH, MPP Lisa Garbus, MPP AIDS Policy Research Center, University of California San Francisco Published July 2002 Last updated July 2003 (c) 2003 Regents of the University of California. All rights reserved. Table of Contents PREFACE 4 DATA SOURCES 5 ACKNOWLEDGMENTS 5 CONTACT INFORMATION 5 EXECUTIVE SUMMARY 6 EPIDEMIOLOGY 6 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 6 IMPACT 8 RESPONSE 9 EPIDEMIOLOGY 13 AT A GLANCE: SUMMARY BULLETS 13 OVERVIEW 14 HIV SENTINEL SURVEILLANCE 14 DATA INTERPRETATIONS AND LIMITATIONS 15 BEHAVIORAL SURVEILLANCE 17 UNAIDS ESTIMATES 18 MORTALITY 18 TRANSMISSION PATTERNS 18 WOMEN ATTENDING ANTENATAL CLINICS (ANCS) 18 SEX WORKERS AND THEIR CLIENTS 19 MILITARY AND POLICE 20 FISHERMEN 20 MEN WHO HAVE SEX WITH MEN (MSM) 20 CONDOM USE 21 INJECTION DRUG USERS 22 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 23 AT A GLANCE: SUMMARY BULLETS 23 OVERVIEW 23 HUMAN DEVELOPMENT 23 ECONOMY 23 POVERTY 23 GOVERNANCE 24 HEALTH SYSTEM 24 GENDER 25 SEX WORK 25 POPULATION MOBILITY 26 KNOWLEDGE OF HIV 26 STIGMA 26 ALCOHOL AND DRUG USE 26 IMPACT OF HIV/AIDS 48 AT A GLANCE: SUMMARY BULLETS 48 DEMOGRAPHIC 48 ECONOMIC 48 HEALTH 48 HOUSEHOLDS 48 ORPHANS AND OTHER VULNERABLE CHILDREN 49 MILITARY 49 RESPONSE 57 AT A GLANCE: SUMMARY BULLETS 57 OVERVIEW 57 GOVERNMENT 58 100% CONDOM USE PROGRAM (CUP) 59 MULTISECTORAL RESPONSE 59 BUDGETS: GOVERNMENT AND DONORS 59 GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS & MALARIA 59 CIVIL SOCIETY 60 PMTCT 60 HOME- AND COMMUNITY-BASED CARE 60 VCT 60 TREATMENT OF OIS AND ART 61 LINKS 73 REFERENCES 74 Preface The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's principal investigator. The project receives additional support from the International Training and Education Center on HIV (I-TECH), a collaboration of the University of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau of the U.S. Health Resources and Services Administration. The views expressed in the outputs of the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH. The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context¾at household, sectoral, and macro levels. This multidisciplinary analysis aims to: * help inform national HIV/AIDS policies * strengthen ability to plan, prioritize, and implement effective interventions * highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS * facilitate multisectoral/interministerial coordination * facilitate intercountry information sharing * increase national and subregional capacity for effective partnerships The project develops and disseminates online, fast-download, continually updated analyses of HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work. All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses. Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include a comprehensive table of key indicators, drawn from a global database that UCSF's AIDS Policy Research Center conceptualized and developed. The database comprises 73 HIV/AIDS and socioeconomic indicators for 168 countries and 13 regions; APRC collected and organized data spanning HIV/AIDS, human development, gender, population, economy, public expenditure trends (including military), debt servicing, general health, sexual & reproductive health, and educational attainment. Project staff continually assesses and incorporates new data to maintain the timeliness of the analyses. Data Sources The profile of Cambodia utilizes reports, articles, studies, and statistics published by Cambodian and international investigators, academic institutions, bi- and multilateral agencies, prevention and care projects, NGOs, and donors. Among publications frequently cited are those of Family Health International (FHI) . FHI is a nonprofit organization working in over 40 countries to prevent the spread of HIV/AIDS/STIs and improve sexual & reproductive health services. In 1998, FHI's Implementing AIDS Prevention and Care (IMPACT) Project, funded by USAID, began to operate in Cambodia. FHI/IMPACT's overarching aim is to strengthen the capacity of Cambodian organizations to respond to HIV/AIDS. FHI/IMPACT works with the national government and NGOs to prevent HIV transmission and promote behavior change. FHI/IMPACT provides technical support to Cambodia's National Center for HIV/AIDS, Dermatology, and STD in designing, implementing, and analyzing data of the HIV Sentinel Surveillance (HSS) survey, the Behavioral Surveillance Survey (BSS), and two national STI prevalence and algorithm validation studies. Acknowledgments The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. Kimberly Page-Shafer and Dr. Janice K. Louie, both of the Center for AIDS Prevention Studies at the University of California San Francisco; Dr. Hor Bun Leng, National Center for HIV/AIDS, Dermatology, and STD, Cambodian Ministry of Health; and Dr. Po Samnang, National Center for Health Promotion, Cambodian Ministry of Health. They are not responsible for any errors of fact or judgment. Contact Information Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu Executive Summary Epidemiology From 1991, when the first case of HIV infection was reported, to 1998, Cambodia experienced rapid spread of HIV. Cambodia's National Center for HIV/AIDS, Dermatology and STD (NCHADS) reported that there were 210,000 adults living with HIV/AIDS in 1997. NCHADS estimated that adult HIV prevalence was 3.2 percent in 1999. Active commercial sex and "bridging" networks played a major role in the rapid spread of HIV, with a large portion of HIV incidence comprising transmission from sex workers to their male clients. The results of Cambodia's 2000 HIV Sentinel Surveillance (HSS) found that the proportion of Cambodians with HIV declined in 2000 compared to the previous two years. The 2000 HSS estimated that 169,000 Cambodian adults were living with HIV/AIDS, with adult HIV prevalence at 2.8 percent. Prevalence decline was observed in all sentinel groups (except beer promotion girls, among whom prevalence remained steady) and appeared to have been strongest among 15-to 19-year-olds. NCHADS posited that the prevalence decline was likely the result of (1) increased deaths among people with HIV infection combined with (2) a slower rate of new infections, probably due, in part, to reductions in risk behavior. NCHADS did not believe that methodological biases were responsible for this decline, though it did highlight the limitations of the 2000 HSS data. It also cautioned that the number of reported AIDS cases rose sharply in 2000, indicating an increasing demand for AIDS care and treatment. Heterosexual transmission of HIV appears to predominate, but there is a paucity of data on transmission via men who have sex with men and injecting drug users. Injecting drug use could, however, become a major mode of transmission. Cambodia's epidemic dynamic renders it particularly sensitive to increases in condom use between sex workers and clients. The results of the 2000 HIV sentinel and behavioral surveillance studies appear to indicate that the government's condom promotion activities have resulted in increased condom use and may be responsible for some of the slowing in the rate of new infections. However, the epidemic in Cambodia is changing rapidly, making it difficult to make any assertions about it. Political Economy and Sociobehavioral Context Numerous factors render Cambodia particularly vulnerable to HIV/AIDS. These include a legacy of genocide, civil war, and famine, which eradicated much of the educated, highly skilled population. In tandem with persistent poverty and political turmoil, this scenario has led to a weak health infrastructure badly in need of rehabilitation. The government is undertaking health reform, including more efficient allocation of resources, but health status¾including sexual & reproductive health¾remains low. Gender inequality is also shaping the epidemic. Other crucial factors include Cambodia's large commercial sex industry. Population mobility, particularly within the country, is high. STI prevalence appears to be declining, though there is a shortage of affordable and accessible STI drugs. The burden of tuberculosis is large, and multidrug-resistant strains an increasing concern. Despite recent progress, the Cambodian economy remains constrained by the legacy of decades of conflict. The average income in Cambodia is US$260. Cambodia relies heavily on foreign aid. About 36 percent of the Cambodian population lives below the national poverty line of US$0.63 a day. The most vulnerable groups vis-à-vis poverty include internally displaced people and returnees, PWHA, war widows and female-headed households, orphans, street children, squatters, people with disabilities, and isolated ethnic minorities. The legal infrastructure for law enforcement is weak, given limited resources and few legal professionals in the country. Cambodia had made progress on human rights. However, problems persist, particularly regarding child labor, the rule of law and the functioning of the judiciary, continued violations of human rights, and political violence. Health care staff tend to be concentrated in urban areas and are poorly paid. Despite the population's poor overall health status, public health services are underutilized. Access and affordability of services for the poor remain major constraints. Household out-of-pocket spending on health accounts for 82 percent of total health spending, with donors and NGOs funding 14 percent, and the MOH 4 percent. Cambodia has the world's 18th highest burden of TB. Among adult (15-49) TB cases, at least 20 percent are infected with HIV. An estimated 4.2 percent of new cases are multidrug-resistant. Nonadherence to DOTS in the private sector and in some large hospitals is a major concern. Coordination between TB and HIV/AIDS programs is limited. Cambodia has one of the highest female labor force participation rates in the region. However, most of this employment is in the informal sector. Women are often in low-paid, unskilled positions and vulnerable to exploitation in the workplace. Cambodian women's workloads have become even greater than those of men because of the nontraditional tasks women have had to take on during two decades of war, civil strife, and the resultant male mortality. Health care service for women is generally limited. Almost 90 percent of women report that they cannot access health care services due to financial constraints. Gender disparities in literacy and educational attainment are wide. Sex work is widespread in large and small urban areas, trading centers, and market towns throughout the country. Many street children in Cambodia sell sex, to support themselves and, sometimes, their families. Sex workers in Cambodia, and throughout southeast Asia, are highly mobile. There is also evidence that women are regularly moved between brothels for business reasons. Cambodia is a source and destination country for persons trafficked for sexual exploitation and forced labor. Cambodia's political history has entailed much mobility, including Khmer Rouge-forced migrations, refugee resettlement, and presence of U.N. and other international military and civilian observers. Cambodia has highly mobile populations within its borders, moving among provinces and between rural and urban areas. Military personnel are highly mobile, as are police. Fishermen are also highly mobile and regularly visit SWs in port cities. There are approximately 140,000 young people working in about 65 garment factories around Phnom Penh. Most of them are women under age 30 who have usually migrated from rural areas to find work and are likely to be separated from their family networks for the first time. Some women move between factory work and short-term sex work. There remain some critical gaps in HIV/AIDS knowledge. Stigma and fear around HIV/AIDS persist at household and community levels. Presently, drug use is not playing a major role in facilitating risk behavior. However, more drugs are being used by wider groups of people, with an increase in the use of amphetamines and inhalants. Cambodia is a major drug transmitting and trafficking route and there have been reports of clandestine amphetamine laboratories being established on the Thai border. Impact Between 1980 and 2000, 37,000 Cambodians died because of AIDS. By 2015-2050, AIDS will increase mortality in Cambodia by 22 percent. By 2010-15, life expectancy will be 7 percent lower because of AIDS. In 2050, Cambodia's population will be 7 percent smaller than it would have been in a "no-AIDS" scenario. The impact of HIV/AIDS is unlikely to be observed in significant declines in an already low per capita income, but rather in terms of poverty increases at household level as well as missed economic opportunities. As infected workers become increasingly ill, their productivity is likely to fall, affecting the public and the private sectors. Garment factories may be particularly hard-hit, given that they are the largest private sector employer in Cambodia. Because employees have few benefits and are easily fired, the private sector may attempt to shift the burden of HIV to the Cambodian government and/or the families of employees. Only a small fraction of PWHA have received limited medical care from government- and NGO-supported health facilities. Although home-based care has been implemented in some places, coverage remains highly inadequate. Cambodian households will bear the largest share of the HIV/AIDS burden. The additional cost of illness associated with AIDS is likely to be overwhelming for already impoverished Cambodian families. AIDS may force nonpoor households into poverty, and the poor into absolute destitution. Women bear primary responsibility for caring for family members with AIDS, as well as for those with other disabilities and illnesses. Because of HIV/AIDS, family structure in Cambodia is changing, as more orphans and grandparents head households. Cambodia had 55,000 AIDS orphans at the end of 2001. The percent of Cambodia's orphans that could be attributed to AIDS rose from 1.4 percent in 1995 to 10.9 percent in 2001; this figure will rise to 20.7 percent by 2005 and 27.5 percent by 2010. Given years of genocide, civil war, and famine, the ability of Cambodian families to cope with AIDS orphans is severely strained. Children affected by HIV/AIDS are exposed to high levels of stigma and psychosocial stress, with girls more vulnerable than boys. Response Over the past few years, HIV prevalence in Cambodia appears to have stabilized and has perhaps begun to decline, given a combination of prevention interventions as well as the rising mortality of people with AIDS. Nevertheless, adult HIV prevalence is 2.7 percent, the highest in the Asia-Pacific region. Cambodia has many of the elements for an effective response to the epidemic in place. These include: * high-level commitment to addressing HIV/AIDS * good sentinel surveillance system * ongoing behavioral research * blood safety measures * prevention interventions focused on "core groups" such as sex workers, the military, police, and fishermen * emphasis on STI treatment and prevention * condom promotion policies * strong collaboration with NGOs * recently passed legislation on HIV/AIDS However, the majority of large-scale prevention and care & support programs target Phnom Penh, the capital; Sihanoukville, the country's largest commercial and fishing port; and the provinces bordering Thailand, including Battambang and Banteay Mean Chey. Given that 84 percent of Cambodia's population is rural, efforts to scale up prevention and care interventions are crucial. Concurrently, Cambodia faces massive challenges, including the socioeconomic, political, and psychological legacy of decades of genocide and civil war and the need to rebuild the country's infrastructure, including the health sector. The country's response is also affected by donors, upon which Cambodia's HIV/AIDS efforts depend heavily. Donors, as well as foreign investors, want to see (sometimes unrealistically) rapid results with regard to control of HIV/AIDS. The government emphasizes a multisectoral response and is working to strengthen provincial ability to respond to the epidemic. It works with numerous local and international partners on a range of prevention activities. The government's current priorities include: * multisectoral response, involving ministries outside health * continued implementation of the 100% Condom Use Program * improved STI prevention and treatment * prevention of mother-to-child transmission of HIV * HIV/STI school-based education and outreach programs to "core groups" * HIV/STI community-based prevention programs HIV was first identified in Cambodia in 1991 during serological screening of donated blood. The first cases of AIDS appeared in late 1993 and early 1994. In 1991, Cambodia's MOH established the National AIDS Program. In 1998, the MOH combined its STI and HIV/AIDS programs to form the National Center for HIV/AIDS, Dermatology, and STDs (NCHADS). NCHADS oversees the national health response to HIV/AIDS, as well as provides technical support to other governmental agencies and national partners. To coordinate a multisectoral approach involving ministries beyond the MOH, the government established the National AIDS Committee in 1993, which was succeeded in 1999 by the National AIDS Authority. The NAA is an interministerial body comprising 15 ministries, the Cambodian Red Cross, and the 24 provincial governments. The priorities of Cambodia's HIV/AIDS policy are: * reduction of HIV transmission through activities in groups at high risk aimed at decreasing STIs and promoting "100% condom use" * provision to the general population of IEC, counseling, and testing services * strengthening of the health delivery system In 2002, Cambodia's National Assembly passed legislation on HIV prevention and control. The Law on the Prevention and Control of HIV/AIDS provides for national HIV/AIDS awareness campaigns, epidemiological monitoring, and free primary health care for PWHA. The law requires the protection of confidentiality of HIV/AIDS information. All forms of discrimination against PWHA are prohibited, as is discrimination against families of PWHA and people thought to be HIV-positive. However, to what degree these edicts are being adhered to is unknown. The 100% condom use program (CUP) was pilot tested in Sihanoukville in 1998. After the pilot phase of CUP was evaluated in late 1999, Cambodia's prime minister approved the National Policy on 100% Condom Use. Implementation of CUP thus far has been limited to two urban areas. The NAA prepared the National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS 2001-2005 (NSP). Currently, several ministries are undertaking major HIV/AIDS activities, including National Defense; Social Affairs, Labor, Vocational Training and Youth Rehabilitation; Women's and Veteran's Affairs; Education, Youth and Sport; and Cult and Religion. In 1994, US$800,000 was spent on HIV/AIDS in Cambodia. By 1999, spending had increased to US$9 million and in 2001, to US$14 million. In 2002, donors and the government spent an estimated US$15.4 million on HIV/AIDS programs within the health sector. Cambodia has been absorbing increasing amounts of HIV/AIDS funding. The government's capacity to manage these resources is improving. Nevertheless, Cambodia continues to depend heavily on external technical and financial resources to address HIV/AIDS. In the first round of GFATM grants, Cambodia's Country Coordinating Mechanism was approved to receive US$15,945,803 for its HIV/AIDS component. In the second round of GFATM grants, Cambodia's HIV/AIDS component was approved for US$14,877,295, pending clarifications. The second Cambodian GFATM proposal on HIV/AIDS addresses interventions not covered in the first, with increased emphasis on ART. Specific objectives include: 1. expanding the coverage and enhancing the quality of interventions for the prevention of HIV/AIDS to include underserved vulnerable populations 2. improving access to quality comprehensive care interventions including ART and promoting greater involvement of PWHA 3. securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART Since the early years of the HIV/AIDS epidemic, NGOs and CBOs have carried out a major portion of the country's HIV/AIDS prevention and care activities. Their work has been crucial, though constrained by limited resources. According to WHO, 2,800 clients received PMTCT services (i.e., basic counseling, testing, and AZT or NVP treatment) at the one public/NGO PMTCT site in Cambodia during 2001; an estimated 2 percent of the population in need of PMTCT services was receiving them. The government finalized its policy on prevention of mother-to-child transmission of HIV in mid-2000. Its main objective is to improve the acceptability, accessibility, and quality of health services and information on reproductive health and HIV/AIDS/STIs. Recognizing that maternal care services are limited, the government is studying the feasibility of providing a package of MTCT prevention services through antenatal, peripartum, and postpartum care treatment points. In its second-round GFATM proposal, the MOH stated that one of its goals is that by 2004, PMTCT services will be available in five provinces. In 1998, the Cambodian MOH established a partnership with several NGOs to develop and implement home-based care for PHWA. The Home-Based Care Network reaches people with AIDS and other chronic illnesses in Phnom Penh. The government continues to focus on home- and community-based care for PWHA. It acknowledges, however, the extra burden this places on poor families, women, and primary caregivers. According to WHO, during 2001, 15,927 clients were seen at Cambodia's 14 publicly funded/NGO VCT centers. Only 2.8 percent of Cambodian women have been tested for HIV. Among women who have not been tested for HIV, 24.8 percent want to be tested. In 1995, Cambodia's first HIV testing and counseling policy was developed; it was revised in 2001 to incorporate use of two different rapid tests for HIV diagnosis. VCT in public health facilities is free of charge. According to Cambodia's new law on HIV/AIDS, in almost all circumstances, HIV testing must be voluntary, anonymous, and subject to written consent and to pre- and posttest counseling. However, to what degree this edict is being adhered to is unknown. Cambodia's second-round GFATM proposal seeks to increase availability of VCT in partnership with the Reproductive Health Association of Cambodia. According to WHO, 11 HIV-positive Cambodian children received cotrimoxazole prophylaxis in 2001. Among HIV-positive adults, 2,640 received cotrimoxazole prophylaxis and 200 received isoniazid prophylaxis during 2001, representing 11 and 1 percent, respectively, of the population in need of such services. Access to HIV/AIDS care and support services outside Phnom Penh and in rural areas is deemed minimal. WHO reported that during 2001, there were three public/NGO sites in Cambodia providing ART. These three clinics (operated by MSF, MDM, and Sihanouk Hospital Center of Hope) were serving 202 clients¾1 percent of Cambodians in need of ART. Cambodia's second-round GFATM proposal addresses securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART. The proposal outlines as one its goals that by 2006, 3,000 Cambodians will be on ART. Epidemiology At a Glance: Summary Bullets * From 1991, when the first case of HIV infection was reported, to 1998, Cambodia experienced rapid spread of HIV. * Cambodia's National Center for HIV/AIDS, Dermatology and STD (NCHADS) reported that there were 210,000 adults living with HIV/AIDS in 1997. NCHADS estimated that adult HIV prevalence was 3.2 percent in 1999. * Active commercial sex and "bridging" networks played a major role in the rapid spread of HIV, with a large portion of HIV incidence comprising transmission from sex workers to their male clients. * The results of Cambodia's 2000 HIV Sentinel Surveillance (HSS) found that the proportion of Cambodians with HIV declined in 2000 compared to the previous two years. The 2000 HSS estimated that 169,000 Cambodian adults were living with HIV/AIDS, with adult HIV prevalence at 2.8 percent. Prevalence decline was observed in all sentinel groups (except beer promotion girls, among whom prevalence remained steady) and appeared to have been strongest among 15- to 19-year-olds. * NCHADS posited that the prevalence decline was likely the result of (1) increased deaths among people with HIV infection combined with (2) a slower rate of new infections, probably due, in part, to reductions in risk behavior. * NCHADS did not believe that methodological biases were responsible for this decline, though it did highlight the limitations of the 2000 HSS data. It also cautioned that the number of reported AIDS cases rose sharply in 2000, indicating an increasing demand for AIDS care and treatment. * Heterosexual transmission of HIV appears to predominate, but there is a paucity of data on transmission via men who have sex with men and injecting drug users. Injecting drug use could, however, become a major mode of transmission. * Cambodia's epidemic dynamic renders it particularly sensitive to increases in condom use between sex workers and clients. The results of the 2000 HIV sentinel and behavioral surveillance studies appear to indicate that the government's condom promotion activities have resulted in increased condom use and may be responsible for some of the slowing in the rate of new infections. However, the epidemic in Cambodia is changing rapidly, making it difficult to make any assertions about it. Overview Over the past few years, HIV prevalence in Cambodia appears to have stabilized and has perhaps begun to decline, given a combination of effective prevention interventions¾including a 100% Condom Use Program (CUP)¾as well as the rising mortality of people with AIDS.[1] However, major challenges remain. At 2.7 percent, Cambodia's adult HIV prevalence is the highest in the Asia-Pacific region.[2] The epidemic is generalized, having moved beyond the "core transmitter" or bridge populations. Cambodia's Ministry of Health notes that, "Over time, the most important route of transmission has moved from the commercial sex circuit to the family."[3] Concurrently, the number of Cambodians with AIDS requiring treatment continues to rise. According to Cambodia's MOH: The impact of providing treatment for the escalating opportunistic infections, and for STIs as prevention and care, on an already fragile and over-stretched health system, on communities and at the household level is crushing. The burden of AIDS cases is already evident in many health care facilities, particularly at national infectious disease hospitals, and the same is being felt at provincial and health center levels...Access to even the most basic of [AIDS] drugs is seriously lacking in many health facilities. The most important obstacle to access is affordability but legal, infrastructural, distribution, and cultural factors are also serious impediments.[3] The country is experiencing myriad impacts of AIDS, not least the additional cost of illness associated with AIDS, largely borne by already impoverished Cambodian households. The need to sustain and adequately fund the nation's response to HIV/AIDS therefore remains paramount.[1] HIV Sentinel Surveillance HIV infection was first reported to the National Blood Transfusion Center in Phnom Penh in 1991. In 1993, the first AIDS case was reported to the Ministry of Health.[4] In 1992, the National AIDS Program, with support from WHO, conducted an unlinked, anonymous seroprevalence survey of selected risk groups in Phnom Penh. In 1994, the National AIDS Program (now the National Center for HIV/AIDS, Dermatology, and STD [NCHADS]) initiated an annual HIV sentinel surveillance (HSS) program. WHO continues to provide support to the HSS, as do the Cambodian Disease Control and Development Project, Family Health International/USAID, UNICEF, and French Cooperation.[4] 2000 HSS In the 2000 HSS, groups sampled included: * direct female commercial sex workers (DFSWs, meaning brothel-based SWs) * indirect female commercial sex workers (IDFSWs; includes beer promotion girls, bar women, and women working in karaoke lounges and massage parlors) * male police * pregnant women attending antenatal clinics (ANCs) * tuberculosis patients * hospital inpatients The results of the 2000 HSS found that the proportion of Cambodians with HIV declined in 2000 compared to the previous two years. In 1997, there were 210,000 Cambodians living with HIV; in 2000, this figure was 169,000. Adult HIV prevalence was estimated at 2.8 percent. (In 1999, NCHADS estimated that adult HIV prevalence was 3.2 percent.[5]) Prevalence decline was observed in all sentinel groups except beer promotion girls, in whom prevalence remained steady (see box 1). The decline was also observed in data extrapolations regarding the general population and appears to have been strongest among 15- to 19-year-olds.[4] 2002 HSS The results of the 2002 HSS have not yet been released. In its most recent proposal to the Global Fund to Fight AIDS, TB & Malaria, Cambodia's Ministry of Health stated that the estimated number of Cambodians infected with HIV in 2002 was 157,500, with a 2002 adult prevalence of 2.6 percent. In 2002, there were an estimated 18,930 new AIDS cases, and 17,973 deaths due to AIDS. The MOH projected that without ART, the cumulative number of AIDS deaths by 2010 would be 230,000. [3] (See also the Demographic Impact section.) Data Interpretations and Limitations Cambodia's 2000 HSS findings attracted much attention. Some observers interpreted the 2000 HSS results to mean that Cambodia was beginning to curb its HIV/AIDS epidemic.[6] But NCHADS sounded a more cautious note. It attributed prevalence decline to (1) increased deaths among people with HIV infection combined with (2) a slower rate of new infections, probably due, in part, to reductions in risk behavior. [4] NCHADS did not believe that methodological biases were likely to be responsible for this decline. The 2000 HSS methodology followed that of the 1999 HSS, except that all clusters were numbered so that they could be classified as provincial capital/remaining area during data analysis. Specific subgroups of IDFSWs were also identified to permit subgrouping during analysis. [4] NCHADS did, however, underscore the limitations of the data. All HSSs have sampled different groups in different years (and not every group in every province), usually because there were not enough individuals in the target population and because of limited resources. For example, ANC data were not included in the 1998 HSS (replaced by married women of reproductive age), but were reinstituted in the 1999 and 2000 HSSs. NCHADS stressed the instability of provincial level estimates of ANC and its efforts to correct for this. [4] Among men, NCHADS noted that there are currently no groups in the sentinel system that can Box 1. "Beer Girls" in Cambodia In Cambodia, beer distributors employ women to promote beer sales at local restaurants and bars. Many "beer girls" also work as IDFSWs, report high-risk behavior, and have high HIV prevalence. NCHADS, the University of California San Francisco, and the CDC-Thailand Ministry of Public Health HIV/AIDS Collaboration are implementing an STI treatment and education intervention to reduce HIV and STI infection risk among beer girls in Battambang, Cambodia. The study team recruited 92 women (median age 22) from five beer companies. They found that prevalence of HIV was 26 percent; of chlamydia, 14 percent; of trichomonas, 12 percent; of bacterial vaginosis, 43 percent; of gonorrhea, 3 percent, and of syphilis, 0 percent. Eighty-two percent of women reported a history of sex work, and 43 percent reported condom use at last sex. Increased number of partners, fewer years of education, and self-reported STI symptoms were significantly associated with HIV infection. These preliminary data suggest that HIV and STI interventions are urgently needed among IDFSWs in Cambodia.[7] be considered representative of the male population at large. As a result, NCHADS estimated male infections by taking the ANC prevalence and multiplying it by a male-to-female ratio to reflect that men are more heavily infected with HIV in Cambodia than women. Yet whether men do carry more of the HIV/AIDS burden than women is unclear. [4] Other limitations of the 2000 HSS include that districts that were inaccessible or accessible only with great difficulty were excluded from sampling. Only police in provincial capitals and some in accessible areas at district levels were included. Hospital patients were sampled in only three provinces. Though the HSS sought to sample groups in provincial capitals as well as districts located throughout provinces, most of the sites that sampled DFSWs and IDFSWs were urban. IDFSWs represented a much broader group than were included in the IDFSW category prior to 1999. Trends among IDFSWs were determined using data only from beer promotion girls, as they were the only subgroup for which data were consistently collected from 1998-2000. Prevalence among groups other than DFSWs fluctuate greatly due to the small sample sizes relative to the HIV prevalence level, and thus it is difficult to evaluate the prevalences in these groups at the provincial level. [4] NCHADS noted that the lower prevalence of HIV among TB patients in 2000 is difficult to explain, as the proportion would be expected to increase as more HIV-infected individuals progress to AIDS and as TB is the most common opportunistic infection in Cambodia. However, over the last several years, there has been an expansion in the number of rural health centers (see Box 2), which have the capacity to diagnose TB. An increase in the proportion of milder TB cases, perhaps more likely to have been diagnosed at rural health centers, would have decreased the observed prevalence of HIV among TB patients as patients with both HIV and tuberculosis are more likely to have advanced disease. [4] Finally, NCHADS cautioned that the number of reported AIDS cases rose sharply in 2000, indicating an increasing demand for AIDS care and treatment. Thus, the 2000 HSS results must be viewed against this backdrop. [4] (See also box 2.) Box 2. HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through HIV seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently used sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and treatment of sexually transmitted infections. The objectives of sentinel seroprevalence surveys include: 1. obtaining information on the prevalence of HIV infection in the sentinel population 2. monitoring trends in HIV prevalence in the sentinel population 3. providing information for estimating future number of AIDS cases 4. providing information for program planning and evaluation of interventions Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women attending antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The surveys are conducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a current pregnancy. Surveys are usually conducted in an unlinked manner, in which serum remaining from routine syphilis screening is tested for HIV infection after all personal identifying information is removed from the specimen. Sampling is usually conducted during an 8- to 12-week period, and all eligible women are sampled consecutively until the desired sample size is achieved. In general, samples of 250 and 400 women are usually sufficiently large as to provide reasonable estimates of HIV prevalence over time. Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey results. The surveys are not based upon a probability sample and therefore may not be representative of the population as a whole. True population-based surveys have found antenatal clinic data may overestimate or underestimate HIV prevalence. Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition, although monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in prevalence cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence in younger populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired HIV infection , as this group is unlikely to have been infected for a long period of time. Prepared by Sandy Schwarcz, MD, MPH Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San Francisco Behavioral Surveillance Cambodia has been undertaking behavioral surveillance surveys since 1997. BSSs I through III (1997-1999) focused on sentinel groups such as police, military, mototaxi drivers, DFSWs, and IDFSWs in five provinces (Battambang, Sihanoukville, Kampong Cham, Phnom Penh and Siem Reap). To capture data regarding men in the "general population" (vs. sentinel or "core" groups),[8] the 2000 BSS (BSS IV) used a household survey among men ages 15 to 49 years in the five provinces covered in BSSs I-III; the provincial capital and three rural districts within each province were included. BSS IV was conducted by NCHADS with support from the Cambodian Disease Control and Development Program, UNICEF, and FHI/USAID.[9] Findings from BSSs I-IV are used below. UNAIDS Estimates UNAIDS estimated that at the end of 2001, there were 170,000 Cambodian adults and children living with HIV/AIDS, of whom 160,000 were adults. The adult HIV prevalence rate was 2.7 percent. According to UNAIDS, women accounted for 46.25 percent of infected adults. (The 2000 HSS found that 42.60 percent of adults with HIV were women.[4]) UNAIDS estimated that the HIV prevalence rate for women ages 15 to 24 was between 1.99 and 2.98 percent; for men in the same age cohort, the range was from 0.77 to 1.16 percent. UNAIDS also estimated that there were 12,000 adult and child AIDS deaths during 2001.[2]) Mortality According to UNAIDS, during 1999, there were 14,000 AIDS deaths in Cambodia.[10] During 2001, there were 12,000 AIDS deaths.[11] According to Cambodia's most recent GFATM proposal, in 2002, there were 17,973 deaths due to AIDS. [3] According to the U.N. Population Division, between 1980 and 2000, there were 37,000 AIDS deaths in Cambodia. The division projects that during 2000-15, there will be 358,000 AIDS deaths, and 1.2 million AIDS deaths during 2015-50.[12] See the Demographic Impact section for more detailed data on AIDS-related mortality. Transmission Patterns HIV infection has been noted in all regions of the country. The highest prevalences are found in the southeast, central provinces, and along the border with Thailand. Cambodia's Ministry of Health estimates that heterosexual transmission accounted for 62.5 percent of new HIV infections in 2002, with mother-to-child transmission accounting for 25 percent of new HIV infections. The MOH notes that: In 2002, there are approximately 24 new [HIV] infections every day. Out of these 24, about 10 are transmitted from husbands to their wives; another 6 are from mothers to their babies; and 5 are from sex workers to their male partners.[3] Thus, 12.5 percent of HIV transmission is from other sources, including contaminated blood/blood products, occupational exposure, unsafe injections, and men who have sex with men (MSM).[13] Injecting drug use could, however, become a major mode of transmission. (See Drug section below.) According to NCHADS, HIV prevalence among blood donors peaked at 4.5 percent in 1995. It fell to 3.6 percent in 1996, rose to 4.2 percent in 1998, and fell to 2.7 percent in 2000.[4] Women Attending Antenatal Clinics (ANCs) The 2000 HSS found that prevalence among women attending ANCs was 2.3 percent. In 1997, ANC prevalence was 3.2 percent, and in 1999, 2.6 percent.[9] (NB: The limitations of ANC data were discussed in box 1. Also note that ANC prevalence within some provinces remains extremely high; for example, in 2000, five provinces recorded ANC prevalences of 4 percent or above.[14]) Sex Workers and Their Clients To a large degree, the epidemic in Cambodia has been driven by SWs and their clients. As mentioned, direct SWs are based in brothels. Non-brothel-based women who participate in commercial sex are considered indirect SWs (these include women who participate in sex work but have other jobs as well). The latter conduct business from a wide array of venues, no one of which predominates after brothels. (See Box 2 for findings from a study being conducted among beer promotion girls.) Among all groups sampled in the 2000 HSS, DFSWs had the highest HIV prevalence (31.1 percent). In 2000, HIV prevalence among IDFSWs was 16.1 percent, almost half that found among DFSWs.[4] Debt-bondage (and concomitant pressure to service as many clients as possible) may play a role in this scenario. UNAIDS cites statistics that 20 to 40 percent of DFSWs have to repay debt to brothel owners.[13] (Though there are male sex workers, the sex industry predominantly caters to heterosexual clients.[13]) (See Population Mobility section for further discussion.) Men play a crucial role in the AIDS epidemic in Cambodia. Men are the bridges between the sex industry, their families, and the general community. BSS IV found that the average age of sexual debut for urban men is about 22, although it is slightly lower for rural men (see table 1 below). The majority of the never married of these urban men studied (71 percent) report never having sex, which means only 29 percent of never married men are sexually active. The median age of first sex is about two years younger than the median age of first marriage, leaving most men two years of sexual activity before marriage. Urban men report an average of twice as many lifetime partners as rural men (8 vs. 4), and significantly more in the past year (1.7 vs. 1.3). More rural men report only having had one lifetime partner (38.9 percent rural vs. 26.4 percent urban), and half as many rural men report having had sex with more than 15 partners than urban men (5.1 percent rural vs. 10.2 percent urban).[9] Table 1. Findings from Cambodian Household Male Survey (BSS IV 2000), Male Sexual Behavior Rural Urban Total Mean age first sex (median) 21.7 (21) 22.2 (21) 22.01 (21) Mean lifetime sex partners (median) 3.98 (1) 8.6 (1) 6.32 Mean # partners past year (median) 1.3 (1) 1.7 (1) 1.5 (1)2 Mean # times sex with wife past month (median) 6.2 (4) 5.8 (4) 5.6 (4) % Ever sweetheart 68.1 65.1 66.6 % Ever sex with sweetheart among those who ever had sweethearts 38.1 41.9 40.1 % Sweetheart past year 9.4 9.1 9.2 % Casual partner past year (not wife, sweetheart, or sex worker) 9.4 13.5 11.42 Notes: 1. p <= 0.05 2. p < 0.005 Source: Cambodian Ministry of Health, National Center for HIV/AIDS, Dermatology and STD. Cambodian Household Male Survey (BSS IV 2000). Phnom Penh. In BSS IV, 10 percent of rural men and 12.5 percent of urban men reported having had sex with both a commercial sex worker and with their "sweethearts"¾a term loosely analogous to girlfriends or mistresses¾or their wives. Over 50 percent of these men have had sex with a DFSW. BSS IV also found that more Cambodian men purchase sex with other men than alone, suggesting that there is social pressure for men to seek commercial sex. (Although most men drink some alcohol, the BSS IV data did not suggest that heavy alcohol use is a major factor in sexual behavior at the time of commercial sex.[9]) Military and Police Male military personnel were included in the HSS between 1995 and 1997; during this latter year, 6 percent were found to be HIV-positive. (In the 1998 HSS, military were omitted as a separate sentinel group as over time their prevalence appeared to be similar to that of the police and a decision was made to survey only one group¾police.)[15] The 2000 HSS found that 3.1 percent of male police were infected with HIV.[4] Data from BSSs I-III found that the mean number of lifetime sexual partners for military personnel and police were 43 and 31, respectively. For urban and rural "general population" men surveyed in BSS IV, these figures were 9 and 4, respectively.[9] When the respondents in BSS IV were stratified by occupation and their use of commercial sex examined, police and military had more sex with SWs than any other occupational group.[9] Fishermen Given their high mobility and frequency of contacts with SWs, fishermen may be a significant bridge population for HIV transmission in Cambodia. A study in three fishing areas in Sihanoukville (the country's largest commercial and fishing port) is being conducted by NCHADS and Cambodia's National Center for Health Promotion, in partnership with the University of California San Francisco. Of 446 fishermen surveyed in June 2000, 16 percent were HIV-positive.[16, 17] Men Who Have Sex with Men (MSM) During June 2000, Family Health International and the Institut Pasteur conducted a study among MSM in 16 sites in Phnom Penh, using a probability sample of 206 MSM ages 18 and above. A total of 185 men (90 percent) were single and the majority (51 percent) unemployed. In the previous 6 months, 167 (81 percent) reported anal sex with male partners and 125 (61.2 percent) reported vaginal sex partners. In the past 6 months, 82.8 percent of the sample reported having male partners who paid them to have sex; among them, 72.6 percent paid for anal sex. Risk factors for HIV infection were anal sex with multiple partners (OR, 3.26; 95% CI 1.26-8.41, P = 0.016); current syphilis (OR, 9; 95% CI 2.01-40.20, P = 0.001); and any STI (OR, 5.9; 95% CI 1.48-23.59, P = 0.007). The authors concluded that the significant proportion of MSM who have had penetrative sex with both males and females suggests that MSM are a potential "bridge group" between male and female commercial sexual partners and regular and nonregular female partners.[18] Condom Use The background of Cambodia's 100% condom use program (CUP) is discussed in the Response section. The probability of men's transmitting HIV/STIs from SWs to their wives (the "bridging" phenomenon) is strongly influenced by their condom use during commercial sex. Men's condom use with their wives tends to be low, suggesting that the motivation for men to use condoms is to protect themselves from infection. Another factor may be that condoms, though not the most reliable contraceptive method, can prevent conception, and having children is an important objective of marriage in Cambodia.[19] The Cambodian 2000 Demographic and Health Survey (CDHS) found negligible condom use among women during last sexual intercourse with a spouse (1.0 percent) or any partner (1.2 percent) (NB: Almost 99 percent of women surveyed on this question were married). Urban women were three times more likely to use condoms than rural women; condom use was also positively associated with education level.[20] (The 2000 CDH was carried out by the National Institute of Statistics in the Ministry of Planning and the Ministry of Health. A total of 15,351 women ages 15-49 spanning 12,236 households were interviewed during February to July 2000.) Researchers from the National University of Singapore, University of Guelph, Siem Reap Province AIDS Office, and Mondol Moi Health Center undertook a study to determine the social and behavioral factors associated with condom use among DFSWs in Siem Reap. They interviewed 140 DFSWs attending the Mondol Moi Health Center for HIV screening. Seventy-eight percent reported consistent condom use with clients, compared with only 20 percent with nonpaying partners. Consistent condom use with clients was significantly higher among higher-income than lower-income SWs (adjusted prevalence ratio: 1.91, 95% CI: 1.15 to 3.18) and those with good rather than poor negotiation skills (adjusted prevalence ratio: 1.51, 95% CI: 1.01 to 2.26), after adjustment for age, educational level, marital status, number of sexual encounters per week, and knowledge of HIV/AIDS and STIs. The most frequently reported reason for not using condoms with clients was inability to persuade them (66.7 percent); with nonpaying partners, the reason most reported was love (60.0 percent).[21] The previously mentioned study of fishermen in Sihanoukville found that consistent condom users reported lower rates of STIs in the past year, but were just as likely to be HIV-positive than inconsistent condom users ("sometimes" or "never"). The study also found that consistent users were more likely to have used a condom the first time they had sex with a person compared to inconsistent condom users. Although over 80 percent of HIV-positive fishermen believed that consistent condom use was protective against HIV transmission, only 48 percent of HIV-positive fishermen who visited SWs in the past year reported always using a condom during sex with SWs.[16, 17] Data from BSSs I-III indicated that consistent condom use by military men increased from 54.2 percent in 1997 to 69.7 percent in 1999, while the percentage of police reporting always using a condom rose from 54.2 percent in 1997 to 81.3 percent in 1999. Mototaxi drivers also showed an increase, from 53.8 percent in 1997 to 74.9 percent in 1999.[22] Among police surveyed in the 2001 STI study conducted by NCHADS, condom use during last sex with a sex worker was nearly universal. Reported condom use with wives was low. Almost half the police reported having sex with another partner who was not a wife or SW during the last year; condom use with these casual partners was much lower than with SWs.[23] (NB: These are preliminary, unpublished findings.) Injection Drug Users See also the Drug section. Data on HIV transmission via injecting drug use are scarce. Injecting drug use may become important in fuelling the HIV epidemic, given that Cambodia is a major drug transmitting and trafficking point.[24] Rather than seeing a doctor first, Cambodians tend to visit a drug seller/pharmacist to buy medicine.[25] Cambodians prefer to use injections to administer prescription drugs, which are obtained from the country's pharmacies. Given the limited means of sterilizing syringes, this may become a significant means of transmitting HIV.[26] [24] Political Economy and Sociobehavioral Context At a Glance: Summary Bullets Overview * Numerous factors render Cambodia particularly vulnerable to HIV/AIDS. These include a legacy of genocide, civil war, and famine, which eradicated much of the educated, highly skilled population. * In tandem with persistent poverty and political turmoil, this scenario has led to a weak health infrastructure badly in need of rehabilitation. * The government is undertaking health reform, including more efficient allocation of resources, but health status¾including sexual & reproductive health¾remains low. * Gender inequality is also shaping the epidemic. Other crucial factors include Cambodia's large commercial sex industry. * Population mobility, particularly within the country, is high. * STI prevalence appears to be declining, though there is a shortage of affordable and accessible STI drugs. * The burden of tuberculosis is large, and multidrug-resistant strains an increasing concern. Human Development * Much of the Cambodian population lacks access to health and educational facilities, safe water, electricity, and sanitation. * Levels of educational achievement in Cambodia are extremely poor. Economy * Despite recent progress, the Cambodian economy remains constrained by the legacy of decades of conflict. The average income in Cambodia is US$260. * Cambodia relies heavily on foreign aid. Poverty * About 36 percent of the Cambodian population lives below the national poverty line of US$0.63/day. The majority of the poor (79 percent) are those with household heads employed in the agricultural sector. * The most vulnerable groups vis-à-vis poverty include internally displaced people and returnees, PWHA, war widows and female-headed households, orphans, street children, squatters, people with disabilities, and isolated ethnic minorities. Governance * The legal infrastructure for law enforcement is weak, given limited resources and few legal professionals in the country. * Cambodia had made progress on human rights. However, problems persist, particularly regarding child labor, the rule of law and the functioning of the judiciary, continued violations of human rights, and political violence. Health System * The health system was largely destroyed by the Khmer Rouge. Over the past decade, the government has made significant progress in reestablishing health services. * However, the country's basic health care infrastructure is weak, and utilization and quality of health services low. * The health status of Cambodians is among the lowest in the Western Pacific Region. * Health care staff tend to be concentrated in urban areas and are poorly paid. * Despite the population's poor overall health status, public health services are underutilized. Access and affordability of services for the poor remain major constraints. * The nonmedical sector is the most popular for those seeking treatment (e.g., legal and illegal pharmacies, traditional healers, monks/religious leaders). The second-most popular is the private sector (e.g., private hospital or clinic, home/office-trained health worker, visit of trained health worker/nurse). Last is the public sector (e.g., central hospital in Phnom Penh, provincial or district hospitals, health centers). * Legal and illegal pharmacies offer wide access to drugs, often prescribed without diagnosis. Health Expenditures * Household out-of-pocket spending on health accounts for 82 percent of total health spending, with donors and NGOs funding 14 percent, and the MOH 4 percent. * In 2000, public expenditure on health represented 2 percent of GDP. Tuberculosis * Cambodia has the world's 18th highest burden of TB. In 2001, the TB incidence rate was 585 cases per 100,000 population. * Among adult (15-49) TB cases, at least 20 percent are infected with HIV. An estimated 4.2 percent of new cases are multidrug-resistant. * Nonadherence to DOTS in the private sector and in some large hospitals is a major concern. * Coordination between TB and HIV/AIDS programs is limited. Sexual & Reproductive Health * Reproductive health indicators in Cambodia are poor. Adolescent pregnancy, low levels of antenatal care and attendance by trained personnel during delivery, and frequent and closely spaced pregnancies contribute to the high maternal mortality ratio. Gender * Cambodia has one of the highest female labor force participation rates in the region. However, most of this employment is in the informal sector. Women are often in low-paid, unskilled positions and vulnerable to exploitation in the workplace. * Cambodian women's workloads have become even greater than those of men because of the nontraditional tasks women have had to take on during two decades of war, civil strife, and the resultant male mortality. * Only about half (52 percent) of Cambodian women have heard of any national laws that protect women's rights. * Health care service for women is generally limited. Almost 90 percent of women report that they cannot access health care services due to financial constraints. * Gender disparities in literacy and educational attainment are wide. * Cambodia is undertaking efforts to build a legal infrastructure; in the interim, the current legal system is inadequate (and underfunded) with regard to addressing sexual violence. Sex Work * Sex work is widespread in large and small urban areas, trading centers, and market towns throughout the country. * Many street children in Cambodia sell sex, to support themselves and, sometimes, their families. * Sex workers in Cambodia, and throughout southeast Asia, are highly mobile, as indicated by the average time at their present brothel (nine months). There is also evidence that women are regularly moved between brothels for business reasons. Population Mobility * Cambodia's political history has entailed much mobility, including Khmer Rouge-forced migrations, refugees resettlement, and presence of U.N. and other international military and civilian observers. * Cambodia has highly mobile populations within its borders, moving among provinces and between rural and urban areas. * Military personnel are highly mobile, often separated from their families, and perhaps more susceptible to peer pressure. Brothels and other venues that offer sex are often located close to military camps. Police are also mobile. * Fishermen are also highly mobile and regularly visit SWs in port cities. * There are approximately 140,000 young people working in about 65 garment factories around Phnom Penh. Most of them are women under age 30 who have usually migrated from rural areas to find work and are likely to be separated from their family networks for the first time. Some women move between factory work and short-term sex work. * Cambodia is a source and destination country for persons trafficked for sexual exploitation and forced labor. Knowledge of HIV * There remain some critical gaps in HIV/AIDS knowledge. For example, AIDS awareness among women is significantly lower in Banteay Mean Chey, Preah Vihear/Stueng Traeng/Kracheh, and Mondol Kiri/Rotanak Kiri than in other regions. * Almost two-thirds of women who have heard of AIDS and have had sexual intercourse do not know a source for condoms; about 36 percent do not believe that they could obtain a condom themselves. Stigma * Stigma and fear around HIV/AIDS persist at household and community levels. * Stigma and discrimination, in addition to the myriad impacts of AIDS mortality of household members, can lead to trauma in a country already severely traumatized. Alcohol and Drug Use * Presently, one may infer that generally, drug use is not playing a major role in facilitating risk behavior. However, more drugs are being used by wider groups of people, with an increase in the use of amphetamines and inhalants. * Cambodia is a major drug transmitting and trafficking route and there have been reports of clandestine amphetamine laboratories being established on the Thai border. In a paper prepared for the WHO Commission on Macroeconomics & Health, David Bloom of Harvard and his colleagues note that: Existing data provide some indication that the relationship between poverty and HIV is growing stronger over time, both between and within continents. But it is not possible to infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or vice versa¾or whether another variable, such as war, inadequate health, or poor education, explains the relationship....In sum, the link between economic status and AIDS is complex.[27] Håkan Björkman, senior adviser on HIV/AIDS to UNDP's Bureau for Development Policy, states that: HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income levels. But evidence from some countries at advanced states of the epidemic shows that new HIV infections disproportionately affect poor people, unskilled workers, and those lacking literacy skills¾especially young women in each of these categories. The relationship among poverty, gender, and HIV vulnerability has important policy implications.[28] This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. In addition to the table of key HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also want to consult the 2003 indicators related to progress on Millennium Development Goals, which are published by UNDP . Overview Numerous factors render Cambodia particularly vulnerable to HIV/AIDS. These include a legacy of genocide, civil war, and famine, which eradicated much of the educated, highly skilled population. Between 1975 and 1979, from 1.7 million to 3 million Cambodians were executed or died of starvation or disease (out of a 1975 population estimated at 7.3 million).[29] In tandem with persistent poverty and political turmoil, this scenario has led to a weak health infrastructure badly in need of rehabilitation. The government is undertaking health reform, including more efficient allocation of resources, but health status¾including sexual & reproductive health¾remains low. Gender inequality is also shaping the epidemic. Other crucial factors include Cambodia's large commercial sex industry, which, though illegal, is mostly tolerated and sometimes exploited by local authorities. Population mobility, particularly within the country, is high. STI prevalence appears to be declining, though there is a shortage of affordable and accessible STI drugs. The burden of tuberculosis is large, and multidrug-resistant strains an increasing concern.[30] Human Development One method of tracking human development is to analyze trends in a country's Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross enrollment ratios; and gross national income (which may be thought of as average income). An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2001, Cambodia's HDI value was 0.556. Cambodia's HDI value has been increasing since 1990, when it stood at 0.501. However, it still remains low compared with that of East Asia & Pacific Region (0.722) and is somewhat lower than that for all low-income countries (0.561). [31] Much of the Cambodian population lacks access to health and educational facilities, safe water, electricity, and sanitation. (See the accompanying table of key HIV/AIDS and socioeconomic indicators.) The country's infrastructure is severely underdeveloped, constraining economic development and impeding access to health and educational facilities. Land mines continue to limit the use of arable land.[32] The Cambodia Landmine Impact Survey, completed in April 2002, found that about half of all villages are either known or suspected to be contaminated by mines or unexploded ordinances.[33] The educated class of teachers, managers, doctors, nurses, and other skilled professionals, which was almost entirely eradicated by the Khmer Rouge, is only now being rebuilt.[32] Levels of educational achievement in Cambodia are extremely poor. Officially, education in Cambodia is free and accessible to all. However, families and communities cover 75 percent of the cost of primary education, as the government's educational contribution is one of the world's lowest.[34] Given the extremely low wages paid to teachers-around US$20 per month, about 20 percent of a living wage-teachers are forced to charge students unofficial daily fees of one or two hundred riel.[35] Public Expenditures In 2001, Cambodia spent 3.0 percent of GDP on military expenditures, down only slightly from 3.1 in 1990.[31] The country's military expenditures, as a percent of GDP, exceed those of the East Asia & Pacific Region and the world (2.0 percent in 1999).[36] The country's military expenditure as a percent of central government expenditure was 26 percent in 1999-2000; the comparable figures for the region and world were 17 and 10 percent, respectively.[36] Cambodia's annual public expenditure on education was 1.9 percent of GDP during 1998-2000; its public expenditure on health was 2.0 percent in 2000. [31] Economy Despite recent progress, the Cambodian economy remains constrained by the legacy of decades of conflict. The average income in Cambodia is US$260.[37] Most Cambodian's are subsistence-oriented farmers heavily dependent on low-input, rainfed rice cultivation for food security and income. Financial markets are underdeveloped, rendering it difficult for most of the population to obtain access to loans at reasonable interest rates. [38] Manufacturing output is concentrated in the garment sector. This sector now employs over 200,000 workers.[29] Cambodia's real GDP grew at 6.3 percent in 2001 and 4.5 percent in 2002, with almost all of this growth in the garment sector.[29] The other main foreign currency earner is tourism, though it has slowed in 2002-03, primarily because of SARS-related fears.[29] Cambodia relies heavily on foreign aid; in 2001, 58 percent of the central government budget depended on donor assistance. Cambodia has had difficulty attracting foreign direct investment, in part because of the unreliable legal environment. The economy has also had difficulty creating jobs in the formal sector. [29] Governance is a critical area of reform and is integral to attracting foreign investment, which would stimulate the country's longer-term growth and reduce its dependence on foreign aid. The legal infrastructure for law enforcement is weak, given limited resources and few legal professionals in the country. The government is undertaking measures to ensure accountability of public institutions and the transparency and integrity of official processes.[32] Poverty The most recent figures on national poverty are from 1997 and indicate that 36 percent of the Cambodian population lives below the poverty line of US$0.46-0.63 a day (using exchange rate from December 2002).[39] The majority of the poor (79 percent) are those with household heads employed in the agricultural sector. Although over 70 percent of Cambodians are employed in agricultural production, between 12 and 15 percent of them are landless. The access of the poor to other natural resources such as forest- and fishery-related resources is also constrained.[39] Cambodia's Poverty Reduction Strategy Paper notes that the most vulnerable groups in the country comprise internally displaced people and returnees, PWHA, war widows and female-headed households, orphans, street children, squatters, people with disabilities, and isolated ethnic minorities. Other vulnerable groups include those who live in areas contaminated with landmines and unexploded ordnances and in areas affected by natural disasters such as flood and drought.[39] Governance Cambodia's Poverty Reduction Strategy Paper, prepared by the country's Council for Social Development, states that: Although, the RGC [Royal Government of Cambodia] has attempted in the past to improve governance within the public system these elements are in fact still lacking in Cambodia. This lack of good governance has actually strong impact on the poor, and is the roadblock to the RGC's fight against poverty. [39] Among the key issues cited by the council are lack of access to government information and decisionmaking; lack of access to law and rights; and corruption, which, among other outcomes, results in Cambodians' being subjected to high under-the-table fees and other costs at many public health facilities.[39] Though still limited, freedom of the press has improved significantly since adoption of the 1993 constitution.[29] According to the U.S. Department of State: Compared to its recent past, the 1993-2003 period has been one of relative stability for Cambodia. However, political violence continues to be a problem. In 1997, factional fighting between supporters of Prince Norodom Ranariddh and Hun Sen broke out, resulting in more than 100 FUNCINPEC [United Front for an Independent, Neutral, and Free Cambodia] deaths and a few CPP [Cambodian People's Party] casualties. Some FUNCINPEC leaders were forced to flee the country, and Hun Sen took over as Prime Minister. FUNCINPEC leaders returned to Cambodia shortly before the 1998 National Assembly elections. In those elections, the CPP received 41% of the vote, FUNCINPEC 32%, and the Sam Rainsy Party (SRP) 13%. Due to political violence, intimidation, and lack of media access, many international observers judged the elections to have been seriously flawed. The CPP and FUNCINPEC formed another coalition government, with CPP the senior partner. Cambodia's first commune elections were held in February 2002. These elections to select chiefs and members of 1,621 commune (municipality) councils also were marred by political violence and fell short of being free and fair by international standards. The election results were largely acceptable to the major parties, though procedures for the new local councils have not been fully implemented. [29] Transparency International, which calls poor governance and corruption "systemic features" of Cambodia, also notes that the first nationwide local elections in February 2002¾which resulted in a 99 percent victory for the ruling Cambodia People's Party¾were marked by political violence, intimidation, and vote-buying. In the private sector, surveys suggest that businessmen engage in frequent bribery of public officials.[40] In mid-2003, the U.N. Commission on Human Rights noted that Cambodia had made progress on human rights. However, it also underlined continued problems related to child labor; the rule of law and the functioning of the judiciary; continued violations of human rights, including torture, excessive pretrial detention, and violation of labor rights; and political violence, including killings of political activists, involvement by police and military personnel in violence, and an apparent lack of protection from mob killings.[41] Health Status According to WHO, the health status of Cambodians is among the lowest in the Western Pacific Region (see the accompanying table of key indicators). Despite improvements in recent years, the country's basic health care infrastructure is weak, and utilization and quality of health services low.[42] The poor have little access to basic social services and facilities. About 21 percent of those in the poorest quintile must travel over 5 km to reach a health clinic. About 6 percent of the poorest two quintiles live over 5 km from the nearest road. [39] According to Cambodia's 2000 Demographic and Health Survey, 1.6 percent of the population is physically impaired (causes of impairment: birth defects [18.3 percent], disease [36.9], landmine [14.3], gun [10.6], road accidents [3.5], other accident [16.4]). [43] The proportion of amputees¾one in every 384 people¾is the highest in the world. Women carry a disproportionate burden of caring for the disabled.[44] Health System The health system was largely destroyed by the Khmer Rouge.[38] Bloom et al. note how Cambodia's rural economy has become increasingly cash-based, with high levels of debt, chronic rice shortages in 17 percent of communes, and a growing gap between those who are increasing their land holdings and those who are becoming landless. About 13 percent of rural Cambodian households are landless, with half of these believed to have lost their land in the last two decades. Concurrently, new economic structures are weak, with poorly functioning markets, inadequate use of technology, degraded infrastructure, and lack of credit. Bloom underscores how this scenario of growing vulnerability of large numbers of people, at a time of rapid economic change, is having a negative impact on health standards. [38] Over the past decade, the government has made significant progress in reestablishing the health services destroyed by the Khmer Rouge.[45] In 2002, there were 75 national, referral, and NGO hospitals and 650 health centers spanning 74 districts. The country's goal is to have a total of 946 health centers.[46] Health care staff tend to be concentrated in urban areas and are poorly paid (as are most civil servants), with most receiving about 20 percent of a living wage. As a result, unofficial charges, or bribes, are levied throughout the system. Public health workers may also operate their own private clinics instead of working at their "official" jobs.[38] Despite the population's poor overall health status, public health services are underutilized. In addition, household survey data indicate that service utilization is inequitable, and access and affordability of services for the poor remain major constraints. Recent studies have found that: 1. Private providers deliver twice as many services as public providers. 2. Both public and private providers offer low-quality services. 3. Neither type of provider effectively reaches the poor population. [45] According to Cambodia's 2000 DHS, the nonmedical sector is the most popular for those seeking treatment (e.g., legal and illegal pharmacies, traditional healers, monks/religious leaders). The second-most popular is the private sector (e.g., private hospital or clinic, home/office-trained health worker, visit of trained health worker/nurse). Last is the public sector (e.g., central hospital in Phnom Penh, provincial or district hospitals, health centers). The 2000 CDHS found that for most of the ill or injured population, the nonmedical (35 percent) and private sectors (33 percent) were the most common for treatment, followed by the public sector (19 percent). [43] The 2000 CDHS posited that people seek treatment from the nonmedical sector for two main reasons. First, the nonmedical sector may be physically closer to the population and thus easier to access (transport costs to the nonmedical sector are lowest). Second, the nonmedical sector is considerably less expensive than the other two sectors.[43] Legal and illegal pharmacies offer widespread access to drugs, often prescribed without diagnosis. [38] The World Bank notes that there are about 2,000 illegal pharmacies in Cambodia, which are not in compliance with the Food and Drug Department's regulations and provide drugs of poor quality.[45] The private sector permits customers to purchase drugs and treatment on credit. However, private practitioners are often poorly trained and heavily dependent upon drug sales to make a profit, which leads to severe over- and misprescription. A recent DfID study describes private health care in Cambodia as "poor quality for money, being both expensive and rather ineffective."[47] Although drug availability has improved since introduction of the Cambodia National Drug Policy in 1995, problems persist: * MOH's limited capacity to adequately purchase pharmaceuticals * problems with drug management and distribution * insufficient funding from the public budget to cope with price and drug consumption increases * inability to control drug quality[45] Drug shortages particularly affect the poor living in the remotest areas. Although theoretically, drugs are free for the indigent seeking care in the public sector, drug quality is poor, and many essential drugs are not available for long periods of time. [45] Health Expenditures In Cambodia, public and private expenditure on health care was US$17 annually during the late 1990s.[37] Most of this expenditure is by households; a DfID study found that household out-of-pocket spending on health accounts for 82 percent of total health spending, with donors and NGOs funding 14 percent, and the MoH 4 percent.[47] According to UNDP, in 2000, public expenditure on health represented 2 percent of GDP.[31] With regard to the MOH budget, the funds centrally allocated to health care are extremely low: the MoH budget amounted to just $2.67 per capita in 2000, far below that recommended by WHO to provide basic public health service in a low-income country.[47] Public expenditures on primary health care are very low, 2.7 percent of total MOH expenditures; expenditures on hospitals are about 6.5 percent of the MOH budget. Expenditures on health administration and training account for 88 percent of the MOH budget.[45] Mortality As the accompanying table of HIV/AIDS and key socioeconomic indicators shows, Cambodia's infant mortality rate in 2000 was 95 infant deaths per 1,000 live births. This figure is very high compared to that for the East Asia & Pacific region (34), though lower than that for least-developed countries (102). The under-five mortality rate in 2000 was 135 per 1,000 live births, again extremely high compared to the regional figures (44), though lower than that for least-developed countries (161). [48] The leading causes of childhood mortality are diarrheal diseases, acute respiratory infections, malaria, and malnutrition.[49] Another key health and development indicator is maternal mortality. The 2000 CDHS found a maternal mortality ratio of 437 deaths per 100,000 live births for 1994-2000.[43] (In 2002, UNFPA put Cambodia's MMR at 590 and those of Southeastern Asia, less-developed regions, and the world at 300, 440, and 400, respectively.[50]) The major direct causes of maternal deaths are hemorrhage, obstructed labor, hypertension, and sepsis.[35] During the late 1990s, the country's leading causes of morbidity and mortality were TB, malaria, acute respiratory infections, road accidents, injuries from landmines, maternal, diarrheal disease, dengue fever, and meningitis. [42, 51] Genocide and civil war have left many Cambodians severely traumatized, and mental health services are acutely needed.[52] Tuberculosis According to WHO, Cambodia is a "high TB burden country." In 2001, it had the world's 18th highest burden of TB in terms of new cases. In 2001, the TB incidence rate was 585 cases per 100,000 population. Among adult (15-49) TB cases, at least 20 percent are infected with HIV. An estimated 4.2 percent of new cases are multidrug-resistant. DOTS was adopted in 1994 and is currently available in 68 referral hospitals. However, only 381 out of a planned 946 health centers were providing DOTS at the end of 2002, suggesting that a large proportion of the population did not have access. Nonadherence to DOTS in the private sector and in some large hospitals is a major concern.[46] In Phnom Penh, DOTS is administered to inpatients at the National Center for Tuberculosis and Leprosy Control (CENAT), to CENAT outpatients, and through the DOTS Home Delivery Program. The home delivery program has expanded to become the Tuberculosis Expanded Response and Access (TB-ERA) Project; it includes referrals to the Home-Based Care Network for TB patients who are also infected with HIV. TB-ERA partners include CENAT, NCHADS, FHI, the Gorgas Memorial Institute of the University of Alabama at Birmingham, Servants to Asia's Urban Poor, and Action IEC.[53] In 2000, almost all notified TB cases were registered for treatment, and outcomes were recorded for all registered patients. Ninety-one percent of registered cases were successfully treated, such that the 85 percent target for treatment success was exceeded for the sixth year in a row. In 2001, the government released a new five-year (2001-2005) policy and strategy for TB control. [46] The major constraints to achieving TB targets include: 1. limited knowledge and low motivation among health professionals resulting in high turnover 2. poor awareness of TB in the general population 3. low access to health services including DOTS 4. TB-HIV epidemic [46] A study published in 2001 by FHI/IMPACT Cambodia found that TB is among the leading opportunistic infections among people with AIDS. Yet, AIDS patients receiving home-based care and DOTS patients have misperceptions around the symptoms, causes, and transmission of AIDS and of TB.[53] At the 2002 International AIDS Conference in Barcelona, the Cambodian NGO Khmer HIV/AIDS NGO Alliance (KHANA) presented data on major barriers to effective collaboration and linking of TB and HIV/AIDS interventions. Parallel programs are failing to address the needs of patients and are inhibiting early TB detection and treatment. HIV/AIDS prevention and care efforts do not specifically target TB patients, and there is currently only limited coordination between DOTS and HIV/AIDS home-based care activities. There are major barriers in accessing free TB services. Private sector providers/traditional healers also present major barriers to case detection and treatment of TB. The study highlighted the need to build capacity of HIV workers, including home care teams, to understand and implement systems for early detection and treatment of TB, in tandem with building capacity of TB DOTS teams to include HIV/AIDS education and counseling as part of their programmatic work. A critical step in scaling up the integration of HIV/TB services will be to link the expansion of home care provision in the provinces to the expansion of DOTS at health centers.[54] Malaria Malaria remains highly prevalent in some areas of the country, particularly the northeast and northwest regions. The National Center for Parasitology, Entomology, and Malaria Control, created in 1984, is the leading institution in malaria control.[45] Malaria is the first cause of hospitalization (14 percent of all hospital admissions and 23 percent of all hospital deaths are due to malaria) and the third cause of attendance at public outpatient services. (Consultations for malaria in the private sector are not recorded.) In 2000, there were about 130,000 patients treated for malaria (half of these were confirmed microscopically) and 600 deaths attributable to malaria. The national program's Strategic and Operational Master Plan for National Vector Borne and Parasitic Disease Control Programs (Malaria, Dengue, Filariasis, Schistosomiasis, and Helminthiasis) 2001 to 2005 aims to reduce malaria morbidity by 20 percent and malaria mortality by 30 percent by strengthening institutional capacity centrally as well as at provincial and district level; improving case management (e.g., dipstick or microscopy for diagnostic, prepackaged affordable drugs distributed with the help of drug vendors, and involvement of private practitioners for appropriate treatment); intensifying prevention in the population at risk (bed nets and hammock nets, social marketing, reimpregnations campaigns); and increasing information, education, and communication in the population at risk and among ethnic minorities.[45] Sexual & Reproductive Health Reproductive health indicators in Cambodia are poor (See the accompanying table of indicators). Adolescent pregnancy, low levels of antenatal care and attendance by trained personnel during delivery, and frequent and closely spaced pregnancies contribute to the high maternal mortality ratio.[55] UNFPA ranks Cambodia a Category "A" Country, meaning that it is furthest from achieving the goals of the International Conference on Population and Development (ICPD), held in Cairo in 1994, and has low levels of development. Group A countries have the greatest need for external assistance and the lowest capabilities for mobilizing domestic resources to close this gap.[56] The country's contraceptive prevalences (both traditional and modern methods) are low compared to the regional averages. UNFPA estimates that 24 percent of women of childbearing age in a union use any method of contraception, and 19 percent use a modern method.[50] According to the 2000 CDHS, 33 percent of currently married women have an unmet need for family planning, with 17 percent having an unmet need for spacing and 15 percent having an unmet need for limiting.[43] Unsafe abortion has been a major cause of mortality in women.[14] (FHI's preliminary evaluation of NGOs conducting HIV/AIDS/STI prevention interventions among sex workers found that many SWs report that they or their friends have had abortions, usually after unprotected sex with a sweetheart.[57]) In August 1997, the Cambodian Parliament approved a new abortion law wherein abortion is offered without a woman's having to provide a reason and without restriction in the first trimester. In the second and third trimesters, abortion is allowed only if diagnosis shows that the pregnancy is abnormal, after birth the child will have a serious incurable disease, or a woman has been raped.[35] (See Gender section below for data on women's knowledge of the abortion law.) Age at First Marriage and at First Sexual Intercourse Over the last two decades, the median age at first marriage among women in Cambodia has remained stable at about 20. There has been a recent sharp decline in the proportion of women married in their early teens. Half of Cambodian women are married by age 20, and 81 percent by age 25. The 2000 CDHS found that the median age at first intercourse for women is the same as the median age at first marriage (20).[43] Youth Cambodia has a very young population, with 43 percent under age 15 and only 4 percent older than 65 years.[58] During 2000, the median age in Cambodia was 17.5.[12] Thus, demand for sexual and reproductive health education and services, including those related to HIV/AIDS, will be great. Moreover, there will be high demand for employment and education. According to recent report from the POLICY Project, knowledge of reproductive health and issues such as birth spacing is lower among adolescents than the population as a whole. POLICY goes on to state that: There has been a cultural emphasis on curative rather than preventive health care in the past, and current moves toward a preventive approach embodied in policies and programs directed to areas like ARH [adolescent reproductive health] involves changing a long-held mindset on the part of senior health officials and policymakers. A recent report on the Cambodian reproductive health context also suggests that the same factors that lead many Cambodian policymakers to deny the existence of sexual activity among young people, lead them to consider that reproductive health training activities are inappropriate for young people prior to marriage.[35] Cambodian urban culture has historically placed high value on female virginity. However, this is changing rapidly in the present day. The influences of television and other media from the neighboring countries of Thailand and Vietnam (and to a lesser extent from Hong Kong and other parts of Southeast Asia) and western culture via movies and cable television is contributing to the growth of an urban youth culture. This culture in turn reaches out from urban areas to provide a model of modernity for rural youth. This model of modern youth culture is one that includes notions of individual autonomy and romantic love and is accompanied by relatively high rates of sexual activity. This is a new feature of Cambodian society, and one that members of Cambodia's older generations find highly threatening. Cambodia's small middle class and political elite are acutely conscious of neighboring Thailand's problems with its contemporary youth "revolution." Therefore, through maintenance of what are viewed to be "traditional" Cambodian cultural practices, such as premarital chastity for women, they strive to differentiate Cambodia and Cambodian culture from Thai culture. As a result, apart from a few key people-primarily those involved in the HIV/AIDS arena-there is a high level of "official denial" of sexual activity among unmarried youth.[35] Sexually Transmitted Infections No mandatory STI testing is undertaken, except among DFSWs in Sihanoukville as part of the 100% Condom Use Program. No routine screening of antenatal women for STIs is undertaken except at the national Maternal and Child Health Center and the MCH service in towns within Seam Reap, Sihanoukville, Kam Pot, and Pursat provinces. A 1996 study, conducted by NCHADS with technical assistance from the University of Washington in Seattle, found high prevalence of STIs among women attending reproductive health clinics, male police and military personnel, and DFSWs.[59] In 2001, NCHADS, with technical assistance from FHI, undertook an STI prevalence survey. A cross-sectional study design was employed in seven provinces where major HIV and STI interventions were occurring or planned: Phnom Penh, Kandal, Kampong Cham, Battambang, Sihanoukville, Banteay Mean Chey, and Pursat. The study populations were: * brothel-based female sex workers (DFSWs) (n=141) * police (n=165) * women attending reproductive health clinics antenatal or family planning services (n=451) [23, 60] (Among these groups, oversampling was conducted in Phnom Penh, Kandal, and Kampong Cham provinces. Additionally, military personnel in Phnom Penh, Kandal, and Kampong Cham provinces and indirect sex workers ["orange sellers"] in Phnom Penh city were sampled. Also note that the 1996 results reflect a convenience sample that is less representative of the underlying populations and not directly comparable to 2001 results. There were also some geographic differences between the two STI prevalence surveys.) [23] Although prevalences among DFSWs found in the 2001 STI survey were much higher than those among the other two groups surveyed, they were still lower than those found in the 1996 study. The 2001 STI survey found that gonorrhea prevalence was 14.2 percent among DFSWs and 0.0 percent for both police and reproductive health clinic women (RHC). Chlamydia prevalence was 12.1 percent (DFSWs), 1.8 percent (police), and 2.8 percent (RHC). Syphilis seropositivity (TPHA+/RPR1:8) was 2.8 percent (DFSWs), 0.0 percent (police), and 0.7 percent (RHC). Genital ulcers due to chancroid were observed in 1.4 percent (DFSWs) and 0.4 percent (RHC), and HSV-2 ulcers in 0.7 percent (DFSWs) and 0.4 percent (RHC). No primary syphilitic ulcer was observed in any group, and no asymptomatic chancroid or syphilis was detected on routine vaginal swabs from DFSWs; 2.4 percent of DFSWs had evidence of asymptomatic HSV-2.[60] As part of BSS IV, male respondents were asked to report the place they first sought care for an STI symptom and the last time they experienced a symptom. The survey found that pharmacies are an important source of care. Overall most men seek treatment first at a pharmacy (46 percent), follwed by a traditional form of care (27 percent). About one-quarter seek medical attention first (23 percent) which includes both private clinics (19 percent) and public hospitals or clinics (4 percent).[9] These data suggest that pharmacies and traditional caregivers may be viable points of entry for efforts to expand access to STI services. In 1998, Cambodia's Ministry of Health approved STI syndromic management guidelines based on WHO recommendations. WHO is supporting the training of health care providers in almost all provinces in STI case management based on these guidelines, but inadequate drug supplies limit widespread implementation. A large proportion of patients seek treatment from pharmacies or traditional healers, which may not be effective.[3] (See Health System section above.) According to the POLICY Project, there are approximately 53,000 STI cases treated each year in Cambodia. Based on Cambodia-specific data, STI cases at clinics are treated at US$8.34 per visit and the cost of syphilis screening for ANC attendees is US$2 per woman screened.[1] Gender Inequality The Khmer HIV/AIDS NGO Alliance (KHANA) highlights that Cambodian women's vulnerability to acquiring HIV: is compounded by low education, low access to information, a lack of bargaining power for safer sex and is increased by social and cultural constructs: inequity in decision-making power; the taboo of discussing sex and sexuality; the acceptance of male promiscuity; the unwillingness of men to be care providers and low levels of education and poverty. These obstacles equate to a population of women unable to protect themselves from men bringing home HIV/AIDS.[61] The POLICY Project report on adolescent reproductive health cited above states that: Cambodia has clear-cut notions of male-female gender differentiation, gender-specific behaviors, and gender-specific work and domestic roles. Traditional Cambodian cultural beliefs portray women's place as in the home and, regardless of statistics that demonstrate that a considerable portion of the household income derives from women's work, the work women undertake outside the home is not as valued as that undertaken by men. Marriage and domestic labor are viewed as the primary goals for girls, and young girls are often removed from school to care for younger siblings and help with household and agricultural tasks. There is a strong double standard of behavior for men and women, and this is particularly pronounced during the period of adolescence. Adolescent girls are expected to uphold the virtue and honor of their family by taking care of their reputation and maintaining not only their actual virginity but also their imputed sexual reputation. However, no such strictures are placed on males; their virginity at marriage is not an issue and it is expected that they will seek out multiple partners both prior to and after marriage because they have irrepressible sexual needs. The adage "men are gold, women are cloth," which suggests that when soiled through their actions men can easily be cleaned but women can never be completely cleaned, illustrates the Cambodian belief about the fundamentally differing natures of male and females.[35] Employment Acccording to the CDHS 2000, women comprise 51.2 percent of the population, and 25.4 percent of Cambodian households are headed by women (urban: 27.9; rural: 25.0).[43] Cambodia has one of the highest female labor force participation rates in the region (73.5 percent). Women account for 54 percent of skilled agriculture and fishery workers and also make substantial contributions in nonagricultural sectors. They contribute 75 percent of the primary labor force in wholesale and retail trade, and two-thirds of the labor force in manufacturing. However, most of this employment is in the informal sector. Women are often in low-paid, unskilled positions and are vulnerable to exploitation in the workplace. [39] Not all women receive earnings for the work they do, and among women who do receive earnings, not all receive earnings in cash. Forty-nine percent of women receive only cash or cash and in-kind payment for their work, and 51 percent are paid either in kind only or do not receive any form of payment. Most of the women who are paid either in kind or receive no payment are employed by family members. Highly educated women and those engaged in nonagricultural occupations are much more likely to earn cash than other women. Seventy-four percent of women with secondary and higher education earn cash, compared with 39 percent of uneducated women. Additionally, almost all women involved in nonagricultural occupations earn cash (95 percent), compared with just one-quarter of women working in agriculture.[43] Marriage POLICY notes that: Once married, the workload of women increases to include responsibilities for child care, household labor, food production, agricultural labor, and contributing to family finances through activities such as petty trading. Within marriage, women experience a considerable lack of autonomy. They rarely have the final say on any marital decision making except about daily household purchases. Only 37 percent of women make decisions about their own health care; 52.5 percent make such decisions jointly with their husbands. In the case of health care for ill children, mothers have the final say in only 21 percent of cases and decisions are made jointly in 74.5 percent of the cases. Decisions about whether a woman should work to earn money are least likely to be made by the woman alone (9 percent). In marriage, much of men's lives continue as before; they work, drink and gamble with friends, and visit brothels and karaoke bars for the entertainment and sexual variety they claim to need.[35] The Cambodian Council for Social Development reports that Cambodian women's workloads have become even greater than those of men because of the nontraditional tasks women have had to take on during two decades of war, civil strife, and the resultant male mortality. [39] Acccording to the 2000 CDHS, 43 percent of ever-married Cambodian women met their husband for the first time at the time of marriage. An additional 7 percent knew their husband for less than one month before their marriage. The likelihood that a woman met her husband for the first time at the time of marriage varies little by the woman's age at first marriage and by urban-rural residence but does increase with women's current age, suggesting that this practice may be declining over time. [43] To measure women's agreement with a woman's right to refuse her husband sex, the CDHS 2000 asked respondents whether a wife is justified in refusing to have sex with her husband under four circumstances: she is tired or not in the mood, she has recently given birth, she knows her husband has sex with other women, and she knows her husband has an STI or AIDS. Although the majority (59 percent) of women ages 15-49 in Cambodia agree that women can refuse sex to their husband for all of the four given reasons, a significant minority (31 percent) replied that women were not justified in refusing their husband sex for any of the given reasons. Agreement with each reason tends to increase with age, such that 42 percent of women ages 15-19 and 33 percent of women ages 20-29 do not agree with any reason to refuse sex to the husband, compared with 25 to 26 percent for women ages 30-49. Women living in urban areas agree more often with each of the four reasons for refusing a husband sex than women living in rural areas, although the differences are not large. Women who are more educated are consistently more likely to agree with each of the four reasons than women who are less educated. Women who work for cash are more likely to agree with all the reasons for refusing sex than women who do not work. These results suggest that although the majority of Cambodian women do agree with all four reasons for refusing sex to their husband, a significant proportion do not feel that a wife has the right to unconditionally decide whether and when she wishes to have sex with her husband.[43] The CDHS 2000 also explored women's involvement in civil society by asking respondents whether they were members of any kind of association, group, or club that holds regular meetings; whether they vote always, sometimes, or never in local or national elections; and about their knowledge of laws in Cambodia protecting women's rights and about the problem of trafficking in women. Few women (3 percent) in Cambodia are members of any association, club, or organization. Although the proportion who are members of associations increases with age, is higher in rural than in urban areas, and declines with education, it is never higher than 5 percent for any subgroup of the population. Women's participation in civil society by exercising their vote is, by contrast, almost universal. Overall, 81 percent of women always or sometimes vote, and among women age 20 and above, over 90 percent do so. [43] Only about half (52 percent) of women in Cambodia have heard of any national laws that protect women's rights, and only 55 percent have heard of trafficking in women. Only 16 percent mentioned knowing about labor laws, and 5 percent mentioned knowing about laws on abortion. Knowledge of any law protecting women increases from 46 percent for women ages 15-19 to 51 percent for women ages 20-29 and 56 percent for women ages 30-49. By employment status, women employed for cash are most likely to know of one or more laws, and women who are employed but do not earn cash are least likely to know any laws.[43] Health and Education Health care service for women is generally limited. The 2000 CDHS found that 88.1 percent of women reported that they could not access health care services due to financial constraints.[43] UNFPA's ranking of Cambodia as a category "A" country connotes a high level of gender inequality, women's low socioeconomic status, and their poor sexual and reproductive health and rights.[62] The accompanying indicator table highlights gender disparities in literacy and educational attainment. According to the 2000 CDHS, there is little difference in the proportion of males and females attending school up to age 12, after which a significantly higher proportion of males than females do so.[43] This gap is perpetuated by a low retention rate of girls in formal education.[39] Violence Genocide, decades of war, unexploded landmines, and the availability of weapons render violence a pervasive aspect of life in Cambodia. (See the Governance section above for discussion of political violence.) The 2000 CDHS found that 23 percent of ever-married Cambodian women ages 15-49 reported physical violence since age 15. About 15 percent experienced violence in the 12 months preceding the survey. The most common form of violence is violence by current or previous husband. The prevalence of violence declines with level of education; however, even among the most educated women, 18 percent reported having experienced violence, with 11 percent reported experiencing violence in the 12 months preceding the survey.[43] Cambodia is undertaking efforts to build a legal infrastructure; in the interim, the current legal system is inadequate and underfunded with regard to addressing sexual violence.[63] Sex Work UNICEF reports that sex work is widespread in large and small urban areas, trading centers, and market towns throughout Cambodia. In 1997, the Human Rights Task Force on Cambodia, an international NGO, stated: "Although the problem is still at its early stage, having appeared in its more organized form only within the last two to three years, the trafficking and sex work of women is spreading fast."[64] According to the International Organization for Migration, there are about 14,000 female commercial sex workers in Cambodia, of whom 40 to 60 percent entered sex work involuntarily.[35] Based on a national registration of DFSWs in the late 1990s, there were 757 brothels with 3,872 SWs throughout the country, of whom 70 percent were Cambodian and 30 percent Vietnamese (this figure does not include IDFSWs and SWs who are underground).[65] UNICEF cites small-scale surveys conducted by NGOs in 1995 that indicated that at least one-third of sex workers in Cambodia were under age 18. In 2001, UNICEF cited a Human Rights Vigilance survey of 6,110 sex workers in Phnom Penh and in 11 provinces, which found that 31 percent of SWs were children ages 12 to 17.[64] Cambodia is a major destination for sex tourism. Over 70 percent of children surveyed near Angkor Wat and nearby villages reported that tourists approached them for sex.[66, 67] Many street children in Cambodia sell sex, to support themselves and, sometimes, their families. [68] Cambodia's Poverty Reduction Strategy Paper notes that there are an estimated 10,000 to 20,000 street children in Phnom Penh. [39] Street children usually report having higher numbers of sex partners than others in their age group. Most of these children will not be able to negotiate condom use with clients nor with other sex partners. Children living on the street may use inhalants or other drugs, including those injected intravenously, to seek respite from their situation, further increasing their vulnerability to HIV. [68] Sex workers in Cambodia, and throughout southeast Asia, are highly mobile, as indicated by the average time at their present brothel (nine months). There is also evidence that women are regularly moved between brothels for business reasons (i.e., to maintain "novelty" for clients).[23, 69] (See also the Population Mobility section below.) FHI/IMPACT supports NGOs that educate sex workers about HIV/AIDS/STIs and pilot empowerment strategies to enable them to assume more control over their lives. The NGOs include: * Cambodian Women for Peace and Development in Phnom Penh, Kandal, Kampong Speu, Kampong Thom, and Kampong Chhnang * Phnom Srey Association for Development in Kampong Cham * Urban Sector Group in Phnom Penh * With Oxfam/Hong Kong's Womyn's Agenda for Change and local partner agencies, SpeakOut empowerment project These projects involve DFSWs, IDFSWs, local authorities, and sex work establishment owners. FHI evaluated these projects and found that: * The NGOs established good relationships with brothel owners and other establishment owners and with SWs. Active involvement by establishment owners is rare; rather, their involvement is limited to allowing activities to occur. Establishment owners did so because they wanted their workforce to: ? be free from HIV ? learn about negotiation skills and condom use to avoid quarrels with clients ? learn social skills to "charm and welcome customers more effectively" ? receive training on personal hygiene (which improves business) ? receive training on household chores, which, as a secondary effect, keeps the establishment clean * SWs and establishment owners believed that the projects were an important factor in decreasing the incidence of STI and increasing condom use. * Non-condom use with customers was still reported by a small minority of SWs. This usually occurred when the sex worker was outside the brothel. Gang rape, especially by groups of youths, was reported in all locations. When a SW enters the trade (especially when she is [or is perceived to be] a virgin), condoms are usually not used. Police and SWs reported that condom use with IDFSWs is sporadic. * Condom use with sweethearts was low, consistent with BSS findings. Reasons include that condoms involve "distrust" and "being strangers to each other." * Certain sexual behaviors, such as fondling, kissing, hugging, protected oral sex, and masturbation--all of which typically fall under the heading of "safer sex"--are considered "dirty" by sex workers. * Collaboration and solidarity among sex workers are undermined by hierarchies and sociobehavioral distinctions among them. * Sex workers exhibit an enormous variety of innovative strategies to protect themselves from unprotected sex or violence.[57] A report released in 2002 by the Cambodian Women's Development Association (CWDA) and the Cambodian Prostitutes Union found that most women working in the sex industry in the Toul Kork district in Phnom Penh are subjected to human rights violations by police. Of the sex workers surveyed, 72 percent responded that they had experienced a human rights violation by police, including arbitrary arrest, denial of the right to work, beating with sticks and guns, rape, forced labor, and extortion. All sex workers reported the belief that the stigma associated with sex work in Cambodian society meant that sex workers were denied the protections to which they are entitled under Cambodian law.[70] Population Mobility Cambodia's political history has entailed much mobility, including Khmer Rouge-forced migrations [38]. In March 1992, the United Nations Transitional Authority in Cambodia (UNTAC) arrived in Cambodia to ensure the implementation of the Agreements on the Comprehensive Political Settlement of the Cambodia Conflict, signed in Paris in October 1991. UNTAC involved approximately 22,000 military and civilian observers. During this period, large numbers of refugees were resettled. In addition, the sex industry grew dramatically, fuelled in part by foreign peacekeepers and newly prosperous Cambodians.[38] With the change from a planned to a free market economy, a large section of the population is mobile, moving from rural to urban and border areas in search of employment. [39] Most migration is intracountry. The 1998 population census classified 31.5 percent of Cambodians as migrants. Of these, 59 percent were migrants within their home province, 35 percent from another province, and only 6 percent from outside Cambodia.[71] BSS IV found that about 16 percent of Cambodian men are mobile, meaning that they travel away from home (BSS IV assumed that this travel represented migration from rural to urban areas for employment during the dry season). Men¾both urban and rural¾who spent over one month away from home in the past year purchased sex significantly more than men who did not travel.[9] Two mini-case studies on intercountry migration are found in Box 3. Other examples include casinos in Battambang Province, which cater primarily to Thais who travel to Cambodia to gamble. The casinos also attract landless, unskilled, and uneducated families from throughout Cambodia who are seeking jobs. Given the high level of movement, sex work and sex traffickers are proliferating.[64] And, as previously mentioned, there are a significant number of debt-bonded sex workers from Vietnam working in Cambodian brothels.[72] Police and Military Military personnel are highly mobile, often separated from their families, and perhaps more susceptible to peer pressure. Brothels and other venues that offer sex are often located close to military camps. This scenario may facilitate sexual behavior characterized by a high number of sexual partners¾including SWs-and unprotected sex.[36] In 1999, 60 percent of military personnel reported buying sex from a sex worker in the last six months.[73] According to the World Bank, Cambodia had 60,000 military personnel in 2000.[36] Police are also mobile; the 2001 STI prevalence study conducted by NCHADS found that although over 90 percent of police had been living in the same place for over five years and nearly all were currently living with a wife, the majority spend a week or more away from home each month. Four out of five police interviewed had had sex with a SW at some time, and over half had done so in the last year, usually at a brothel.[23] Fishermen Fishermen are also highly mobile and regularly visit SWs in port cities. The previously mentioned study of fishermen in Sihanoukville found that HIV prevalence was significantly higher among those who usually spent more than one day in port compared to those who spent less.[74] (See box 3.) Garment Factory Workers There are approximately 140,000 young people working in about 65 garment factories around Phnom Penh. Most of them are women under age 30 who have usually migrated from rural areas to find work and are likely to be separated from their family networks for the first time. Some women move between factory work and short-term sex work. Recent work by CARE suggests that although the majority of these young women know about HIV/AIDS and that it is transmitted through sex as well as other transmission routes, there is a strong belief that HIV/AIDS and STIs are found only among commercial sex workers. Moreover, CARE's work suggests that "there is a strong belief that there is no risk of infection from sex with someone that you trust."[35] Trafficking Cambodia is a source and destination country for persons trafficked for sexual exploitation and forced labor. Many Cambodian men, women, and children who cross into Thailand, often as illegal migrants, are forced into labor or sex work by traffickers. Cambodian children are trafficked into Vietnam and forced to work as street beggars. Vietnamese women and girls are trafficked into Cambodia for sex work. Cambodian women and children are trafficked internally for sexual exploitation. [75] Cambodia has strong legislation against trafficking, and there are heavy penalties for those engaged in the trafficking of women. The Ministry of Women's and Veterans' Affairs (MOWVA) has also established a Counter Trafficking Bureau and, together with the International Organization for Migration, has recently conducted a major antitrafficking campaign.[35] MOWVA and the Ministry of Social Affairs, Labor, Vocational Training and Youth Rehabilitation (MOSALVY) have worked with NGOs and international organizations to create community-based networks in high-risk provinces to inform potential victims of the risks of trafficking. The Ministry of Tourism works with NGOs to produce workshops and pamphlets to combat trafficking dangers associated with sex tourism.[75] However, the POLICY Project notes that the substantial profits made from trafficking have led to systemic corruption among many of those charged with enforcing antitrafficking legislation, with the result that antitrafficking legislation is not effectively enforced. [35] The government has procedures to assist victims of trafficking, but they are limited, not uniformly implemented, and underfunded.[75] Box 3. Population Mobility Cambodian Fishermen Working in Thailand Rayong is a port city on the east coast of Thailand. About 40,000 Cambodians work in Rayong's fishing industry. Over 90 percent are illegal immigrants who pay up to $US 90 to agents who recruit them from their home villages. Many fishermen are not able to send their earnings back home and have no safe place to keep them; this scenario--combined with the stress of difficult, physically risky work--renders them more likely to spend their earnings on alcohol and sex. Given languages barriers, many Cambodian fishermen in Thailand are not able to access condoms; moreover, they often buy sex from indirect sex workers (vs. those working in brothels) who are less likely to have condoms. Family Health International works with Cambodian fishermen in Rayong as well as their families in Prey Veng, the home province of many Cambodian migrants in Rayong. In Rayong, Thai-Cambodian teams conduct outreach education, working within social networks and with government and private STI and health clinics to offer or expand their services to the target population. They also ensure that condoms are available around the areas where sexual contacts often take place. The project also involves offering reproductive health education and HIV/AIDS counseling to families of Cambodian migrants. For those already ill with AIDS, home care services are being established.[76] Koh Kong Province Koh Kong Province is situated along the border with Thailand. Its population is approximately 150,000, 40 percent of whom are under age 14. Koh Kong's inhabitants earn a living through fishing, trading, logging, or farming. In April 1998, the area was declared the second official land border crossing between Thailand and Cambodia. The high volume of cross-border traffic--coupled with the promise of economic prosperity in Koh Kong and in the Thai province of Trad--has resulted in the internal migration of many Cambodians from other areas. These migrants include significant numbers of sex workers who cater to the male population. The 2000 HSS found that 53.6 percent of DFSWs, 15.7 percent of IDFSWs, and 10.7 percent of police/military were HIV-positive (the police/military prevalence was the highest of any Cambodian province). Among the most vulnerable groups in the province are women and their dependent children. The 2000 HSS found that 5 percent of women attending ANCs in Koh Kong were HIV-positive; this was the country's second-highest ANC prevalence, surpassed only by Siem Reap Province. The majority of these women contract HIV through unprotected sex with their husbands. Data on women who have died due to AIDS are not available; however, the Provincial AIDS Office in Koh Kong reported that between January and June 2000, 45 members of the police, military police, and military (many of whom were married) died due to complications associated with AIDS. Currently, there are no governmental or NGO programs targeting children infected with or affected by HIV/AIDS in the province.[4, 34] Knowledge of HIV Despite numerous governmental and NGO interventions, there remain some critical gaps in HIV/AIDS knowledge. For example, despite the 100% Condom Use Program in Sihanoukville, researchers have found that knowledge of HIV is moderate among fishermen in the area. Consistent condom users reported misconceptions about HIV transmission through mosquito bites (47 percent), sharing of a public toilet (27 percent), or coughing and sneezing (24 percent). (The comparable figures for inconsistent condom users were 25, 16, and 13 percent, respectively.)[17] Among HIV-positive fishermen, 34 percent believed that sharing a public toilet posed a risk for HIV transmission (the comparable figure for HIV-negative fishermen was 21 percent). Eighteen percent of HIV-positive fishermen believed that having casual contact with a person infected with HIV posed a risk for HIV transmission (comparable figure for HIV-negative fishermen: 11 percent). The researchers concluded that prevention programs would benefit from using media and peer education that combines condom use promotion and HIV education.[16] According to the CDHS 2000, 97.6 percent of urban women in Cambodia and 94.3 percent of rural women having heard of AIDS. However, three regions have a significantly lower level of AIDS awareness among women: Banteay Mean Chey (79 percent), Preah Vihear/Stueng Traeng/Kracheh (69 percent), and Mondol Kiri/Rotanak Kiri (62 percent). Almost one-quarter of women (24.1 percent) either have not heard of AIDS or do not know whether it can be avoided (urban-rural differentials are strong, 12.1 vs. 26.7 percent, respectively.) Among women who know ways to avoid AIDS, 66.3 percent spontaneously mentioned condoms, 35.5 percent having only one sexual partner, 22.9 percent abstinence, and 19.0 percent limiting number of partners.[20] Among women who had heard of AIDS and had had sexual intercourse, 91.6 percent knew about condoms. However, among these women, 63.3 percent did not a source for condoms and 35.5 percent did not believe that they could obtain a condom themselves.[20] FHI's evaluation of NGO projects that work with SWs found that correct knowledge and awareness of HIV/AIDS/STIs was generally high (except among transgendered sex workers in Phnom Penh). There were, however, some misperceptions. These included that because the anus is not a reproductive organ, HIV cannot be transmitted via anal sex; the evaluation found that condom use during anal sex was almost zero. Also, some clients washed condoms before using them, believing the condoms might have been infected with HIV.[57] As mentioned, a study published in 2001 by FHI/IMPACT Cambodia found misperceptions around the symptoms, causes, and transmission of AIDS and of TB among the populations surveyed (AIDS patients receiving home-based care and DOTS patients.)[53] Stigma In Cambodia, stigma and fear around HIV/AIDS persist at household and community levels, often due to a lack of basic information.[77] Stigma and discrimination, in addition to the myriad impacts of AIDS mortality of household members, can lead to trauma in a country already severely traumatized. According to the 2000 CDHS, 45.9 percent of Cambodian women responded that they would not be willing to care for a relative sick with AIDS; there was little urban-differential on this item (27.5 percent vs. 21.6 percent, respectively). The urban-rural differential was somewhat larger on the issue of whether the respondent believed that a person with AIDS should be allowed to continue working; overall, 64.8 percent of women replied in the negative (urban: 54.5 percent; rural: 67.0 percent). On the question of whether children ages 12-14 should be taught to use condoms, 54.5 percent of women believed that they should (urban: 63.8 percent vs. rural: 52.5 percent). Those with more education were more likely to be willing to care for relative with AIDS, believe that a person with AIDS should be allowed to continue working, and believe that children ages 12-14 should be taught to use condoms.[20] Alcohol and Drug Use As mentioned, the BSS IV data did not suggest that heavy alcohol use is a major factor in sexual behavior at the time of commercial sex.[9] Presently, one may infer that generally, drug use is not playing a major role in facilitating risk behavior. According to the Center for Harm Reduction at Australia's Macfarlane Burnet Institute for Medical Research and Public Health, "We still have no estimates of the numbers of drug users in Cambodia and it is not considered a problem of great significance." However, the institute notes that more drugs are being used by wider groups of people, with an increase in the use of amphetamines and inhalants. Cambodia is a major drug transmitting and trafficking route and there have been reports of clandestine amphetamine laboratories being established on the Thai border.[24] FHI, in its evaluation of an HIV prevention project that targets street children, recommended that outreach workers be equipped to address drug prevention as well, [34] thus signaling that drug use among street children is a growing concern. The Burnet Institute also notes that several NGOs have begun to give attention to drug use as part of their work with street children, sex workers, fishermen, prisoners, and migrant workers. There are still no drug treatment or rehabilitation centers in Cambodia. [24] Impact of HIV/AIDS At a Glance: Summary Bullets Demographic * Between 1980 and 2000, 37,000 Cambodians died because of AIDS. * By 2015-2050, AIDS will increase mortality in Cambodia by 22 percent. * By 2010-15, life expectancy will be 7 percent lower because of AIDS. * In 2050, Cambodia's population will be 7 percent smaller than it would have been in a "no-AIDS" scenario. Economic * The impact of HIV/AIDS is unlikely to be observed in significant declines in an already low per capita income, but rather in terms of poverty increases at household level as well as missed economic opportunities. * As infected workers become increasingly ill, their productivity is likely to decline, affecting the public and the private sectors. Garment factories may be particularly hard-hit, given that they are the largest private sector employer in Cambodia. * Because employees have few benefits and are easily fired, the private sector may attempt to shift the burden of HIV to the Cambodian government and/or the families of employees. Health * Only a small fraction of PWHA have received limited medical care from government- and NGO-supported health facilities. Although home-based care has been implemented in some places, coverage remains highly inadequate. Households * Cambodian households will bear the largest share of the HIV/AIDS burden. The additional cost of illness associated with AIDS is likely to be overwhelming for already impoverished Cambodian families. * AIDS may force nonpoor households into poverty, and the poor into absolute destitution. * Women bear primary responsibility for caring for family members with AIDS, as well as for those with other disabilities and illnesses. * Because of HIV/AIDS, family structure in Cambodia is changing, as more orphans and grandparents head households. Orphans and Other Vulnerable Children * Cambodia had 55,000 AIDS orphans at the end of 2001. * The percent of Cambodia's orphans that could be attributed to AIDS has risen from 1.4 percent in 1995 to 10.9 percent in 2001; it is projected to continue to rise, to 20.7 percent in 2005 and to 27.5 percent in 2010. * Given years of genocide, civil war, and famine, the ability of Cambodian families to cope with AIDS orphans is severely strained. * Children affected by HIV/AIDS are exposed to high levels of stigma and psychosocial stress, with girls more vulnerable than boys. Military * By 1997, estimates of HIV infection among military personnel had already exceeded 7 percent. Demographic Life Expectancy According to the U.N. Population Division, Cambodia's life expectancy is projected to increase, to 57.4 during 2000-05, to 59.2 during 2010-15, and to 69.8 during 2045-50. However, the U.N. projects that during 2000-05, life expectancy would have been 59.9 without AIDS. For 2010-15 and 2045-50, life expectancy would have been 63.9 and 74.0, respectively, without AIDS. Thus, AIDS will reduce life expectancy by up to 7 percent. (table 2). [12] Table 2. Life Expectancy with and without AIDS, 2000-2005, 2010-2015, and 2045-2050 Period 2000-2005 2010-2015 2045-2050 With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction 57.4 59.9 2 4 59.2 63.9 5 7 69.8 74.0 4 6 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Population The U.N. also examined population under a "no-AIDS" scenario. Tables 3 and 4 indicate that Cambodia's population will be 7 percent smaller in 2050 than it would have been in a "no-AIDS" scenario. Table 3. Cambodia: Projected Population with and without AIDS, 2000, 2015 AND 2050 (Thousands) Period 2000 2015 2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 13,147 13,188 18,421 18,914 29,567 31,898 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 4. Cambodia: Projected Population Reductions, 2000, 2015 AND 2050 Period 2000 2015 2050 Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction 41 0 492 3 2,330 7 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Mortality Tables 5 and 6 demonstrate that by 2015-50, AIDS will increase mortality in Cambodia by 22 percent. Table 5. Cambodia: Projected Number of Deaths with and without AIDS, 1980-2000, 2000-2015, and 2015-2050 (Thousands) Period 1980-2000 2000-2015 2015-2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 2,441 2,404 2,303 1,945 6,676 5,481 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 6. Cambodia: Excess Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050 Period 1980-2000 2000-2015 2015-2050 Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase 37 2 358 18 1,196 22 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Economic The macroeconomic impact of HIV/AIDS in Cambodia has not been calculated. The POLICY Project notes that because the Cambodian economy is already so impoverished, the impact of HIV/AIDS is unlikely to be observed in significant reductions in an already low per capita income, but rather in terms of poverty increases at household level as well as missed economic opportunities.[1] POLICY also notes that as infected workers become increasingly ill, their productivity is likely to fall, affecting the public and the private sectors. Garment factories may be particularly hard-hit, given that they are the largest private sector employer in Cambodia. However, POLICY posits, it is also possible that because employees have few benefits and are easily fired, the private sector may attempt to shift the burden of HIV to the Cambodian government and/or the families of employees.[1] Education As a result of genocide and civil war, Cambodia was already struggling with a shortage of teachers. Whether and how this shortage is being exacerbated by AIDS mortality is unknown. However, educational attainment in Cambodia is a concern. In a 2002 study on education and HIV/AIDS, the World Bank ranked Cambodia "at risk on primary completion," meaning that it projected that Cambodia was not moving toward meeting the Education for All objective of completion of universal primary education. It also ranked Cambodia "at risk of gender disparity in primary completion."[78] (And see accompanying Table of HIV/AIDS and Key Socioeconomic Indicators.) Health (See also the Household section below.) According to NCHADS: The escalating HIV epidemic in Cambodia is producing an expanding need for HIV/AIDS care, as people progress to advanced and symptomatic HIV disease, which will increase considerably over the next decade, with an estimated three-fold increase in the number of new AIDS cases between 1999 and 2005. The limited resources of the health care system will be further stretched due to this impact of HIV/AIDS on care needs....Most health care for PLWHA will be delivered within the general private and public health care systems in Cambodia. The majority of people with HIV infection are undiagnosed and initially present with conditions which do not require specific HIV/AIDS management. Unfortunately, the present weakness of the health care services means that many opportunities to provide this first level of care are missed, often with serious health status and economic consequences. At later stages, however, specific HIV/AIDS initiatives and services are often needed. [79] Only a small fraction of PWHA have received limited medical care from government- and NGO-supported health facilities. Although home-based care has been implemented in some places, coverage remains highly inadequate.[3] (See also the Response section.) The POLICY Project estimates that in 1999, the annual cost of care per PWHA was US$291 without ART.[1] (NB: In 2000, Cambodia's average income was US$260.[37]) Households According to an economic cost study undertaken in the late 1990s, Cambodian households will bear the largest share of the HIV/AIDS burden.[13] The additional cost of illness associated with AIDS is likely to be overwhelming for already impoverished Cambodian families[1]. As previously mentioned, household out-of-pocket spending already accounts for 82 percent of total health care spending.[47] According to Bloom, a single inpatient hospital visit may account for more than total normal annual nonfood household expenditure. Consequently, households are forced to forgo treatment or to take crisis actions (selling productive assets, taking out loans at high interest rates) to afford health care. These crisis actions can force nonpoor households into poverty, and the poor into absolute destitution.[38] Women bear primary responsibility for caring for family members with AIDS, as well as for those with other disabilities and illnesses.[39] Because of HIV/AIDS, family structure in Cambodia is changing, as more orphans and grandparents head households.[68] Orphans and Other Vulnerable Children According to UNAIDS, there were 55,000 AIDS orphans (ages 0 to 14) in Cambodia at the end of 2001.[80] Family Health International projects that there will be about 140,000 AIDS orphans (approximately 3 percent of all children under the age of 15) by 2005.[34] Children on the Brink 2002, a report on AIDS orphans undertaken by USAID, UNAIDS, and UNICEF, estimated that the percent of Cambodia's orphans that could be attributed to AIDS rose from 1.4 percent in 1995 to 10.9 percent in 2001; the report projected that this figure would rise to 20.7 percent by 2005 and to 27.5 percent by 2010.[81] Cambodia's 2000 DHS found that 84 percent of children under 15 live with both parents, 9 percent live with only their mother, about 1 percent live with only their father, and 4 percent live with neither parent.[43] According to the MOH, anecdotal evidence from NGOs indicates that in the western region of the country, about 20 percent of families are looking after children who are not their own.[3] There is a traditional sense of communal responsibility for children's well-being in Cambodia.[68] Birth families often place their children with another family if they feel it could provide better care. However, given years of genocide, civil war, and famine, the ability of Cambodian families to cope with AIDS orphans is severely strained.[68] War and poverty have left community and government social support structures fragile, limiting options for protection of vulnerable members of society. Few grandparents are still alive, and many parents are themselves orphans. Forced labor, neglect and property grabbing are serious problems for orphaned children, particularly girls.[82] Cambodia's Ministry of Social Affairs, Labour, Vocational Training and Youth Rehabilitation undertook a series of workshops with FHI. Discussions from the workshop found that (1) families that did not want to take AIDS orphans cited poverty and the burden of taking in additional household members as reasons; (2) older children are often adopted by the extended family or looked after by NGOs; and (3) admission to government institutions such as orphanages is restricted and their capacity limited in terms of the numbers of children than can absorb.[34] (See also Box 4.) A 2000 study undertaken by the Khmer HIV/AIDS NGO Alliance (KHANA) found that approximately 21 percent of children in families affected by AIDS have had to begin working to support their family in the last six months. Over 30 percent have to provide care and assume other major additional household tasks. Of these children, 40 percent have had to leave school, and the same percentage have had to forego necessities such as food and clothes. Twenty-eight percent of children surveyed had left home or been sent away from home. The study found that all children affected by HIV/AIDS were exposed to high levels of stigma and psychosocial stress. Girls were more vulnerable than boys with regard to all these impacts.[34] Box 4. Children Affected by AIDS (CAA) in Koh Kong Province Family Health International/Cambodia directed a baseline survey in Smach Meanchey district (the most dense and populous area of Koh Kong province) among 350 households. The objective was to determine the level of community support provided to vulnerable children and people with chronic illness. Among the survey findings: * 22.6 percent of households are caring for children not their own. This figure is more than quadruple the national average of 5 percent. * The main reasons given for responsibility of an additional child include: (1) 27 percent reported child's family was too poor to care for him/her, (2) 27 percent reported the child lives in household to provide additional labor, and (3) 23 percent reported that the child's parents were dead. * Only 6 percent of households caring for an additional child responded that they received outside support. The majority of support came from friends and family. * 67 percent of respondents reported that they would care for a child whose parents died of AIDS, and 76.6 percent reported that they would care for a relative with HIV/AIDS in their own household. * 27 percent of households had been caring for a person with illness lasting more than 3 months; nearly 50 percent of ill individuals were between ages 18 and 44.[34] * The USAID-funded IMPACT Project, managed by FHI, is supporting Cambodian NGOs that assist children and families affected by HIV/AIDS.[72, 83] These include the following four projects, which have been evaluated by FHI:[34] ? Mith-Samlanh, or "Friends"; works to educate and support Phnom Penh's street children. Among its activities, Friends seeks to equip street children with the tools to protect themselves from HIV and to build self-esteem. Friends reaches about 1,000 street children each day with programs such as life skills development, sexual health education, peer education, and counseling. The FHI evaluation highlighted the need for flexibility and mobility in providing interventions to street children as the environmental context of the street children in Phnom Penh fluctuates; the need to integrate HIV/AIDS interventions with the many needs and vulnerabilities of street children; and the need to equip outreach workers with skills to address drug prevention. ? Nyemo Counseling Center for Women and Children Living with HIV/AIDS; also receives support from UNICEF; provides a safety net for families headed by women who are infected with HIV in Phnom Penh. Services include kindergarten and literacy classes, instruction in life skills, and nutrition education. Nyemo also seeks to strengthen the well-being of children by providing mechanisms to help mothers living with HIV reintegrate into their extended families. Nyemo aims to strengthen existing coping mechanisms and encourage a sense of communal responsibility for the welfare of HIV-positive women and their children. ? Homelands in Battambang; seeks to improve the standard of living and well-being of children through education, vocational training, and family reunification; strengthens fostering of orphans into families in the community and provides related support, including small cash loans or loan of livestock; aims to combat discrimination against children whose parents have died of AIDS. Currently supports 354 families. FHI evaluation noted limited staff capacity to deal with complex psychological issues of children affected by AIDS, as well as limited reach of the project, given enormous needs. ? Kien Kes Volunteer Network, Battambang; involves community members in providing support for children and family members affected by chronic illness, including AIDS; brings together villagers, monks, and military personnel in the Thmor Kol District; provides orphan care, facilitates reintegration of orphans into the community; advocates for compassion for and nondiscrimination of people living with HIV/AIDS. Evaluation highlighted need to replicate this model of collaboration. ? FHI supported CARE/Cambodia to implement a pilot project focusing on community care of children affected by HIV/AIDS in Koh Kong Province. The Children in Distress project developed a life skills and STI/HIV/AIDS prevention program for vulnerable children in the target communities; collaborated with youth advocates to work with the community, care staff, and other partners to provide, monitor, and evaluate the services provided to children and their families in the targeted areas; and sought to enhance the capacity of the target communities to support children affected by HIV/AIDS. FHI recommended that CARE/Cambodia continue the project. FHI notes that responses to children affected by AIDS are still in the embryonic stage and are inadequate, given the scope of the problem. FHI underscores the lack of formal training in Cambodia to help project staff deal with the psychosocial problems of children affected by AIDS; key areas for training include how to deal with bereavement in children, handling behavioral problems, and crisis counseling skills. FHI also notes that the lack of absorptive capacity at the national level, coupled with inadequate resources, renders it difficult for the government to keep pace with the growing problem of children affected by AIDS.[34] (The Response section includes more information on organizations providing care and support to children affected by AIDS.) Agriculture Although FAO has published data on the impact of HIV/AIDS on the agricultural labor force in sub-Saharan Africa, no data on impacts in Southeast Asia, including Cambodia, have yet been released. Given that over 70 percent of Cambodia's population is employed in agricultural production[39], the impacts are likely to be significant. Impacts seen in high-prevalence African countries, which may occur to varying degrees in Cambodia, include: * reduction in land under cultivation * inability to cultivate all available land * dependence on outside labor * land left fallow * delayed or poorly timed planting * declining yields * less attention to conservation measures and resultant soil erosion * decline in crop variety * changes in cropping patterns * switch to less labor-intensive crops * abandonment of cash crops * decline in nutritional quality of food * decline in livestock production * loss of agricultural skills and knowledge * selling off of assets such as livestock[84] Military According to UNAIDS and Cambodia's Ministry of National Defense, by 1997, estimates of HIV infection among the military had already exceeded 7 percent.[73] Response At a Glance: Summary Bullets Overview * Over the past few years, HIV prevalence in Cambodia appears to have stabilized and has perhaps begun to decline, given a combination of prevention interventions as well as the rising mortality of people with AIDS. Nevertheless, adult HIV prevalence is 2.7 percent, the highest in the Asia-Pacific region. * Cambodia has many of the elements for an effective response to the epidemic in place. These include: ? high-level commitment to addressing HIV/AIDS ? good sentinel surveillance system ? ongoing behavioral research ? blood safety measures ? prevention interventions focused on "core groups" such as sex workers, the military, police, and fishermen ? emphasis on STI treatment and prevention ? condom promotion policies ? strong collaboration with NGOs ? recently passed legislation on HIV/AIDS * However, the majority of large-scale prevention and care & support programs target Phnom Penh, the capital; Sihanoukville, the country's largest commercial and fishing port; and the provinces bordering Thailand, including Battambang and Banteay Mean Chey. Given that 84 percent of Cambodia's population is rural, efforts to scale up prevention and care interventions are crucial. * Concurrently, Cambodia faces massive challenges, including the socioeconomic, political, and psychological legacy of decades of genocide and civil war and the need to rebuild the country's infrastructure, including the health sector. * The country's response is also affected by donors, upon which Cambodia's HIV/AIDS efforts depend heavily. Donors, as well as foreign investors, want to see (sometimes unrealistically) rapid results with regard to control of HIV/AIDS. * The government emphasizes a multisectoral response and is working to strengthen provincial ability to respond to the epidemic. It works with numerous local and international partners on a range of prevention activities. The government's current priorities include: ? multisectoral response, involving ministries outside health ? continued implementation of the 100% Condom Use Program ? improved STI prevention and treatment ? prevention of mother-to-child transmission of HIV ? HIV/STI school-based education and outreach programs to "core groups" ? HIV/STI community-based prevention programs Government National Center for HIV/AIDS, Dermatology, and STDs (NCHADS) * HIV was first identified in Cambodia in 1991 during serological screening of donated blood. The first cases of AIDS appeared in late 1993 and early 1994. * In 1991, Cambodia's MOH established the National AIDS Program. In 1998, the MOH combined its STI and HIV/AIDS programs to form the National Center for HIV/AIDS, Dermatology, and STDs (NCHADS). * NCHADS oversees the national health response to HIV/AIDS, as well as provides technical support to other governmental agencies and national partners. National AIDS Authority * To coordinate a multisectoral approach involving ministries beyond the MOH, the government established the National AIDS Committee in 1993, which was succeeded in 1999 by the National AIDS Authority. * The NAA is an interministerial body comprising 15 ministries, the Cambodian Red Cross, and the 24 provincial governments. National Policy and Priority Strategies for HIV/AIDS Prevention and Control (1999-2004) * The priorities of the HIV/AIDS policy are: ? reduction of HIV transmission through activities in groups at high risk aimed at decreasing STIs and promoting "100% condom use" ? provision to the general population of IEC, counseling, and testing services ? strengthening of the health delivery system * Other key areas include provision of STI, blood safety, PMTCT, AIDS care and support, VCT, and epidemiological surveillance and research. Law on the Prevention and Control of HIV/AIDS * In 2002, Cambodia's National Assembly passed legislation on HIV prevention and control. The Law on the Prevention and Control of HIV/AIDS provides for national HIV/AIDS awareness campaigns, epidemiological monitoring, and free primary health care for PWHA. The law requires the protection of confidentiality of HIV/AIDS information. All forms of discrimination against PWHA are prohibited, as is discrimination against families of PWHA and people thought to be HIV-positive. However, to what degree these edicts are being adhered to is unknown. 100% Condom Use Program (CUP) * The 100% condom use program (CUP) was pilot tested in Sihanoukville in 1998. After the pilot phase of CUP was evaluated in late 1999, Cambodia's prime minister approved the National Policy on 100% Condom Use. * Implementation of CUP thus far has been limited to two urban areas. Multisectoral Response * The NAA prepared the National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS 2001-2005 (NSP). Currently, several ministries are undertaking major HIV/AIDS activities, including National Defense; Social Affairs, Labour, Vocational Training and Youth Rehabilitation; Women's and Veteran's Affairs; Education, Youth and Sport; and Cult and Religion. Budgets: Government and Donors * In 1994, US$800,000 was spent on HIV/AIDS in Cambodia. By 1999, spending had increased to US$9 million and in 2001, to US$14 million. In 2002, donors and the government spent an estimated US$15.4 million on HIV/AIDS programs within the health sector. * Cambodia has been absorbing increasing amounts of HIV/AIDS funding. The government's capacity to manage these resources is improving. Nevertheless, Cambodia continues to depend heavily on external technical and financial resources to address HIV/AIDS. Global Fund to Fight AIDS, Tuberculosis & Malaria * In the first round of GFATM grants, Cambodia's Country Coordinating Mechanism was approved to receive US$15,945,803 for its HIV/AIDS component. * In the second round of GFATM grants, Cambodia's HIV/AIDS component was approved for US$14,877,295, pending clarifications. * The second Cambodian GFATM proposal on HIV/AIDS addresses interventions not covered in the first, with increased emphasis on ART. Specific objectives include: 4. expanding the coverage and enhancing the quality of interventions for the prevention of HIV/AIDS to include underserved vulnerable populations 5. improving access to quality comprehensive care interventions including ART and promoting greater involvement of PWHA 6. securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART Civil Society * Since the early years of the HIV/AIDS epidemic, NGOs and CBOs have carried out a major portion of the country's HIV/AIDS prevention and care activities. Their work has been crucial, though constrained by limited resources. PMTCT * According to WHO, 2,800 clients received PMTCT services (i.e., basic counseling, testing, and AZT or NVP treatment) at the one public/NGO PMTCT site in Cambodia during 2001. An estimated 2 percent of the population in need of PMTCT services was receiving them. * The government finalized its policy on prevention of mother-to-child transmission of HIV in mid-2000. Its main objective is to improve the acceptability, accessibility, and quality of health services and information on reproductive health and HIV/AIDS/STIs. Recognizing that maternal care services are limited, the government is studying the feasibility of providing a package of MTCT prevention services through antenatal, peripartum, and postpartum care treatment points. * In its second-round GFATM proposal, the MOH stated that one of its goals is that by 2004, PMTCT services would be available in five provinces. Home- and Community-based Care * In 1998, the Cambodian MOH established a partnership with several NGOs to develop and implement home-based care for PHWA. The Home-Based Care Network reaches people with AIDS and other chronic illnesses in Phnom Penh. * The government continues to focus on home- and community-based care for PWHA. It acknowledges, however, the extra burden this places on poor families, women, and primary care givers. VCT * According to WHO, during 2001, 15,927 clients were seen at Cambodia's 14 publicly funded/NGO VCT centers. * Only 2.8 percent of Cambodian women have been tested for HI. Among women who have not been tested for HIV, 24.8 percent want to be tested. * In 1995, Cambodia's first HIV testing and counseling policy was developed; it was revised in 2001 to incorporate use of two different rapid tests for HIV diagnosis. * VCT in public health facilities is free of charge. According to Cambodia's new law on HIV/AIDS, in almost all circumstances, HIV testing must be voluntary, anonymous, and subject to written consent and to pre- and posttest counseling. However, to what degree this edict is being adhered to is unknown. * Cambodia's second-round GFATM proposal seeks to increase availability of VCT in partnership with the Reproductive Health Association of Cambodia. Treatment of OIs and ART * According to WHO, 11 HIV-positive Cambodian children received cotrimoxazole prophylaxis in 2001. Among HIV-positive adults, 2,640 received cotrimoxazole prophylaxis and 200 received isoniazid prophylaxis during 2001, representing 11 and 1 percent, respectively, of the population in need of such services. Access to HIV/AIDS care and support services outside Phnom Penh and in rural areas is deemed minimal. * WHO reported that during 2001, there were three public/NGO sites in Cambodia providing ART. These three clinics (operated by MSF, MDM, and Sihanouk Hospital Center of Hope) were serving 202 clients¾1 percent of Cambodians in need of ART. * Cambodia's second-round GFATM proposal addresses securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART. The proposal outlines as one its goals that by 2006, 3,000 Cambodians will be on ART. Overview Over the past few years, HIV prevalence in Cambodia appears to have stabilized and has perhaps begun to decline, given a combination of prevention interventions¾including a 100% Condom Use Program (CUP)¾as well as the rising mortality of people with AIDS. [1] A June 2003 report on HIV/AIDS in the Mekong Region undertaken by the POLICY Project notes that: Some people have suggested that the experience from Thailand and Cambodia shows that prevalence will not rise above 3 percent in Asia. But the declines in prevalence in these two countries did not occur because of any "natural" epidemic dynamics. Instead they resulted from significant behavior change in both countries. AEM, a computer simulation model of the HIV/AIDS epidemic in Asia developed by the East-West Center, has been used to investigate what would have happened if behavior had not changed. The model shows that HIV prevalence would have continued its rapid rise of the early 1990s and could have reached 10-15 percent before stabilizing. The most relevant lesson from Thailand and Cambodia may be that, with good programs and strong political support, populations can respond to rapidly emerging epidemics and change behavior quickly enough to reduce prevalence.[85] Cambodia has many of the elements for an effective response to the epidemic in place. These include: * high-level commitment to addressing HIV/AIDS * good sentinel surveillance system * ongoing behavioral research * blood safety measures * prevention interventions focused on "core groups" such as sex workers, the military, police, and fishermen * emphasis on STI treatment and prevention * condom promotion policies * strong collaboration with NGOs * recently passed legislation on HIV/AIDS However, adult HIV prevalence is 2.7 percent, the highest in the Asia-Pacific region [2]. The majority of large-scale prevention and care & support programs target Phnom Penh, the capital; Sihanoukville, the country's largest commercial and fishing port; and the provinces bordering Thailand, including Battambang and Banteay Mean Chey. Given that 84 percent of Cambodia's population is rural[58], efforts to scale up prevention and care interventions are crucial. Concurrently, Cambodia faces massive challenges, including the socioeconomic, political, and psychological legacy of decades of genocide and civil war and the need to rebuild the country's infrastructure, including the health sector. The country's response is also affected by donors, upon which Cambodia's HIV/AIDS efforts depend heavily. Donors, as well as foreign investors, want to see (sometimes unrealistically) rapid results with regard to control of HIV/AIDS. In its most recent GFATM proposal, the Ministry of Health noted Cambodia's many achievements, but also stated that: The nation still faces serious challenges of prevention and rapidly increasing challenges related to care. HIV prevalence among indirect sex workers has dropped less rapidly - from 19.2% in 1998 to 14.8% in 2002; consistent condom use among this group, too is 56.3% as compared to 89.8 % among direct sex workers - the need to provide effective services to this population is clear. Similarly, the vulnerability of young people needs to be addressed. Among the indirect sex workers, prevalence of HIV was 16.2% among those below the age of 20, and 8.7% among those above the age of 20; for direct sex workers the rate among those below 20 was 31.2% compared to 19.2% in those above the age of 20 years. For ANC women, too, the prevalence among women aged 15-19 was slightly higher than women above the age of 20. Most significantly, projections using the Asian epidemic model show that reaching young people with information and services, and changing social norms that affect their behavior is a major undertaking that lies ahead to maintain a decline in the epidemic.[3] The government emphasizes a multisectoral response and is working to strengthen provincial ability to respond to the epidemic. It works with numerous local and international partners on a range of prevention activities. The government's current priorities include: * multisectoral response, involving ministries outside health * continued implementation of the 100% Condom Use Program * improved STI prevention and treatment * prevention of mother-to-child transmission of HIV * HIV/STI school-based education and outreach programs to "core groups" * HIV/STI community-based prevention programs National Center for HIV/AIDS, Dermatology, and STDs (NCHADS) HIV was first identified in Cambodia in 1991 during serological screening of donated blood. The first cases of AIDS appeared in late 1993 and early 1994.[35] In 1991, Cambodia's MOH, with support from WHO, established the National AIDS Program. In 1998, the MOH combined its STI and HIV/AIDS programs to form the National Center for HIV/AIDS, Dermatology, and STDs (NCHADS).[65] NCHADS oversees the national health response to HIV/AIDS, as well as provides technical support to other governmental agencies and national partners. National AIDS Authority To coordinate a multisectoral approach involving ministries beyond the MOH, as well as the voluntary and private sectors, the government established the National AIDS Committee in 1993, which was succeeded in 1999 by the National AIDS Authority.[35] The NAA is an interministerial body comprising 15 ministries, the Cambodian Red Cross, and the 24 provincial governments[86]. The NAA is also responsible for overseeing the country's 24 provincial AIDS committees. David Bloom et al. of Harvard note the "confusing presence of two national' AIDS bodies in Cambodia: The National Center for HIV/AIDS, Dermatology and STD (NCHADS) is situated within the Health Ministry; it is the older body and has responsibility for a "health" response to AIDS. The National Aids Authority (NAA), meanwhile, was created by political accident but has survived and is evolving into a cross-cutting body promoting (but not executing) action against AIDS across government. While the remit of the two bodies is clear, there is some hostility between the two organizations. Considerable progress will therefore be needed if they are to accept inevitable fuzzy areas where division of responsibility is unclear, and avoid competing for government and donor funds.[38] National Policy and Priority Strategies for HIV/AIDS Prevention and Control (1999-2004) The priorities of the HIV/AIDS policy are: 1. reduction of HIV transmission through activities in groups at high risk aimed at decreasing STIs and promoting "100% condom use" 2. provision to the general population of IEC, counselling, and testing services 3. strengthening of the health delivery system Other key areas include provision of STI services using both public and private providers; blood safety; prevention of mother-to-child transmission; AIDS care (treatment of OIs, guidance on AIDS case management, guidance for health providers to avoid stigmatization of PWHA, expansion of home-based AIDS care programs); VCT; and epidemiological surveillance and research.[45] Law on the Prevention and Control of HIV/AIDS In 2002, Cambodia's National Assembly passed legislation on HIV prevention and control. The Law on the Prevention and Control of HIV/AIDS provides for national HIV/AIDS awareness campaigns, epidemiological monitoring, and free primary health care for PWHA. The law requires the protection of confidentiality of HIV/AIDS information, with fines and imprisonment for up to six months for breaches. All forms of discrimination against PWHA are prohibited, as is discrimination against families of PWHA and people thought to be HIV-positive. In almost all circumstances, HIV testing must be voluntary, anonymous, and subject to written consent and to pre- and post-test counselling. HIV screening is prohibited in connection with employment, education, freedom of residence and movement, and access to medical and other services.[87] However, to what degree these edicts are being adhered to is unknown. The legislation, which is based on the Philippines' AIDS Prevention and Control Act of 1998, charges Cambodia's National AIDS Authority with responsibility for developing HIV education programs in the workplace, establishing and monitoring infection control standards, and regulating advertising standards for HIV prevention and treatment products. The NAA is also responsible for ensuring standards in HIV testing centers and for collecting epidemiological data in coded (i.e., nonidentifying) form. [87] Human Rights See also the Governance section above for a discussion of human rights. The POLICY Project and the Cambodian People Living with HIV/AIDS Network (CPN+) have begun advocacy initiatives based on the recently passed law mentioned above. In September 2002, POLICY and the Australian Federation of AIDS Organizations conducted a related seminar in Phnom Penh for HIV/AIDS and human rights organizations. CPN+ is drafting a Bill of Rights for PWHA, drawing on the provisions of the new law. [87] 100% Condom Use Program (CUP) The 100% condom use program (CUP) was pilot tested in Sihanoukville in 1998. Sinhanoukville was selected because of: * commitment of local authorities * commitment and motivation of health staff * high HIV prevalence among DFSWs * large number of DFSWs * geographic accessibility[65] The pilot phase was financed by the Government of Cambodia, WHO, and the European Union. High-level national and provincial advocacy was crucial, with the MOH, NCHADS, and NAC playing key roles. [65] After the pilot phase of CUP was evaluated in late 1999, Cambodia's prime minister approved the National Policy on 100% Condom Use. The policy states that "All entertainment places providing sex services and other services related to sex are obliged to apply 100% condom use without exception."[65] If a client refuses to use a condom, sex workers are urged to withhold services and refund the client's money. All sex establishments are required to be involved in the project to limit clients' ability to purchase sex in other places without using condoms. If establishments are found repeatedly to allow sex to be sold without condom use, then the establishment can be closed. The two key elements of this program are: (1) the active cooperation of the local authority, police, public health officials, the owners of entertainment establishments, sex workers, and condom use working groups; and (2) that, when condom use is a requirement of commercial sex, sex workers, clients, owners and the general public benefit.[55] Implementation of CUP thus far has been limited to two urban areas. In addition, many sex workers are underground to avoid police harassment, arrest, and possible detention (e.g., those trafficked from Vietnam) and are not reached by outreach efforts.[88] Multisectoral Response In October 2002, Cambodian Prime Minister Hun Sen, addressing the Second National Cambodian AIDS Conference in Phnom Penh, stated that HIV/AIDS had become "a major threat to the socio-economic development of Cambodia."[89] Using a broad consultative process, the NAA prepared the National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS 2001-2005 (NSP). The NSP represents a significant shift in strategic planning for the national response to HIV/AIDS. The NSP provides guidance and direction to nonhealth ministries to assist them in developing their own workplans for responding to HIV/AIDS.[86] Among current activities in nonhealth ministries: * Within the Ministry of National Defense, the HIV/AIDS Section of the Department of Health is responsible for all HIV/AIDS-related activities targeting the military. The ministry has established HIV/AIDS prevention committees (HAPCs) at regional and provincial levels; 256 military commanders have been sensitized on HIV/AIDS; HIV/AIDS sessions have been integrated into the existing military training program nationally; and 12,000 military personnel have received HIV/AIDS education and condoms. The ministry has drafted a Strategic Plan for the Military's Response to HIV/AIDS.[73] * With financial and technical support from UNDP/CARERE and WHO, the Ministry of National Defense implemented an STI/HIV/AIDS prevention peer education project. FHI/IMPACT is working with the department to develop behavior change communication messages for HIV/AIDS prevention and care targeted to military personnel and their families. The materials developed will be used in the prevention peer education project. FHI/IMPACT is also collaborating with the department to develop best practices in STI/HIV/AIDS prevention and care. The provinces covered by the FHI/IMPACT collaboration are Phnom Penh, Kandal, Kampong Cham, Kampong Thom, Kampong Chhnang, and Kampong Speu.[15] The Cambodian Red Cross also works with uniformed servicemen, such as police and military, on a peer education project. The POLICY Project also supports the HIV/AIDS efforts of the ministry. * The Ministry of Social Affairs, Labour, Vocational Training and Youth Rehabilitation is seeking to transform government orphanages from large-scale institutions to smaller group homes monitored by social workers. The ministry collaborates closely with UNICEF; FHI; and local NGOs that work with street children, orphans, and other children affected by AIDS. Future projects may involve developing guidelines for vulnerable children and for provision of alternative care, as well as expanding the number of institutions involved in providing care to AIDS orphans and other vulnerable children. Proposals to encourage Buddhist monks to care for children affected by AIDS have been made, but there are concerns about the capacity of monks to do so.[34] * In October 2002, Cambodia's Ministry of Women's and Veteran's Affairs (MWVA) formally adopted the MWVA Policy on Women, the Girl Child, STIs, HIV, and AIDS. The policy had been revised to fall in line with the NSP objective of targeting men as well as women. [90] * Ministry of Education, Youth and Sport (MoEYS): The school curriculum has recently been revised to incorporate reproductive health and HIV/AIDS information. A POLICY Project review of adolescent health in Cambodia rated these materials as meeting a high standard; however, their effectiveness depends upon their implementation by teachers, who are generally not adequately qualified to present the information and who may choose to pay little attention to this portion of the curriculum due to a lack of reproductive health teaching experience or beliefs about the appropriateness of sexuality as a part of the school curriculum. An additional concern raised by POLICY is that although this reproductive health component of the curriculum is of high quality in the final year of primary school and throughout the secondary curriculum, only a small percentage of the population remains in school long enough to access such material. Of adolescents ages 15-19, only 9.1 percent of females have completed primary school, and only 10.9 percent of males have done so.[35] * UNICEF and UNESCO have cofunded an HIV/AIDS focal point in the MoEYS. Among activities funded by the two agencies is an HIV/AIDS newsletter distribute to an estimated 20,000 education stakeholders, including heads of provincial and districts offices of education, all directors of primary and secondary schools, inspectors of education, parents teacher associations, provincial AIDS committees/secretariats, and the NGO sector. * Ministry of Cult and Religion (MOCR): Works with the POLICY Project on HIV/AIDS activities. Other projects involving Buddhist monks include Kien Kes Volunteer Network in Battambang; Wat Norea Peaceful Children, and Salvation Center Cambodia. With support from UNDP/CARERE and the Interchurch Organization for Development Cooperation, monks in Phnom Penh and Battambang have been trained to become core trainers for other monks and for people in their communities. Monks have been involved in distributing HIV/AIDS prevention materials, have been trained to provide care for PWHAs, and have trained villagers to provide home-based care. And under this project, the Sisters of Charity operate a clinic for PWHA.[13, 91] * FAO reports that Cambodia has begun developing and promoting mitigation strategies in the agricultural sector, including: less labour-intensive agricultural techniques, preservation of agricultural knowledge and technology transfer through extension services, and improved nutrition for PWHA. [92] Budgets According to NCHADS, in 1994, US$800,000 was spent on HIV/AIDS in Cambodia, comprising US$600,000 from the U.N. and US$200,000 from NGOs. By 1999, spending had increased to US$9million, of which US$2.5 million was from the U.N.; US$5 million through NGOs; and the remainder from a World Bank loan (Disease Control and Health Development Project 1996-2002) and multi- and bi-lateral grants to the government. In 2001, HIV/AIDS spending was US$14 million, accounting for 20 percent of all public funding to the health sector. In that year, the U.N. contribution had fallen to US$1.4 million. Funds through the government totaled US$5 million (of which US$3 million was from the World Bank loan); NGOs represented US$7.6 million, of which US$5.7 million was primarily large grants by DfID and USAID to Population Services International and FHI.[93] In 2002, donors and the government spent an estimated US$15.4 million on HIV/AIDS programs within the health sector (US$6.7 million through NCHADS and US$8.7 million through NGOs and other sources). Of this amount, NCHADS estimates that 16 percent was spent on care and treatment, up from 12 percent in 2001.[1] In December 2002, the World Bank approved Cambodia's Health Sector Support Project, which will run until 2007. Within this US$31.84 project is a US$2 million International Development Association (IDA) grant for STIs/HIV/AIDS, which will support the procurement of STI drugs and the implementation of CUP.[45] (IDA lends money to the world's poorest countries at zero interest with a 10-year grace period and maturities of 35 to 40 years.) See below for information on grants to Cambodia from the Global Fund to Fight AIDS, TB & Malaria. In September 2002, the POLICY Project of the Futures Group International costed out the resources required to implement Cambodia's National AIDS Strategy in the year 2005. The 19 specific items costed were: 1. strengthening the managerial structures, processes and mechanisms to increase the capacity for coordinating, monitoring and implementing HIV/AIDS actions, and enhance cooperation with stakeholders at national and international levels 2. enhancing legislative measures and policy development 3. strengthening Cambodia's capacity to conduct and lead a multisectoral HIV/AIDS response 4. strengthening national capacity for monitoring, evaluation, and research 5. ensuring support for orphans affected by HIV/AIDS 6. empowering the individual, the family, and community in dealing with the consequences of HIV/AIDS through the promotion of a social, cultural, and economic environment that is conducive to the mitigation of HIV/AIDS 7. providing palliative care to those infected with HIV/AIDS 8. treating opportunistic infections (OIs) 9. offering HIV-infected individuals OI prophylaxis 10. ensuring that reliable ARV treatments are available 11. providing HIV/AIDS prevention services for youth in-school and out-of-school 12. expanding interventions with SWs and their clients 13. ensuring existing STI services are accessible 14. strengthening and expanding VCT 15. strengthening and expanding workplace programs and programs for mobile populations 16. ensuring a safe blood supply 17. reducing transmission of HIV from mothers to their children 18. strengthening and expanding IEC, BCC and outreach to promote behavior change 19. encouraging behavior change through a mass media campaign[1] The POLICY Project estimated that full implementation of HIV/AIDS programs spanning the 19 items above would cost US$54.7 million for 2005. Of this amount, about 56 percent would be allocated to prevention, 22 percent to care and treatment, 17 percent to management/policy/research, and 6 percent to mitigation.[1] Donors As demonstrated above, Cambodia has been absorbing increasing amounts of HIV/AIDS funding. The government's capacity to manage these resources is improving. [93] Nevertheless, Cambodia continues to depend heavily on external technical and financial resources to address HIV/AIDS.[85] Cambodia's major donors are the Asian Development Bank, UNDP, World Bank, International Monetary Fund, Australia, Canada, Denmark, the EU, France, Germany, Italy, Japan, Sweden, Thailand, U.K., and U.S.[29] The Links section contains more information on major HIV/AIDS donors. Global Fund to Fight AIDS, Tuberculosis & Malaria In the first round of GFATM grants, announced in April 2002, Cambodia's Country Coordinating Mechanism was approved to receive US$15,945,803 for its HIV/AIDS component, "Partnership for Going to Scale with Proven Interventions for HIV/AIDS." The objective of the proposal was to slow the spread of HIV infection among vulnerable populations; extend the reach and improve the quality of STI services; provide care and treatment for PWHA; reduce vulnerability of selected populations at higher risk; and make condoms readily available. Activities include extending peer education programs to the military and the police and to newly identified populations at risk, including garment factory workers and youth; extending model STI case management in five provinces not yet fully covered by the national STI program; significantly expanding care and treatment programs for PWHA, including limited antiretroviral therapy; extending impact mitigation programs in areas of heavy HIV prevalence; and extending the social marketing of condoms. Major partners include: 1. National Centre for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases 2. Ministry of Social Affairs, Labour, Vocational Training and Youth Rehabilitation 3. Ministry of Defense 4. Cambodian Red Cross 5. Youth Council of Cambodia 6. Khmer HIV/AIDS NGO Alliance 7. Sihanouk Hospital Center of Hope 8. Médicins du Monde 9. Douleur Sans Frontières 10. Pharmaciens Sans Frontières 11. Population Services International Disbursement of funds to Cambodia's CCM from round 1 has begun.[94]According to AIDSpan, as of April 17, 2003, US$95,919 had been disbursed.[95] In the first GFATM round, the NGO Sangaha Thor Initiative (SANTI) was approved for a US$9,609,770 grant, pending clarifications.[96] In the second round of GFATM grants, announced in January 2003, Cambodia's HIV/AIDS component was approved for US$14,877,295, pending clarifications. No grant agreement has yet been signed for the second round. [97] The second Cambodian GFATM proposal on HIV/AIDS addresses interventions not covered in the first, with more emphasis on ART. Specific objectives include: 1. expanding the coverage and enhancing the quality of interventions for the prevention of HIV/AIDS to include underserved vulnerable populations. The proposal outlines specific targets for interventions (VCT, STI treatment, BCC, PMTCT) and subpopulations (rural villagers, pregnant women, migrant workers [including women working in garment factories, fishermen], IDFSWs, in- and out-of-school youth, couples, and rape victims. Existing workplace intervention with garment workers will be expanded to include HIV/AIDS/STI prevention through peer educators. Major partners: Reproductive Health Association of Cambodia (RHAC), MOSALVY, and CARE. A new program will be initiated for fishermen, through peer educators to conduct BCC activities and to refer their friends for VCT and other STID/AIDS services at RHAC or government clinics in Kampong Som. An existing program for beer promotion and massage girls will be expanded with peer and group education, and referral for clinic services. RHAC will develop a peer education program targeting staff of hotels, guesthouses, large restaurants, nightclubs, and other venues where young Cambodians come into regular contact with foreign and domestic tourists in Siem Reap.[3] 2. improving access to quality comprehensive care interventions including ART and promoting greater involvement of PWHA. Main activities: ? increased access to ART in Phnom Penh and Kompong Som province. (The GFATM asked for clarification on this section, specifically the Cambodian CCM's basis for estimating that one-third of AIDS patients will be able to afford ART; one-third will receive ART from NGOs, employers, etc; and one-third will have coverage through an Equity Fund. [96]) Major partners: Pharmaciens sans Frontières and French Red Cross. ? care of children living with HIV/AIDS attending the National Pediatric Hospital of Phnom Penh. ? training of Cambodian physicians and pharmacists. Major partners: Sihanouk Hospital Center of Hope, Institute of Tropical Medicine Antwerp, and Brown University ? development of continuum of care in Kompong Som Province in collaboration with Cambodian Red Cross and local NGOs.[3] 3. securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART. Improve national guidelines on medical treatment and palliative care; increase capacity of health facilities and communities to provide care and treatment (e.g., OI management and palliative care and counseling) linked to VCT and PMTCT services; make PMTCT services available in five provinces; establish effective OI management services in two regional military hospitals; implement ART in Kompong Som PHD and National Paediatric Hospital; secure adequate supply of OI, PMTCT, and ART drugs to support the above activities.[3] Under the second-round GFATM grant, in year one, government would receive 30 percent of the funds and NGOs would receive 70 percent. By year five, NGOs would be receiving 100 percent of the funds.[3] NGOs and CBOs Local and international NGOs occupy a relatively influential position in Cambodia, given their role in general development activities and in rebuilding Cambodian civil society. They are also a major employer of the middle-class.[35] Since the early years of the HIV/AIDS epidemic, NGOs and CBOs have carried out a major portion of the country's HIV/AIDS prevention and care activities. Their work has been crucial, though constrained by limited resources. Several NGOs implement activities funded by multi-, bilateral, and other donors. The Khmer HIV/AIDS NGO Alliance (KHANA) functions as a linking organization for Cambodian NGOs, facilitating financial and technical resources to expand and strengthen their activities. Cambodia has three active PWHA organizations involved in and advocating for prevention and care work. These organizations focus their work largely in Phnom Penh. See the Impact section for a discussion of NGOs providing care and support to orphans and OVC. In addition to Nyemo Center, Kien Kes, Homeland, Mith Samlanh-FRIENDS, Children in Distress, and KHANA, Partners in Compassion, a collaboration between Christians and Buddhists, works with FHI/IMPACT on a project to provide care and education for children affected by AIDS in Takeo. Wat Norea Peaceful Children, led by monks, also provides support to orphans and OVC. The Links section provides a compendium of national and international NGOs working on HIV/AIDS in Cambodia. PMTCT According to WHO, 2,800 clients received PMTCT services (i.e., basic counseling, testing, and AZT or NVP treatment) at the one public/NGO PMTCT site in Cambodia during 2001. An estimated 2 percent of the population in need of PMTCT services was receiving them.[98] In its most recent GFATM proposal, the MOH reported that in 2002, 1,600 pregnant women received VCT and 50 HIV-positive pregnant women received PMTCT counseling and referral.[3] The government finalized its policy on prevention of mother-to-child transmission of HIV in mid-2000. Its main objective is to improve the acceptability, accessibility, and quality of health services and information on reproductive health and HIV/AIDS/STIs. Recognizing that maternal care services are limited, the government is studying the feasibility of providing a package of MTCT prevention services through antenatal, peripartum, and postpartum care treatment points. To this end, three pilot projects have been established: Battambang Referral Hospital, the National Maternal and Child Health Center (NMCHC) in Phnom Penh, and Calmette Hospital in Phnom Penh. The first is primarily a research site and has been under way for some time. The other two are primarily operational and were planning to begin offering services toward the end of 2001.[14] In its second-round GFATM proposal, the MOH stated that one of its goals is that by 2004, PMTCT services would be available in five provinces and 15 percent of HIV-positive pregnant women would be receiving a complete course of ART prophylaxis to prevent MTCT. [3] Home- and Community-based Care In 1998, the Cambodian MOH established a partnership with several NGOs to develop and implement home-based care for PHWA. The Home-Based Care Network reaches people with AIDS and other chronic illnesses in Phnom Penh. A team coordinator is based at the Municipal Health Department, and care is provided by government health center staff, as well as staff and volunteers from KHANA, World Vision, Sihanouk Hospital Center of Hope, Maryknoll, Copha, and Servants to Asia's Urban Poor.[53] The government continues to focus on home- and community-based care for PWHA. It acknowledges, however, the extra burden this places on poor families, women, and primary care givers.[39] VCT According to WHO, during 2001, 15,927 clients were seen at Cambodia's 14 publicly funded/NGO VCT centers. (There were no VCT services offered in the commercial sector.) During 2001, WHO estimates that 20 percent of the population in need of VCT services in Cambodia was receiving them.[98] According to the 2000 CDHS, only 2.8 percent of Cambodian women have been tested for HIV. Of them, 68 percent were tested in the public medical sector, 21 percent in the private medical sector, and the rest in other settings. Urban women were four times more likely to have been tested than rural women. Among women who have not been tested for HIV, 24.8 percent want to be tested. Of women never tested, only 15.6 percent know of a place where they could be tested.[20] In 1995, Cambodia's first HIV testing and counseling policy was developed; it was revised in 2001 to incorporate use of two different rapid tests for HIV diagnosis. VCT sites were established in 1995, with two sites in Phnom Penh (at the National STD and Dermatology Clinic and the Prea Norodum Sihanouk Hospital) and three others in Battambang, Seam Reap, and Kampong Cham provinces. [5] VCT in public health facilities is free of charge [5], and provision of VCT is a key component of the National Policy and Priority Strategies for HIV/AIDS Prevention and Control (1999-2004). As mentioned above, according to Cambodia's new law on HIV/AIDS, in almost all circumstances, HIV testing must be voluntary, anonymous, and subject to written consent and to pre- and post-test counselling. HIV screening is prohibited in connection with employment, education, freedom of residence and movement, and access to medical and other services.[87] However, to what degree these edicts are being adhered to is unknown. Cambodia's second-round GFATM proposal seeks to increased availability of VCT, with RHAC introducing VCT in seven of its urban clinics.[3] The POLICY Project estimates that it will cost US$2,244,000 in 2005 to provide VCT to 47,000 clients.[1] Treatment of OIs and ART The impact of providing treatment for the escalating opportunistic infections, and for STIs as prevention and care, on an already fragile and over-stretched health system, on communities and at the household level is crushing.[3] According to WHO, 11 HIV-positive Cambodian children received cotrimoxazole prophylaxis in 2001. Among HIV-positive adults, 2,640 received cotrimoxazole prophylaxis and 200 received isoniazid prophylaxis during 2001, representing 11 and 1 percent, respectively, of the population in need of such services. Access to HIV/AIDS care and support services outside Phnom Penh and in rural areas is deemed minimal.[98] WHO reported that during 2001, there were three public/NGO sites in Cambodia providing ART. These three clinics (operated by MSF, MDM, and Sihanouk Hospital Center of Hope) were serving 202 clients¾1 percent of Cambodians in need of ART[98]. In its most recent GFATM proposal, Cambodia's MOH reported that in 2002, 350 patients were on ART. [3] The third component of the second-round GFATM proposal noted above addresses securing reliable and adequate drug supplies to improve access to quality comprehensive care interventions, including OIs, STIs, PMTCT, and ART. The proposal outlines as one its goals that by 2006, 3,000 Cambodians will be on ART. [3] According to the POLICY Project, it will cost US$4,112,000 in 2005 to treat OIs in 51 percent of PWHA in need of such care. To provide palliative care to 62 percent of PHWA in need would cost US$1,252,000 in 2005. To provide 11,000 Cambodians with HAART in 2005 would cost US$6.3 million in medications and additional laboratory costs (based on an estimate of US$392 per patient per year for medications and US$140 for lab costs.[1] Private Sector Currently, Cambodia has a relatively small private sector and very limited HIV/AIDS workplace programs. Various organizations are scaling up their HIV/AIDS workplace activities in Cambodia, with interventions including peer education, STI treatment, and condom distribution. (See also the section on garment workers above.) According to the POLICY Project, providing 25 percent of workers in Cambodia's formal sectors with access to STI treatment and 3 percent of these workers with access to peer education programs would cost US$773,000 in 2005 (at a unit cost of US$7 per employee reached with peer education, US$8 per employee treated for an STI, and US$0.10 per condom distributed at the workplace).[1] Links Queries concerning links may be sent to the project director: Lgarbus@psg.ucsf.edu References 1. Forsythe, S., Resource Requirements for Cambodia's 2001-2005 HIV/AIDS National Strategic Plan. 2002, The POLICY Project, The Futures Group International: Washington, DC. 2. UNAIDS, Report on the Global HIV/AIDS Epidemic, http://www.unaids.org/barcelona/presskit/barcelona%20report/contents_html.html. 2002: Geneva. 3. Cambodia GFATM Country Coordinating Mechanism, Partnership for Going to Scale with Proven Interventions for HIV, Tuberculosis and Malaria: HIV/AIDS Component. 2002, Proposal to the Global Fund to Fight AIDS, TB & Malaria: Round 2: Phnom Penh. 4. Cambodian Ministry of Health, National Center for HIV/AIDS, and Dermatology and STDs, Report on HIV Sentinel Surveillance in Cambodia 2000. 2000: Phnom Penh. 5. Personal communication with Dr. Hor Bun Leng, deputy director, National Center for HIV/AIDS, Dermatology and STD, Cambodian Ministry of Health. 2002. 6. MAP, The Status and Trends of HIV/AIDS/STI Epidemics in Asia and the Pacific, http://www.unaids.org/hivaidsinfo/statistics/MAP/MAP2001FINAL.doc. 2001, Monitoring the AIDS Pandemic Network (MAP): Melbourne, Australia. 7. Personal communication with Dr. Kimberly Page-Shafer, assistant professor of medicine, University of California San Francisco, June 20. 2002: University of California San Francisco. 8. Bun Leng, H., et al. 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