Experts fear Cambodia’s well-earned reputation as a leader in the fight against HIV/AIDS could be undermined by government policy targeting the country’s high-risk groups.
Experts fear Cambodia’s well-earned reputation as a leader in the fight against HIV/AIDS could be undermined by government policy targeting the country’s high-risk groups.
Over the past 15 years, government action and large amounts of money from donors have seen the infection rate drop from 2 per cent in 1998 to an estimated 0.7 per cent today.
The bulk of the $50 million the country spent tackling HIV in 2012 has come from donors such as the Global Fund, the United States Government and the Australian Government.
All those millions have allowed the Cambodian Government to target high-risk groups, to put in place a well-regarded prevention program and to ensure those who need treatment receive it.
That has helped to cut the rate of HIV infection in the adult population to 0.7 per cent.
Cambodia did so well that it met its 2015 Millennium Development Goal of 1 per cent infection five years ahead of schedule.
Marie-Odile Emond, the UNAIDS country for Cambodia, says 83 per cent of the 76,000 HIV-positive Cambodians receive antiretroviral drugs, one of the highest rates of any low-income country.
In addition, HIV education is being introduced into the secondary school curriculum to teach the next generation of its dangers.
But with a low HIV prevalence, and just 1,000 infections a year in the 15 million-strong population, it’s becoming harder to find the newly infected.
So UNAIDS and others are retargeting their efforts to locate people who are slipping through the net.
They also need to do better reaching high-risk, marginalised groups such as sex workers, intravenous drug users, men who have sex with men, transgender people, prison inmates and migrants.
Cambodia’s HIV efforts at ‘a cross roads’
Two controversial pieces of legislation – A 2008 law to combat human trafficking and another to improve security in communes and villages – risk undermining HIV efforts.
The human trafficking law outlawed brothels and drove much sex work underground.
“And the impact of those laws has been really to lead a lot of those populations who are at risk for HIV – sex workers or drug users – to be afraid of being arrested and to then operate in a more hidden way,” Ms Emond said.
“Every day we hear issues of people not accessing services or being denied services or being really harassed or detained for a few days, abused also – and that’s a very serious concern from a public health perspective for the HIV epidemic, because this really could undermine the last steps that Cambodia needs to do to reach the elimination of new infection.”
Meanwhile, the Global Fund has effectively halved its funding to Cambodia.
Ms Emond hopes the Cambodian Government will increase the money it puts into combating HIV to compensate for cuts in donor funding.
All of this, she adds, means the country is “coming to a crossroads”.
The drop in funding has already hurt half of the 120 non-governmental organisations and civil society groups that belong to the umbrella group HIV/AIDS Coordinating Committee, or HACC.
That has affected programs and outreach work from at-risk groups, such as sex workers, of whom around 14 per cent are HIV-positive.
HACC says mother-to-child transmission remains a problem too, with prevalence at around 8 per cent.
The NGO network says these pockets of high prevalence must be addressed, but that effort won’t be helped if, for instance – as happened most recently in June – Cambodia’s courts allow the presence of condoms as evidence of prostitution.
Not surprisingly, some owners of beer gardens and karaoke bars won’t allow condoms on their premises for fear they will be accused of operating a brothel.
Low-cost invention key to winning HIV fight
Dr Mean Chhivun is the person tasked with combating HIV and AIDS, which he does from the offices of the National Centre for HIV/AIDS, Dermatology and STDs, known as NCHADS.
Dr Chhivun has run NCHADS, which is part of the Ministry of Health, since 1998.
Although he wouldn’t be drawn into criticising the actions of other government departments, Dr Chhivun admits that reaching key groups was easier prior to the passage of the anti-trafficking law.
Despite the challenges, Dr Chhivun is confident that the structure of the program he has helped build will help.
NCHADS and its partners already work with groups representing the most marginalised, such as sex workers, and it has undertaken other low-cost steps too.
A year ago, it introduced finger-prick testing for HIV. That now reaches 40 per cent of those in the highest risk groups, he says, and should reach 90 per cent within a year.
“So based on the experience we have in the past 15 years, based on the lessons we learned to fight against HIV and to provide better care to people who are living with HIV and AIDS, we set up a very ambitious goal to eliminate new HIV infection by 2020.”
Dr Chhivun says the funding cuts simply mean doing more with less.
“We have to identify the low-cost intervention but with high impact or good result. This is very important because we use our capacity that already built in the past 15 years to maintain our effort and also to maintain the coverage – this is the main challenge that we are facing in the future for the financial gap.”
As Cambodia works toward its ambitious goal of zero HIV infections by 2020, it will have to do a better job reaching out to marginalised groups.
But logic dictates it will be harder for the Ministry of Health to succeed unless the police and the courts stop targeting high-risk groups for prosecution and abuse.