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Comment: The changing face of Aids


New ways of thinking about at-risk populations are needed


An HIV-positive sex worker displays her anti retroviral medication.

Cambodia's third national Aids conference, the first one since 2003, ended September 12, with Deputy Premier Sok An giving the closing remarks and outlining some of the challenges that lie ahead - the need to find out more about populations most at risk for acquiring HIV, mobilising more resources for the national response, and  minimising the negative impact of new anti-trafficking policies on HIV prevention and outreach work.

Cambodia deserves a pat on the back for its achievements in HIV/Aids over the past decade: an adult zero-prevalence rate that has decreased from 2.6 percent in 1999, to 0.9 percent in 2006; the massive scale-up of anti-retroviral therapy (ART), with almost 28,000 people on treatment, which covers an estimated 80 percent of those who need it, a rate that many countries with stronger health systems can only hope for. The current figures indicate that one in 100 adults has HIV, and zero-prevalence studies among brothel-based female sex workers are still unacceptably high, at 12.7 percent, though this has decreased almost threefold over the past seven years. These gains, however are threatened by recent efforts to implement anti-trafficking initiatives; closure of brothels and arrests of sex workers have made it increasingly more difficult and dangerous to provide information and services.

"This is a  blatant, moralistic crusade against sex work, masquerading as an anti-trafficking initiative," remarked a key UN official. Sok An was pragmatic: "Given that prostitution has been around in many forms over the centuries, what can be done to reduce its more despicable effects and at the same time allow protection from HIV and STIs to those who are most vulnerable?" Beyond arresting the sex workers and "rescue operations", nobody has talked openly about the clients and arrested the traffickers. But that's another story.

Where are the next 1,000 new infections coming from? That's a major question, and the health authorities, NGOs and the UN will need to look at that more closely. Take the expanded ‘Voluntary Confidential Counselling and Testing' (VCCT) facilities, for example. The 2007 Cambodia country profile reports that 274,025 persons had been tested for HIV in 156 VCCT centres, as of March 2007, with 20,678 testing positive. We need to find out more about the demographics and risk behaviour patterns of those who test positive for the first time, to give a better idea of where the epidemic is heading. Are these people members of the "high-risk populations"? Are they sexual and/or drug-injecting contacts of those already known to have tested positive? What are the age and sex categories, what proportion are coming from antenatal clinics?

Information from hospital-based treatment centres indicates that a big proportion of people present for ART are in the late stages of infection, where ART is likely to be less effective. We also need to study more about the profile of recent entrants to ART. If a big proportion of people continue to show up at health facilities in an advanced stage of the illness, perhaps then we need to rethink the prevention and counselling strategies to get people on treatment earlier. One can also look more closely at treatment access - who gets treatment, and who doesn't. A significant proportion of women working in the brothels are said to be Vietnamese. If non-Khmers test positive and need ART, what sort of access do they have?

With the decreasing rates of HIV among the brothel-based female sex workers and the "general population" there has also been a shift towards working with "men at risk". However this population is quite loosely characterised, and the main emphasis here is on prevention of sexual transmission with females working in various entertainment establishments. While these measures are necessary these are not sufficient as they do not address other risky practices such as concurrent sex with multiple partners, the phenomenon of ‘bauk' or gang rape, and the antecedent behaviours of drug and alcohol use, or sex between men.

Likewise in Cambodia, there have been no studies about HIV in prisons and other closed settings. Risky behaviour also occurs within closed settings. Opportunities for HIV prevention work are being missed.

Finally, it is well-known that the success of Cambodia's responses has been heavily funded by external donors. A significant proportion of this goes to local and international NGOs, and some of it eventually trickles down to community-based groups of men who have sex with men and people living with HIV/Aids. The government contribution is a mere three percent of annual HIV expenditures. An analysis of the resource gap shows that it will continue to enlarge over the years to come, as the resources for treatment take precedence, and as Cambodia's success becomes a reason for donors to reduce their involvement over the longer term. Sok An announced that negotiations would begin in a month's time for much of bilateral donor money to be coursed through the government in the future. This of course will have implications on how NGOs and civil society groups will be responding.

Cambodia may have "turned the tide", but  it may not be prepared for the second wave - with the epidemic now apparently safely ensconced in men who have sex with men/transgenders, particularly those selling sex, in women in the sex industry, and the attendant waves of TB, of Hepatitis C, and the devastating impact on families and communities. These demand new and different ways of thinking and dealing with most at risk populations, less NGO ‘turfing', and more inclusive and accountable partnerships with government, civil society, donors and the private sector. 

Vicente Salas is a medical doctor and health-care consultant based in Phnom Penh.



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