E arlier this month hundreds of people marched through Phnom Penh to mark World AIDS
Day. Cambodia has its own unique problems that are causing an explosion in the deadly
virus. Katya Robinson reports.
DESPITE skyrocketing HIV infection rates, safe sex is a tough sell in Cambodia.
There are a host of problems that take precedent - war, mines, malaria, tuberculosis;
while socially, much of the population remain ill-informed, embarrassed, or distrustful
of condoms. Patients aren't even always told by health authorities when they are
diagnosed as being infected with HIV.
Om Chhen, sales manager for Population Services International's (PSI) condom sales
program, says: "When I went outside Phnom Penh and tried to sell my condoms
to people in the rice fields of Kompong Cham, they said, 'Oh, you brought us some
sugar candies!' They had no idea what a condom was."
Despite the best efforts of local and international NGOs and the National AIDS Program,
HIV/AIDS prevention and education messages haven't yet reached everyone.
"Basically, we have the situation of Thailand with the infrastructure of Africa,"
says Richard Renas, technical officer for the Global Program on AIDS at the World
Health Organization. He cites a lack of money for HIV/AIDS programs, the legacy of
the Khmer Rouge and the presence of so many other national issues as key obstacles.
Dr. Hor Bunleng, coordinator for the National AIDS Program, says the government needs
significantly more funds for AIDS projects. In 1995, $450,000 was spent, of which
approximately $400,000 came from the WHO. "That means $450,000 for 9.8 million
people in Cambodia, compared to $90 million in Thailand for 65 million people,"
Bunleng says, noting that Cambodia's rate of HIV infection exceeds that of Thailand.
"In Cambodia, we need at least $1 per person."
Cambodia is mirroring - even exceeding - the rise of HIV in the Thailand of the 1980s.
A WHO study of HIV prevalence among blood donors last year revealed a close correspondence
between HIV cases in 1988-1992 in Chiang Mai and Phnom Penh between 1991 and 1995.
Already home to the world's fastest rate of HIV infection, Southeast Asia is expected
to surpass the number of people infected in Africa by the year 2000. WHO says that
between 50,000 and 90,000 people in Cambodia are HIV positive. But with only 86 documented
AIDS cases in the country, the disease remains remote to many Cambodians.
To get the attention of the general public, AIDS workers are employing a wide range
of strategies, including videos, advertising, puppet shows, and education in the
schools, villages and brothels.
To succeed, these messages not only have to break through the clutter of competing
concerns, but also have to drown out the large amount of misinformation about AIDS.
Erroneous reports in Khmer newspapers have linked condom use to breast cancer; said
HIV can be transmitted through nail clippings; and once announced a local cure to
AIDS. A study by CARE International uncovered many misconceptions, including HIV
transmission through mosquitoes, clothing and tainted fish. Many said they could
tell whether someone was HIV positive just by looking at them.
According to a study released by Christian Outreach this fall, 63 percent of migrant
workers and their families surveyed had little to no knowledge of HIV and AIDS.
William Mackie, PSI's information, education and communication specialist, says PSI
had come across pharmacy owners in the provinces who have never seen a condom. His
mainly USAID-funded program, which markets condoms throughout Cambodia, seeks to
both stimulate demand for condoms through education and advertising and increase
availability through aggressive marketing.
Om Chhen says: "One afternoon, I was only 40 kilometers from Phnom Penh in Phnom
Baset, I met a young woman with five children. I asked why she had so many children
and she said she didn't want so many, but they just kept coming nonstop. I told her
about condoms. I was only 40 kilometers from Phnom Penh, and she had no idea what
Overcoming misinformation and seizing the attention of the general public requires
delicacy. For example, early AIDS education programs in Thailand were based on fear.
Graphic and gruesome pictures of people with advanced AIDS, and skeletons and ghosts
were used. The campaigns got the attention of the people but also promoted fear,
not only of AIDS but of people with AIDS. Thailand is still struggling to overcome
discrimination against those with HIV and AIDS with newer messages of compassion.
AIDS workers in Cambodia are thus faced with the dilemma of getting attention by
generating healthy concern without creating unhealthy dread. They must sometimes
skirt the subject of sex, a sensitive one in Cambodia, while making it clear that
HIV/AIDS is not only a problem of commercial sex workers.
Bunleng says "I would like to say that people should fear their behavior, not
AIDS itself. AIDS may be incurable, but it is preventable."
His National AIDS program urges monogamy and condom use through colorful posters,
brochures, t-shirts and signs. The National AIDS program aims to relay these messages
to the "highest risk groups": commercial sex workers and mobile men, such
as policemen, military and truck drivers.
The program also teaches about needle use. Cambodians prefer injections as treatment
for most illnesses, and many can't afford to buy clean needles from pharmacies. Cambodia's
proximity to opium-producing countries could increase intravenous drug use in the
future, further spreading HIV, says the WHO.
These trends are spurring a big push for education. While the National AIDS Program
is concentrating on brothels and migrant groups of men, many NGOs are targeting schools
and villages as well. PSI provides a kit for primary and secondary school students
that contains pencils, erasers, crayons, toothbrushes and soap, in addition to facts
on AIDS. The primary school kit explains what AIDS is; the secondary school kit describes
how it is spread and how it can be prevented.
In another approach, one World Vision program trains villagers to teach their friends
and neighbors on HIV and AIDS. At a recent three-day workshop in Tuol Kork, six men
and 12 women learned about the causes, prevention and care of HIV/AIDS.
Pil Sokkhoeun, a 32-year-old woman who completed the course, says that before she
was picked by her village leader to participate she knew very little about AIDS.
"Now I will try to explain about AIDS to others," she said. "I will
talk to the wives and the neighborhood men."
But will they listen? She said she thought so, but that men would probably continue
to visit sex workers. And her own husband? "I don't know if my husband has sex
with other partners," she said. "He wouldn't tell me and I dare not ask."
Sokkhoeun said she did not expect her husband to use condoms with her. "Condoms
for married people are only for birth control," she explained.
Herein lies the crux of the problem in promoting safe sex: creating understanding
is one thing, but changing behavior is another. While people may understand the importance
of practicing safe sex, they may not have the power, the position, the means or the
desire to do so.
"The biggest barrier to HIV/AIDS prevention is the status of women in Cambodia,"
says Sue Grant, an HIV/AIDS consultant for the WHO. "Women may not be in a position
to insist on condom use." According to Hanna Phan of CARE, "Cambodian women
are secondary. It's not considered acceptable for wives to insist on condoms, and
single women are not allowed to talk about sex."
Grant says: "It's time to stop blaming sex workers for the spread of this disease.
Commercial sex workers are not the main vectors of HIV/AIDS. It is often men who
give AIDS to sex workers." A new WHO report found that for every woman with
HIV in Cambodia, there are three men who are HIV positive.
Such attitudes toward prostitutes have prompted government crack-downs on brothels,
which only drives brothel owners to relocate elsewhere, making monitoring and education
still more difficult.
Availability of condoms is another problem. Condoms are widely available in Phnom
Penh, but are often a rare commodity in outlying areas.
"We try to follow the five-minute rule," says Renee Wessels, PSI's vice
president for communications in Washington, D.C. "That means a condom is within
five minutes when you need one. If it's farther than that, it's not likely that people
will go to the trouble to find one."
The five-minute rule is a challenge in the provinces, says Om Chhen. "In some
areas, there is no pharmacy, and condoms are hard to find." He has been selling
condoms to drink and cigarette shops.
Perhaps the largest obstacle, though, is a lack of motivation. "It's difficult
to think about dying in ten years from AIDS when there are many, more immediate threats
to life here," says Grant.
"I met a man who was 62 years old," said Young Setha of World Vision. "He
asked me how long he could live if he had HIV. When I said, 'seven to ten years,'
he said, 'I'll be happy to live until then anyway.'
"It was only after I explained the possible reaction of his neighbors and the
problems it might create for his family that he understood it might be a problem."