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Logo of Phnom Penh Post newspaper Phnom Penh Post - Fight against AIDs stacked with problems

Fight against AIDs stacked with problems

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

they were."

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."

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