With the highest infection rate of any country in Southeast Asia, Cambodia is
now facing an Aids epidemic. Sarah Stephens talked to health care professionals
about new directions for AIDS programs in 1999: Tackling the Nation's No. 1 social
NO CONDOM - NO SEX, PLEASE
Geoff Manthey is an agitated man: "There are 100 new cases of HIV a day. That's
700 per week. That means in the seven weeks that I've been here, 4,900 people have
become infected and I haven't been able to do anything about it. "The UNAIDS
Country Program Advisor may be new to Cambodia, but already his determination to
have a lasting effect on the AIDS epidemic is evident.
"In most countries the epidemic takes place in stages - you have the ëluxury'
of being able to focus on solely preventative measures for the first stage."
But, Manthey believes, Cambodia, because of its recent social history, is in a unique
situation which calls for a unique response. "Already you're starting to see
many cases of full-blown AIDS, much earlier than we did in other countries, and what
we need to do now is focus on the care and support aspect. There needs to be a mix
of facility-based care in hospitals and hospices, but the burden of support will
fall on the community."
This is a sentiment which other health care professionals echo. Since the first cases
of HIV began appearing in 1991, most HIV/AIDS projects have concentrated on preventative
measures - promoting effective condom use, disseminating information to commercial
sex workers and trying to educate both men and women about the various ways the virus
can be transmitted. But at the end of 1998, with recent government statistics showing
a frightening increase in rate of infection (150,000 Cambodians are now thought to
be HIV positive), many professional health workers are beginning to review their
strategies for the future.
"I think there has not been enough (focus) on support and care," said Dr.
Oum Sopheap, Project Manager for World Vision's AIDS Prevention and Care Project.
In response to the rapid spread of the virus to the general population, "we
have to reconsider our target groups, strategies and monitoring systems... this year
we started a new initiative in response to the need of our patients, which is home
According to Sopheap, over 50% of AIDS patients his project deals with are ëneedy'
people - that is, poorer people who cannot care for themselves or who have limited
family help available to them. The World Vision pilot project, which started in February
1998, sends out teams comprised of NGO workers and Government Health Center workers
to provide support for a number of Phnom Penh's AIDS sufferers.
The carers, who offer counseling, social work, nursing and health education, visit
the patients regularly, sometimes even continuing to visit families after the AIDS
patient has died.
"Some they will visit every day, or even twice a day, depending on (how advanced)
the illness" said Sopheap. Although the pilot project ends in February, Sopheap
explained that there were plans to expand the operation to the provinces next year,
if the results prove encouraging.
Caroline Francis, Project Manager for CARE's border HIV/AIDS project, agreed that
there were likely to be policy shifts in approaches to AIDS. "The new trend
for the future will be an emphasis on care and counseling," simply because there
will be more and more fully developed AIDS cases in Cambodia," she said. "CARE
in general will be moving in that direction."
The need for a more care-based approach is only too clear to one Phnom Penh-based
volunteer, who works with one of the most vulnerable sections of the community, HIV-positive
children. Despite the obvious sympathy that such children elicit, there are simply
not enough projects or resources available to take care of the AIDS orphans that
have been flooding into Phnom Penh over the last year.
"I call them my throwaway children," said the volunteer, who declined to
be named. "There's not enough money in Cambodia for the healthy kids - what
are you going to do with kids that are going to die?" She estimated that in
certain orphanages in the city, the infection rate stands at around 50-60%, with
more children arriving each day. "Some staff are taking them home at night because
there's just no room (in the orphanage)."
In addition to the issues of care and counseling, according to Manthey, in 1999 Cambodia
will need to look hard at the lessons learnt by other countries, and to start modeling
its own prevention programs on those successfully adopted elsewhere. One example
is the recent ë100% condom' policy being implemented in Kampong Som, which is modeled
on a similar program in Thailand.
"This kind of operation takes an immense amount of cooperation from the local
authorities," Man-they said of the program, which aims to persuade all brothels,
nightclubs, karaoke rooms and massage parlors to pursue a strict ëno condom, no sex'
policy. Despite Dr. Sopheap's optimism that preliminary findings showed STDs had
dropped by 10% in the area, Manthey was more cautious.
"The devastation that AIDS causes is still not getting through to many Cambodians,"
he said. "What we need is for the highest-level authorities in the government
to stand up and say we must have 100% condom policies across the country ."
Perhaps the most important issue for AIDS care next year in Cambodia, at least at
a national level, will be effective coordination of the myriad of AIDS programs and
projects by a centralized coordinating committee. According to Dr. Sopheap, in several
of the projects supported by World Vision, "we saw many NGOs doing the same
thing in the same area."
Manthey agreed that an effective collaborative effort was vital: "There's a
great need for effective policy development and strategic planning in this area,"
he said. "From this will flow the resources we need. I've been impressed by
what I've seen so far - over the last 12 months there seems to have been a much improved
collaborative response (between NGOs and coordinating bodies)".
Indeed, the Prime Minister himself has already pledged that AIDS will be a priority
in health care, with the new government ready to respond in a much stronger fashion
and at a much higher level.
Yet despite these promises, there is still a mood of despondency that it's clear
the AIDS workers find hard to shake. "It will get worse before it gets better,"
"People here haven't really seen the face of AIDS yet. Many are HIV-positive,
but the cases of full-blown AIDS are relatively low. Until Cambodians see what the
disease can really do, it just won't hit home."