Drug users could keep fuelling Cambodia’s Aids epidemic
By Vicente Salas
Dirty needles collected by harm-reduction NGO Korsang.
It's just a 10-minute walk from the affluent Boeung Keng Kang area and just a few streets off from the impressive-looking government offices along Norodom Boulevard. Yet here the squalor and poverty hits you in the guts. Along a concrete wall, lightly shaded, sits Sophal, who at 19 looks a decade older - thin, in tattered clothes, looking like he hasn't had a bath for a week. He looks slightly dazed and passive, with eyes that are half-open, as if in a nap, and some spittle trails out of the corner of his mouth. His arm is slightly extended and just out of the crook of his elbow, amidst a few bruises, a syringe dangles, its tip still embedded just beneath the skin.
Heroin addiction is now acknowledged as growing problem in Cambodia, and while there are limitations in estimates of the numbers of people who inject drugs, the National Authority for Combating Drugs (NACD) estimates that in 2007 there were between 600 to 1,000 injectors. The trends are disturbing, with a local NGO, Mith Samlanh, reporting that in some vulnerable populations, the prevalence of injecting drug use has risen from less than one percent of the drug-using population, to 10 percent in 2004.
There have been no official estimates of HIV prevalence rates among injecting drug users, however, small-scale surveys and routine surveillance indicate prevalence rates between 14 and 31 percent in IDUs, and up to 18 percent in non-injecting DUs. Either way, the HIV rates among these populations are skyrocketing way, way, beyond the national prevalence rates of 0.9 percent.
While sexual transmission of HIV remains the major mode of transmission in the country, the high prevalence in injectors, the "overlap" with sex work will continue to provide fuel to the HIV epidemic in Cambodia over the coming years. This could potentially keep the HIV epidemic burning like a slow fire, ready to burst once again into flames should prevention efforts taper off. And there are challenges to ARV treatment among people with a history of unsafe injecting - it means many of them will have other associated blood borne infections, such as Hepatitis B and Hepatitis C. Such conditions complicate routine antiretroviral treatment. One study presented at last month's national AIDS conference showed that 10 percent of those on ARV treatment also had Hepatitis C.
Drug use per se, or even injecting drug use, does not need to be associated with HIV. It is the re-use of needles and syringes, as well as the sharing of unclean injecting equipment, that leads to the transmission of HIV. Of course the problem is that a large majority of people who have HIV do not know of their status.
Respond now to prevent crisis
Yet Cambodia is more advanced than other countries in the region in its response to the growing threat of HIV associated with IDU. There have been small-scale services provided by two NGOs, for the past three years, and the NACD has authorised them to provide clean needles and syringes and needle-disposal projects. They reach about 20 percent of IDU in Phnom Penh. On some days you will see volunteers from the NGO Korsang scurrying around "injection street"wearing rubber gloves, thick-soled shoes, plastic pail, sorting through the piles of rubbish and deftly picking out the syringes and needles with a pair of tongs.
However, a comprehensive approach to reducing HIV and drug-related harm goes beyond needle provision - there should be education and information efforts for both the drug users and the community where they reside, there should be equal access to health care services, as well as access to drug treatment and rehabilitation services. Several strategies proven effective also need to be adopted more widely, such as the use of peer workers, outreach sites, as well as drop-in centres. Psychological support is key, as well as behavioural modification.
Involvement of law enforcement and public security officials is crucial - they are partners, but in many instances, the projects designed to prevent HIV come in conflict with the policies on use and abuse of illegal drugs. Therefore common ground is needed for collaboration to ensure that both law enforcers and health workers agree on the shorter term goals of HIV prevention, and stigma reduction for people who inject as well as people who are HIV infected.
And this is where a recently published National Strategic Plan for Illicit Drug Use related to HIV (NSP HIV & IDU 2008-2010) comes into play. This plan, developed by the National AIDS Authority and NACD, is the culmination of a series of consultations with all sectors and tries to address the major policy issues and aims to develop a comprehensive approach to prevent HIV transmission associated with illicit drug use and to provide treatment, care and support for drug users at risk of infection and living with HIV.
The NSP is bold in that it proposes several interventions that have not been tried in Cambodia before. However, resources are still being sought to implement the three year plan, which is projected to cost a little over US$9,000,000. The NSP for IDU and HIV was presented by Teng Kunthy, secretary general of the National Aids Authority, at a multi-country Coordination and Consultation Forum last October 6. [The second such forum is currently under way in Phnom Penh.]
So the rhetoric and the plans are in place - the next challenge comes, the political will to provide resources, and implement plans as intended. The road ahead will be rocky, but this is one initiative that demands the support of all sectors, and all donors. The price of failure will be much too high, as countries like China, India, Myanmar/Burma, Indonesia and Vietnam, with their drug-used fuelled HIV epidemics, are now belatedly learning.
Vicente Salas is a public health and HIV consultant based in Phnom Penh.