Dear Editor,

In your article “Govt, NGOs note drop in HIV infections” (December 31), it was reported that there was a drop of about 1,000 in the number of people registered as living with HIV in the Kingdom compared with the previous year. While on the surface it seems like good news, it would have been more useful to look beyond the numbers, or even at what goes into those numbers.

For example, these are people who are “registered” – meaning there are probably many who are not, and who do not know their HIV status. The accuracy of a registration system is also important, given that HIV carries with it major stigma and people may not wish to be on the registry for various reasons.

Second, it would be good to know if there were more people who died from AIDS and opportunistic infections than those who got newly infected in the past year, because the number of deaths also affects the total number of people living with HIV. In other words, if people died because they were untreated (and this is likely given that in 2000-2002, when HIV prevalence rates were over 2 percent, the estimated numbers of people with HIV in the Kingdom was more than 100,000). Simply by doing nothing for treatment, people will die of AIDS, given the natural history of the illness.

That, too, results in a drop.

Third, the provision of antiretroviral treatment also increases life expectancy. Therefore, many people who would have died without receiving treatment are still living – and they also figure into the numbers.

Fourth, and most important, where are the new infections coming from? Is it from women or men? What age groups? Is it from sex workers, men who have sex with men, injecting drug users or partners of people with HIV? Is it from perinatal transmission? At what stage of illness are people diagnosed? This is where the focus of prevention should be. How well is the registration system able to capture this ?

The recent government decision to stop salary top-ups and incentives for health workers may also have an effect – if services are more difficult to access, or if there are more costs involved for clients, then these may also affect the numbers of people who are registered and who seek and receive treatment at the optimal stage. Others may wait to see a doctor only when they are in the very late stages of AIDS, where treatment is no longer effective and much more costly.

Finally, the January 4 issue of the Post headlined the expiry of Korsang’s licence and its non-renewal. Whatever the reasons for this, it does not look good for the future of HIV prevention in the Kingdom. While the NACD mentions that Korsang has not been stopped from doing its work, the lack of a valid licence means that Korsang staff may be vulnerable to sanctions or harrassment from authorities for not having the required permits.

If the NACD and the NAA are serious about stopping the spread of HIV (and Hepatitis B) through injecting drug users, then they should immediately scale up programmes that have been shown to have public health benefits – such as needle and syringe exchanges, opiate substitution, access to counselling and antiretrovial treatment, peer outreach and drop-ins, condoms, and longer-term detox and rehab services – rather than put their hopes in an unproven form of treatment such as Bong sen.

Vic Salas, MD, MPH

Consultant – HIV/AIDS, Health & Development

Phnom Penh

Send letters to: [email protected] or PO?Box 146, Phnom Penh, Cambodia. The Post reserves the right to edit letters to a shorter length.

The views expressed above are solely the author’s and do not reflect any positions taken by The Phnom Penh Post.