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Neglect of most vulnerable threatens HIV/AIDS success

Neglect of most vulnerable threatens HIV/AIDS success

A parade in Phnom Penh on December 1 promoted condom use and urged people not to discriminate against those living with HIV/AIDS.

In just a few years, Cambodia has transformed itself from an apocalyptic scenario

for the spread of HIV/AIDS into a success story being touted by the United Nations.

It is one of only a handful of countries to have reduced the prevalence of the disease

in the last decade.

The numbers back up the hope. Between 1999 and 2002, the country's infection rate

dropped from 3.8 to 2.6 percent of the general population. Most experts attribute

that decline to vigorous prevention programs and exhaustive community education about

condom use.

Despite the triumph, the UN warns that any reduction in HIV/AIDS programs could easily

reverse the promising successes of the last few years. While funding still seems

plentiful, there is growing concern it might not be targeted at the groups most vulnerable

to the disease.

Cambodia's HIV prevalence rate remains the highest in Southeast Asia. Among marginalized

groups, the figures are even more grim. Some, such as men who have sex with men (MSM),

may have HIV/AIDS prevalence rates five times higher than the national average.

Unlike in the West, where the lion's share of funding, support, advocacy and education

was initially focused on the gay community, the MSM population has largely been ignored

in Cambodia's battle against AIDS.

"The overall focus of CARE in HIV/AIDS Cambodia is to make sure that we're reaching

the people who are most vulnerable, such as MSM," explained Kim Green, the HIV/AIDS

coordinator for CARE Cambodia, an NGO dedicated to issues of poverty with an interest

in reproductive health and the AIDS epidemic.

CARE is now putting the finishing touches on a report dealing specifically with MSM

and the spreading epidemic. The CARE study surveyed 24 MSM in the border towns of

Koh Kong and Poipet, regions in which mobility is high, a recognized factor in HIV


"It's very difficult to find information about this topic because of the stigma

and ignorance surrounding sexual practices between men," said Green. As a result,

many of the interviewees were afraid of being identified as gay and as men who may

be vulnerable to HIV. "What that means is that many of these men don't identify

themselves as homosexual, and are difficult to reach and educate."

The results of the report are unsettling. The interviews with MSM in the border regions

reveal that these men routinely have unsafe sex; that they sometimes have unprotected

sex with women; and that due to sexual stigma and routine physical and sexual violence,

they are afraid to seek out support and services.

Despite HIV/AIDS education programs that have raised awareness about HIV transmission,

there is a scarcity of information about the risks of anal and oral sex. Most educational

programs focus largely on vaginal sex.

"Of those who knew that [unprotected sex] was risky, many said that they would

have unprotected sex if the man was well-groomed, if they were in love or, for sex

workers, if clients requested it," said Green.

In one interview, a man in Poipet acknowledged that condoms were a part of his sexual

practices, and added, "I rarely have sex without condoms."

"Only if the man is handsome will I not use condoms," he said. "I

will let him do whatever. Most of the time, handsome or not, they do not want to

use condoms."

The reality of sexual violence also makes these men vulnerable to HIV transmission.

Many of the CARE subjects spoke of being sexually assaulted by the police, the military

and other officials.

"When I went to Bangkok the first time I was arrested and put in prison,"

said one interviewee. "I was forced to have sex by the chief of the prison.

If I did not agree with him I would be tortured."

Some of the CARE findings come as no surprise to Dr Song Ngak, program officer for

Family Health International (FHI).

In 2002, FHI published the first report on male homosexuality to focus specifically

on MSM and HIV/AIDS in Phnom Penh. As with the CARE report, the results were startling.

The prevalence rate for MSM in the capital was a staggering 14.4 percent. The majority

of the 206 men interviewed did not identify themselves as gay, but reported having

unprotected sex with both men and women.

Deputy Prime Minister Sar Kheng speaking at the World AIDS Day event near Wat Phnom on December 1.

In one of the interviews conducted by CARE in Poipet, the subject expressed embarrassment

about homosexuality even as he alluded to his own sexual activities with men: "It

is inappropriate, it is shameful. I am afraid that I will have no children in the


This conflict between beliefs and practice is common for men who have sex with men

in Cambodia, say researchers.

"In Cambodian culture there is tremendous pressure to get married and have children

who will support you in your old age," said Dr Ngak. What this means is that

some men who desire homosexual sex find it covertly-often without condoms-and then

have unprotected sex with wives or girlfriends.

"As such, they represent a bridge group bringing HIV from one community to another,"

he said. "It's very important that they be educated about safer sexual practices."

There are many obstacles to implementing change in this population. With interest

rising in MSM, the situation may improve. Groups such as FHI, KHANA [Khmer HIV/AIDS

NGO Alliance] and the Policy Project are designing research to study the problem.

"The government has been invited to join the discussion about how to develop

programs which meet the needs of MSM," said Green. "There is finally a

dialogue about the problems, which is hopeful."

Certainly, things have changed since FHI began its study in 1999.

"It is better now; there is more awareness of the MSM population but there is

still a sense that the group is too small to merit funding and evaluation,"

said Dr Ngak. He agrees with Green's assertion that the social stigma around homosexuality

deters MSM from seeking information and support, and adds that it limits the statistical

information about the MSM population.

"Limited statistics also limit funding," he said. "If we have numbers,

we can plan human resources and financial resources but if we have little information,

it's hard to justify our efforts."

Beyond funding, Green said there needs to be a real advocacy effort by MSM. There

are some nascent initiatives to do that.

"Currently there is nothing, no real forums that exist for these populations,"

said Green. "But the Policy Project is working at the national level to create

an association of MSM-for bisexuals, gay women and the transgendered as well-to create

a space for talking about the issues confronting people who have sex with the same

gender, such as HIV/AIDS."

Change seldom comes without hard data so FHI is initiating another study to gather

more information about MSM in Phnom Penh this month, said Dr Ngak. It will launch

another study of MSM and HIV/AIDS early next year.

"There needs to be more outreach, education and awareness on the level of policymakers

and NGOs," insisted Dr Ngak. "We need to give these people concrete information

so they understand the importance of addressing the MSM population. It is getting

better, but much work remains."


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