A

n increasing number of young couples are opting to have HIV/AIDS tests before getting

married, statistics indicate at the Institut Pasteur du Cambodge in Phnom Penh. The

testing represents a public health achievement in the developing world, but one that

could be undermined if other precautions against the disease are not taken, say health

officials.

"Premarital HIV testing is very popular and common and has been since the beginning

[when the Institut Pasteur opened in 1995]," says Dr Philippe Glaziou, a researcher

at the health facility which offers free and anonymous testing for up to 40 patients

a day.

In a two-year study by the Institut Pasteur, nearly 30,000 people were tested for

HIV between 2000 and 2002. Of those, ten percent were premarital tests. The number

of premarital tests more than doubled during the study, indicating a marked increase

in their popularity.

The increase is likely due to health awareness campaigns in the country, says Dr

Ly Penh Sun of the Ministry of Health's National Center for HIV/AIDS, Dermatology

and STI (NCHADS). Penh Sun says that even among those who are functionally illiterate,

knowledge about the virus has been conveyed "not just through print, but through

TV, radio and even during holidays like the Khmer New Year".

Institut Pasteur statistics show that males make up more than two-thirds of those

visiting the clinic for premarital tests. The average age is 27.

The typical person to seek a test at the clinic is Cambodian, from Phnom Penh and

functionally literate. The study revealed that about 6 percent of prospective grooms

who came to the clinic for the tests, and 2 percent of the women, were HIV-positive.

The popularity of premarital AIDS testing "might be particular to Cambodia,"

said Glaziou. "It is not something I have ever seen before."

While Glaziou says that this might be part of a new trend, it is also probably linked

to the majority of the country knowing something about AIDS.

Knowledge of HIV/AIDS is widespread, at least among women contacted in the Cambodia

Demographic and Health Survey (CDHS) conducted in 2000 by the government. Nearly

16,000 women were surveyed, making it the largest ever performed in the country.

It found that 95 percent of Cambodian women had heard of HIV/AIDS, including those

living in rural areas. Even among those without a formal education, 91 percent of

those knew about the AIDS virus.

The survey also showed that 72 percent of women knew about how condoms reduce the

risk of catching HIV. A majority also knew several additional methods that prevent

infection.

But among those women having sex, most of whom were married, a negligible number

reported using condoms in the CDHS study. Only 1 percent said they used condoms the

last time they had sex. Women apparently must rely on tests and little else to protect

them in their sexual relations.

Men, however, are still engaging in dangerous sexual practices before and during

marriage, says Dr Tith Khimuy, a program manager with an HIV/AIDS NGO working with

the government. He says most Cambodian men have sex with prostitutes before marriage,

and statistics from the NCHADS study suggest between 12 and 18 percent continue to

visit prostitutes once they are married. Cambodian women could be exposed to infections

from their husband's partners, many of who may be sex workers.

The study by NCHADS found that 25 percent of the male participants between the ages

of 20 and 25 had visited sex workers in 2000. It estimated that the average number

of sex partners for males was roughly four in rural areas and nine in urban areas.

This is also the age group with the most men getting married.

Glaziou agrees that although men might take an HIV test before marrying, they often

continue to visit brothels. He explains how some people come to the Institut Pasteur,

test negative repeatedly, then later test positive.

With the level of HIV infection among prostitutes estimated at 33 percent, the disease

has begun to spread into different demographics, including married women and children.

So why do men who have sex with prostitutes not use condoms?

"Some men say they don't know of the risks," says Dr Khimuy. "They

find out that they are HIV-positive afterwards and then it's too late."

NCHADS's study found that "about 5 percent of Cambodian men recently have been

at very high risk for HIV/AIDS".

Khimuy adds, "Others are drunk when they go to a brothel so they are careless,

don't know what they are doing or forget to use a condom. Or some prefer [sex] without

a condom and so don't use one."

Men increasingly bring sexually transmitted infections back to their spouses, says

David Lowe, a researcher at the POLICY Project, an HIV/AIDS civil society group.

"It's estimated that 50 percent of HIV infections occur from husbands to their

wives," he told the Post in April.

The number of women who tested positive at the Institut Pasteur last year, about

23 percent, contrasts significantly with the 14 percent of men who tested positive,

says Glaziou. The statistic for women is higher because many women who come to the

clinic have seen their husbands die of AIDS and suspect that they are sick, he says.

They come seeking confirmation.

With awareness of the virus so high among women, they are usually the ones to insist

on the tests, says Glaziou.

"Mostly, the family is asking for a test before the marriage," Glaziou

says. "The future mother-in-law is usually the one requesting it."

Cambodia has the highest HIV infection rate in Asia, estimated at 2.6 percent of

the population. The UN estimates it has been decreasing since 1998, but Glaziou says

the epidemic remains a major health priority. Donors indicated they will give more

than $30 million to HIV/AIDS programs in 2003-2004, the most funding to date.