A head of former US President Bill Clinton's December 4 arrival to assess the HIV/AIDS epidemic in Cambodia, health officials and activists are saying the face of the situation is masking a fragile future marked by discrimination, misinformation and disturbing trends in sexual behavior.
On the surface, however, it's beaming. Hong Sun Huot, chairman of the National AIDS Authority, various health officials and US Ambassador Joseph Mussomeli have proclaimed Cambodia a bona fide "success story" with its AIDS prevalence reduced from 3 percent in 1997 to 1.9 percent by 2003.
Health organizations have documented massive improvements in testing, counseling, awareness and anti-retroviral treatment (ART). And on November 30 the US Embassy in Phnom Penh released a statement claiming the AIDS rate has dropped to 1.6 percent this year.
But the battered visage and shorn skull of AIDS-stricken Penh Peab, 33, tell a different story. The widowed mother of four lives in fear and confusion. She worries that she'll succumb to the virus and orphan her children.
Peab says discrimination keeps her unemployed, and her family has abandoned her in shame. She doesn't know if her children are infected because, living outside Phnom Penh, she has no access to medical care, and couldn't afford it if she did.
An NGO provided her with ART for a few months, but she wasn't instructed on how to take them. The Clinton Foundation HIV/AIDS Initiative (CHAI) estimates there are 123,000 adult Cambodians living with the virus, 15,000 under the age of 15, and almost 80,000 orphans left behind by parents who died of AIDS.
Between the extremes is Pen Mony, 26. A tireless HIV/AIDS activist who was infected five years ago by her husband, she launched AIDS outreach programs for sex workers and now sits on the board of a support group for infected Cambodians.
Mony told the Post on November 29 that people living with HIV/AIDS (PLHA) bear tremendous social stigmas handed down by a society that is either unwilling discuss the virus openly, or too eager to assume an infection is karmic retribution for immorality. She admits there have been decline in new infections, but says the government never includes PLHA in policymaking or "listens to their voice."
On November 30 the Cambodian Alliance for Combating HIV/AIDS (CACHA), an alliance of PLHA organizations, presented a letter of appeal to CPP Parliamentarian Hor Naun, vice-chairman of the Committee on Health Care and Women's Affairs.
"CACHA calls for greater accountability and a more effective approach that targets the basic needs of HIV-positive people such as: access to affordable drugs, employment opportunities, education, healthcare and housing services," the letter read.
At a workshop for journalists funded by the UK Department for International Development from November 24 to 26 in Sihanoukville, a UNAIDS representative cautioned participants to think critically of reports that Cambodia is a "success."
"We have success, but it can change at any time," said Jane Batte of UNAIDS, citing Uganda, where after positive reports, the problem is now increasing.
At the same forum, Sou Sotheavy, coordinator for Women's Network for Change, urged the UNAIDS panel to look for the truth behind the numbers.
"I think you have to be careful before publishing [HIV/AIDS] figures. Be sure it is accurate," Sotheavy said. "Figures are there but sometimes you need to look at what the reality is on the ground."
Health consultant David Wilkinson, who co-authored an August 2006 UNAIDS publication, Turning the Tide: Cambodia's Response to HIV/AIDS 1991-2005, which called Cambodia a success story in its introduction, voiced a similar concern.
"The 'success story' phrase comes with a caveat," he told the Post. "Cambodia is low income country in a state of recent post-conflict. It's achievements should be acknowledged and applauded. But the caveat is that success must be maintained and this emerges as a donor and funding issue. If things look rosy there's a danger that donors would reduce levels of funding."
According to Wilkinson, who served as facilitator for Karol & Setha, an NGO-funded awareness campaign launched in November to tackle "the deep-rooted sources of risky sexual behavior," the problem of AIDS will only dissipate when underlying issues are addressed.
"The level of commercial-sex-seeking behavior is as high as any place I have ever worked - it seems acceptable behavior to visit brothels and sex workers," said Wilkinson, a sexual and reproductive health specialist with experience in Kenya and India. "Even within marital relationships men will seek commercial sex - particularly when the wife is pregnant.
"I would define the highest-risk groups [in Cambodia] as wives and children. The husband transmits the virus to the wife and then it travels from mother to child. This is a critical issue in prevention."
In April an UNAIDS report found that married, monogamous women represented 40 percent of new HIV infections.
"Much attention has been paid to drug users and sex workers, and that's appropriate," a UNAIDS Cambodia coordinator said at the time. "But the trend of sexual networking is changing... to be a married woman is now to be at risk for AIDS."
Chan Dina, head of the Cambodian Prostitutes' Union, estimates that about half of the sex workers in Phnom Penh are informed about HIV/AIDS prevention tactics. Still, she said, many clients become unruly, and even violent, when asked to wear a condom.
"In my area in Toul Kok there are 200 sex workers and about 60 have HIV/AIDS; six have died from AIDS this year," she told the Post on November 30. "The problem now with sex workers is the increasing number of drug users who are taking yama and ice [forms of methamphetine]. It's difficult to teach them about HIV/AIDS because they just don't care."
Drug use was identified as an "emerging risk" by the August 2006 UNAIDS research.
"'Sweetheart' relationships with various degrees of transactional sex pervade all age groups and increasing numbers of young people are engaging in casual and commercial sex often in conjunction with substance abuse," the report reads.
According to research conducted for the Karol & Setha project, large increases were found in reports of rape and domestic violence. More troubling was the finding that 59 percent of "in-school" students knew someone that had been involved in a gang rape, known by the common term bauk.
"This figure - more than half - is extremely worrying, extremely disturbing and doesn't bode well for the future pattern of the epidemic," Wilkinson said.
"It's not just a public health issue it's related to human rights and violence against women. It's a phenomenon associated with younger men and in many cases the perpetrators are middle-class or well-off. I think addressing this needs policies and a legal framework that needs to come from the very top."