Cambodia needs to face up to AIDS reality

In June, groups such as Amnesty International openly condemned authorities in Phnom Penh, when twenty families with HIV were forcibly evicted from their homes in the Borei Keila district of the city. The families were then resettled in an isolated flood-prone area called Tuol Sambo, 25 kilometres outside the capital, creating a de facto AIDS colony.

When the international news media started paying attention to the story in mid-July, more than forty families had been resettled in Tuol Sambo. At the end of the same month, more than one hundred international and domestic AIDS campaigners, NGOs, and human rights groups sent an open letter addressed to Cambodian Prime Minister Hun Sen and Minister of Health Mam Bunheng highlighting their concerns. They argued that the settlement does not meet minimum international standards for temporary housing, and its inhabitants have no access to a clean water supply, electricity, or proper sanitation. Moreover, with weakened immune systems from the progression of the HIV virus, many of these people are especially vulnerable to disease. Living in such inadequate conditions removed from hospitals and emergency services is nothing short of a death sentence for the older members of the community. Tuol Sambo is far from the health services which supply the antiretroviral medicines crucial for living with HIV. And even those healthy enough to work have no job prospects in this isolated area, leaving them with no means of supporting their families.

Recent testimonies from residents revealed that there is a serious lack of food and drinking water in the settlement, and the green metal sheds which function as housing for the families are built too close together and without proper ventilation thus making the heat unbearable and the occupants worry that their medicines are spoiling in such high temperatures. To date, the letter has met no response from government officials and the groups will now be waiting with bated breath to hear the outcome of a joint visit to the area by the heads of UNAIDS Cambodia and the National AIDS Authority which took place at the end of August.

UNAIDS estimates that there are around 75,000 people living with HIV in Cambodia, with roughly 4,400 of them children. However, widespread prejudice against those with HIV makes data collection difficult, as people are discouraged from getting themselves tested. The organisation admits that there could be anything from 67,000 to 84,000 Cambodians who are HIV positive.

The organisation’s First Quarterly Report for 2009 goes on to assert that those infected with HIV face discrimination in employment and education, as well as being subjected to social exclusion. Although the prevalence rate is declining (currently estimated at 0.8 percent among adults, compared with 1.2 percent in 2003), the rate of infections is still among the highest in Asia. Almost half of new infections are amongst married women, and consequently the transmission rate from mothers to newborns is also high. According to UNAIDS, the main challenges in curbing the transference rates are found in the newly developing non-brothel based sex trade, the lack of contraception use between married couples, as well as needle-sharing amongst drug users, and homosexual activity amongst men.

The evolution in the sex trade is one of the biggest difficulties faced by authorities trying to slow the spread of the HIV virus as, up until this point, Cambodia has had one of the most successful HIV prevention programs in the developing world, due mainly to its astuteness in tackling the commercial sex industry head on rather than leaving it unchecked as is the case in many developing countries. In 1998, the government launched the 100% Condom Use Program which required the use of condoms in all sexual encounters between commercial sex workers and their clients. This, combined with an intense media campaign promoting awareness of the disease, was immensely effective in reducing the transmission rate among both prostitutes and their clients. However, as condom use within the brothels increased, the numbers of clients decreased and a sideline of non-brothel based commercial sex expanded to places such as massage parlours, bars, and beer halls where women may not necessarily identify themselves as sex workers thus making the use of contraception less common. Furthermore, in recent years Cambodia has seen the development of a “sweetheart” culture, with more and more men having extra-marital affairs that are not related to the commercial sex industry. In these instances too, contraception is often not used and between married couples themselves the use of condoms is extremely rare as they are associated with infidelity, casual, or commercial sex. This stigma towards condoms combined with sexual infidelity of husbands means that housewives in Cambodia make up the largest group of new infections each year.

The success of Cambodia’s HIV prevention programs has been further jeopardised by the country’s growing drug problem. Only a decade ago, injecting drug use was virtually unheard of in the country but since 2000 it has spread rapidly, particularly in the capital. Obviously, those sharing needles and syringes are at a high risk of contracting HIV and in one year alone alone the percentage of injecting drug users found to be HIV positive increased from 14 percent in 2006 to a shocking 35 percent in 2007. As is always the case, heroin is common, but NGOs have voiced particular concern about the use of crystal meth which is cheap but highly addictive. Although usually smoked, the drug can also be injected, but NGOs are trying to draw attention to the possibility of contracting HIV while under the influence as users have admitted they are more likely to hire prostitutes after they have taken it.

Although homosexuality is not illegal in Cambodia, sexuality and sexual behaviour is rarely spoken about. Furthermore, many Cambodian men who sleep with other men do not view themselves as gay and are therefore referred to as the MSM (men who have sex with men) population. The fact that many members of the MSM community are married with families means they do not speak openly about their homosexual relationships, which poses a crucial problem for those trying to address the issue. Misinformation seems to be the major cause for the high transmission rates among this community as many Cambodian men believe that HIV can only be passed on between men and women having unprotected sex. However, NGOs such as KHANA (a derivation of the international HIV/AIDS Alliance) have begun to develop the first MSM networks in the country, working on educating men about the need for contraception as well as drawing attention to the presence of a gay which the government needs to factor into its National HIV Strategies.

The Cambodian government has made great strides in reducing HIV transmission rates, particularly within the commercial sex industry, but the National HIV Strategies seem to skim over many sections of the population. Moreover, while the government is intensely focused on reducing rates of infection, the forced segregation in Tuol Sambo would appear to indicate not only serious neglect of but blatant discrimination against Cambodians who are already living with the virus. Perhaps it is naivety but considering the tens of millions of dollars of donor aid the government receives for its HIV/AIDS programs, specifically to help those living with HIV, it is difficult for this writer to comprehend how such a situation ever arose in the first place.