Can India learn from Cambodia’s Successful HIV Program?

An Interview with Dr. Mean Chhivun-Gaining Ground Against AIDS: The Cambodian Solution

July 2008-Cambodia is one of the poorest countries in the world, but it is also one of the few where HIV/AIDS prevalence is in decline-a success story that has been attributed in good part to the countrys national prevention and treatment program. As director of Cambodias National Centre for HIV/AIDS, Dermatology and STIs (NCHADS) since 1998, Dr. Mean Chhivun has been deeply involved with planning and implementing the countrys AIDS control efforts. In this interview, he speaks about how and why HIV/AIDS is losing ground in Cambodia.

Treat Asia

TREAT Asia Report: Cambodias AIDS prevention and control program has had striking success in fighting HIV/AIDS. Exactly what is Cambodia doing right?

Dr. Vun: The first HIV case in Cambodia was detected in 1991 and the first AIDS case was diagnosed in 1993. During those years, HIV transmission increased rapidly, spreading from high risk groups to the general population, from urban to rural populations. By 1998, Cambodia had one of the highest HIV prevalence rates in Asia.

Because of the combined efforts of government, civil society, the international community, people living with HIV/AIDS (PLWHA), and the private sector, HIV prevalence in Cambodia has been declining steadily-from two percent in 1998 to 1.2 percent in 2003 and to 0.9 percent in 2006. By 2012, we project, using the Asian Epidemic Model, that we will see HIV prevalence at 0.6 percent. A number of factors have helped us slow the advance of HIV. The first has been our education campaign, which has generated basic HIV awareness though TV, radio, and special events such as mobile talk shows and entertainment. Cambodia has also stressed 100 percent condom use, both for high-risk groups and for the general population. In addition, we emphasize early diagnosis and treatment of sexually transmitted infections, a strong blood safety program, and positive prevention among PLWHA.

Cambodias national AIDS program works because we have a clear common vision and a strong sense of ownership, from the national level down to the local. The national program has developed clear and appropriate interventions and the partnerships between all stakeholders work well. Budgets and programs are managed with transparency and in an accountable manner. Weve also decentralized our HIV programs and have built up the capacity for managing programs at the local level.

Cambodia has also integrated care, treatment, and support services for PLWHA into the existing healthcare system. That includes voluntary counseling and confidential testing (VCCT), antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) services, tuberculosis treatment, as well as HIV care and treatment. We do not have a separate care and treatment program for PLWHA. The cooperation and involvement of the community, including civil society and PLWHA peer support groups, is a very important factor for HIV prevention and treatment in Cambodia.

TREAT Asia Report: Which problems have been the most difficult to address?

Dr. Vun: As with other developing countries, one of the main challenges we are facing is with human resources, especially retaining healthcare workers at the provincial level. Second, limited leadership at the provincial level presents problems, and providing financial support for the program is also difficult. In this regard, many of our partners look at the success of our HIV programs and they say, OK, the support should be reduced. Thats what we call the punishment of success!

Stigma and discrimination are also an important challenge, but at the beginning of the HIV/AIDS program it was much worse. Over the last three years, I would say that stigma and discrimination against PLWHA have significantly declined, although it still exists, especially at the community level.

TREAT Asia Report: How has Cambodia been able to sustain its commitment to such a complex national HIV prevention and treatment program over so many years?

Dr. Vun: Its important to recognize the political support in this country-the government is committed to fighting HIV/AIDS and it stands behind the national program. The partnerships we have with all stakeholders are also very important for sustaining our joint efforts over the last seven to 10 years. Many groups work together on this and we all have a sense of ownership-we have a culture of partnership.

In addition, Cambodia has a good model for HIV prevention, care, and treatment using low-cost and high-impact interventions. These sorts of interventions are crucial to sustaining our momentum. For example, 90 percent of HIV transmission in Cambodia comes from heterosexual contact, primarily among commercial sex workers. So we focus on this specific population group using the 100 percent condom message, and all partners agree and support this model. Its necessary to look for that sort of low-cost intervention, which can have a high impact. We also focus our interventions on men who have sex with men and drug users.

TREAT Asia Report: NCHADSs HIV program is called the Continuum of Care. What does that name refer to when it comes to treating HIV/AIDS?

Dr. Vun: Before 2002, the care and treatment of PLWHA in Cambodia was severely limited. In 2001, only 71 PLWHA were receiving ART in the entire country! We had only a very few counseling and testing centers, clinics that could treat OIs, or locations that could provide ART, and all were concentrated in large towns.

To increase access to care and treatment, NCHADS with its partners developed a comprehensive model called the Continuum of Care based on the experiences of countries in Asia and Africa. The main components of the Continuum of Care are voluntary counseling and confidential testing, treatment for OIs, ART, PMTCT, pediatric AIDS care, laboratory support, and, most important, referrals and links to community support. Our model involves providing treatment through district level referral hospitals and local health centers, and support activities through home and community-based care programs.

TREAT Asia Report: You mentioned voluntary counseling and confidential testing as one of the main components of the Continuum of Care. How has testing contributed to Cambodias fight against HIV/AIDS?

Dr. Vun: HIV testing is very important for the success of HIV prevention, care, and treatment in Cambodia because testing is the starting point. In Cambodia, VCCT started in 1995 and grew from then. When the Continuum of Care started in 2003, we further scaled up VCCT from fewer than 20 sites to 230 sites in 2008. In addition, the average VCCT caseload has increased fivefold, from around 60 to around 300 clients a month. Its very important for people to do HIV testing, to know their HIV status at the earliest stage. Our new approach is to improve reproductive health and to increase HIV testing, including among pregnant women so we can prevent mother-to-child transmission. And all infants born to HIV-positive mothers should be tested.

Its very important to talk about positive prevention, because more than 40,000 people in Cambodia are on ART and treatment for OIs, including children. Positive prevention can help these positive people from transmitting HIV to others.

At the beginning of the HIV epidemic here, twice as many men were infected with HIV as women, but over the last seven or eight years the situation has changed. Now the ratio for HIV transmission is 1:1, 50 percent male and 50 percent female. We do not separate care and treatment services for male and female PLWHA; we provide equal services to both. As a result, 51.5 percent of the 26,000 adults receiving ART are women, and 51 percent of the 2,700 children receiving ART are girls.

TREAT Asia Report: Cambodia has very few healthcare workers-only around 2,000 doctors and 8,000 nurses covering all specialties, according to the Global Fund. What can a country such as Cambodia do to combat the doctor shortage and how does that shortage impact treatment and care?

Dr. Vun: The issue of healthcare workers is paramount and chronic for developing countries, including Cambodia. To cope with that, weve chosen to integrate the Continuum of Care into the existing healthcare system, which means that care and treatment for PLWHA are not separated from regular health care at regional referral hospitals and local health centers. Instead, weve trained regular clinicians and pediatricians in OIs and ART with five-month courses. And weve trained 295 nurses on ART counseling. In addition, more than 100 PLWHA have received training on HIV counseling and they work side by side with healthcare workers. Essentially, we are providing one-stop shopping for people who need treatment and care.

Despite shortages, weve made great progress getting people on treatment. In March of this year, Cambodia had 28,000 patients on ART-85 percent of those who are eligible. For children, 2,700 are on ART-more than 89 percent of those who need the medications.

TREAT Asia Report: Cambodia has the highest rate of tuberculosis (TB) in Southeast Asia and one of the highest in the world. Since TB often goes hand in hand with HIV, NCHADS has developed ways to fight both diseases, as well as other opportunistic infections. What approaches have proven the most effective?

Dr. Vun: For TB/HIV coinfection interventions-especially OI care and treatment-NCHADS works together with the national program for combating TB. Both programs emphasize early screening among their patients-HIV counselors and clinicians screen for TB among seropositive people, and TB programs screen and refer all their TB patients for HIV testing. Its very important to know because earlier diagnosis and treatment is crucial among TB/HIV coinfection patients. As a result, 65 percent of TB patients were tested for HIV last year, and 30 percent of PLWHA were screened for TB.

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