Aids Alert International-Cambodia's HIV rate ranks highest in Asia
An estimated 180,000 people are infected
Cambodia's decades of civil war have left a fertile ground for HIV, which has exploded among a populace that is characterized by wide spread illiteracy, poor education, high levels of sexually transmitted diseases (STDs), a dismantled health care system, and severely disrupted social and familial structures.
An estimated 20,000 people have died of AIDS in Cambodia, and recent figures from the National AIDS Authority of Cambodia put the daily death toll from AIDS at 20, says Geoff Manthey, country programme advisor for UNAIDS Cambodia in Phnom Penh.
With an estimated 180,000 people infected with HIV, the nation's HIV rate includes 3.75% of the population between 15 and 49 years. This means Cambodia's HIV prevalence rate is higher than any country in Asia, including China, India, and Thailand, all of which have higher absolute numbers of infection, he adds.
"The Cambodian AIDS epidemic has the potential to destabilize the region — a region that is presently experiencing significant turmoil," Manthey says. "The time bomb is ticking with 100 new daily HIV infections in Cambodia alone, although it is difficult to predict whether the profound epidemic of Africa will be repeated here."
AIDS has spread beyond high-risk groups to the general Cambodian population, infecting almost 2.5% of all pregnant married women. Police and military personnel have HIV rates of 6% to 8%. Because Cambodia already has a shortage of educated and trained people, a legacy of Pol Pot's killing fields, the epidemic now threatens to decimate the country's most productive populace.
"Cambodia should now be looking forward to a period of peace and stability following too many years of conflict and pain," Manthey says. "Instead, it is facing a threat that could prove more lethal than its recent history."
Cambodian officials have said that increasing numbers of HIV-positive babies are being abandoned at orphanages, and about 1,700 children may die from the virus this year.
"Thousands of Cambodian children are already orphaned by AIDS," Manthey says. "But the number of AIDS-caused orphans is likely to increase dramatically over the next decade."
While the country's commercial sex industry has fanned the epidemic's flames, there are other contributing factors, including the nation's extreme poverty and high migration patterns, which also are the result of years of civil war.
The nation's per capita gross national product (GNP) was $270 in 1995, which is one-tenth of Thailand's $2,740 per capita GNP, says Jacob Gayle, PhD, technical advisor/liaison for UNAIDS for the World Bank in Washington, DC.
"So, clearly, this is a country that still is feeling the pain of postwar and its struggling economy," Gayle says. "Given the role that migration and migratory employment play in Cambodia, it shows that moving populations in and out of Cambodia presents a threat for further transmission of HIV."
Also, Cambodia is part of a region that has been struggling with the spread of HIV and AIDS for years. "Unlike its neighbor Thailand, Cambodia is only now beginning to face the impact and issues of the epidemic," Gayle says.
Like other Southeastern Asian countries, there is less disparity between the AIDS infection rates of men and women in Cambodia than is seen in the United States. HIV has mostly been spread through heterosexual sex. Very few HIV-infected men acknowledge having had sex with men. About 36% of the HIV cases are listed as having been caused by sex among heterosexuals, and 44% of the cases are listed as "other" or unknown, Gayle says.
Plus, information about injecting drug use HIV transmission in Cambodia is almost nonexistent, Gayle adds. "We don't have the kind of fully accurate data in populations that we need to have, and so in countries such as Cambodia, it might be difficult to follow injecting drug populations."
Manthey says the Cambodian government first began to respond to HIV/AIDS in the early 1990s, and it received support from the United Nations and international organizations. Last year, the government established the National Center for HIV/AIDS, Dermatology and STD as part of the Ministry of Health. Then in January 1999, the government established the National AIDS Authority, which is an independent body established to facilitate a broad multisector response from 12 government ministries.
"Commitment to fighting the epidemic exists at the highest levels now, including His Majesty King Norodom Sihanouk and the Prime Minister, His Excellency Samdach Hun Sen," Manthey says.
Government to cooperate with brothel owners
In September, Cambodian officials announced a plan to enforce condom use in brothels as part of the National 100% Condom Use Program. Local police and governments will cooperate with brothel owners and sex workers to promote condom use.
However, the government has no plans to close brothels or crack down on the commercial sex industry because this has not proven useful, Manthey explains.
The Phnom Penh municipality, which tried to stop prostitution in its area, only pushed sex workers further underground, making them unreachable for HIV intervention, health care, and support, he adds.
Cambodia also has made STD prevention a priority by setting up STD clinics, developing prevention materials, and training health care staff. The program is funded by the Ministry of Health's budget, World Bank loans, and technical and financial assistance from donors, Manthey says.
But the government cannot provide antiretroviral drugs to infected individuals, and in most clinics, patients receive only pain management and treatment for opportunistic infections, such as pneumonia.
"Drugs are available in the private sector for those who can afford it," Manthey explains. "But providing antiretroviral therapy to people with AIDS will remain unaffordable to the Cambodian government for some time to come."
Also, few resources are available to prevent HIV transmission from pregnant women to their babies. Most women do not have access to prenatal services, and HIV testing and counseling also are rarely available. A working group on mother-to-child-transmission has begun some activities in Cambodia, with a vertical transmission pilot project scheduled to begin soon, Manthey says.
For its part, UNAIDS is working to expand and strengthen the United Nations' support to Cambodia, along with other nations affected by AIDS. The World Health Organization gives the country technical and financial support to prevent STDs, develops surveillance for HIV/AIDS and STDs, and works to ensure safe blood supplies and to provide care to people who are infected with HIV or STDs.
Other organizations, such as UNICEF, are working to prevent HIV transmission among young people and are protecting children from sexual exploitation. Still other groups supply condoms, train reproductive health information and service providers about HIV/AIDS, create education and communication programs, and offer education activities to children of school age.
Despite current international efforts, Cambodia's epidemic is spiraling out of control, and more financial and technical resources are urgently needed, Manthey says.
"The key to stopping the epidemic is in the hands of the Cambodian people themselves," he says. "However, the international community definitely has a role to play in the response in Cambodia."
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