By Dr. Mean Chhi Vun, Director, National Center for HIV, Dermatology and STDs, Ministry of Health Cambodia
In the mid-1990s, Cambodia faced one of the fastest growing HIV epidemics in Asia and became within five years one of the few countries to have reversed its trend. Cambodia received a millennium development goal (MDG) award in 2010 from the United Nations as a global recognition of the country’s response to HIV. My plenary presentation reviewed Cambodia’s response in the past two decades and included a discussion of the way towards Elimination of New HIV infections in Cambodia.
Cambodia has had a three-phase response to HIV.
Phase 1 (1991 – 2000)
The country confronted HIV under extremely vulnerable conditions in the early 1990s as the country emerged from instability. Fuelled by unprotected sex work, HIV and STIs spread rapidly through networks of sex workers and clients in the early to mid-1990s. Early interventions focusing on HIV and STI prevention in sex work settings from 1998 to 2001 began to slow transmission. Self-reported condom use in sex work increased from less than 40% in 1996 to consistently over 90% since 2001. HIV prevalence among direct brothel-based sex workers decreased from 42% in 1996 to 14% by 2006. Reported STIs declined by more than half between 1996 and 2001 among both sex workers and high-risk males.
Phase 2 (2001 – 2011)
Rapid scale-up of HIV counseling, testing, care and treatment took place during this period.
Voluntary Confidential Counseling and Testing was expanded to all 77 operational districts and one in five health centres. Provider-initiated testing and counseling targeted to TB cases and pregnant women were scaled-up to most health centres. ART was made available in 55 of the 77 operational districts where 92% of HIV-positive cases were found.
A key strategy was expanding HIV Continuum of Care (CoC). This approach involved establishing community linkages so that those who are at high risk are encouraged by home-based care teams or self-help groups to access HIV testing and counseling and then linked to early care and treatment at district-level hospitals. Once patients enrolled in pre-ART care, with the help of PLHIV volunteers at the hospitals, they are referred back to home-based care teams or self-help groups to be supported in their own communities. Systematic linkages between HIV and MCH services (Linked Response; LR) and HIV and TB services were also expanded.
As a result, HIV testing coverage among pregnant women and TB cases increased progressively to over 75% while the coverage among sex workers, MSM and PWID remained low; 65% (2010), 51% (2010) and 53% (2007), respectively. ART coverage exceeded 80% and retention during ART at 12, 24 and 60 months achieved 92.6%, 84.2% and 78.0%, respectively. Since 2009, HIV prevention among MARPs and their linkages to HIV testing and counseling and other services (Continuum of Prevention to Care and Treatment; COPCT) has been intensified in collaboration with NGOs.
These efforts resulted in a decline of HIV prevalence from an estimated 1.7% (among adults aged 15-49) in 1998 to a projected 0.7% in 2011. The estimated number of new HIV infections plummeted from 20,000 annually in the early 1990s to around 1300 in 2012.
Phase 3 (2012-2020)
Building on the progress made during the previous phases, a new initiative “Cambodia 3.0” has been launched. The Cambodia 3.0 aims to achieve the elimination of new HIV infections by 2020 with the implementation of the three main components;
(i) Elimination of mother-to-child transmission through Boosted Linked Response;
(ii) MARPS prevention and links to health services through Boosted COPCT; and
(iii) ART as Prevention as part of the Boosted CoC
A consolidated package of services and their systematic linkages will be expanded starting from high burden operational districts while intensive efforts will be made to strengthen surveillance and case reporting and program monitoring systems and to produce evidence-base to inform the adjustment of the Cambodia 3.0 strategies. Interim review of the strategies including mathematical modeling will be conducted in 2015.