The HIV/AIDS Rate in Cambodia is going down: How was it done? Good Governance: Implementing Behavioral Change April 29-30, 2004, Sunway Hotel Phnom Penh, Cambodia Ty Chettra, MD, MPH Ty Chettra, MD, MPH Country Director The POLICY Project Cambodia

Outline Background Background Strategic framework Strategic framework Specific objectives regarding behavioral change Specific objectives regarding behavioral change Actions taken Actions taken Empirical evidence of success Empirical evidence of success Challenges ahead Challenges ahead Lesson learnt Lesson learnt Conclusion Conclusion

Background (1) First case of HIV infection diagnosed in 1991 First case of HIV infection diagnosed in 1991 First person diagnosed with AIDS in 1993 First person diagnosed with AIDS in 1993 National prevalence rate among adults aged dropped from 3.3% in 1997 National prevalence rate among adults aged dropped from 3.3% in 1997 Estimated 157,000 people living with HIV/AIDS Estimated 157,000 people living with HIV/AIDS Unprotected sexual intercourse with many partners is the main cause of transmission Unprotected sexual intercourse with many partners is the main cause of transmission

Background (2): HIV/AIDS in South East Asia, 2000 CountryCambodiaThailand Viet Nam Lao PDR Myanmar HIV prevalence 2.6% 1.8% 0.3% 0.05% %

Strategic Framework HIV/AIDS is not a health, but a social development issue HIV/AIDS is not a health, but a social development issue Fighting HIV/AIDS has been going through behavioral change at all level: Fighting HIV/AIDS has been going through behavioral change at all level:  Individual  Family  Community  Society

Specific Objectives regarding BC Getting the prevalence of HIV/AIDS infection down among target groups and general population Getting the prevalence of HIV/AIDS infection down among target groups and general population Generate an enabling social and policy environment for PLWHA living free from stigma and discrimination Generate an enabling social and policy environment for PLWHA living free from stigma and discrimination Mobilize national and international resources to fight HIV/AIDS and to address its socio- economic impact Mobilize national and international resources to fight HIV/AIDS and to address its socio- economic impact

Actions taken (1): Outline Specific intervention: 100% condom use Specific intervention: 100% condom use IEC campaigns with peer educations IEC campaigns with peer educations Faith-based interventions Faith-based interventions Establish a Multi-sectoral framework Establish a Multi-sectoral framework Formulating law and policies Formulating law and policies Empirical evidence of success and of further policy & strategy development Empirical evidence of success and of further policy & strategy development

Actions taken (2): Specific intervention - 100% CUP Promoting ‘always using condom when having sex’ – no condom, no sex Promoting ‘always using condom when having sex’ – no condom, no sex Involvement of wide range of stakeholders - local government, police, and brothel owners Involvement of wide range of stakeholders - local government, police, and brothel owners Potential to create normative behavior concerning condom use Potential to create normative behavior concerning condom use Placing responsibility for condom use with brothel owners and not just with sex workers Placing responsibility for condom use with brothel owners and not just with sex workers

Actions taken (3): IEC & Peer Educations All relevant sectors including uniform sectors, youth, and workers All relevant sectors including uniform sectors, youth, and workers Promote normative prevention behaviors and practices: protected sexual intercourses with one partner Promote normative prevention behaviors and practices: protected sexual intercourses with one partner Having reduced stigma and discrimination and greater support and care to PLWHA Having reduced stigma and discrimination and greater support and care to PLWHA Lots of technical and financial resources have been used to develop IEC materials and to conduct training Lots of technical and financial resources have been used to develop IEC materials and to conduct training

Actions taken (4): Faith-based interventions Using religious theory & principles to promote HIV/AIDS prevention Using religious theory & principles to promote HIV/AIDS prevention Depending on believe & trust of people to religious organizations Depending on believe & trust of people to religious organizations Changing from traditional perception on social roles of religious organizations Changing from traditional perception on social roles of religious organizations Effective in reducing stigma & discrimination and greater care and support to PLWHA Effective in reducing stigma & discrimination and greater care and support to PLWHA Need commitments and support from its hierarchy Need commitments and support from its hierarchy

Actions taken (5): Development a multisectoral framework NAA Established in 1999 NAA Established in 1999 Cross-government multi-sectoral policy and coordination body for Cambodia’s response to HIV/AIDS Cross-government multi-sectoral policy and coordination body for Cambodia’s response to HIV/AIDS Members represent 26 line Ministries, Cambodian Red Cross, and 24 provinces and municipalities Members represent 26 line Ministries, Cambodian Red Cross, and 24 provinces and municipalities Based on community involvement, gender equality, respect for human rights principles Based on community involvement, gender equality, respect for human rights principles

Actions taken (6): Development a multisectoral framework (cont.) NAA strategic plan is a holistic approach involving government, civil society, international community and PLWHA NAA strategic plan is a holistic approach involving government, civil society, international community and PLWHA Strategies to fight HIV/AIDS was included in the National Poverty Reduction Strategy (NPRS) Strategies to fight HIV/AIDS was included in the National Poverty Reduction Strategy (NPRS) Institutional policies were developed to fight HIV/AIDS Institutional policies were developed to fight HIV/AIDS Strong support from international community, e.g UNAIDS, Global Fund Strong support from international community, e.g UNAIDS, Global Fund

Actions taken (7): Formulation Law on the Prevention and Control of HIV/AIDS Passed in June 2002 Passed in June 2002 Prohibition of discrimination Prohibition of discrimination Prohibition of HIV screening in connection with employment, education, freedom of movement or abode, the provision of medical services Prohibition of HIV screening in connection with employment, education, freedom of movement or abode, the provision of medical services Legal protection of confidentiality of information about a person’s HIV/AIDS status Legal protection of confidentiality of information about a person’s HIV/AIDS status Comprehensive epidemiological monitoring Comprehensive epidemiological monitoring

Actions taken (8): facilitation the Implementing the HIV/AIDS Law An implementing Code of Conduct has been drafted to: Explain the law in plain language Explain the law in plain language Identify the people and institutions with responsibilities under the law Identify the people and institutions with responsibilities under the law Identify means and timetables for fulfilling these responsibilities Identify means and timetables for fulfilling these responsibilities

Empirical evidence of success(1): Reduced HIV/AIDS Prevalence

Empirical evidence of success (2): Consistent Condom Use with Clients, Source: NCHADS, BSS, 2004

Challenges ahead Fighting HIV/AIDS is conflicting with other social development agenda, Fighting HIV/AIDS is conflicting with other social development agenda, Implementation of multisectoral framework is always difficult and some time not feasible Implementation of multisectoral framework is always difficult and some time not feasible Questions of sustainability Questions of sustainability Stigma, discrimination and Human rights violation against PLWHA remain a critical problem Stigma, discrimination and Human rights violation against PLWHA remain a critical problem

Challenges ahead: Sexual behaviors MilitaryPoliceMoto Mean age at 1 st sex % 1 st sex partners : Wife Wife Sweetheart Sweetheart DFSW DFSW IDFSW IDFSW Source: NCHADS, BSS, 2004

Challenges ahead: Reasons for not using condoms with sweethearts Source: NCHADS, BSS, 2004

Lessons learnt (1) Political commitment and support from all level are essential to the success of the program to fight HIV/AIDS Political commitment and support from all level are essential to the success of the program to fight HIV/AIDS Resources and support mobilized from national and international community have significantly contributed to the success Resources and support mobilized from national and international community have significantly contributed to the success Behavioral change is center Behavioral change is center Behavioral change can be done by a combination of different actions Behavioral change can be done by a combination of different actions

Lessons learnt (2) Building holistic approaches with multisectoral engagement and framework has added value to behavioral change Building holistic approaches with multisectoral engagement and framework has added value to behavioral change Participation from all stakeholders including people infected & affected is of utmost importance Participation from all stakeholders including people infected & affected is of utmost importance Empirical evidence is needed for good governance and providing guidance for further actions Empirical evidence is needed for good governance and providing guidance for further actions

Conclusions Cambodia’s response to HIV/AIDS is recognized internationally for achieving successes Cambodia’s response to HIV/AIDS is recognized internationally for achieving successes Behavioral change is center to generate an enabling environment to fight HIV/AIDS Behavioral change is center to generate an enabling environment to fight HIV/AIDS Good governance can be reflected in HIV/AIDS program as it associates with responsibility, accountability, participation, evidence based and respond to needs of community and society Good governance can be reflected in HIV/AIDS program as it associates with responsibility, accountability, participation, evidence based and respond to needs of community and society