1. Workshop on HIV and AIDS related Research Agenda in Cambodia 28-29 March 2007 28-29 March 2007 Dr. MEAN CHHI VUN NCHADS Director mchhivun@nchads.org

2. HIV/AIDS situation in Cambodia First HIV detected in 1991 and first AIDS case diagnosed in 1993 Main route of HIV transmission: heterosexual In 2003: Estimated adult population infection rate: 1.9 % Estimated number of PLHAs among adult population: 123,100 (women 57,500) and AIDS patients: ~ 20,000 No official data on HIV infected children (estimated number was 9,000 HIV infected children including 3,000 AIDS patients) Estimated number of children newly infected through infected mother per year: 300 (under PMTCT); ~ 2540 (without PMTCT)

3. Bridging High risk Men Spouse HIV, STI  A : Abstinence (Youth & Young People...)  B : Be faithful (Spouse...)  C : Condom used with multiple partners

4. Route of HIV Transmission over time in Cambodia Source: ‘AIDS in Asia: Face the facts’, MAP, July 2004

5. Summary of Prevention activities Summary of Prevention activities100%CUP STI case management IEC/BCC Health Workers Local Authority Police brothel owners - CUMEC - CUWG - POT Sex workers Special campaigns (Posters, leaflets, bill boards…) Media (TV, radio, News paper) STD Clinic 200 HCs (syndromic approach) HC 33 clinics (Laboratory diagnosis) Advocacy Monitoring

6. Prevention Activity: STI Case Management  STI case management for entertainment workers introduced in 1998  33 special STI clinics providing services for sex workers in 22 provinces (except Kep and MondulKiri).  STI syndromic approach for general population implemented in 1998  In 2007, 200 selected Health Centers providing integrated STI services in 24 provinces.

7. Outreach and Peer Education Activity  In 2006: OPC are implemented in 61 Districts (High Risk Areas) of 186 AD  DTOP operated by NGO to cover all entertainment workers  Coordination and Monitoring: PHD/PAO and OD team

8. Knowledge of HIV in Cambodia

9. Consistent Condom Use with Clients: Female Groups Percentage

10. Consistent condom use with sex worker in past 3 months %

11. Beer Girls - Consistent Condom Use by Type of Partner* % * condom use with client among those with clients; condom use with sweethearts among those with sweethearts

12. Brothel-based sex workers - Consistent Condom Use by Type of Partner %

13. Adjusted HIV prevalence* among DFSW, by age group and year, 1998-2003 *Adjusted for results of quality assurance testing

14. Adjusted HIV prevalence* among IDFSW, by age category and year, 1998-2003 *Adjusted for results of quality assurance testing

15. Adjusted HIV prevalence* among ANC women, by year, 1996-2003

16. Estimated National HIV Prevalence* among Adults Aged 15-49, 1995-2003, Cambodia * From the modeled numbers of PLHA

17. Incidence trends among different sentinel groups in Cambodia Source: Vonthanak Saphonn, Doctoral dissertation, UCLA, October 2003 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% CSWIDSWPOLICEANC 199920002002

18. Estimated number of people aged 15-49 living with HIV/AIDS, 1990-2003, Cambodia

19. Condom use, HIV prevalence, Brothel-based SWs, 1996-2003, Cambodia Condom use HIV prevalence

20. CARE and TREATMENT for PLHA and AIDS Patient including HIV infected and affected children: CONTINUUM of CARE (CoC)

21. HIV/AIDS Treatment and care in Cambodia: before 2003 OI & ART commenced in few centres in Phnom Penh in 1999 (OI), (ART) 2001. Then expanded to a few provinces – by NGOs Home-based care commenced in Phnom Penh and a few provinces in 1998 VCCT centers confined in Phnom Penh and provincial towns (fewer than 20 ) in 1996 PMTCT demonstration project in NMCHC (NOV 2001) Pediatric AIDS Care started in 2003 in NPH No systematic framework for continuum of care especially linkages of relevant services within hospital and between HBC

22. Lab support OI/ART (adults) TB Services Public Health Facility Health service delivery IPD MMM COMMUNITIES / VILLAGES OTHER CBOs HBC PLHA SUPPORT GROUPS PLHAs Comprehensive CoC in Cambodia OI/ART (children)  Family Private clinics (VCCT…… etc) NGO clinics (VCCT, STD… etc.) Maternity mmm OPD/Health centre (VCCT, ANC, etc.)     PMTCT TB/HIV

23. VCCT  VCCT: entry point for both Prevention and Care  First VCCT established in 1995 at Institute Pasteur of Cambodia  Between 1996-2001 - 6 VCCTs:  4 VCCTs - stand-alone  2 VCCTs – integrated in the Public Hospitals  From 2002 to Dec 2005, 102 new VCCT sites established:  73 VCCT sites - in the public health sector  24 VCCT sites – NGOs (RHAC, Center of Hope, K. Angkor Hosp, Maristopes)  5 VCCT sites – Private Clinic: Sun Health Quality Clinic (PSI)  By end of December 2005 : 109 VCCT sites in all provinces  Plan by 2006: 160 VCCT sites => Achievement in 2006 = 150 VCCT sites  Increasing VCCT uptake: HBC, PLHA Network, PITC (providers initiated testing and counseling)  QA for HIV counseling through counselor network (Provincial, Regional)  QC in collaboration with Pasteur Institute (yearly basis)

24. Trend in number of people tested for HIV from 1997 to December 2006 Average client-load per VCCT increase from 65 per month In 2003 to 165 per month in 2006

25. Result of HIV Testing, 2005-2006 : 101 Sites : 138 Sites (150 sites)

26. VCCT Sites, December 2006 40 December 2006 = 150 sites

27. By 2006: Achievement of the Continuum of Care for PLHA  CoC for Adult pop. in 36 ODs (44 OI and ART sites) at 19 Provinces;  20,131 AIDS patients are on ART including 1,787 children

28. Pediatric AIDS CARE  Pediatric AIDS Care integrated into CoC package, implemented by pediatric services at RH – introduced 2005.  Pediatric AIDS Care: As of Dec 2006 = 18 sites 2003: 1 site at NPH (collaboration with Maryknol) 2003: 1 site at NPH (collaboration with Maryknol) 2004: 3 sites (Komar AngKor, AKSH, Maryknol) 2004: 3 sites (Komar AngKor, AKSH, Maryknol) 2005: 4 sites (Takeo, KgCham, SRieng, SHNVille) 2005: 4 sites (Takeo, KgCham, SRieng, SHNVille) 2006: 10 sites (C.Neas, NLoeung, BBang, KKong, Kg Speu, SSPhon, Kg Chhnang, SHC/NCHADS, Pursat, MAGNA) 2006: 10 sites (C.Neas, NLoeung, BBang, KKong, Kg Speu, SSPhon, Kg Chhnang, SHC/NCHADS, Pursat, MAGNA)  2006: 1787 HIV inf. children on ART  2007 Plan : 8 new sites (Prey Veng, KgThom and Kampot, Romeas Hek, Koh Thom, Maung Reussey, Kirivong, Kratie)

29. Number of patients receiving ART (35.7%) (53.7%) (56.4%) Number of patients receiving ART as of December 2006 Number of patients receiving ART as of 2005 (59.5%) (80.5%) (83.38%)

30. OI and ART Sites, 2006 7                  Adult : 44 sites Pediatric : 18 Sites Plan 2007: 6 Sites Plan 2007: 8 Sites        

31. Home & Community Based Care (HCBC)  HCBC established in 1998 with 8 HBC teams, organized by NCHADS/ WHO  From 1998-2000: 48HCBC teams performed in 4 Provinces: KCN,BTB, SHV and SRP.  As of Dec 2006: 292 HCBC teams in 18 provinces and Phnom Penh supporting 22,634 PLHA – now NGOs managing

32.  Reduce stigmatization and discrimination of PLHA by care givers  Bringing all stakeholders (local authorities, PH officers, Clinicians, Counselors, Religious, NGOs, CBOs, HBC, PLHA) to work together to support PLHA  Linkage between the community responsibility and the clinical care and support to PLHA  Started : 23 August 2003 in Maung Russey OD  On average : 200 PLHA participate monthly in MMM monthly activities (meditation, exercise, dialogue  sharing experiences, income generating, side effects, health education, reproductive health, relevant care services, medical care and treatment).  By 2006: 36 MMMs Mondul Mith Chuoy Mith (MMM) - RIPA

33. PLHA Peer Support Groups  CPN+ established in July 2001  By 2006: 640 peer support group networks in 14 provinces with 29,064 members.  Involving in policy, strategy, guideline formulation, and MMM activities. Meetings between HCBC network and PSG network conducted once every quarter.  PPN+ network at provincial level and DPN+ network will set up at district level in 2006.

34. PMTCT SITES COMPARE WITH OI/ART in 2006

35. Referral and Follow up Mechanism for Mother and Baby Referral and Follow up Mechanism for Mother and Baby

36. ANC Integration of PMTCT, Pediatric AIDS Care, and Early Diagnostic Services for the HIV-Exposed Infant Pediatric AIDS care, Pediatric Services (Testiing, Cotrimoxazole prophylaxis, OI treatment OI & ART ServicesMaternity WardMother Class Follow-up: ZDV Regimen Start ART Voluntary HIV Testing (accepted referral) HIV Education, Reproductive Health, Infant Feeding, etc. Refer all mothers. HIV- Mother HIV+ Mother CD4>250 CD4<250 Delivery Midwife Follow-up HCBC

37. Role of Community Based Care to Support PMTCT Plus - HBCs - NGOs OI & ART Services 20,131 ART Pediatric AIDS Care in 2006 1787 on ART mmm - HBCs - NGOs - CBOs ANC (HIV Testing) MMM Referred Follow up HIV+ Community

38. Laboratory Support for OI/ART  Before July 2005: cost for CD 4 testing was $14/test  main barrier for accessing ART  Through leasing agreement of CD 4 FACS Count machines: CD 4 testing is free (subsidized by partners)  42,000 tests in 2006  CD4% for children are available at IPC and NIPH  Upgrading general laboratory: PCR (viral load and Real time PCR): 4 machines (NIPH, IPC, UHS) PCR (viral load and Real time PCR): 4 machines (NIPH, IPC, UHS)

39. Capacity Building  Set up OI/ART team in RH: 8 members (2 clinicians, 2 nurse ART counselors, 1 logistic officer, 1 X-Ray, 1 lab. Technician, 1 team leader)  Training programmes: Training curriculum already developed: OI/ART for clinicians is 5-month course, ART Counseling is 3-week course, logistics management is 3- week course; OI/ART for pediatricians is 5- month course. Training curriculum already developed: OI/ART for clinicians is 5-month course, ART Counseling is 3-week course, logistics management is 3- week course; OI/ART for pediatricians is 5- month course. Training activities: (1) OI/ART for clinicians: 125 clinicians trained (5 th Batch); (2) ART counseling: 82 counselors trained (4 th Batch), (3) Logistic Management: 30 logistic officers trained (3 rd Batch); (4) OI/ART for pediatricians started in Aug 1, 2006 with 23 participants. Training activities: (1) OI/ART for clinicians: 125 clinicians trained (5 th Batch); (2) ART counseling: 82 counselors trained (4 th Batch), (3) Logistic Management: 30 logistic officers trained (3 rd Batch); (4) OI/ART for pediatricians started in Aug 1, 2006 with 23 participants. Secondment training for clinical practice at National Hospitals for two weeks before commencing OI/ART services Secondment training for clinical practice at National Hospitals for two weeks before commencing OI/ART services

40. Challenges (1)  Sex work shifting from brothels to other entertainment venues (karaoke, massage parlours, beer gardens, etc)  100% Condom use programme covers only Brothel-based Sex Workers  Implementation revised Outreach and PE Strategy for sex workers outside brothels  Need strategies for emerging situations: MSM, IDU, youth  Ensuring quality and coverage of STI services  Maintaining long-term HIV prevention efforts in situation of declining prevalence and incidence

41. Challenges (2)  Limited Access to Pediatric AIDS Care (Human resources, facility, laboratory,...);  Poor coordination and collaboration between HBC and Health Facility to increase PMTCT uptake;  Slow extension and expansion of the model of good referral mechanisms and linkages between HBC and HFC, as well as relevant services within CoC (PMTCT, Pediatric AIDS Care, OI/ART,...)  Limited capacity of integrated monitoring and data management of CoC (PMTCT, Pediatric AIDS Care,...)

42. Conclusion The programme is committed to Universal Access: with ownership, targets, political commitment, capacity building and appropriate technical decision-making…. …with wide-ranging partnerships to utilize the contribution of all stakeholders……and committed to effective, transparent, accountable management – and high quality services.

43. THANK YOU