Vo 1 Aneka Vo Honors 391 HIV/AIDS: Issues and Challenges Professors Kasprzyk and Montao 07 June 2013 An AIDS-Free Generation

n in Cambodia 1991the first case of HIV is detected in Cambodia. By 1997, the prevalence rate has escalated to two percent, among the highest in Asia. By 2012, however, that rate has dropped to 0.7 percent. This can be attributed to Cambodias high antiretroviral therapy (ART) coverage rates, one of the best among low and middle-income countries. What makes this feat even more remarkable is that Cambodia was able to achieve this despite having a politically unstable past and being one of the lowest-income countries in the Southeast Asia.1 Cambodia has one of the most successful campaigns against HIV/AIDS, leading the World Health Organization (WHO) to predict that Cambodia will achieve zero transmissions by 2020.2 The US Obama Administration has set a goal to achieve an AIDS-free generation (a goal of zero HIV infections). Will Cambodia be able to reach this goal by the end of this decade (2019) and meet WHO predictions? How will it be achieved? This paper will discuss the programs that have made the campaign against HIV/AIDS in Cambodia so successful. It will also include recommendations for improvement that will help Cambodia achieve an AIDS-free generation by 2019. EPIDEMIOLOGICAL OVERVIEW (Disease Transmission and Spread) Following a high of 2 percent in 1997, the HIV prevalence rate has progressively dropped to 0.7 percent among the general population (people aged 15 to 49) by the end of 2012. This is a high estimate, as some sources indicate the rate has dropped to 0.5 percent.3 63,000 of the 13.8 million people in Cambodia are estimated to be HIV positive.4 This translates to an infection

Vo 2 rate of approximately 1,202 people over the age of 15 per year.5 The main risk groups are female entertainment workers (FEW), injection drug users (IDU), and men who have sex with men (MSM). The most recent available data indicate the following prevalence rates among these risk groups: 13.9 percent among female entertainment workers, 24.4 percent among injection drug users, and 2.1 percent among men who have sex with men.6 Beyond sexual activities and infected needles and syringes, HIV can be transmitted from mother to child (MTCT) through birth or breastfeeding. It is estimated that 11.4 percent of children born to HIV-positive mothers in Cambodia acquire the virus.7 There are approximately 8000 HIV-positive children in Cambodia.8 TESTING AND ANTIRETROVIRAL USE While Cambodia has one of the best antiretroviral therapy (ART) coverage programs for those that have been identified as needing it, this does not provide a full representation of the situation, as there are many people who need ART but have not been tested and identified. Only 69.0 percent of women and 69.3 percent of men report knowing where to get tested, and of these, only 23.3 percent of women and 24.2 percent of men have ever been tested and received results. Over 75 percent of men and women who know where to get a test have never been tested.9 This indicates that while the 92 percent ART coverage rate10 is impressive and among the best in the world, efforts need to be made in order to test a larger proportion of the population to identify everyone that is in need of the treatment. The National Center for HIV/AIDS, Dermatology, and STDs (NCHADS) has expanded services in an effort to provide testing and care for a greater proportion of the population. It expanded its Voluntary and Confidential Counseling and Testing (VCCT) services from 12 sites

Vo 3 in 2000 to 246 sites by 2010.11 Also, as one of the 22 countries in the world with a high burden of tuberculosis (TB),12 programs have been created to integrate HIV testing with TB treatment programs. To simplify the process, patients that come into TB clinics have blood samples sent to be tested for HIV. By referring blood samples rather than patients, HIV testing rates among TB patients have increased from approximately 50 to 90 percent.13 Additionally, return visits to the TB clinic allow providers to talk with patients about the importance of testing. Patients who return to TB clinics while receiving care are likely more receptive to what their providers tell them about HIV. They are already trying to improve their health and would likely be more willing to follow their providers advice in regards to other health matters, such as HIV. What has allowed such widespread treatment for HIV/AIDS is that the health system focuses on decentralizing HIV care rather than centering it on HIV/AIDS specific clinics. Additionally, many factors were taken into consideration in decentralizing the care, including the geographical distribution of needs, physical access to health facilities, the capacity and caseload per health facility, and management and technical support services to maintain the quality of care.14 The Continuum of Care (CoC) Framework established in 2003 sought to unite health workers, people living with HIV/AIDS (PLHIV), their families, and the community in their efforts in fighting HIV/AIDS by establishing district-based services that encouraged team work, community linkages, and a public health approach.15 Current plans indicate a goal to expand the number of health centers to 1697 by 2015, a significant increase from 957 in 2007. There are also plans to increase the number of referral hospitals from 74 in 2007 to 89 in 2015.16 In addition to health facilities, there were 356 home-based care teams that linked to 848 health centers in 2010.17

Vo 4 Cambodia was able to reach 92 percent ART coverage by 2010 through expansion of services.18 This overall coverage rate includes 96 percent coverage among adults and 71 percent among children.19 The country only had 3 sites with ART services in 2001, with none providing pediatric ART. By 2010, that number increased to 51, with 32 of those providing pediatric ART.20 Current country guidelines state that ART should be started at WHO clinical Stages 3 and 4 for everyone, regardless of their CD4 count. If a patient is in Stage 2, ART should be started if the CD4 count is less than 350 cells/mm3, the patient has a TB co-infection, or is pregnant.21 Patients categorized as being in Stage 1 are asymptomatic and have generalized lymphadenopathy. Stage 2 patients may have angular chelitis and recurrent oral ulcers. Stage 3 patients may have persistent oral candida, oral hairy leukoplakia (OHL), and tuberculosis (TB). Stage 4 patients may have HIV wasting syndrome, Kaposis sarcoma, and lymphoma.22 Additionally, CD4 counts are sufficient indicators of when to start ART. An HIV viral load test is not required, and guidelines indicate that treatment with antiretroviral drugs should not be delayed if labs cannot be completed within two weeks.23 STIGMA Stigmatization of HIV/AIDS is high among the Cambodian population, as it is in other countries. This is largely due to the fact that it is a sexually transmitted disease and is currently incurable. While surveys indicate that people are relatively accepting of others with AIDS, their reluctance in making that news known to others shows the large impact stigma has on discussing the topic. 83.3 percent of women and 91.5 percent of men surveyed indicated that they were willing to care for a family member with AIDS in their home. 79.1 percent of women and 82.4 percent of men responded that they would buy fresh vegetables from a shopkeeper with AIDS. 88.9 percent of women and 90.2 percent of men indicated that they believed a female

Vo 5 schoolteacher should be allowed to keep teaching if she had AIDS but was not sick.24 These numbers support that people are aware of how HIV can be transmitted, as they appear to be accepting of others HIV statuses. However, when asked about whether they would want to keep the status a secret, only 56.3 percent of women and 48.4 percent of men responded that they would not want to do so.25 This shows that fear of judgment is still a factor in seeking HIV prevention and treatment. As a part of the CoC, the Mendul Mith Chouy Mith (MMM, or Center for Friends Help Friends) was established.26 In addition to providing referrals for health care services, the program includes social support and community education for PLHIV. The program also contains a pediatric component for children whose parents were utilizing MMM services. The pediatric MMM encourages children to adhere to their treatment regimens and provided them with a place to relax, play, and receive support.27 The MMM programs provide an outlet for patients where they will not be judged or stigmatized. POPULATION TESTING AND TREATMENT IMPROVEMENTS While improvements to prevention and treatment plans are necessary to target high risk groups, there are changes that can be made on a population level that will help Cambodia achieve zero HIV infections. Accessibility to Testing To increase testing, there should be increased usage of rapid tests. Providing these tests at all health centers will drastically increase the number of tests done, as blood samples do not need to be sent away to be tested. Additionally, patients are more likely to receive their results

Vo 6 as they only have to wait a short period of time rather than having to return on a later date to receive their results. Setting up programs for rapid testing in community centers will expand testing coverage, making testing coverage available at locations that are already being visited for other reasons. The establishment of a mobile testing facility (such as a van) that uses rapid tests could also increase testing by traveling to sites where large concentrations of people can be reached. This also eliminates the need for people to travel to health facilities, which is often a barrier to getting tested. Additionally, all patients seeking emergency or scheduled care should be tested, regardless of the reason they are seeking care. Patients are more likely to agree to get tested if they are already at the clinic than if they have to return or travel to another location. In order to reach zero transmissions, testing needs to be made readily accessible to the entire population. HIV testing should be made a routine part of seeking healthcare by integrating it into all healthcare visits, especially if the patient is at high risk for HIV. Adherence Equally important to ART coverage is ART adherence. This is especially true in Cambodia, as a third-line regimen is not available if patients gain resistance to their medications.28 This is why it is more important to support adherence than to simply assess it. Services need to focus on the needs of the patient, as there are various contributing factors that influence adherence, such as side effects or issues with timing or number of pills. It should also be made clear to patients that stopping their treatment, while making them feel better in the short term, will put them at risk for resistance and could potentially leave them without a source of successful treatment. Adherence will lower the rate of HIV resistance, allowing treatments to be more successful. Adherence also keeps patients viral loads down, lowering the risk of transmission.

Vo 7 New Drugs Additional ARV drugs need to be made available in Cambodia if it is to maintain and increase the level of success it has had in fighting HIV/AIDS. This is especially true because of the viruss extremely high mutation rate. Currently, patients are instructed to continue their regimens even if they are failing, if other drugs are not available. Care providers then have to contact HIV/AIDS experts to see if there is an alternative regimen that may be more successful in suppressing the virus.29 Having third-line regimens readily available will increase the rate of successful treatment by providing a means to fight resistant strains. This will decrease the viral load and decrease transmission. Condom Use As one of the most effective methods of preventing HIV transmission, use of condoms needs to be increased. Condoms should be made available at all healthcare facilities, and their use should be encouraged as a way for men and women to protect themselves as well as their loved ones from HIV, other sexually transmitted infections, and unwanted pregnancies. Male Circumcision Randomized control trials have shown that that male circumcision has a 60 percent protective effect on HIV infection, and more recent data shows that this rate has increased to approximately 75 percent.30 In order to have a significant impact on AIDS prevention, the WHO has stated that 80 percent of men between the ages of 18 and 30 should be circumcised.31 Male circumcision is very uncommon in Cambodia, with fewer than 20 percent of men circumcised.32 Boosting male circumcision in Cambodia could lead to a significant reduction in

Vo 8 transmission that would aid in achieving an AIDS-free generation. With HIV infections primarily occurring through heterosexual contact, improving the rate of male circumcision even by small amounts will likely have an impact on transmission. With the practice being so uncommon in the country, it may be difficult to convince men to get the procedure done. Studies have shown that circumcised men are the most likely group to influence whether other men get the procedure.33 This is why it is important to identify men who have been circumcised to serve as peer educators advocating for the procedure. Additionally, the procedure should be made widely available. Resources and education about where to get the procedure done, details on the procedure, and the benefits should be provided in schools, community centers, and health clinics. Additionally, medical personnel trained to provide male circumcision should be available at all healthcare facilities so that all men have access to the procedure. The increase in use of technology and the resultant increase in the influence of media can be used to target young men between the ages of 18 and 30 who are most likely to be making use of new technology. Finding a famous and well respected public figure or celebrity to advocate for the procedure through short video ads could have a large impact on that group. As it is an uncommon procedure, men are likely uncomfortable with talking about the topic. However, if news of a celebrity advocating it is spread, the men may be more likely to look into the procedure and make use of the resources created. Adequate care and support services should be provided so that men who have the procedure done have a positive experience. That, in addition to the health benefits, will be encouraging factors. Other than concerns about the procedure itself, men report uncertainty about how the procedure would be received by women and their friends.34 The situation among their friends

Vo 9 can be addressed through the same methods that are used to advertise and advocate for the procedure. Similarly, resources and education should be provided to women through similar methods but targeting women rather than men. Approaching the topic as a means to protect themselves as well as their families could make women more receptive to the procedure. Dissipating the fear of disapproval and rejection by women will make men more comfortable about and willing to have the procedure done. Peer Educators The use of peer educators will provide people with an easy source to reach out to without feeling stigmatized, especially if the peer educator reaches out to them first. Peer educators can also be from and trained to target specific groups, making people more comfortable about being approached by them. As research has shown, it is important to train peer educators in how to effectively take that role.35 Addressing Stigma Widespread distribution of materials providing information about how HIV is transmitted can contribute to reducing stigma. This can be made more effective by using media outlets and having the support of popular and well respected public figures and celebrities. Exposure to information about HIV/AIDS in settings other than healthcare facilities will likely have a positive impact on lowering stigma by making people more comfortable with the topic. The more people know about what the disease is and how it is transmitted, the more that rumors and misconceptions will clear up, reducing stigmatizing opinions. MAJOR RISK GROUPS

Vo 10 The following sections will discuss specific treatment programs targeted at major risk groups. ENTERTAINMENT WORKERS The primary means of HIV transmission in Cambodia is through unprotected heterosexual contacts. This is largely due to the common practice of seeking sexual contact from entertainment workers. Entertainment workers are defined as individuals who sell sex, and the classification includes those formerly referred to as sex workers. The term used has changed from sex workers to entertainment workers as the work has expanded from brothels to other entertainment venues, such as karaoke bars. Risk Behaviors The high prevalence rate among entertainment workers is due to having unprotected sex with multiple partners. This not only puts uninfected entertainment workers at risk, but also their other sexual partners, such as their spouses, at risk. If the entertainment worker is infected, the virus can be transmitted to men who could in turn spread to other partners, such as their wives. This puts not only those directly involved in the risky behaviors at risk but also jeopardizes the health of their significant others as well. The network involving entertainment workers is extremely large and includes those that have never had sex with an entertainment worker. Current Statistics and Treatment Programs One of the programs that can be credited in lowering transmissions in Cambodia is the 100% Condom Use Program, which was implemented nationwide in 1999. Its implementation nationwide was a result of a successful 1998 pilot program in one province, Sihanoukville. The project was so successful that it increased condom use among sex workers from 43 to 93 percent.

Vo 11 The program required that condoms must be used in providing all sexual services, and closure of the establishment providing these services would be consequential for non-compliance.36 The program has made a significant impact on condom use in establishments that house sexual services. A survey among entertainment workers who have two or more sexual partners a day indicated that 95 percent used a condom with their last client. While this number is high, reported condom use with husbands (22 percent) and sweethearts (48 percent) was much lower.37 However, there are still undisputable benefits to the increased condom usage with clients. Entertainment workers are much less likely to become infected by the virus, and in turn are less likely to transmit to their husbands or sweethearts. Likewise, they are much less likely to infect clients who would otherwise put their significant others at risk. With the implementation of the 2008 Law on Suppression of Human Trafficking and Sexual Exploitation and the introduction of new technology, the success of the 100% Condom Use Program was curtailed. The 2008 Law on Suppression of Human Trafficking and Sexual Exploitation criminalized all forms of trafficking.38 This pushed sex workers to move their work from direct establishments such as brothels to other, more indirect, entertainment establishments, such as karaoke bars, saunas, and massage parlors, where they are much harder to identify. The development and widespread availability of technologies such as cell phones has also allowed work to shift outside of brothels. Clients can contact workers using their cell phones, dissipating the need for them to meet at a brothel or other entertainment venue.39 This shift is what resulted in the change from the term sex worker to entertainment worker. In 1995, only 30 percent of entertainment workers worked out of an indirect establishment, such as karaoke bars, but that has shifted to 90 percent in 2010.40 40 percent of beer promoters and 56 percent of karaoke singers have reported selling sex.41

Vo 12 This shift to the use of indirect entertainment establishments has made the 100% Condom Use Program much more difficult to enforce, as there is not a central location that serves as a base to sell sexual services. Additionally, it creates the difficulty of having to reach individual entertainment workers rather than direct entertainment establishment owners, who would enforce the policy with their workers to avoid closure of their establishment. Future Treatment Looking forward, entertainment workers need to be involved in the design of programs that are targeted at preventing infection involving them. With the shift in the selling of sexual services from direct entertainment establishments such as brothels to indirect entertainment establishments such as karaoke bars, entertainment workers become much harder to identify, and their behaviors much harder to track. Entertainment workers know best about their work and clients, and involving them in program design would aid in making a program that would successfully target that population. Additionally, the entertainment workers can act as peer educators among themselves. Making condoms readily available at entertainment venues that are occupied by entertainment workers will increase use as it eliminates the need to obtain the condoms from another location. Setting up facilities, even if temporary and transportable, near these locations with rapid HIV tests will make testing readily available. Encouraging people to get tested and making the testing easily accessible will increase the number of people who know their status. Educational materials should also be provided at these facilities to encourage people to use condoms in order to protect themselves and their significant others. People are more likely to take active measures to have safe sex if they know their status, as they want to protect others

Vo 13 from contracting the virus. If they are negative for the virus, they would be more willing to use protection in order to maintain that status. Most men are willing to use condoms to protect their wives, with 96.3 percent of men believing that women are justified in asking their husbands to use a condom if he has a sexually transmitted infection. While only 1.5 percent of men report having two or more sexual partners in the past 12 months, only 39.5 percent of them used a condom during their last intercourse.42 This puts both of their partners, as well as themselves, at risk. Even if a man is faithful to his wife, the average number of sexual partners a man has had is 2.8, while that for women is approximately 1.43 This means that men could potentially transmit to their wives if they contracted the virus prior to meeting her. As entertainment workers are one of the major risk groups for HIV transmission in Cambodia, making changes to programs to adapt to changes in entertainment work are essential in maintaining the work that has already been done to prevent HIV transmission. Improvements upon this can only be made if the work already done can be sustained. INJECTION DRUG USERS The second largest means by which HIV is transmitted in Cambodia is through the use of injection drugs. Risk Behaviors High infection rates among injection drug users are due to sharing of contaminated needles and syringes. Additionally, the use of drugs can compromise judgment, leading to increased unprotected sexual activities, which increase the risk of HIV infection.

Vo 14 Current Statistics and Treatment Programs In 2010, two NACD-licensed needle and syringe exchange programs were initiated. Both of the programs are located in Phnom Penh.44 There are approximately 2100 injection drug users in Cambodia, and the program provides an average of 43.8 syringes per user.45 The program seeks to prevent transmission of HIV and other infectious diseases transmitted through blood by discouraging the use of shared needles. Also in 2010, a methadone maintenance treatment (MMT) program was established, and in four months had 61 heroin users enrolled. Although only 16 percent of the users were HIV-positive and on ART, it was successful in lowering transmission risks due to the fact that it reduced heroin use from four to one time a day.46 The less injection drugs are used, the fewer opportunities there are for HIV infection. Current law in Cambodia requires detention of drug users in compulsory drug centers.47 While this could be beneficial in the campaign against AIDS if proper treatment was provided to the users, this is not the case. Oftentimes, compulsory drug centers lack effective, evidencebased treatment programs. Additionally, they may be increasing transmission rates, as it is usually the case that they do not provide condoms or sterile injection equipment.48 Future Treatment Detention of drug users in compulsory drug centers is doing more harm than good. Conditions in these centers increase the risk of HIV transmission, which is the opposite of what they should be doing. Additionally, there have been claims of torture and violence against detainees.49 As a result, in order to stop what is happening in these centers and to reduce HIV transmission, these centers need to be closed. If they are to remain open, significant changes need to be made.

Vo 15 First and foremost, for the health and well-being of detainees, the issues of torture and violence against the detainees should be resolved. Due to the scope of the issue, however, details on how this will be done will not be discussed in this paper, but they should involve education and replacement of those working in the centers. The most important issue that needs to be dealt with in terms of HIV prevention is to address circumstances that encourage risky behavior. The first order of action that can be taken without addressing system-level issues is to provide condoms and sterile injection equipment. To address the underlying cause of these risky behaviors, drug addiction rehabilitation programs need to be established. Programs that are necessary to prevent HIV transmission should be primarily focused on injection drug users. These should include methadone maintenance treatment and counseling services. By establishing these drug centers as treatment facilities, injection drug users can be treated for their addictions, decreasing their participation in risky behaviors that put them at risk for HIV infection. These centers should allow for long-term treatment programs that will give users sufficient time to overcome their addiction, or they should refer patients to outside treatment centers for them to do so. While providing injection drug users with the resources to feed their addiction as safely as possible in terms of HIV prevention will reduce transmission, to get at the root of the problem and to eliminate these risky behaviors, treatment programs need to address these addictions and to help users overcome them. Encouragement to participate in a drug rehabilitation program should be given at sites of needle exchange programs, indicating incentives such as improvement in financial situation, as users need to spend a large amount of money to fund their addiction. MEN WHO HAVE SEX WITH MEN

Vo 16 Contrary to the stereotype that HIV/AIDS is a homosexual disease, men who have sex with men (MSM) and transgenders account for fewer HIV transmissions than heterosexuals (or those that participate in sexual activities between males and females) and injection drug users. Risk Behavior HIV transmission among MSM and transgenders (particularly individuals with male sex organs) can be attributed to the nature of sexual intercourse and decreased concerns about the necessity of condom use. Due to their anatomy, anal sex is the primary form of insertive sexual intercourse. This form of sex increases the likelihood of HIV transmission because the lining of the anus is more prone to tearing and breakage, providing a pathway for the virus to enter.50 Current Statistics and Treatment Programs Only 51 percent of MSM and transgenders have received an HIV test and results in the past 12 months. HIV prevention and treatment programs specialized for MSM and transgenders in Cambodia are extremely limited. The main program is Mens Health Cambodia (MHC), which has locations in Phnom Penh and Siem Reap. MHC aims to reduce high risk behaviors, increase health seeking behaviors, and strengthen referral networks for HIV care and support. MHC accomplishes these goals through education of peers and through outreach as well as distribution of condoms and lubricants.51 Future Treatments In order to reduce HIV infections to zero, the MHC program should be scaled up, providing more locations so that its services are accessible to all MSM and transgenders. Programs such as MHC are important in providing care for MSM and transgenders because of

Vo 17 the discrimination against them that is widespread in the health system. While it is important to address the issue of discrimination in health centers through education, MSM and transgenders are more likely to make use of MHC locations. Research supports that MSM prefer programs that are targeted rather than generic.52 Additionally, encouragement of condom use and lubricants needs to increase. Oftentimes condom use is neglected among these groups because they are not concerned about pregnancy. Program and education need to stress that condoms need to be used for reasons other than contraception. Lubricant use should be encouraged to further reduce the possibility of HIV infection by decreasing tearing and breaking of the skin during anal intercourse. MOTHER TO CHILD TRANSMISSION While mother to child transmission (MTCT) is not a major form of HIV infection in Cambodia, prevention of mother to child transmission (PMTCT) is a necessary component in achieving an AIDS-free generation. Risk Behaviors Transmission of HIV from mother to child can occur at birth or through breastfeeding. Fetuses cannot contract HIV from their mothers unless damage has occurred to the placenta, allowing exchange of mothers blood with fetuss blood. Under healthy conditions, the fetuss blood vessels are separated from the mothers by the placenta.53 Current Statistics and Treatment Programs To encourage pregnant women to test for HIV, antenatal clinics (ANC) can collect blood samples for testing from consenting women.54 Studies show that only 57 percent of pregnant

Vo 18 women were tested in 2010. Of those, only 49 percent that were HIV positive were on ART.55 Cambodian ART guidelines indicate that pregnant women who have a CD4 count of less than 350 cells/mm3 should start ART and continue it after the pregnancy. The recommended regimens for antenatal care and labor and delivery are either AZT + 3TC + NVP or AZT + 3TC + EFV. Women who have CD4 counts greater than 350 cells/mm3 should receive antiretroviral (ARV) prophylaxis with triple drug therapy starting from the 14th week of pregnancy until a week after breastfeeding is discontinued. The recommended regimen for antenatal through postnatal care is a combination of AZT, 3TC, and EFV. All infants are treated from birth for 6 weeks with NVP.56 The Linked Response program, implemented nationwide in 2009, aims to improve integration of the different aspects of healthcare for women, centralizing around HIV, sexual reproduction, and maternal and newborn health.57 The program was widely successful, reaching its third year goal of 80 percent HIV testing coverage for pregnant women within its first year.58 One of its missions is to improve referral mechanisms by educating health care providers on how and when to refer patients.59 Another aim of the Linked Response is to increase testing by promoting earlier testing at ANC, providing point of care testing, and partnering with private clinics to reach a larger population.60 Prevention of unwanted pregnancies is another method used to prevent MTCT. Oral contraceptives and injectable progestogen are being made available at ART clinics to make them more accessible, increasing their use. Additionally, the concept of dual protection is stressed. Medications used by HIV positive individuals can interfere with the effectiveness of contraceptive drugs, so they should always be used in combination with a condom.61

Vo 19 If a mother fails to prevent an unwanted pregnancy, abortion is an option. Legalized in Cambodia in 1997, abortions must be performed before the 12th week of the pregnancy, unless there are extenuating circumstances. Additionally, the procedure must be performed by individuals authorized by the Ministry of Health, including medical doctors and practitioners and midwives. The procedure must be done in a hospital, health center or clinic, or a maternity ward.62 Future Treatment Many of the necessary programs for PMTCT are already available; they only need to be scaled up. Linked Response testing coverage needs to be expanded to 100 percent. Pregnant women need to be educated on the importance of early testing as a matter of protecting their children. Health facilities should require testing when women come in to give birth, and midwives should be educated and trained to give rapid tests and to get those women that test positive on antiretrovirals. Oftentimes, women go into denial about their HIV status and the risks to their newborns. Education should stress that the disease can be managed, but that treatment must begin early, especially to prevent infection of the newborn. The importance of condom and contraceptive use should be stressed as a way to prevent unwanted pregnancies, especially so that HIV-positive women can avoid transmitting the disease to children they did not intend to have. WILL CAMBODIA MEET THE GOAL? Cambodia has established a strong framework for fighting HIV/AIDS. Many of its programs, if scaled up to achieve 100 percent coverage and testing, will identify all individuals in the population that need to receive treatment. ART coverage will need to expand to reach the

Vo 20 8 percent that are currently identified as needing treatment and have not yet received it as well as to provide treatment for those that will be newly identified. The main concerns that have not been addressed in the country that need to be are male circumcision and attainment of a third-line ART regimen. Foreign donors provide over 90 percent of funding for HIV prevention and treatment programs in Cambodia.63 This funding will need to be sustained for Cambodia to stay on the track it is on. Additional sources of funding will need to be gained in order to scale up the outlined programs in order to achieve zero HIV infections. This can be difficult as the economy is forcing funding cuts for such programs. To offset this, Cambodia should seek to provide the most cost-effective care where it will make the largest impact before it focuses on more specialized programs that will impact smaller proportions of the population. More grant applications will have to be written in an effort to secure more funding. Given sufficient funding to make improvements based on these recommendations, Cambodia will be able to meet the US Obama Administrations goal to achieve an AIDS-free generation (a goal of zero HIV infections) by 2019 and will prove the WHO prediction to be correct.

REFERENCES
1

The World Bank, GDP per capita (current US$), http://data.worldbank.org/indicator/NY.GDP.PCAP.CD?order=wbapi_data_value_2011+wbapi_ data_value+wbapi_data_value-last&sort=asc (June 1, 2013).
2

International AIDS Society, Cambodia on Track to Eliminate New HIV Infections by 2020, WHO Says, http://www.iasociety.org/Default.aspx?pageId=5&elementId=15204 (May 31, 2013).
3

Joint United Nations Programme on HIV/AIDS, Global Report: UNAIDS Report on the Global AIDS Epidemic (Geneva, Switzerland: UNAIDS, 2012), A6.

Vo 21
4

World Health Organization, UNAIDS, and UNICEF, Global HIV/AIDS Response: Epidemic Update and Health Sector Progress Towards Universal Access (Geneva, Switzerland: World Health Organization, 2011), 101.
5

Mean C. Vun, Cambodia at the Forefront in Applying a Strategic Investment Approach to Its AIDS Response, 31st Meeting of UNAIDS Programme Coordinating Board (Geneva, Switzerland), December 11-13, 2012.
6 7

Vun, Cambodia at the Forefront.

Evident to Action: HIV and AIDS Data Hub for Asia-Pacific, Cambodia Country Review December 2011 (Cambodia: Evidence to Action, 2011), 15.
8

The Henry J. Kaiser Family Foundation, People living with HIV/AIDS (Adults and Children), http://kff.org/global-indicator/people-living-with-hivaids/ (June 1, 2013).
9

National Institute of Statistics, Cambodia Demographic and Health Survey 2010 (Phnom Penh, Cambodia and Calverton, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF Macro, 2011), 187.
10 11 12

Global HIV/AIDS Response, 190. Narain, 78.

World Health Organization, Global Tuberculosis Report 2012 (France: World Health Organization, 2012), 17.
13 14 15 16 17 18 19 20 21

Narain, 84. Narain, 82. Narain, 78. Narain, 83. Narain, 78. Global HIV/AIDS Response, 190. Global HIV/AIDS Response, 163. Narain, 78.

Center for HIV/AIDS, Dermatology and STD, National Guidelines for the Use of Antiretroviral Therapy in Adults and Adolescents (Cambodia: Ministry of Health, 2012), 19.
22

Sharon Martens, HIV Clinical Manifestations, April 16, 2013.

Vo 22
23 24 25 26 27

National Guidelines for the Use of Antiretroviral Therapy, 19. Cambodia Demographic and Health Survey, 180-181. Cambodia Demographic and Health Survey, 180-181. Narain, 78.

UNICEF Cambodia Friends helping friends affected by HIV, http://unicefcambodia.blogspot.com/2013/04/friends-helping-friends-affected-by-hiv.html (May 31, 2013).
28 29 30

National Guidelines for the Use of Antiretroviral Therapy, 49. National Guidelines for the Use of Antiretroviral Therapy, 49.

Daniel Montao and Danuta Kasprzyk, Male Circumcision for HIV Prevention, May 21, 2013.
31 32 33 34 35 36

Montao and Kasprzyk, Male Circumcision. Global HIV/AIDS Response: 21. Montao and Kasprzyk, Male Circumcision. Montao and Kasprzyk, Male Circumcision. Danuta Kasprzyk and Daniel Montao, HIV/AIDS Research in Zimbabwe, May 16, 2013.

World Health Organization Regional Office for the Western Pacific, 100% Condom Use Programme in Entertainment Establishments, 2000 (Manila, Philippines: World Health Organization, 2000), 32.
37 38

Narain, 76.

U.S. Department of State, Bureau of Democracy, Human Rights, and Labor, 2009 Human Rights Report: Cambodia, http://www.state.gov/j/drl/rls/hrrpt/2009/eap/135988.htm (Jun. 1, 2013).
39 40 41

HIV in Asia and the Pacific, 47. Narain, 81.

Joint United Nations Programme on HIV/AIDS, HIV in Asia and the Pacific: Getting to Zero (Bangkok: UNAIDS, 2011), 47.
42

Cambodia Demographic and Health Survey, 182.

Vo 23
43 44 45 46

Cambodia Demographic and Health Survey, 185. Narain, 85. Global HIV/AIDS Response, 130.

Cambodia Methadone Maintenance Program, Newsletter for The Center for Mental Health and Drug Dependence, November 2010.
47 48 49

HIV in Asia and the Pacific, 114. HIV in Asia and the Pacific, 115.

Human Rights Watch, Cambodia: Close Compulsory Drug Detention Centers, http://www.hrw.org/news/2010/01/25/cambodia-close-compulsory-drug-detention-centers (June 1, 2013).
50

Danuta Kasprzyk and Daniel Montao, HIV/AIDS: Sex, drugs, gender, risk factors, April 23, 2013.
51

Kha Sovannara and Chris Ward, Men Who Have Sex with Men in Cambodia: HIV/AIDS Vulnerability, Stigma, and Discrimination (Policy, 2004) 6-7.
52 53 54

HIV in Asia and the Pacific, 117. Thor Wagner, Pediatric HIV & Mother to Child Transmission of HIV, May 14, 2013.

NCHADS and MCMCH, Joint NCHADS-NCMCH Statement on the Implementation of the Prevention of Mother-to-Child Transmission of HIV/AIDS (Cambodia: NCHADS and MCMCH).
55 56 57 58 59

Narain, 85. National Guidelines for the Use of Antiretroviral Therapy, 90. HIV in Asia and the Pacific, 63. HIV in Asia and the Pacific, 63.

Cambodia Ministry of Health, Standard Operating Procedures (SOP) to Initiate a Linked Response for Prevention, Care, and Treatment of HIV/AIDS and Sexual and Reproductive Health Issues (Cambodia: Ministry of Health, 2007), 9.
60 61 62

Narain, 85. National Guidelines for the Use of Antiretroviral Therapy, 50. Cambodia Demographic and Health Survey, 67.

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63

Cambodia on Track to Eliminate New HIV Infections, http://www.iasociety.org/Default.aspx?pageId=5&elementId=15204.