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Joint Statement from Cambodian HIV and AIDS Networks
1st December 2010 - World AIDS Day
Civil Society Concerns about Meeting Millennium Development Goal 6 Targets by 2015
As Cambodia marks World AIDS Day 2010, HIV infection rates are now at an estimated 0.7% of the population and over 90% of all adults living with HIV receive antiretroviral treatment (ART). A testament to what can be achieved with strong leadership, political commitment and cooperation and engagement from all stakeholders these gains were recently recognized with the presentation of a United Nations Millennium Development Goal Award (MDG) to The Royal Government of Cambodia for outstanding national leadership, commitment and progress towards the nation’s MDG6 targets.
Whilst Cambodia may have come far in combating the spread and treatment of HIV, it is not yet far enough. The challenges of the maturing epidemic now call for continued funding for high impact interventions and sustained treatment services, as well as the development of financing solutions to meet medium to long term response goals.
With Universal Access targets now achieved, the psychological, social and economic supports needed by people living with HIV (PLHIV) need to be equally comprehensive to ensure that factors such as poverty, inadequate nutrition, poor living standards, discrimination from health workers and compromised access to education do not mitigate treatment benefits.
Moreover, if Cambodia is to halt and reverse the spread of HIV by 2015, persistently high infection rates among most-at-risk populations (MARP) - these include entertainment workers (EW) injecting and non-injecting drug users (IDU/DU), men who have sex with men (MSM) and transgender people (TG)–also need to be addressed. In addition, legal barriers to education and prevention interventions, discrimination from service providers and human rights violations undermining the effectiveness of a range of prevention, treatment, care and support measures for MARP must stop.
The active and meaningful involvement of civil society organizations (CSO) and affected population networks has been a key aspect to the success of the national HIV response thus far. These organizations now hold concerns that if the afore mentioned challenges are not adequately addressed, Cambodia will not meet the 2015 MDG6 targets, nor will civil society be able to fulfil National Strategic Plan III (NSPIII) objectives.
To alert the government and other relevant stakeholders to the challenges facing civil society response efforts and posit recommendations to address these, the HIV/AIDS Coordinating Committee (HACC) in partnership with the ARV Users Association (AUA), Bandanh Chaktomuk (BC), the Cambodian Business Coalition on AIDS (CBCA),The Cambodian Community of Women living with HIV and AIDS (CCW), The Cambodian Network of People Living with HIV (CPN+), Korsang, and the Women’s Network for Unity (WNU) release the following joint statement:
Treatment Care and Support Challenges Facing People Living with HIV
Cambodia’s achievement of its Universal Access targets has the potential to be undermined by a number of service delivery and treatment adherence challenges. In particular PLHIV face a range of financial challenges that can reduce adherence rates and in turn lead to increased rates of morbidity and mortality.
With many PLHIV not covered by social insurance and too sick to work, HIV can precipitate a cycle of poverty and debt for both PLHIV and their households .Poverty also prevents some PLHIV from accessing adequate nutrition or paying for crucial testing services, such as viral load tests or x-rays. In addition, some insufficiently funded hospitals charge fees for testing and treatments a practice that contravenes the Law on Prevention and Control of HIV/AIDS . Even when treatments are free, transportation costs to attend consultations or receive test results prove a major barrier to accessing appropriate and regular treatment and care.
The financial burdens on PLHIV have only increased since the removal of the Merit-Based Pay Initiative (MBPI) for service providers. Since these payments ceased, some HACC members have reported diminished motivation from health service staff and there have been anecdotal reports of extortion or refusal of service without under the table fees for consultations and medication.
Additionally, there have also been anecdotal reports of expired or close to expired Anti Retroviral (ARV) being sold, highlighting the need for programmes and funding to be focused on delivering sustainable access to all medications, including but not limited to ARV.
Despite the increased coverage of ART, the National Centre for HIV/AIDS Dermatology and STD (NCHADS) estimates that there will still be 1,900 Cambodian adults dying from AIDS related complications per year and this number could increase if access to free hospitalization is limited. With funds for palliative care and pain management from Global Fund Round 4 now finished, a number of health centres providing palliative care are now under resourced, despite clear ongoing service demands.
To the Ministry of Health, the Ministry of Interior and the National Centre for HIV/AIDS Dermatology and STD, National AIDS Authority, UNAIDS and the World Health Organization:
To the Cambodian Government, the Ministry of Health and the National AIDS Authority:
Challenges facing Most at Risk Populations: Stigma and Discrimination and Human Rights Abuses
Stigma and Discrimination
Discrimination towards PLHIV and MARP is undermining the effectiveness of a range of prevention, treatment, care and support measures.
There are widespread reports of prejudiced and discriminatory behaviour from health service providers towards PLHIV, leading to reluctance to seek medical assistance and a compounding of self-stigma. In an extreme recent case of discrimination investigated by CCW, HACC and KHANA, an HIV positive woman died during childbirth because health workers at Sihanoukville Referral Hospital refused to provide her with the necessary care to address birth complications once her status was known.
Discrimination towards DU/IDU, MSM and TG from healthcare workers is also common. As reported to BC, CCW and Korsang representatives, discrimination from health care providers leads to MARP mistrust of health services: a major disincentive to seeking out appropriate and timely treatment, information or assistance.
In light of widespread stigma and discrimination toward MARP and PLHIV, there is also stigma surrounding Voluntary and Confidential Counseling and Testing (VCCT). This hinders willingness and early uptake of this crucial service, not only for MARP, but also for the general population.
To the National AIDS Authority and the Ministry of Health:
To the National AIDS Authority, the Ministry of Health and the Ministry of Interior:
To The Ministry of Health and the National Centre for HIV/AIDS Dermatology and STD
Human Rights Abuses
NGOs working with EWs, MSM and DU/IDU receive regular reports of Human Rights abuses against these communities, often committed by Cambodia’s police. Fear of arrest or extortion is a major barrier for MARP seeking assistance from authorities or to report abuses.
As documented by Human Rights Watch in July 2010 EW are regularly subject to rape, violence, arbitrary detention and bribery with money or sex by local authorities and law enforcement. The 2008 Law on Suppression of Human Trafficking and Sexual Exploitation and subsequent enforcement of brothel closures, has seen many sex workers move to entertainment establishments such as karaoke bars, beer gardens, massage parlours or the street to work. As has been widely reported, this dispersal has made prevention interventions, empowerment programmes and the monitoring of this group much more difficult to implement.
In addition to hindering prevention measures, there have been many anecdotal reports and a number of documented cases of article 25 of the Law being interpreted by law enforcement in such as way that condoms can be used as evidence of procurement: a major disincentive for EW and their clients to carry and use condoms.
Also of concern is that article 24 on “soliciting” of the Law gives police leverage to extort money or commit violence against sex workers. MSM and TG have also had condoms confiscated under this article as evidence of sex work .
In effect, the 2008 Law on Suppression of Human Trafficking and Sexual Exploitation neutralizes the impact of the Minister’s highly successful Prakas 66 100% Condom Use Policy (CUP) and has moved the sex trade underground, leaving EW, MSM and TG more vulnerable to HIV, STIs and human rights abuses.
With regard to human rights abuses against DU/IDU, Korsang outreach teams have reported being tracked by police on a number of occasions in order to arrest or extort groups of DU/IDU once the NGO representatives have left. This has created mistrust among MARP communities of the very services that they should be the beneficiaries of.
To National Centre for HIV/AIDS Dermatology and STD (NCHADS) and the Ministry of Health (MOH):
To the Cambodian Government, National AIDS Authority and the Ministry of Health:
Challenges to Civil Society’s Response Effectiveness
The active and meaningful involvement of civil society and affected population networks has been a key aspect to the success of the national HIV response. However there are major gaps in community representation and the sector is under-resourced.
There are no national affected population networks for EW or DU and only a limited number of community based organizations working on MSM. This environment leads to oversights in policy development and effective programme implementation. Moreover, since the collapse of the Cambodian Human Rights and HIV/AIDS Network (CHRHAN) there is no longer a network charged specifically with advocating for, or protecting the rights of PLHIV and MARP, or reporting abuses against these groups. This is a major service gap in light of the human rights abuses and discrimination these communities face.
To date, funding for Cambodia’s HIV and AIDS response has been highly dependant on international donor funding. Having now exceeded MDG 6 targets for 2015, CSO have concerns that the expected financing vacuum will threaten the effectiveness of existing successful programmes and the implementation of critical new programmes. This would prevent the sector from fulfilling its National Strategic Plan III (NSP III) goals.
To the National AIDS Authority:
To the Cambodian Government:
To the Cambodian Government and the Private Sector
Phnom Penh 01.12.2010
Asia Pacific Coalition on Male Sexual Health, (August 2010) Cambodia MSM Country Snapshot: Country Specific Information on HIV, men who have sex with men (MSM) and transgender people (TG)
Commission on AIDS in Asia (2008), Redefining AIDS in Asia: Crafting an Effective Response, New Delhi: Oxford University Press
CCW, HACC and KHANA, (November 2010) Human Rights Violation against PLHIV. Draft report from the civil society investigation
Family Health International (December 2008), HIV prevention and anti-trafficking in conflict? The public health consequences of Cambodia’s fight against trafficking. Presentation from the 2nd Phnom Penh Symposium on HIV and AIDS Prevention, Care and Treatment
Family Health International (2008) Population Size Estimation of MSM in Cambodia, 2008Capture - Recapture Methodology in 6 Cities
Human Rights Watch (July 2010) Off the Streets: Arbitrary Detention and Other Abuses against Sex Workers in Cambodia
KHANA and CPN+ (September 2010) “People Living with HIV Stigma Index”, Draft Report
Kampuchea Thmei Daily, (August 19th, 2010) Preah Sihamouk Police Use Condoms as Evidence to Arrest and Imprison BiBi Restaurant Owners
National AIDS Authority (2010), Universal Access to HIV Prevention Treatment, Care and Support, AIDE MÉMOIRE
National Centre for HIV/AIDS Dermatology and STD (2007), HIV Prevalence Study Among Drug Users
National Centre for HIV/AIDS Dermatology and STD (2009) Third Quarterly Report
National Centre for HIV/AIDS Dermatology and STD HIV Estimates and Projections for Cambodia 2006-2012
United National Development Programme (2010), The Socioeconomic Impact of HIV at the Household level in Cambodia 2006-2012, Executive Summary
National AIDS Authority, UNGASS Country Progress Report, Cambodia, Reporting Period January 2008 – December 2009, March 2010
Statements and supporting documents received from:
AgenceD’Aide a la Cooperation Technique et au Developpement-Pharmaciens Sans Fronteres (ACTED-PSF) - Ms. Anne Rouve-Khiev, Country Director
Croix-Rouge Française (FRC),Sandrine Leymarie, Health Coordinator
Cambodian Business Coalition on AIDS Dr. Chantha Thun (CBCA) Executive Director
Khmer HIV/AID GO Alliance (KHANA) – Mey Sovannara, Communication and Advocacy Coordinator
Sharing Experience for Adapted Development (SEAD) - Dr Pierre-Régis Martin, Programs Director
The Joint United Nations Programme on HIV/AIDS (UNAIDS) - Cambodia UNAIDS Country Office
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© 2018 Health Action Coordinating Committee. All rights reserved.
© 2018 Health Action Coordinating Committee. All rights reserved.