Cambodia: Prisoners and sex workers

HIV/AIDS care in Cambodia on the increase…for some

Cambodia is a country languishing in poverty, still reeling from the effects of its recent history. Dealing with suffering that is still so tangible, its people are fighting to recover from the past, struggling to rebuild both financially and psychologically.  For more than 30 years now, Cambodia has been tormented by an avalanche of events which have torn at its very fabric. The mass killings perpetrated by the Khmer Rouge in the 1970s during which around two million out of seven million people died, the following occupation by the Vietnamese 'liberators' and a bloody coup in 1997 have all led to the current climate of political instability. As the country struggles to recover from its past, millions of Cambodians are still living in poor conditions, compounded by sub-standard public health services.

With one of the worst levels of poverty in Asia, the vast majority of Cambodians are living on less than 2 USD a day. International financial assistance is flooding into the country but as infrastructure and tourism booms, there remains a significant proportion of the population who are forgotten by the national system.

Medecins Sans Frontieres (MSF) is providing care to people living with HIV/AIDS in Cambodia by delivering free antiretroviral (ARV) treatment to over 7000 patients. In addition, there are a plethora of NGOs working in the fight against HIV/AIDS and international donations have given the Cambodian national HIV/AIDS program a much-needed financial boost. The willingness of the national program to scale up treatment has meant that many people are now receiving the vital care they need. MSF’s program of decentralisation handing over stable patients to the Ministry of Health, and its training of Cambodian medical staff to care for HIV/AIDS, aims at further expanding the reach of treatment.

But there are many people suffering from HIV/AIDS who are abandoned and left without treatment, to whom the national system has turned a blind eye. MSF is currently launching programs to address these neglected segments of society in order that life-extending care can be delivered to people who would otherwise not receive it.

Prisoners: HIV treatment now reaching those in urgent need

Sovann was sentenced to 10 years on drug charges and has now been in prison for two years. As he fights charges which he strongly denies, he is also battling against HIV without adequate medical assistance from the government. Living in deplorable conditions in a Phnom Penh prison where medical treatment, food and water are scarce, the outlook for Sovann, up until a year ago, would have been bleak. He is now receiving free ARV treatment from MSF.

MSF launched its HIV/AIDS program targeting inmates in Phnom Penh in September of 2006. The program was begun when, in early 2006, one of the many patients being treated for HIV/AIDS by MSF at the Khmer-Soviet Friendship Hospital in Phnom Penh was sent to prison. Without essential treatment, his health would have quickly deteriorated. MSF was able to continue monitoring his situation and provide ARV drugs. A subsequent assessment of the health conditions in the prison system in Phnom Penh found that this was not an isolated incident and that there were many infected inmates in need of medical care

The evaluation found that 150 inmates were in urgent need of ARV treatment. Initially, MSF began treating the inmates at the clinic but due to the logistical difficulties of transporting the inmates to the clinic and associated security risks, teams are now going directly to the prisons. MSF is currently providing HIV treatment to over 20 inmates from three different prisons in Phnom Penh: CC (Correctional Centre) 1, CC2 and PJ (Police Judicial).

Conditions in Cambodian prisons are dire at best. "The inmates always complain of hunger," said Christine Wagari, Head of Mission for two of MSF's projects in Cambodia. "What we could see during the assessment is that there is a high concentration of inmates in a very small area. Even in the medical department there are one or two rooms dedicated to patients who need close follow up. But in these rooms, contamination is rife." According to a LICADHO* report which looked specifically at conditions in CC1, inmates are undernourished, only receive recreation time once a week, live in dirty and cramped conditions and drink unclean water.

"The inmates should be considered by MSF as a vulnerable population and a forgotten population," added Christine. "This is a perfect mandate for MSF and we should avail the adequate human resources and any kind of resources that are needed to properly conduct this project. Similar access to ARV treatment should be offered to the inmates as any other population could receive in Cambodia."

The challenge in reaching sex workers

"I was diagnosed with HIV in 1998. I was working in a beer hall at the time. Three of my colleagues tested positive as well. My 'boyfriend' at the time had lots of mistresses, but he also had a wife and children." Chenda, a former sex worker from Siem Reap, finally sought free ARV treatment from MSF in 2003, after initially being ostracised from her family. She is representative of a population with a growing need for HIV assistance, but who, due to the stigma associated both with the disease and their profession, are not necessarily seeking treatment.

While the HIV prevalence among the general population in Cambodia is 1.9%, the prevalence among commercial sex workers is a staggering 20%. As the sex industry in Cambodia grows, so too does the scale of the problem. UNAIDS reports that there has been a rapid increase in the amount of 'indirect' sex work, where the women offering sex for money work in places such as massage parlours and beer halls and do not necessarily identify as sex workers. This makes the task of targeting sex workers in order to provide care even harder.

MSF has recently started looking at the HIV/AIDS issue with commercial sex workers in Siem Reap, a bustling tourist town in the north of the country with a huge sex industry. As Philippe Berneau, Head of Mission for three projects in Cambodia explains, the implementation of the project has not been easy: "This is a very difficult task as commercial sex workers are a mobile population. Many of them are not from Cambodia but from neighbouring countries. This is one of the most vulnerable populations and this is why we decided we must do something to assist them."

Further problems exist with the stigma associated with HIV/AIDS, resulting in many women being embarrassed to seek help. MSF is also finding that due to lack of education and economic hardship, sex workers are more concerned with unwanted pregnancies than the contraction of HIV.

MSF will invest resources in an attempt to combat the high HIV prevalence among the sex worker population. Following a community education program that MSF plans to implement, it is hoped that women will start turning to clinics that can provide them with much-needed testing, counselling and treatment.

MSF has been working in Cambodia since 1989. Currently teams are providing treatment for patients with HIV/AIDS in five locations: Phnom Penh, Kompong Cham, Takeo, Siem Reap and Oddar Meanchay.  In two of these sites, Takeo and Siem Reap, teams are also treating other chronic diseases such as diabetes and hypertension.

Patient names in this article have been changed.