Healthcare and HIV prevention for Sex Workers in Siem Reap, Cambodia

Tourism in Siem Reap is booming, with more holidaymakers coming every year to visit the nearby temples in Angkor. In the last few years, Siem Reap has been undergoing a total face-lift.  Yet behind the trendy new cafes and the luxury resorts under construction lies a grimmer reality. As the local economy takes on a new lease of life, scores of young women from poor rural provinces are lured to Siem Reap by the prospect of a better life. Many will swell the ranks of the sex workers. MSF has been providing HIV/AIDS treatment and care in Siem Reap since 2002.  A new project was opened at the end of 2007 to offer health education on HIV/AIDS to the sex workers and improve their access to healthcare.

Night is falling on Siem Reap. Across the city, red neon lights outline the silhouettes of girls singing into microphones. After dark, another type of tourism brings life to the town. Asian visitors from Malaysia, Korea, Japan and China along with Western tourists and local Cambodians flock to the scores of restaurants and karaoke bars that line the streets around the city centre.

Dream World is just one of them. Slender girls on high heels stroll across the car park into what looks like a garage.  It's a bare room, with rows of benches under a pallid neon light. A large open window runs along the whole length of one wall. From the outside, clients can pull open the curtain and handpick girls, before leading them in the next building for karaoke.

Tonight however, the girls came earlier to dedicate a little of their time to a local NGO, Cambodia Women for Peace and Development (CWPD), one of the three NGOs that MSF is working closely with. These local organisations have been supporting sex workers for years, offering a wide range of services such as a place to seek advise at the drop-in centre, or a temporary shelter if needed, as well as vocational training and support to find another job if they wish to.

In the evening, CWPD tour different sites to run workshops on health education and family planning for sex workers. MSF comes along to push the girls to get tested for HIV or Sexually Transmitted Infections (STIs) and provides information about free healthcare and treatment.  

"What we want to do is to support and reinforce these NGOs' health promotion activities so we train their peer workers in HIV/AIDS prevention. We help them referring those who need it to the local hospital for voluntary counselling and testing (VCCT) and ARV treatment, we facilitate transport to health centres and  access to   treatment for HIV or STI," explains MSF field worker, Om Malchich.

Cambodia has made significant inroads into controlling the spread of HIV/AIDS. National AIDS policies have helped reverse the epidemic, with HIV prevalence rates among the general population falling from 3.1 % in 1997 to an estimated 0.9% in 2006*. Yet, the country has the highest HIV prevalence in Asia and sex workers remain one of the most exposed segments of the population.

Cambodia's 100% condom use policy played a key role in significantly reducing the number of new infections. MSF and its partners also distribute condoms for free directly to sex workers and make sure they remain easily available.

"Things have improved, finding condoms used to be difficult," explains 26-year-old Chanda who has been working in a karaoke bar for two years, "girls are much more aware now and they can protect themselves much more easily." Like many sex workers, Chanda was driven into prostitution by poverty. In total seven members of her family depend on her salary, including her child, parents, brothers and sisters. None of them know the true nature of her work. Most women working in karaoke parlours, bars, restaurants or massage parlours do not really see themselves as prostitutes. They call themselves "Sweethearts" and supplement their income by selling sex.  "The karaoke pays us US$50 a month, but you can't live on this in Siem Reap," explains Chanda, "I can make on average US$80 with the tips and see one to four clients a month. My family is very poor and I send them most of my salary and get by on the rest."

Knowledge about HIV/AIDS among this group has improved thanks to the work of NGOs and the government's health promotion campaigns.  But stigma about HIV/AIDS continues to run high among Sweethearts and they often hide their status for fear of losing their clients. Most of the women who MSF works with go for a test at some point and so far very few turned out to be positive. 

If most women say they use condoms with their clients, hammering on about the risk of unsafe sex remains critical. In karaoke bars, the women are in competition with each other and pressure can be high. "When clients insist on having unprotected sex and I tell them that I can't get sick or pregnant, I have a family to feed," explains Chanda "but some will offer more money and this can be a strong temptation."

A lot of the sweethearts see their job as temporary until they marry or save up enough money to open their own business to continue supporting their family, but for many the dreams never come true.

"Working with sex workers isn't easy. They are extremely mobile, often difficult to access and stigma around their job or their status can easily drive them underground," explains MSF head of mission, Philippe Berneau, "but as one of the most exposed part of the population, it is critical to address their healthcare needs."

 In Cambodia, prostitution ranges from bars, massage parlours, karaoke establishments and restaurants to brothels, at the extreme end of the spectrum. Officially illegal, most brothels in the country hide behind the façade of karaoke. Women there, work full time and live on the premises. They are called "direct" sex workers by NGOs.  Their working conditions can vary considerably but the contrast with the Sweethearts is blatant.

In a narrow alleyway, in the shadow of a bright new backpacker guesthouse stands a grim looking two-storey building. The place reeks of poverty.  The ground floor is split in 8 rooms along a dark corridor, where frail young women stealthily scurry in and out. Jana is a 32-year old woman from Battambang, western Cambodia. Dressed in a cheap blue satin gown, she sits in a plastic chair at the entrance and waits for clients from dawn till dusk. Her daily wage rarely reaches more than US$2.50 for 4 to 6 clients a day. With this, she says, she rents her room and supports her family back in her village. Like many other women, she speaks of family and personal problems that led her to this place - a failed marriage, her lack of education and work opportunities and most of all poverty forced her into prostitution. She left her village and small business selling vegetables, dreaming of a better life, and ended up in a brothel in Siem Reap.

Jana is a shy woman with dim tired eyes and soft-spoken words. She has nothing of the brash young women in the karaoke bars.  She discovered she was HIV positive two years ago and receives free ARV treatment from MSF. For her, prevention is less an issue than treatment. 

"There's no competition among us here, everyone knows who is HIV positive and we all use condoms," she explains, "but I'm not earning enough to pay for my treatment. I came here knowing very little about HIV, but now I can get the information easily, and I can have regular check ups at the hospital."

The situation faced by sex workers can vary considerably. MSF has been liaising closely with local NGOs helping sex workers to improve their access to healthcare and is currently targeting around 3000 women in Siem Reap. On average, 94 women are referred to the clinic for VCCT per month, and around 150 for STI screening and treatment.

"Many factors can hamper sex workers' access to care and treatment: the stigma associated with their profession and HIV, their lack of knowledge on HIV/AIDS, poverty, their mobility or the language if they are not Cambodian, " explains Berneau, "As a medical organisation we want to ensure as much as possible that these women know how to protect their health and know where to turn to when they need medical assistance. "

* From HIV sentinel Surveillance and  UNAIDS epidemic update 2007