HIV/AIDS in Cambodia – where to next?

With a population of about 14 million, the vast majority of whom live on less than 2 USD a day, Cambodia ranks as one of the poorest countries in Asia. Struggling to rebuild itself following its tumultuous past, a weak public health system means that only one-fifth of the population has an operational health facility in their village. Moreover, the quality of health services is so poor that people are often forced to pay for private care.

HIV/AIDS is the main focus of Médecins Sans Frontières (MSF) in Cambodia. Although HIV prevalence, currently 1.9%, is low compared to many African nations, there are still approximately 180,000 people affected by the disease in the country. MSF’s HIV/AIDS program is its largest in Asia and teams are working providing antiretroviral drugs (ARVs) for over 7000 patients.

Vanna is one of these patients. She lives in the rural province of Takeo, in southwest Cambodia. She is 45 years old. She tested positive for HIV four years ago and since then has struggled to cope with the discrimination that she faces within her own community. Vanna's income consists of the small amount of money that she can earn from growing vegetables, but since contracting HIV, she's found it difficult to be able to make any money and provide for her four children.

With a high level of stigma still attached to HIV in Cambodia, some people in Vanna's small village think they will 'catch' the disease from her and so will not buy produce from her market stall. Her son works for a farmer to bring in a small income for the family. Médecins Sans Frontières (MSF) is working to combat the stigma affecting patients like Vanna by offering treatment in chronic disease clinics. In these clinics, patients are treated alongside diabetes and hypertension patients, where their HIV status does not have to be necessarily apparent.

Vanna has been coming to the MSF chronic diseases clinic in Takeo since she was diagnosed with HIV and has been taking life-extending ARV drugs for the last three years. Previously very frail, the drugs have allowed Vanna to put on 14 kilograms and overall, she feels much better. Although often a tiring process for some patients, she has no problem adhering to the drug regime: "It doesn't bother me that I have to take the drugs every day for the rest of my life," she says. "The ARVs are saving me so I am very happy".

Tuberculosis – the challenge continues
The work of MSF, along with a plethora of NGOs and a strong will from the Cambodian government to improve the situation, means that the fight against HIV/AIDS in Cambodia is in full force. However, the country is now facing another significant health crisis, with tuberculosis (TB) rapidly emerging to be a major concern. Tuberculosis is one of the most common co-infections of HIV/AIDS and a leading cause of death in patients. And it is not just HIV/AIDS patients that are affected.

The World Health Organisation (WHO) reported in 2006 that Cambodia has the 22nd highest TB burden worldwide. Approximately two-thirds of all Cambodians carry the tuberculosis bacterium, and around 13,000 die annually from the disease.

With statistics like this, in a context where the government has been slow to react and also does not have the resources to provide an adequate solution right now, the need for better treatment and diagnosis is acute. TB is a highly infectious disease, and patients have to undergo treatment, with drugs developed fifty years ago, for periods of 6-8 months to which they must strictly adhere.

The problem does not stop there. Yet another obstacle facing Cambodia is the emergence of multi drug resistant TB (MDR-TB). "TB is the main challenge in Cambodia", says Laurent Ferradini, MSF's medical coordinator. "There are problems with drugs in terms of supply and cost and we are very concerned about the emergence of MDR-TB. This has the potential to be a huge issue in the near future. The situation is bad and largely uncontrolled." The treatment for the multi-drug resistant form of the disease is extremely costly, and patients must follow a strict regime for two years and suffer side effects including severe nausea. What's more, there is no guarantee that MDR-TB can be cured.

At the HIV/AIDS inpatient ward in Kompong Cham to which MSF provides support, a staggering 75% of patients are affected by TB. Kiri (pictured) is HIV positive and also has TB. She has no family to take care of her. There are many patients just like Kiri in Cambodia without family, and without financial means to seek treatment. Fortunately, Kiri was able to make it to the MSF clinic to receive the essential drugs she needs.

MSF is currently scaling up its focus on TB in Cambodia by renovating existing facilities and building new wards in order to be able to provide care for the growing number of TB patients. It is hoped that the fight against HIV/AIDS will be equalled with a strong effort against TB, both from the national program and international actors, to combat the rapid emergence of this much-neglected disease.

There are still between 25,000 and 30,000 people in urgent need of ARV treatment in Cambodia. Currently, MSF teams are working to treat HIV/AIDS patients in five locations: Takeo, Siem Reap, Oddar Meanchay, Phnom Penh and Kompong Cham. In two of these sites, Takeo and Siem Reap, teams are also treating other chronic diseases such as diabetes and hypertension.

MSF has been working in Cambodia since 1989.

The patients' names in this article have been changed.