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PHNOM PENH, Cambodia - While HIV prevalence in Cambodia is still the highest in Asia, it appears to be falling both among commercial sex workers (CSWs) and the general population. The 100% condom use policy in commercial sex establishments is widely credited, and PSI is the leading non-governmental organization (NGO) educating CSWs and providing them access to affordable, high quality condoms. Among "direct" (brothel-based) CSWs, HIV has dropped from 42.6% in 1998 to 28.8% in 2002. Among the general population, it has fallen from 3.3% in 1998 to 2.6% in 2002 (Data source: HIV Sero-Surveillance Survey). Sexually-transmitted infections (STIs) are also on the decline. "Prostitution is no longer the major driving force of the AIDS epidemic in Cambodia because of widespread condom use," the World Health Organization (WHO) announced in August 2003. WHO said the sex industry now accounts for only 21% of new HIV infections in Cambodia in 2002, down from 90% a few years ago. The WHO has lauded the "remarkable turnaround" of the AIDS epidemic in Cambodia. "This is not the end of the HIV epidemic in Cambodia but it shows that a sound epidemiologically-based prevention strategy can work," said Shigeru Omi, WHO Western Pacific Director. The UNAIDS AIDS Epidemic Update confirmed the trend in December 2003 when it reported that "seroprevalence appears to have dropped significantly among brothel-based sex workers … and among urban police, largely due to the vigorous condom promotion programme supported by the government and nongovernmental organizations. Cambodia's Ministry of Health recently estimated that the country would have seen three times as many HIV infections had it not mounted this response." Cambodia learned from the experience of Thailand, where the government
instituted a 100% condom use program in sex establishments in 1989,
resulting in the dramatic fall of HIV prevalence. Inspired, Cambodia
adopted the 100% condom use policy in brothels in 1998. HIV prevalence
began declining the following year. Since 1997, consistent condom use has been increasing among important high risk groups. In "sweetheart relationships ," consistent condom use by men has increased from 5% in 1998 to 21% in 2001. In commercial sex relationships, the military's consistent use has increased from 55% in 1998 to 87% in 2001, police officers have increased from 69% to 85%, and female sex workers from 51% to 90%. In October 2003, PSI launched the Care female condom in two areas of the country specifically to give sex workers a safe alternative when clients refuse to wear male condoms. Although it is too early to declare female condoms a success in Cambodia, the initial reaction has been encouraging. PSI also markets female condoms to commercial sex workers in Botswana, Mynamar, Tanzania, Togo, Zambia and other countries. But condom use outside of brothels remains low, especially among couples in "sweetheart" and married relationships. Household surveillance survey data demonstrates that transmission from husband to wife has increased dramatically, accounting for 25% of new infections in 1995 and now representing the largest vector of transmission. In response to this changing face of the AIDS epidemic, PSI/Cambodia launched OK Condom, a second male condom brand, in February 2004 to attract new condom users who are at risk of HIV. Less than 20% of sexually active men and women have ever used a condom, representing an enormous unmet need. HIV/AIDS prevention programs targeting prostitutes have recently come under scrutiny in the highly-charged political environment of the U.S. Some activists doubt that prostitution can ever be a voluntary choice, and that the only response should be rescue and rehabilitation. Others recognize that not all prostitutes are working against their will, even if they are there due to a lack of economic alternatives. The reality is that there is a great variety of people engaging in commercial sex, and they defy easy stereotypes. Some work in fixed sites, like brothels and massage parlors; others are in karaoke bars or roam the streets. In Cambodia, there is a distinction between the brothel-based "direct sex workers" and the floating "indirect sex workers." Some work for an employer; others are self-employed. Some don't consider themselves sex workers at all; they have a normal life, with a boyfriend or even a husband, but also another, secret life to supplement their conventional income-generating activities. And some combine different aspects of these different characteristics. Some activists say that distinct strategies should be developed for the victims of forced prostitution and sex trafficking, and voluntary sex workers. Of course, that is ideal but, in reality, difficult to implement on the ground. One manager of a program targeting sex workers in Cambodian brothels puts it this way: "We know that the brothels in Svay Pak (the main red light district in Phnom Penh) are populated by Vietnamese girls who may or may not be there against their will. Brothels in general are serviced by a mix of girls who are there one month, gone the next… A trafficked girl might be initially there against her will but, after a few years, chooses sex work because she has no option. In reality, it is impossible to differentiate between the types of workers. Our moral responsibility is to reduce HIV transmission among the most vulnerable and at-risk populations." Despite these problems, however, PSI increasingly recognizes the importance of addressing the different realities of direct and indirect CSWs. In both Cambodia and Thailand, for example, PSI has developed strategies to reach the more elusive indirect CSWs. PSI/Cambodia has just piloted a project in Phnom Penh aimed at disseminating information and condoms in beer gardens, karaoke bars and massage parlors. PSI/Thailand has initiated outreach to girls living in dormitories on industrial estates and working in entertainment venues in northern Thailand. The President's Emergency Plan for AIDS Relief affirmed the importance
of reaching CSWs in the strategy it released in February 2003 which
stated: "…recognizing that condoms are an essential means of HIV
prevention for populations who engage in risky behavior, rapid scale-up
of activities that target specific at-risk populations with outreach,
prevention messages, testing, and condoms will be undertaken."
This campaign elicited praise by King Norodom Sihanouk and Prime Minister Hun Sen. In giving his royal blessing to the campaign, King Sihanouk said: "In expressing my admiration to PSI/Cambodia for its many achievements extremely beneficial to the health of the Cambodian people, I would like to express my deep gratitude to its members and to present my warmest congratulations and fervent wishes for the continued success of their noble endeavor." Prime Minister Hun Sen wished upon PSI/Cambodia "the five blessings of Buddha." The success of the government and NGOs such as PSI does not mark the
end of the HIV/AIDS epidemic in Cambodia, but it does indicate that
well-targeted social marketing efforts, including the strategic promotion
of condoms, undertaken in close collaboration with the government and
other NGOs, can have a significant impact on the epidemic. Condom social
marketing efforts - like this one in Cambodia - must be scaled up to
reach high risk groups in low prevalence countries where HIV is concentrated,
and to reach both the general population and high risk groups in high
prevalence countries where everyone is at risk. — David J. Olson, PSI/Washington
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