The HIV/AIDS Rate in The HIV/AIDS Rate in Cambodia is going down: Cambodia is going down:

How was it done?How was it done?

Good Governance: Good Governance: Implementing Behavioral ChangeImplementing Behavioral Change

April 29-30, 2004, Sunway Hotel April 29-30, 2004, Sunway Hotel Phnom Penh, Cambodia Phnom Penh, Cambodia

Ty Chettra, MD, MPHTy Chettra, MD, MPHCountry DirectorCountry Director

The POLICY Project CambodiaThe POLICY Project Cambodia

OutlineOutline

BackgroundBackground Strategic frameworkStrategic framework Specific objectives regarding behavioral Specific objectives regarding behavioral

changechange Actions taken Actions taken Empirical evidence of successEmpirical evidence of success Challenges ahead Challenges ahead Lesson learntLesson learnt ConclusionConclusion

Background (1)Background (1)

First case of HIV infection diagnosed in First case of HIV infection diagnosed in 19911991

First person diagnosed with AIDS in 1993First person diagnosed with AIDS in 1993 National prevalence rate among adults National prevalence rate among adults

aged 15-49 dropped from 3.3% in 1997aged 15-49 dropped from 3.3% in 1997 Estimated 157,000 people living with Estimated 157,000 people living with

HIV/AIDSHIV/AIDS Unprotected sexual intercourse with many Unprotected sexual intercourse with many

partners is the main cause of transmissionpartners is the main cause of transmission

Background (2): HIV/AIDS in Background (2): HIV/AIDS in South East Asia, 2000South East Asia, 2000

CountryCountry

CambodiaCambodia

ThailandThailand

Viet NamViet Nam

Lao PDRLao PDR

MyanmarMyanmar

HIV prevalenceHIV prevalence

2.6%2.6%

1.8%1.8%

0.3%0.3%

0.05%0.05%

0.04-2.2%0.04-2.2%

Strategic FrameworkStrategic Framework

HIV/AIDS is not a health, but a social HIV/AIDS is not a health, but a social development issue development issue

Fighting HIV/AIDS has been going Fighting HIV/AIDS has been going through behavioral change at all through behavioral change at all level: level: Individual Individual Family Family Community Community SocietySociety

Specific Objectives regarding Specific Objectives regarding BCBC Getting the prevalence of HIV/AIDS Getting the prevalence of HIV/AIDS

infection down among target groups infection down among target groups and general populationand general population

Generate an enabling social and policy Generate an enabling social and policy environment for PLWHA living free from environment for PLWHA living free from stigma and discriminationstigma and discrimination

Mobilize national and international Mobilize national and international resources to fight HIV/AIDS and to resources to fight HIV/AIDS and to address its socio-economic impactaddress its socio-economic impact

Actions taken (1): OutlineActions taken (1): Outline

Specific intervention: 100% condom Specific intervention: 100% condom useuse

IEC campaigns with peer educationsIEC campaigns with peer educations Faith-based interventionsFaith-based interventions Establish a Multi-sectoral frameworkEstablish a Multi-sectoral framework Formulating law and policies Formulating law and policies Empirical evidence of success and of Empirical evidence of success and of

further policy & strategy further policy & strategy developmentdevelopment

Actions taken (2): Specific Actions taken (2): Specific intervention - 100% CUPintervention - 100% CUP Promoting ‘always using condom when Promoting ‘always using condom when

having sex’ – no condom, no sexhaving sex’ – no condom, no sex Involvement of wide range of stakeholders - Involvement of wide range of stakeholders -

local government, police, and brothel local government, police, and brothel ownersowners

Potential to create normative behavior Potential to create normative behavior concerning condom useconcerning condom use

Placing responsibility for condom use with Placing responsibility for condom use with brothel owners and not just with sex brothel owners and not just with sex workersworkers

Actions taken (3): IEC & Peer Actions taken (3): IEC & Peer EducationsEducations All relevant sectors including uniform All relevant sectors including uniform

sectors, youth, and workers sectors, youth, and workers Promote normative prevention behaviors Promote normative prevention behaviors

and practices: protected sexual and practices: protected sexual intercourses with one partnerintercourses with one partner

Having reduced stigma and discrimination Having reduced stigma and discrimination and greater support and care to PLWHAand greater support and care to PLWHA

Lots of technical and financial resources Lots of technical and financial resources have been used to develop IEC materials have been used to develop IEC materials and to conduct trainingand to conduct training

Actions taken (4): Faith-Actions taken (4): Faith-based interventionsbased interventions

Using religious theory & principles to Using religious theory & principles to promote HIV/AIDS preventionpromote HIV/AIDS prevention

Depending on believe & trust of people Depending on believe & trust of people to religious organizations to religious organizations

Changing from traditional perception on Changing from traditional perception on social roles of religious organizationssocial roles of religious organizations

Effective in reducing stigma & Effective in reducing stigma & discrimination and greater care and discrimination and greater care and support to PLWHAsupport to PLWHA

Need commitments and support from its Need commitments and support from its hierarchy hierarchy

Actions taken (5): Actions taken (5): Development a multisectoral Development a multisectoral frameworkframework NAA Established in 1999NAA Established in 1999 Cross-government multi-sectoral Cross-government multi-sectoral

policy and coordination body for policy and coordination body for Cambodia’s response to HIV/AIDSCambodia’s response to HIV/AIDS

Members represent 26 line Members represent 26 line Ministries, Cambodian Red Cross, Ministries, Cambodian Red Cross, and 24 provinces and municipalitiesand 24 provinces and municipalities

Based on community involvement, Based on community involvement, gender equality, respect for human gender equality, respect for human rights principlesrights principles

Actions taken (6): Actions taken (6): Development a multisectoral Development a multisectoral framework (cont.)framework (cont.)

NAA strategic plan is a holistic approach NAA strategic plan is a holistic approach involving government, civil society, involving government, civil society, international community and PLWHAinternational community and PLWHA

Strategies to fight HIV/AIDS was included Strategies to fight HIV/AIDS was included in the National Poverty Reduction in the National Poverty Reduction Strategy (NPRS)Strategy (NPRS)

Institutional policies were developed to Institutional policies were developed to fight HIV/AIDSfight HIV/AIDS

Strong support from international Strong support from international community, e.g UNAIDS, Global Fund community, e.g UNAIDS, Global Fund

Actions taken (7): Actions taken (7): Formulation Law on the Formulation Law on the Prevention and Control of Prevention and Control of HIV/AIDSHIV/AIDS Passed in June 2002Passed in June 2002 Prohibition of discriminationProhibition of discrimination Prohibition of HIV screening in connection Prohibition of HIV screening in connection

with employment, education, freedom of with employment, education, freedom of movement or abode, the provision of movement or abode, the provision of medical servicesmedical services

Legal protection of confidentiality of Legal protection of confidentiality of information about a person’s HIV/AIDS information about a person’s HIV/AIDS statusstatus

Comprehensive epidemiological monitoringComprehensive epidemiological monitoring

Actions taken (8): facilitation Actions taken (8): facilitation the Implementing the the Implementing the HIV/AIDS LawHIV/AIDS Law

An implementing Code of Conduct An implementing Code of Conduct has been drafted to:has been drafted to:

Explain the law in plain languageExplain the law in plain language Identify the people and institutions Identify the people and institutions

with responsibilities under the lawwith responsibilities under the law Identify means and timetables for Identify means and timetables for

fulfilling these responsibilitiesfulfilling these responsibilities

Empirical evidence of Empirical evidence of success(1): Reduced success(1): Reduced HIV/AIDS PrevalenceHIV/AIDS Prevalence

Empirical evidence of Empirical evidence of success (2):success (2): Consistent Condom Use Consistent Condom Use

with Clients, 1997-2003with Clients, 1997-2003

0

20

40

60

80

100

120

1997 1998 1999 2001 2003

Per

cent

age

DSW BEERSource: NCHADS, BSS, 2004

Challenges aheadChallenges ahead

Fighting HIV/AIDS is conflicting with Fighting HIV/AIDS is conflicting with other social development agenda,other social development agenda,

Implementation of multisectoral Implementation of multisectoral framework is always difficult and framework is always difficult and some time not feasible some time not feasible

Questions of sustainability Questions of sustainability Stigma, discrimination and Human Stigma, discrimination and Human

rights violation against PLWHA rights violation against PLWHA remain a critical problemremain a critical problem

Challenges ahead: Sexual Challenges ahead: Sexual behaviorsbehaviors

MilitarMilitaryy

PolicePolice MotoMoto

Mean age at 1Mean age at 1stst sexsex

21.121.1 2323 21.721.7

% 1% 1stst sex sex partnerspartners: :

WifeWife

33.433.4 42.742.7 43.643.6

SweetheartSweetheart

28.828.8 31.531.5 27.827.8

DFSWDFSW 34.834.8 22.722.7 26.926.9

IDFSWIDFSW 0.20.2 1.81.8 0.30.3Source: NCHADS, BSS, 2004

Challenges ahead: Reasons Challenges ahead: Reasons for not using condoms with for not using condoms with sweethearts sweethearts

11.9

1.4 10.4 0.05 0.1

20.6

6.35

1.50.7 0.3

13.2

5.1

2.41.3

0.70.1

0

5

10

15

20

25

Trust SH don't want Wantingchildren

SH givesmoney

Lost sexualfeeling

No condom

Perc

enta

ge

Beer Karaoke DFSWSource: NCHADS, BSS, 2004

Lessons learnt (1)Lessons learnt (1)

Political commitment and support from Political commitment and support from all level are essential to the success of all level are essential to the success of the program to fight HIV/AIDSthe program to fight HIV/AIDS

Resources and support mobilized from Resources and support mobilized from national and international community national and international community have significantly contributed to the have significantly contributed to the successsuccess

Behavioral change is centerBehavioral change is center Behavioral change can be done by a Behavioral change can be done by a

combination of different actions combination of different actions

Lessons learnt (2)Lessons learnt (2)

Building holistic approaches with Building holistic approaches with multisectoral engagement and multisectoral engagement and framework has added value to framework has added value to behavioral changebehavioral change

Participation from all stakeholders Participation from all stakeholders including people infected & affected is including people infected & affected is of utmost importanceof utmost importance

Empirical evidence is needed for good Empirical evidence is needed for good governance and providing guidance for governance and providing guidance for further actionsfurther actions

ConclusionsConclusions

Cambodia’s response to HIV/AIDS is Cambodia’s response to HIV/AIDS is recognized internationally for achieving recognized internationally for achieving successessuccesses

Behavioral change is center to generate Behavioral change is center to generate an enabling environment to fight an enabling environment to fight HIV/AIDSHIV/AIDS

Good governance can be reflected in Good governance can be reflected in HIV/AIDS program as it associates with HIV/AIDS program as it associates with responsibility, accountability, responsibility, accountability, participation, evidence based and participation, evidence based and respond to needs of community and respond to needs of community and societysociety