Cambodia
The first case of HIV/AIDS in Cambodia was officially identified in 1991 through screening of blood donors, although HIV had been detected in Cambodian refugees in Thailand two years earlier. Sex workers and men seeking treatment for sexually transmitted infections were among the first groups to report high levels of HIV infection. Today, with an adult prevalence rate of 2.7 percent, Cambodia, one of the region’s poorest countries, has the highest infection rate in Asia, with an estimated 170,000 persons living with HIV/AIDS in 2001. Under the President's Emergency Plan for AIDS Relief, Cambodia received more than $16.8 million in Fiscal Year (FY) 2004, approximately $17.4 million in FY 2005, approximately $19.3 million in FY 2006, and is providing $19 million in FY 2007 to support an integrated HIV/AIDS prevention, treatment and care program. 2008 Country Profile: CambodiaNational HIV prevalence rate among adults (ages 15 to 49): 0.8 percent1
Adults and children (ages 0-49) living with HIV at the end of 2007: 75,0001
AIDS deaths (adults and children) in 2007: 6,9001
AIDS orphans at the end of 2007: not available1
Under PEPFAR, Cambodia received more than $16.8 million in Fiscal Year (FY) 2004, approximately $17.4 million in FY 2005, approximately $19.3 million in FY 2006, and $19 million in FY 2007 to support an integrated HIV/AIDS prevention, treatment and care program. PEPFAR is providing nearly $17.9 million in FY 2008.
Recognizing the global HIV/AIDS pandemic as one of the greatest health challenges of our time, President George W. Bush announced the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 — the largest international health initiative in history by one nation to address a single disease. The United States is changing the paradigm for development, rejecting the flawed “donor-recipient” mentality and replacing it with an ethic of true partnership. These partnerships are having a global impact and transforming the face of our world today.
Partnership to Fight HIV/AIDS
The Royal Government of Cambodia has committed significant resources to fighting HIV/AIDS. Through PEPFAR, the U.S. Government (USG) and its partners are working in partnership with the Royal Government of Cambodia to implement Cambodia’s National Strategic Plan for HIV. Close cooperation between partner governments; non-governmental, community-based and faith-based organizations; and people living with HIV/AIDS are essential in building effective and sustainable HIV prevention, treatment and care services. Given the limited health care resources and capacity in many communities, PEPFAR is committed to building integrated HIV/AIDS prevention, treatment and care services that maximize the effectiveness of available services.
PEPFAR Results in Cambodia
# of individuals receiving antiretroviral treatment in fiscal year 2007 5,700
# of pregnant women receiving prevention of mother-to-child HIV transmission (PMTCT) services in fiscal year 2007 31,200
# of pregnant women receiving antiretroviral prophylaxis for PMTCT in fiscal year 2007 170
# of counseling and testing encounters (in settings other than PMTCT) in fiscal year 2007 108,100
Note: All USG bilateral HIV/AIDS programs are developed and implemented within the context of multi-sectoral national HIV/AIDS strategies, under the host country’s national authority. Programming is designed to reflect the comparative advantage of the USG within the national strategy, and it also leverages other resources, including both other international partner and private-sector resources. The numbers reported reflect USG programs that provide direct support at the point of service delivery. Individuals receiving services as a result of the USG’s contribution to systems strengthening beyond those counted as receiving direct USG support are not included in this total. Numbers may be adjusted as attribution criteria and reporting systems are refined. Numbers above 100 are rounded to nearest 100.
HIV/AIDS in Cambodia
HIV prevalence in Cambodia is among the highest in Asia. Although Cambodia is one of the poorest countries in the world, extraordinary HIV prevention and control efforts exerted by the Royal Government of Cambodia and its partners have helped to reduce the spread of HIV.2 Cambodia’s HIV/AIDS epidemic is spread primarily through heterosexual transmission and revolves largely around the sex trade. HIV transmission occurs mainly in sexual partnerships where one partner has engaged in high-risk behaviors.3 This increased proportion of infections among women may reflect declining prevalence rates among males, as well as deaths among males infected in the early years of Cambodia’s epidemic. Significantly, a low prevalence rate in the general population masks far higher prevalence rates in certain sub-populations, such as injecting drug users, people in prostitution, men who have sex with men, karaoke hostesses and beer girls, and mobile and migrant populations.
1 UNAIDS, Report on the Global AIDS Epidemic, 2008.
2 Vonthanak Saphonn, MD, PhD, et al. “Trends of HIV-1 Seroincidence Among HIV-1 Sentinel Surveillance Groups in Cambodia, 1999-2002.” Journal of Acquired Immune Deficiency Syndromes. 39(5), August 15, 2005: pp. 587-592.
3 Elizabeth Pisani, et al. “Back to Basics in HIV Prevention: Focus on Exposure,” British Medical Journal. 326(21), June 2003: pp. 1384 -1387.
Cambodia Logo PEPFAR Achievements in Cambodia to Date
Challenges to PEPFAR Implementation
Cambodia is a post-conflict country, making scaling up activities a significant challenge. Major constraints to the implementation of HIV/AIDS activities include:
* High levels of high-risk sexual and substance use behaviors;
* Poverty, which drives prostitution, survival sex, and corruption;
* Barriers limiting access to prevention, treatment and care services, including distance to service locations, limited financial resources, a lack of transportation and infrastructure, and geographic barriers;
* Low salaries in the public health care sector; and
* Limited skills and capacity of health care providers.
Reducing Stigma and Discrimination against People Living with HIV/AIDS
With support from PEPFAR, Pact Cambodia, an indigenous non-governmental organization, and the Cambodia People Living with HIV/AIDS Network are implementing the Community Response to Reducing HIV/AIDS Stigma and Discrimination Project. The project uses community fora to educate community members about HIV/AIDS. Lorn Khoeun, an HIV-positive 35-year-old from Tanuk village, witnessed the positive impact of the PEPFAR-supported community forum in her village. After losing her husband to an HIV/AIDS-related illness three years ago, Lorn Khoeun and her daughter faced stigma and discrimination from members of the community as a result of Lorn Khoeun’s HIV-positive status. Neighbors were afraid to buy watermelons or food from Lorn Khoeun, and her food selling business suffered as a result. Lorn Khoeun and fellow community members attended the community forum in her village where they discussed HIV/AIDS awareness; stigma and discrimination; HIV/AIDS law; and raising and mobilizing support for people living with HIV/AIDS from communities, local authorities, health care providers and opinion leaders. Since the forum, community members have altered their behavior and are more supportive of people living with HIV/AIDS. They are also friendlier towards Lorn Khoeun, buying her food and products, visiting her house, playing with her children, and eating together with her. Now, she can continue her business and support her daughter.
Lorn Khoeun’s food selling business is supported by community members.
Lorn Khoeun’s food selling business is supported by
community members.
Phally lives positively and teaches others to do the same.
Phally lives positively and teaches others to do
the same. Phally: The Story of a Courageous Woman
When the home-based care team first visited Phally in December 1999, she was depressed and sick with an HIV-related illness. At that time, there were minimal HIV/AIDS services available in her area, and a referral system linking patients to other available services was non-existent. Support from PEPFAR helped to establish a continuum of care for people living with HIV/AIDS in Phally’s home district. Phally never gave up her desire to make a positive difference in the lives of people living with HIV/AIDS. The involvement of Phally and other people living with HIV/AIDS in the continuum of care is central to the process of integrating and improving the quality of HIV/AIDS care, treatment and support services. Phally is now a skilled and active peer-educator and counselor, who serves as a positive role model for her peers. Her friendly, lively personality inspires all who meet her. “I’m a member of the care and treatment team at Moung Russey Referral Hospital,” Phally said. “I facilitate the ‘Friends Help Friends’ monthly support group meetings at the hospital. I also conduct counseling sessions with people living with HIV/AIDS, to prepare them for beginning antiretrovirals. An important part of my job is to visit people living with HIV/AIDS and their families while they are hospitalized, to provide moral support and information about HIV/AIDS and self care.”
Buddhist Monks Provide HIV/AIDS Care
With support from PEPFAR, Buddhism for Development is helping to bridge the gap between the religious and secular communities in Cambodia. Buddhism for Development provides home-based care to people living with HIV/AIDS and services to children who have lost parents to HIV/AIDS. The group operates a six-week “Peace Development School,” at which monks learn to provide HIV/AIDS-related health care and study vocational training and agricultural extension methods. Of the monks who have gone through the Peace Development School, many returned to their home villages and established HIV/AIDS associations that provide HIV-prevention services and home-based care. These monks also established centers at pagodas, providing direct care and support for orphans and vulnerable children, and working to find ways to keep these children in school.
Overview of AIDS and HIV in Asia
In the early to mid-1980s, while other parts of the world were beginning to deal with serious HIV & AIDS epidemics, Asia remained relatively unaffected by this newly discovered health problem. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries, and by the end of that decade, HIV was spreading rapidly in many areas of the continent.
Today, HIV/AIDS is a growing problem in every region of Asia. East Asia has been identified by UNAIDS as one of the areas of the world where ‘the most striking increases’ in the numbers of people living with HIV have occurred in recent years (along with Eastern Europe and Central Asia).1 Although national HIV prevalence rates in Asia appear to be relatively low (particularly in comparison with sub-Saharan Africa), the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. The latest statistics compiled by UNAIDS suggest that at the end of 2007, 5 million people were living with HIV in Asia.2
Various factors make Asia vulnerable to the spread of HIV, including poverty, inequality, unequal status of women, stigma, cultural myths about sex and high levels of migration.3 4 Some experts predict that Asia may eventually overtake Africa as the part of the world with the highest number of HIV-infected people. Others, however, argue that Asia’s epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely occurring among members of ‘high-risk groups’, unlike Africa where HIV and AIDS are widespread amongst all sections of some countries’ populations.5
Although its useful to understand the overall impact that AIDS is having on the Asian region as a whole, there is no single ‘Asian epidemic’; each country in the region faces a different situation.
“It’s very difficult to speak about ‘the Asian epidemic’. Whatever we come up with, we always find a big exception in Asia.”
Peter Piot, head of UNAIDS 6
Asian countries are experiencing different trends. HIV infection rates are growing in parts of India, but have stabilised or declined in other parts of the country. In Cambodia, Myanmar and Thailand, there has been evidence of declines in HIV infection levels. In Indonesia, Pakistan and Vietnam, meanwhile, the number of people living with HIV has rapidly increased. In Vietnam, this number more than doubled between 2000 and 2005, and HIV has now been detected in every province and city in the country. It is feared that the the speed and severity of the growing HIV epidemic in Pakistan, is outpacing the response. The number of people newly infected with HIV is also rising in China and Bangladesh, although at a much slower pace.7
How HIV is transmitted in Asia
* When HIV is transmitted through unprotected sex in Asia, it’s often during paid sex. More people in Asia engage in sex work (either as a client or a worker), than any other type of behaviour that can carry a high risk of HIV infection.8 High levels of HIV infection have been documented among sex workers and their clients in parts of India, and this situation is mirrored in other Asian countries; in South and South East Asian countries outside India, it’s thought that sex workers and their clients accounted for almost half of people living with HIV in 2005.9
* Injecting drug use is a major driving factor in the spread of HIV throughout Asia, notably in China, Indonesia, Malaysia and Vietnam. In China, nearly half of all people infected with HIV are believed to have become infected through injecting drug use, and in North-East India injecting drug use is the most common HIV transmission route.10 There is often an overlap between communities of IDUs and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.11
* Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries’ epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children.12 This means that MSM can serve as a ‘bridge’ for HIV to spread into the broader population. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand and Vietnam.13
* Mother-to-child transmission is also a significant HIV transmission route in Asia. At the end of 2007, it was estimated that 140,000 children in South and South-East Asia, and 7,800 children in East Asia, were living with HIV, most of whom became infected through mother-to-child transmission.14
HIV prevention in Asia
HIV prevention sign, Ho Chi Minh City, Vietnam
HIV prevention sign in Ho Chi Minh City, Vietnam
Asia has been the base for some extremely successful large-scale HIV prevention programmes. Well-funded, politically supported campaigns in Thailand and Cambodia have led to significant declines in HIV-infection levels, and HIV prevention aimed at sex workers and their clients has played a large role in these achievements. The Indian state of Tamil Nadu is another area where HIV prevention has had a substantial impact. Here high-profile public campaigns discouraged risky sexual behaviour, made condoms more widely available, and provided STI testing and treatment for people who needed them. These efforts resulted in a large decline in risky sex.15
Successes such as these prove that interventions can change the course of Asia's AIDS epidemics. As HIV infection rates continue to grow however, it's clear that more needs to be done. The groups most at risk of becoming infected – sex workers, IDUs, and MSM – are all too often being neglected. For instance, although injecting drug use is one of the most common HIV transmission routes in Asia, it is estimated that less than one in ten IDUs in the region have access to prevention services.16 Similarly men who have sex with men are overlooked and poorly monitored by most governments, even though it is firmly established that this group play a significant role in some countries’ epidemics.17
The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In South-East Asia, less than 5% of pregnant women are offered HIV counselling and testing.18 Across East, South and South-East Asia, the proportion of HIV-infected pregnant women receiving ARVs is just 5%.19
See our HIV prevention around the world page for more about efforts to stem the spread of HIV in Asia and other parts of the world.
AIDS treatment in Asia
The availability of AIDS treatment has more than tripled in Asia since 2004. At the end of 2007 an estimated 420,000 people in the region were receiving antiretroviral drugs (ARVs). Although this rise is encouraging, access to treatment varies widely across the region. Overall it is estimated that three quarters of people in need of ARVs in Asia still have no access to them.20
HIV Positive man and antiretroviral medicines
HIV positive man sitting at home
before taking his antiretroviral medicines
A major constraint is the high cost of ARVs, as both first- and second-line drugs are still unaffordable to most governments. Cheaper generic drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it’s hoped that this will make it easier for governments to obtain and distribute the drugs. Yet even where drugs are available, the poor state of healthcare in many Asian countries, particularly a shortage of trained doctors, is hindering governments' abilities to organise life-long treatment programmes for millions of people living with HIV.21
For the latest statistics for treatment provision in individual countries in Asia, see our AIDS treatment targets page.
Country profiles - South East Asia
Cambodia
Cambodia’s HIV epidemic can be traced back to 1991. After an initial rapid increase, HIV infection levels declined after the late 1990s, and have reached a steady level in recent years. It’s believed that interventions with sex workers, carried out by the government and non-governmental organisations (NGOs), played a role in this decline; the adoption of a ‘100% condom’ policy that enforced condom use in brothels led to a substantial rise in condom use among sex workers and their clients, and a drop in HIV infection levels among brothel-based sex workers. Despite these achievements, Cambodia still has the second highest HIV prevalence rate in Asia, with 0.8% of the adult population infected. Ongoing concerns include low levels of condom use among MSM, an increase in sex work occurring outside of brothels (making it harder to reach sex workers with interventions), and mother-to-child transmission of HIV – around one third of new infections occur through this route. HIV is mostly transmitted through heterosexual sex in Cambodia, and almost half of those infected are women.22 23
Indonesia
High levels of HIV infection are found amongst IDUs in Indonesia, and also among sex workers and their clients. Around 270,000 people in Indonesia are living with HIV, this number has risen sharply in recent years due to several factors: the country’s extensive sex industry; limited testing and treatment clinics and laboratories for sexually transmitted infections (STIs); a highly mobile population; a rapidly growing population of people who inject drugs; and the challenges created by major economic and natural crises that Indonesia has experienced (the Asian financial crisis heavily affected the country in 1997, and the 2004 Tsunami devastated parts of Northern Sumatra, the largest island in Indonesia).24Lao People's Democratic Republic (Laos)
Despite being surrounded by countries that have relatively high HIV infection levels (Thailand, China, Vietnam, Cambodia and Myanmar), Laos has a comparatively small HIV problem. There are various reasons for this: the government was quick to acknowledge AIDS when it first emerged in the country, and took action to warn people about it; Laos has not seen the same level of large-scale migration that has occurred in other parts of Asia; there are relatively high rates of condom use among sex workers and their clients; and it’s thought that very few people in the country inject drugs.25 26
Malaysia
Malaysia’s HIV epidemic is largely driven by injecting drug use. Other than IDUs, HIV is spreading quickly amongst women, fishermen, lorry drivers and factory workers. A senior health official in Malaysia has warned that the number of people living with HIV in the country – currently around 80,000 – could rise to 300,000 by 2015 if nothing is done. The government launched a five-year strategic plan to tackle HIV in 2006, which includes drug substitution therapy and needle exchange programmes for drug users.27
Myanmar (Burma)
After first appearing in the mid-to-late 1980s, HIV became increasingly common in Myanmar. Today, with an estimated 0.7% of the adult population infected, the country faces a serious epidemic. Myanmar’s authoritarian military regime is widely condemned for its human rights abuses, and in 2005 these concerns led the Global Fund to Fight HIV, TB and Malaria to withdraw it’s proposed $98.4 million grants for the country.The Philippines
The Philippines has a very low HIV prevalence, with well under 0.1% of the population infected. Even in groups such as sex workers and MSM that are typically associated with higher levels of HIV, prevalence rates above 1% have not yet been detected – in the case of sex workers, this is possibly due to efforts to screen and treat those selling sex since the early 1990s. There are reasons to believe that this situation may not last, however. Condom use is not the norm in paid sex, drug users commonly share injecting equipment in some areas, and among Filipino youth, there is evidence of complacency about AIDS.Singapore
Although the number of people living with HIV in Singapore is relatively small, the country’s status as an international travel and business hub, along with the high number of infections found in surrounding countries, make it possible that the country will experience a more serious epidemic in the future. In 2006 a record 357 people in Singapore were newly diagnosed with HIV. To combat these rising figures, the government has chosen to focus on preventing mother-to-child transmission, but controversially, has rejected widespread condom promotion.28 Another controversial policy in Singapore is the strict law banning sex between men, which campaigners argue undermines efforts to promote safe sex among MSM.29Thailand
Thailand is an example of a country where a strong national commitment to fighting AIDS has paid off, with widespread access to treatment and an admirable history of HIV prevention efforts. However, some of these past prevention successes are starting to be undermined by a current lack of HIV prevention, rising STI rates, and a growing number of MSM becoming infected with HIV.Vietnam
Around 40,000 people are becoming infected with HIV each year in Vietnam, mostly through injecting drug use or paid sex. The number of people living with HIV in Vietnam doubled between 2000 and 2005, and this rise included a large increase in the number of people who became infected through injecting drug use. Levels of HIV among injecting drug users reached as high as 63% in Hanoi, and 67% in Hai Phong, in 2005.
See our South East Asian statistics page for more data on this region.
East Asia
China
China is seen as a major source of concern by many AIDS experts, because of the large size of its population and the existence of social, economic and cultural factors that make it easy for HIV to spread. At the moment 700,000 people in China are living with HIV (0.1% of the adult population), but it’s feared that this number will increase dramatically in future years, as HIV spreads from the groups most at risk – injecting drug users and those who buy or sell sex – to the general population.30 31Japan
In 2007, around 9,600 adults and children were living with HIV in Japan.32 Data released by the Japanese government in February 2007 showed that annual numbers of new HIV infections and AIDS cases has risen to an all time high in 2006, to 914 and 390 people respectively.33 The most prominent rise occurred among MSM, who it’s previously been documented account for at least 60% of annually reported HIV infections in Japan.34South Asia
Afghanistan
There have only been a small number of cases of HIV in Afghanistan, in contrast to the relatively large numbers recorded in the neighbouring nations of Pakistan and Iran. Nonetheless HIV and AIDS are growing problems. Conditions are in place for an epidemic to develop, including high numbers of displaced people, high levels of illiteracy, low social status for women, and a shortage of health facilities. Afghanistan is one of the world’s leading producers of opium, and the availability of drugs could lead to increased levels of injecting drug use.35 A 2006 study found that around one third of IDUs in the capital city of Kabul had shared contaminated injecting equipment, and that 4% were infected with HIV.36Bangladesh
The first HIV/AIDS case in Bangladesh was reported in 1989. Since 1994, HIV infection levels have increased, although the problem is still relatively small scale, with around 12,000 adults – 0.2% of the total population – infected. It's nonetheless predicted that Bangladesh may gradually be heading towards an epidemic, unless a greater response is developed. At the moment HIV is mainly confined to groups such as IDUs, migrant workers and MSM, and it's reported that this focus on risk groups has led to a lack of urgency among policy makers in dealing with the problem.37
India
India is experiencing a diverse HIV epidemic that affects states in different ways, and to different extents. The groups most affected include injecting drug users, sex workers, truck drivers, migrant workers, and men who have sex with men. Some have predicted that India will soon be experiencing a ‘generalised’ epidemic, where the HIV prevalence rate – currently 0.3% in India – rises above 1%. Others have played down current estimates of the numbers infected, and have argued that, because HIV transmission in India still largely occurs among risk groups, its unlikely that HIV will spread widely among the general population.38 Regardless of the future path of India’s epidemic, it’s undeniable that AIDS is having a devastating impact, and that there are still many major issues – including stigma and poor availability of AIDS treatment – that urgently need to be addressed.Pakistan
Pakistan’s first reported case of HIV occurred in 1987. Until the late 1990s, most subsequent cases occurred in men who had become infected while living or working abroad. After 1999, HIV and AIDS cases began to be recorded among Pakistani sex workers, IDUs, and prisoners.39 Despite a low overall HIV prevalence (0.1%), social and economic conditions in Pakistan – including poverty, low levels of education, and high levels of risk behaviour among IDUs and sex workers – are likely to facilitate the spread of HIV in coming years.40Preference From… http://www.pepfar.gov/pepfar/press/81877.htm. http://www.avert.org/
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