A Situation and Response Analysis of HIV and AIDS in 2007 ... · A Situation and Response Analysis...

A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update

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Table of contents

Table of contents

ACRONYMS ......................................................................................................................................... 4 ACKNOWLEDGEMENTS ...................................................................................................................... 6

EXECUTIVE SUMMARY .................................................................................................................... 7

1. INTRODUCTION............................................................................................................................. 9

1.1 BACKGROUND AND OBJECTIVES OF THE SRA............................................................................. 9 1.2 METHODOLOGY ............................................................................................................................ 9

2. THE CONTEXT .............................................................................................................................. 10

2.1 DEMOGRAPHIC FEATURES OF CAMBODIA AND PROGRESS IN DEVELOPMENT GOALS............ 10

3. THE RESPONSE ANALYSIS: PROGRESS IN IMPLEMENTING NSP II .............................. 12

3.1 PROGRESS MADE UNDER NSP II ................................................................................................ 12 Universal Access............................................................................................................... 12

3.1.1 Implementation of NSP II’s seven strategies.................................................................. 12 Sex workers ....................................................................................................................... 12 Men who have sex with men .......................................................................................... 12 Injecting drug users/drug users .................................................................................... 13 Female partners of high risk males ................................................................................ 13

Youth .................................................................................................................................. 13Mobile populations and workplace ............................................................................... 14 Uniformed services .......................................................................................................... 14 Condoms............................................................................................................................ 15 Mother-to-child transmission ......................................................................................... 15 Blood safety ....................................................................................................................... 15 HIV testing ........................................................................................................................ 15

Continuum of care............................................................................................................ 16TB/HIV .............................................................................................................................. 16 Contributing to health system strengthening .............................................................. 16 Governance and coordination ........................................................................................ 17 Multisectoral response..................................................................................................... 18 Decentralisation ................................................................................................................ 18 Civil society ....................................................................................................................... 18 Policy development.......................................................................................................... 19 Enabling environment ..................................................................................................... 19

3.2 PROGRESS MADE UNDER NSP II: KEY CONCLUSIONS .............................................................. 20 3.2.1 Key areas which need to be addressed ........................................................................... 21

3.3 CHALLENGES AND THREATS IN MEETING NSP II TARGETS ..................................................... 21 3.3.1 Resource needs ................................................................................................................... 21 3.3.2 Resource mobilisation........................................................................................................ 21 3.3.3 Resource tracking and allocation ..................................................................................... 22 3.3.4 Key capacity constraints.................................................................................................... 22 3.3.5 Quality ................................................................................................................................. 23 3.3.6 Fragility of the gains? – Key risk areas............................................................................ 23

4. THE SITUATION ANALYSIS ...................................................................................................... 24

4.1 THE EPIDEMIOLOGY OF HIV IN CAMBODIA: WHO IS MOST AT RISK OF HIV AND WHY? ....... 24 4.1.1 Reduced HIV prevalence in the general population ..................................................... 24

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4.1.2 HIV prevalence in most-at-risk populations .................................................................. 25 Sex workers and clients ................................................................................................... 25 Men who have sex with men .......................................................................................... 25 Injecting and other drug users........................................................................................ 26 Pregnant women .............................................................................................................. 26 Key conclusions ................................................................................................................ 26

5. OPPORTUNITIES FOR AN ENHANCED RESPONSE TO HIV............................................. 28

5.1 POLICY IMPLEMENTATION AND ENFORCEMENT ...................................................................... 28 5.2 CONTINUED SCALING-UP AND QUALITY IMPROVEMENT OF KEY PROGRAMS......................... 28

5.2.1 Prevention for most at risk populations ......................................................................... 28 5.2.2 Vulnerable populations ..................................................................................................... 29 5.2.3 Strategic behaviour change communication .................................................................. 29 5.2.4 Prevention of mother-to-child transmission .................................................................. 29 5.2.5 Improving access to HIV testing ...................................................................................... 30 5.2.6 Continuum of Care ............................................................................................................ 30 5.2.7 Impact mitigation ............................................................................................................... 30 5.2.8 Safe blood supply ............................................................................................................... 31

5.3 CONTRIBUTING TO HEALTH SYSTEM STRENGTHENING............................................................ 31 5.4 STRENGTHENING ORGANISATIONAL AND TECHNICAL CAPACITY TO IMPROVE QUALITY..... 31 5.5 IMPROVING GOVERNANCE AND COORDINATION..................................................................... 32

5.5.1 GDJTWG.............................................................................................................................. 32 5.5.3 Priority setting and resource allocation .......................................................................... 32 5.5.4 Mainstreaming.................................................................................................................... 33 5.5.5 NAA ..................................................................................................................................... 33 5.5.6 Decentralisation.................................................................................................................. 33

5. 6 IMPROVING THE COLLECTION AND USE OF STRATEGIC INFORMATION.................................. 33 5.7 CRITICAL SUCCESS FACTORS IN THE NATIONAL RESPONSE...................................................... 34 5.8 KEY CONCLUSIONS ..................................................................................................................... 34

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Acronyms

Acronyms

ANC ante‐natal care ART anti‐retroviral therapy ARV anti‐retroviral ATS amphetamine‐type stimulants AusAID Australian Agency for International Development BBCWST BBC World Service Trust BBFSW brothel‐based female sex workers BSS Behavioural Surveillance Survey CoC continuum of care CBCA Cambodian Business Coalition on AIDS CBO community based organisation CCW Cambodian Community of Women Living with HIV CDC‐GAP Centres for Disease Control and Prevention – Global AIDS Program CDHS Cambodia Demographic and Health Survey CG Core Group CMDG Cambodia Millennium Development Goals CPN+ Cambodian Network of People Living with HIV/AIDS DFID Department for International Development DoLA Department of Local Administration FHI Family Health International GDJTWG Government‐Donor Joint Technical Working Group on HIV/AIDS HACC HIV/AIDS Coordinating Committee HCW health care worker HSS HIV Sentinel Surveillance HSS health system strengthening IDU/DU injecting drug user/drug user ILO International Labour Organisation IFSW indirect female sex worker KHANA Khmer HIV/AIDS NGO Alliance MARP most‐at‐risk populations MSM men who have sex with men MoCR Ministry of Cults and Religions M&E monitoring and evaluation MoEYS Ministry of Education, Youth and Sport MoINT Ministry of Interior MoLVT Ministry of Labour and Vocational Training MoND Ministry of National Defence MoPWT Ministry of Public Works and Transport MoSVY Ministry of Social Affairs, Veterans and Youth Rehabilitation MoWA Ministry of Women’s Affairs NAA National AIDS Authority NACD National Authority to Combat Drugs NBTC National Blood Transfusion Centre NCHADS National Centre for HIV/AIDS, Dermatology and STDs NCMCH National Centre for Maternal and Child Health NGO non‐government organisation NSP I National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS, 2001‐

2005 NSP II National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS, 2006‐

2010 QA/QI quality assurance/quality improvement OD Operational District OI opportunistic infection

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update OP Operational Plan OVC orphans and vulnerable children PEPFAR President’s Emergency Plan for AIDS Relief PITC provider‐initiated testing and counselling PLHIV person living with HIV PMTCT prevention of mother‐to‐child transmission PSI Population Services International RGC Royal Government of Cambodia RHAC Reproductive Health Association of Cambodia SF Strategic Framework SOP standard operating procedures SRA situation and response analysis SSS STI Sentinel Surveillance STD sexually transmitted infection STI sexually transmissible infection TA technical assistance TB tuberculosis TWG Technical Working Group UA Universal Access UNAIDS United Nations Joint Program on AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Emergency Fund USAID United States Agency for International Development VCCT voluntary confidential counselling and testing WFP World Food Program 100% CUP 100% Condom Use Program

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Acknowledgements

Acknowledgements

The National AIDS Authority (NAA) wishes to express its appreciation to everyone who contributed to the development of the Situation and Response Analysis 2007. In particular we would like to thank the members of the Core Group who oversaw and guided this process, representing key stakeholders from government, civil society, private sector, donors and technical assistance agencies. The Core Group was made up of representatives from the NAA, the National Centre for HIV/AIDS, Dermatology and STDs (NCHADS), the National Centre for Maternal and Child Health (NCMCH), the Ministry of Health’s Global Fund Principal Recipient’s Office, the Ministry of National Defence (MoND), the Ministry of Women’s Affairs (MoWA), the Khmer HIV/AIDS NGO Alliance (KHANA), the HIV/AIDS Coordinating Committee (HACC), the Cambodian Network of People Living with HIV/AIDS (CPN+), the Cambodian Business Coalition on AIDS (CBCA), the United Nations Joint Program on AIDS (UNAIDS), the United Nations Children’s Emergency Fund (UNICEF), the Department for International Development (DfID), the United States Agency for International Development (USAID), the Centres for Disease Control and Prevention – Global AIDS Program (CDC‐GAP), and Family Health International (FHI). Sincere thanks are also provided to a large number of stakeholders who made input into to the Situation and Response Analysis through interviews, consultation meetings and by making documents available for review. In particular, thanks are extended to Dr Joyce Neal from the US Centres for Disease Control and Prevention Global AIDS Program for providing input on the epidemiology of HIV and AIDS and commenting on drafts of the epidemiology section. The National AIDS Authority expresses its thanks to David Lowe who led the Situation and Response Analysis process, supported by Jan de Jong and Dr Tia Phalla. Finally we are grateful for the financial support provided for the SRA by DfID, UNAIDS (through the Government of France), and the United Nations Population Fund (UNFPA).

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Executive Summary Executive Summary

The 2007 update of the Situation and Response Analysis (SRA) provides a strategic overview of HIV and AIDS in Cambodia, as well as the progress and lessons learned in the first 21 months of implementing the National Strategic Plan for HIV/AIDS 2006‐2010 (NSP II). This update has been used in revising the NSP II for the next three years, 2008‐2010. Estimated adult HIV prevalence has declined from a peak of 2.0% in 1998 to 0.9% in 2006. Of the 71,100 people living with HIV (PLHIV) aged 0‐49 years in 2006, an estimated 33,100 were in need of antiretroviral therapy (ART). By 2010 the number in need of ART will increase to 38,600. A key conclusion of the 2007 Consensus Workshop on HIV Estimates and Projections is that prevalence in the general population has declined and will stabilise, if interventions are sustained. The main risk of a second‐wave of HIV infections occurring in Cambodia (i.e., significantly increased HIV incidence), is from female sex workers, their clients and sweethearts. Men who have sex with men (MSM) and injecting drug users/drug users (IDU/DU) may also potentially be significant contributors to any second‐wave of HIV infections. Populations who may be especially vulnerable for HIV infection are female partners of high‐risk males, mobile populations, and urban and out‐of‐school youth. There are three key conclusions to be drawn from the epidemiological and other risk assessment data, with implications for program development over the next three years and beyond. Firstly, it cannot be assumed that incidence will remain low. Changes in the structure of the commercial sex industry and the difficulty of sustaining prevention programs in brothels where there is a high turnover of sex workers, along with the possibility of significant epidemics among MSM and IDU/DU, mean that sustaining and improving prevention efforts to maintain the reduction in HIV incidence will need to attract high priority. Secondly, the maturing of the Cambodian epidemic means that there are a growing number of PLHIV in need of ART. Delivering on the commitment to provide long‐term Universal Access to ART and associated care and support will need to be a continuing high priority. Thirdly, the high death rate from AIDS has resulted in many orphans and widows. PLHIV, especially those with advanced stage HIV, have high social and economic support needs. Meeting the substantial impact mitigation needs for those already infected and affected needs to be a key priority. In general, good progress has been made in the first 21 months of implementing NSP II. This has particularly been the case in the health sector with rapid scale‐up of the continuum of care. There has been less significant growth in prevention programs, but condom and lubricant sales and distribution have grown strongly. The national response has increasingly been focused on key priorities, assisted by the participatory Universal Access target setting process. Most Universal Access indicators for 2008 will be either met or surpassed, although some areas will fall significantly short of meeting targets. There has been extensive planning in prevention programs for MSM and IDU/DU and in impact mitigation programs for orphans and vulnerable children (OVC). Full implementation of these plans is dependent upon additional resources becoming available. Civil society has continued to make a strong and central contribution to the national response to HIV and AIDS in the areas of prevention, impact mitigation, care, support and treatment. A dynamic policy environment has seen new policies developed and existing policies revised, although a stronger emphasis on implementation is needed. Some ministries have developed HIV policies for the first time. While most policies are HIV specific, there is an increasing number of mainstream policies with HIV content. Policy linkages within and between sectors are actively being developed. The inclusion in NSP II of a specific monitoring and evaluation strategy has paid dividends in fostering a greater focus in this area. Governance and coordination has improved, with significantly improved collaboration between partners, focused on priority issues.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update There are a number of constraints and threats facing the Cambodian response to HIV. The cost of financing HIV programs in Cambodia is rising rapidly and the financial resource gap is widening. The government’s financial contribution is very limited (3% of annual HIV expenditures), resulting in dependence on donors, with a particular reliance on a small number of donors. More than 70% of total HIV funding in Cambodia comes from the United States Agency for International Development (USAID), the United States Centres for Disease Control and Prevention – Global AIDS Program (CDC‐GAP) and the Global Fund. There is no resource tracking system; Organisational capacity and technical skills in some ministries and some NGOs are weak, and the quality of many programs needs strengthening. While the Cambodian response to HIV has recorded many substantial achievements, these gains are still fragile. The key risks faced over the next 3 years and beyond are increasing HIV infections in most at risk populations (MARPs) driving a second wave of the epidemic; increasing (injecting) drug use by MARPs resulting in a difficult to control drug use driven epidemic; increased incidence as a result of PLHIV living longer, (which may be offset by reduced viral load, resulting from effective treatment); the development of drug‐resistant HIV; organisational and human capacity not being built quickly enough to facilitate scale‐up of priority programs; additional funds to support scale‐up of under‐funded program areas not being mobilised; reduced donor funding of the National AIDS Authority (NAA); and changes to the way donors fund the Cambodian health system resulting in reduced HIV funding for the health sector. While progress has been made in all of the following areas in the last 21 months, improving on current initiatives will be critical to success over the next 3 years: improving the coverage and quality of the prevention of mother‐to‐child (PMTCT) programming through strengthening of ante‐natal care (ANC) services; achieving higher coverage of HIV testing for pregnant women, tuberculosis (TB) patients and most‐at‐risk populations; contributing to health system strengthening by developing stronger linkages between different parts of the health system; and mainstreaming HIV into key sectors. The key opportunities that need to be addressed in the next phase of NSP II, 2008‐2010 are scaling up of prevention programs for MARPs: indirect female sex workers (IFSWs) in the entertainment industry, freelance sex workers, MSM and IDU/DU, while sustaining and improving prevention programs for brothel based female sex workers; focussing prevention programs for larger populations of vulnerable groups to evidence of risk; keeping the commitment to scale‐up care, support and treatment for PLHIV; implementing impact mitigation initiatives for orphans and vulnerable children; developing broader impact mitigation strategies for all PLHIV and those affected by HIV; according significantly higher priority to developing organisational and technical capacity in key ministries and non government organisations/community based organisations (NGOs/CBOs); rational and effective use of technical support to address capacity gaps in priority areas to ensure improved and efficient absorption of resources; responding to challenges in mitigating underlying determinants of the epidemic such as gender inequality and stigma and discrimination; mainstreaming HIV into the work of key sectors and social sector planning and improved cross program and sectoral linkages for related HIV programs; mobilising resources for under‐funded key priorities to achieve Universal Access targets; development of a resource tracking system; priority setting and alignment of resource allocation to priorities; an emphasis on quality improvement for all program areas; improving governance and coordination; and better use of strategic information.

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1. Introduction

1. Introduction

1.1 Background and objectives of the SRA

1.1 Background and objectives of the SRA

The most recent Situation and Response Analysis (SRA) was conducted in 2005. The findings of the 2005 SRA were used in developing the National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS 2006‐2010 (NSP II). Significant developments since the commencement of NSP II are improved priority setting through the development of Universal Access targets, the development of costed strategies and operational plans for some MARPs and key sectors, and revised estimates and projections of HIV prevalence. It has been decided to undertake a 2007 SRA update to assess the changed context and national needs for the response to HIV and AIDS. The findings of the 2007 updated SRA were used to revise NSP II for the next 3 years, 2008‐2010. The SRA focuses on key trends, strategic issues, constraints, threats and opportunities. The SRA is not intended to be a comprehensive review of the national response to HIV, and choices have been made regarding its contents.

1.2 Methodology

1.2 Methodology

The National AIDS Authority (NAA) led the SRA update, in partnership with a Core Group (CG). The CG membership was made up of key partners from ministries, technical assistance agencies, civil society, donors and the private sector. To review the progress made in implementing the NSP II a small team of consultants reviewed available monitoring and evaluation data (including surveillance data), research, planning documents and sectoral and sub‐population strategic frameworks and operational plans developed by ministries and technical working groups (TWGs). Focus groups and interviews were held in a number of key thematic areas where additional information was needed to supplement data and documents. The SRA was informed by progress in relation to targets set in NSP II and Cambodia’s 21 Universal Access Indicators. All information was reviewed and analysed and preliminary key findings were presented to the CG. This updated SRA was then written and reviewed by the CG. The findings of the SRA were used in revising the NSP II for 2008‐2010. The draft updated SRA and draft revised NSP II were discussed at a National Consensus Meeting in November 2007. The SRA and revised NSP II were finalised to reflect the input of the National Consensus Meeting. A limitation of the SRA is that only the ante‐natal care (ANC) data from the 2006 HIV Sentinel Surveillance survey was available at the time of writing. Data from the 2007 Behavioural Surveillance Survey was not available.

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2. The Context 2.1 Demographic features of Cambodia and progress in development goals

2. The Context

2.1 Demographic features of Cambodia and progress in development goals

Of the total Cambodian population of 14.33 million, fifty percent are under age 20. 1 Eighty two per cent of the population lives in rural areas. Cambodia has made significant progress in rebuilding its human and physical capital. Cambodia is now at a critical juncture as it moves away from a post‐conflict situation towards a more normal development status. However, a significant array of development challenges remain, especially in the health and social sectors. Good progress has been achieved against the targets for Cambodia’s Millennium Development Goals (CMDG) in many areas. 2 Key achievements include a significant reduction in poverty in urban and more accessible rural areas; a noteworthy reduction in the prevalence of communicable diseases, especially HIV and AIDS; significant reductions in mortality rates for infants and under‐5 year olds; improved breastfeeding rates; and a reduction in gender disparity in most areas, especially in primary education and adult literacy. Areas where little or no progress against CMDGs has been made include high rural poverty rates; access to quality health services, especially for women and maternal health; and gender disparity in secondary and tertiary education. Health status in general and health service utilisation improved between 2000 and 2005. 3 Exceptions are the areas of women’s health and nutrition for women and children. The infant mortality rate has declined significantly from 95 to 66 per 1,000 live births. The maternal mortality rate, however, remained statistically unchanged between the years 2000 and 2005 (437 to 472 per 100,000 live births). A challenge for the national response to HIV has been program development in the context of financial, human resource and infrastructure constraints in health and social services. The Cambodian health sector is generally weak, although this varies between urban and rural areas and between provinces. Some national programs, including NCHADS, have been able to make significant gains in providing quality health services, although this is hampered by the overall financial, human resource and infrastructure constraints . Utilisation of public sector health services in Cambodia is low, with only 22% of people seeking initial treatment in the public sector. 4 However, most HIV and AIDS care and treatment is provided by the public sector and NGOs/CBOs. The level of government investment in health and social services is low, with a high reliance on out of pocket expenditure and donor funding for some programs. Government per capita expenditure on health was US $7 in 2005. 5 Private expenditure on health care is high by comparison at $21.60 per capita ($18.60 per capita out‐of‐pocket and $3 per capita by NGOs). Economic growth has been strong in recent years, ranging from 13.4% in 2005 to a forecast 8.5% in 2007. 6 There is the possibility of stronger economic growth in coming years, led by extraction of natural resources. This could lead to an increase in government revenues, providing an opportunity 1 CIPS, 2004. 2 Ministry of Planning and UNDP, 2005. 3 Cambodia Health Sector Review 2003‐2007. 4 CDHS, 2005. 5 National Health Accounts, 2005. 6 Ministry of Economics and Finance web site.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update for greater public sector investment in health and social services, although it is not clear that this will occur. Cambodia still remains one of the poorest and least developed countries in Asia, with gross domestic product per capita estimated at US $506 in 2006. 7 It is estimated that 35% of Cambodians live below the poverty line. 8

7 Ibid. 8 CDHS, 2005.

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3. The Response Analysis: progress in implementing NSP II 3.1 Progress made under NSP II

3. The Response Analysis: progress in implementing NSP II

3.1 Progress made under NSP II

This section provides an overview of progress in the national response to HIV in key areas since the commencement of NSP II in January 2006 through to September 2007, concentrating on new developments. It is not intended to be a comprehensive review. The review of progress has been structured around an examination of the implementation status of each of NSP II’s seven strategies.

Universal Access In 2006 the NAA and NCHADS led a participatory process involving government, civil society, technical assistance agencies and donors, to develop 21 key Universal Access indicators for prevention, treatment and impact mitigation, with targets for 2008 and 2010. Actions for key thematic areas were developed, aligned to the 5 year targets. The process has provided additional focus on the need for scaling‐up HIV programs in key areas and an additional measure by which to gauge progress under NSP II.

3.1.1 Implementation of NSP II’s seven strategies

Strategy 1: Increased coverage of effective prevention interventions and additional interventions developed

Sex workers A number of initiatives have been taken by NCHADS to address the results of the 2005 SSS which showed no significant change in STI prevalence in BBFSWs between 2000 and 2005. These include revisions to the National Policy and Priority Strategies for STD Prevention and Control; enhanced training of laboratory workers to ensure correct diagnoses of STIs; and development by NCHADS of standard operating procedures for Outreach, Peer Education and the 100% Condom Use Program (CUP) to Sex Workers, designed to expand the scope of the 100% CUP to IFSW in the entertainment industry. A Technical Working Group on sex worker peer education, outreach and the 100% CUP has been established, bringing together the Ministry of Women’s Affairs (MoWA), NAA, NCHADS and NGOs to more effectively address issues relating to sex work. Key challenges are making condoms available in entertainment establishments, greatly improving the access of prevention programs to entertainment establishments, and development of programs to reach clients of sex workers. When the 2006 HIV Sentinel Surveillance survey and 2007 Behavioural Surveillance Survey data become available, it will be possible to compare consistent condom use by sex workers and clients against the Universal Access targets.

Men who have sex with men MSM HIV prevention programs currently reach only an estimated 7% of sexually active MSM. 9 The 2008 Universal Access indicator of 60% of MSM being exposed to prevention interventions will not be met. The principal reason is the failure of Cambodia’s Global Fund round 6 proposal. This has held back scale up. However, the inclusion of MSM in NSP II, coupled with leadership from NAA, NCHADS, CBOs, donors and technical assistance agencies, has provided a good foundation for scaling‐up the response. NAA has established a National MSM TWG. An MSM Situation and

9 Cambodia’s Global Fund Round 7 Proposal, 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update Response Analysis, Strategic Framework and Operational Plan have been recently developed. A limited expansion of HIV prevention services has occurred since 2006. More significant scale‐up will take place from 2009 with Cambodia’s Global Fund Round 7 funding. Surveillance data for MSM became available for the first time in 2006 with the release of the 2005 STI Sentinel Surveillance (SSS) data. NCHADS has made good progress in its commitment to provide quality and stigma‐free STI services to MSM through training of STI health professionals. A National MSM network, Bandanh Chaktomuk, was launched in 2006.

Injecting drug users/drug users A Drugs and HIV TWG has been established by the NACD. The NACD and TWG are developing a National Strategic Plan for Illicit Drug Use and HIV/AIDS. Policies and Guidelines for the Operation of Needle and Syringe Programs in Cambodia were released by the NACD in December 2006. Currently two NGOs are operating needle and syringe programs in Phnom Penh, but coverage is limited. A pilot methadone program is planned for 2008. Drug treatment services in Cambodia are limited and lack a professional, evidence‐informed approach. HIV prevention programs for injecting drug users/drug users (IDU/DU), beyond the existing needle and syringe programs are limited. NGOs working with sex workers and MSM have started to address IDU/DU issues, although this work needs to be strengthened and extended. Some HIV prevention work has commenced in prisons and other closed settings (e.g. drug rehabilitation centres). There is a need for evidence on the type and extent of HIV risk in closed settings to guide interventions, assess the level of risk and determine the relative priority for this area. The Australian Agency for International Development’s (AusAID) regional harm reduction program, the HIV/AIDS Asia Regional Program (HAARP), will open a small country program in Cambodia in 2008. Funding for HIV and illicit drugs work has also been made available by the Swedish International Development Cooperation Agency (SIDA). Cambodia’s Global Fund round 7 funding includes a significant drug use component which will enable scale‐up to take advantage of the extensive recent planning work. Coverage estimates of IDU/DU programs will soon be possible, following the completion of population size estimation work.

Female partners of high risk males The MoWA has developed a Strategic Plan on Women, Girls and HIV/AIDS 2007‐2011. The plan includes a national action plan for the prevention of spousal and partner transmission. Gender inequities continue to fuel sexual transmission. The major impediment to prevention of spousal transmission is the difficulty of achieving significant levels of condom use in marriage. For this reason prevention programs have concentrated on making extra‐marital sex safer through prevention programs targeting sex workers. There is a growing recognition of the need to address responsible male sexual behaviour and the issue of gender power imbalance. The PMTCT Program has placed an emphasis on HIV couple testing. Couple testing accounted for 20% of all HIV testing in the PMTCT Program in the first 6 months of 2007. 10 There is potential for VCCT sites to place greater emphasis on couple testing.

Youth MoEYS is developing a new HIV Strategic Plan for 2008‐2012 to replace the previous 5 year strategic plan. The School Health Policy was released in August 2006. It contains commitments to behaviour change education and non‐discrimination against PLHIV in the context of a mainstream policy. HIV has been mainstreamed into the work of MoEYS in a number of areas. This has taken the form of integration of HIV into pre‐service teacher training, the school curriculum, and into the work plans of MoEYS 15 Departments. There has been a significant expansion of MoEYS co‐curricular Life Skills for HIV Education Program from 50% of schools in 2 provinces in 2005 to 14 provinces in 2007. Coverage of school students has increased from 174,000 in 2006 to 312,000 in 2007 and for out‐of‐school youth

10 PMTCT Program, 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update from 23,000 in 2006 to 58,000 in 2007. MoEYS has also funded a programme implemented by a local NGO to provide especially vulnerable street children in Phnom Penh with skills‐based HIV education.. With the loss of DfID funding post‐2007, the reach of the Life Skills Program to out‐of‐school youth will be significantly reduced unless it can be integrated with other activities. Funding constraints will also give rise to the need to use strategic information to focus MoEYS work on priority actions. In 2006 and 2007 there has been limited expansion of peer education services for youth by some NGOs/CBOs.

Mobile populations and workplace The Ministry of Labour and Vocational Training’s (MoLVT) 2006 Prakas on Education of HIV/AIDS, Safe Migration, and Labour Rights for Cambodian Workers Abroad, requires HIV education for Cambodian workers going abroad. Pre‐departure training of external migrant workers has commenced, but is confined to the relatively small number of documented workers. The establishment of the TWG on Mobility, accompanied by capacity building, has resulted in increased activities. The Inter‐Ministerial Task Force on Migration has developed a Safe Migration Policy focussing on trafficking and sexual exploitation of Cambodian women. Cambodia has endorsed the Regional Strategy on Mobility and HIV Vulnerability Reduction in South East Asia and Southern China 2006‐2008. A number of small‐scale mobility projects have commenced. In September 2006 the MoLVT issued a Prakas on Creating HIV/AIDS Committees in Enterprises and Establishments and Managing HIV/AIDS in the Workplace. The Prakas requires the establishment of HIV Committees and workplace HIV education programs in all private sector workplaces of 8 or more employees. The MoLVT has also developed an HIV plan and there are signs that HIV and workplace activities may be sustainable following the end of the International Labour Organisations (ILO) workplace project. There has been increased support from the private sector, as evidenced by the formation of the Cambodian Business Coalition on HIV/AIDS in 2007. The Coalition will provide a forum for enhancing a coordinated private sector response. HIV prevention interventions in garment factories have expanded. The MoEYS is the first Ministry to develop an HIV workplace policy. The policy is expected to be endorsed in the near future. The Ministry of Public Works and Transport’s (MoPWT) Policy on HIV/AIDS and Prevention in the Public Works and Transport Sectors, issued in August 2006, provides for an HIV impact assessment study for all major construction and infrastructure projects, with 1% of the budget for these projects to be set aside for HIV prevention programs. The policy also requires HIV information dissemination to transport operators, passengers, construction workers, and mobile populations.

Uniformed services The Ministry of National Defence (MoND) has developed a new HIV/AIDS/STI Strategic Plan 2007‐2011 and a costed Operational Plan. The Ministry of Interior (MoI) plans to develop an HIV Strategic Plan for police. Both ministries have a long record of HIV prevention education and have achieved very high coverage levels (Defence: 100% and Police: 87% 11). Uniformed services personnel have been accorded a high priority due to mobility and their high use of commercial sex. Given the high coverage achieved and the ageing of uniformed service personnel due to recruitment freezes, some have questioned whether these groups should be accorded as high a priority as has previously been the case. This could result in less intensive refresher education to sustain safe behaviour and targeting of prevention work to those uniformed service personnel who are at high risk.

11 FHI Cambodia, Annual Report, 2007.

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Condoms The total number of condoms socially marketed by Population Services International (PSI) increased from 20.9 million in 2005 to 26.3 million in 2006, an increase of 26%. First‐half year data for 2007 indicates a further 7% increase. If this growth rate is sustained, Cambodia’s 2008 Universal Access target of 27.4 million condoms sold and distributed will be exceeded, one year ahead of schedule. Sales of the OK Condom brand, marketed to sweethearts, increased by 134% from end‐2005 to mid‐2007. Sales and distribution of lubricant increased from 1 million sachets in 2005 to 1.7 million sachets in 2006, an increase of 72%. First‐half year data for 2007 indicates a growth rate of 163% over 2006. Lubricant is marketed to sex workers and MSM. Reasons attributed by PSI for these significant increases in condom and lubricant sales and distribution include expanded behaviour change communication, greater use of evidence‐informed marketing directly addressing barriers to behaviour change, improved targeting, expanded distribution, and increased donor support for lubricant.

Mother-to-child transmission There has been significant scale‐up of PMTCT services (from 28 sites in 18 ODs in 2005 to 77 sites in 42 Operating Districts (OD) in 2007) and training of over 700 health care workers. It is likely that Cambodia’s 2008 Universal Access Target of at least one PMTCT sites in 49 ODs will be met or exceeded. The national PMTCT policy was amended to adopt a provider initiated testing and counselling (PITC) approach to HIV testing of women seeking ANC. Uptake of HIV testing at PMTCT sites has increased significantly in the past year, as has the number of women and infants receiving full PMTCT services. However, overall coverage of PMTCT services at a population level is low. Less than 10% of pregnant women are tested for HIV (the 2008 Universal Access target is 20%), and only half of identified HIV positive pregnant women deliver in a health facility. In 2006, an estimated 7% of HIV‐positive mothers and HIV‐exposed infants received anti‐retroviral (ARV) prophylaxis. 12 Based on current trends, ARV prophylaxis coverage is expected to increase to 11% by the end of 2007. 13 The majority of HIV positive children in need are receiving ART. A PMTCT Program Review was conducted in 2007 and identified pathways for scale‐up of PMTCT services (see Section 4, Opportunities for an Enhanced Response).

Blood safety Universal HIV screening of donated blood is a long established policy and in Cambodia. The National Blood Transfusion Centre is continuing in its efforts to eliminate the small number of donations that are not screened. New guidelines for donor screening, combined with training, has reduced HIV prevalence among blood donors from 1.8% in 2005 to 0.7% in mid‐2007. 14 While the number of voluntary blood donors has increased, a significant increase in the total number of blood donations has seen the percentage of voluntary donations decreasing from 24% in 2005 to 21.5% in mid‐2007.

Strategy 2: Increased coverage of effective interventions for care and support and

additional interventions developed

HIV testing The NCHADS Policy, Strategy and Guidelines for HIV Counselling and Testing was revised to provide for PITC for all ANC, STD and tuberculosis (TB) patients, as a supplementary approach to voluntary confidential counselling and testing (VCCT). VCCT sites, the entry point to the CoC, increased from 109 in 2005 to 190 by September, 2007. Cambodia’s 2008 Universal Access target of 230 sites is likely to be met. The number of people tested for HIV at VCCT sites increased from 152,147 in

12 Cambodia Joint PMTCT Program Review Findings and Recommendations. 2007. 13 Tom Heller, personal communication, 2007. 14 Dr. Hok Kim Cheng, personal communication, 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update 2005 to 212,789 in 2006, a 40% increase. Half‐year data for 2007 show a growth rate of 16% in HIV testing. Ninety seven percent of people return for their test result.

Continuum of care The most significant progress for NSP II has been the rapid scale‐up of the continuum of care (CoC) for PLHIV. A full range of CoC services is now available in 36 ODs, compared to 23 ODs in 2005. 15 This exceeds Cambodia’s 2008 Universal Access target of 34 ODs. The number of adult ART treatment sites has increased from 30 in 2005 to 43 by September 2007. The number of paediatric sites has increased from 11 in 2005 to 22 in 2007. A total of 23,587 PLHIV were receiving ART in July 2007 (21,432 adults and 2,155 children), up from 12,355 in 2005. This represents a 91% increase. It is estimated that 71% of the total number of people in need of ART are currently receiving treatment. The 2008 Universal Access target is 80% of the number of people in need of ART being on treatment. NCHADS is on track to meet, or possibly exceed, this target. Adherence is estimated to be 87%. Over 95% of patients are still on first line therapy. The number of home based care teams has increased from 261 in 2005 to 310 by June 2007, with 22,253 PLHIV receiving support in July 2007. Coverage has increased from 366 health centres to 603 health centres. This is well in excess of Cambodia’s 2008 Universal Access target of coverage of 452 health centres. A 2007 external review concluded that the CoC is a good quality program in terms of accessibility, a client‐centred approach, and good practice standards. Costs relative to similar programs in developing countries are low. Areas for improvement are outlined in Section 4.

TB/HIV The Revised Standard Operating Procedures for Prompt Testing of TB/HIV and Rapid Access to Treatment and Care was issued in January 2006. Training of health staff on expanded TB/HIV collaboration is being rolled‐out rapidly. The number of health centres with collaborative TB/HIV activities was 467 in the second quarter of 2007. This exceeds Cambodia’s 2008 Universal Access target of 452. Health staff in a total of 43 ODs had been trained by September 2007, representing an additional 24 ODs compared to December 2005. The number of TB patients tested for HIV and number of PLHIV screened for TB has increased over the last two years as a result of PITC, health provider education, increased collaboration between OI/ART and TB services, and assistance by Home Based Care teams in transporting TB patients to VCCT. However, only one‐third of TB patients from ODs where training on expanded TB/HIV collaboration has occurred are tested for HIV. Problems with referral and the cost of travel to VCCT sites appear to be the main obstacles. Screening of HIV patients for TB is often hampered by limited supplies of X‐ray film at referral hospitals.

Contributing to health system strengthening Although HIV and AIDS health services are delivered through a strong vertical program, there have been contributions to health system strengthening in the following areas: ‐ establishment of integrated laboratories, across national programs, in 6 referral hospitals; ‐ strengthening of ANC through the PMTCT program, including an increase of deliveries in health

care facilities; ‐ increasing utilisation of the public sector health system; ‐ health staff training in opportunistic infection management has cross‐over value for a broad range

of health conditions; and ‐ strengthening of general paediatric services through paediatric AIDS care sites.

15 All CoC data is from NCHADS Annual Report, 2005, NCHADS Second Quarter Report, 2007 and Mean Chhi Vun, personal communication, 2007.

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Strategy 3: Increased coverage of effective interventions for impact mitigation and additional interventions developed

NSP II has been instrumental in according higher priority to impact mitigation. The most significant development in this area has been the establishment of the National Orphans and Vulnerable Children Task Force, under the Ministry of Social Affairs, Veterans and Youth Rehabilitation (MoSVY). Overall, 8.8% of Cambodians aged 0‐17 years are orphans, while 6.1% have a chronically ill parent, with little overlap between these two populations. 16 The 2005 Cambodia Demographic and Health Survey CDHS found that death of a father significantly drives household poverty in rural areas. 17 The OVC Task Force has led a national assessment of OVC/impact mitigation policies, strategies and services. An OVC National Strategic Framework and costed Operational Plan will be finalised in 2007. MoSVY issued a Policy on Alternative Care for Children in April 2006. This is a mainstream policy incorporating HIV, which provides models of alternative care for orphaned and vulnerable children. The 2008 Universal Access targets for impact mitigation (30% of households with OVC receiving a minimum package of support and 50% of communes with at least one organisation providing care and support to households with OVC) are unlikely to be met as implementation of the OVC Operational Plan is delayed until 2009 when Global Fund round 7 monies become available. The Ministry of Cults and Religions (MoCR) Buddhist pagoda based initiatives have been scaled‐up, including the construction of hospices. MoCR has expanded HIV training for religious leaders from 5 to 11 provinces in 2006‐07. A 2006 evaluation of the World Food Program’s (WFP) food support for PLHIV and OVC found a positive impact on food security, nutrition and livelihoods. There is, however, limited understanding by NGOs and PLHIV of the specific nutritional needs of PLHIV in general and PLHIV on ART. Some stakeholders have questioned the nutritional value of WFP support. UNICEF is in the process of mobilising technical assistance to the National Nutrition Program to provide therapeutic feeding services to children.

Strategy 4: Increased capacity of government sectors and civil society to respond to

HIV/AIDS

Governance and coordination There has been considerable improvement in a number of aspects of governance and coordination. The Government‐Donor Joint Technical Working Group on HIV/AIDS (GDJTWG) has brought together key government sectors, donors, civil society and technical assistance agencies, providing a forum to share progress in key areas, consolidate the partnership and discuss key strategic issues. NAA has demonstrated increasing focus on its core functions of leadership, coordination, advocacy, resource mobilisation and M&E. NCHADS has continued to demonstrate strong leadership of the health sector response. New TWGs have been established (MSM, Drugs and HIV, Decentralisation, Mobility, and M&E), and are working effectively. NAA has played an important role in auspicing TWGs. There has been a strengthening of the capacity of a number of TWGs, resulting in improved performance. TWGs have promoted a stronger partnership between government and civil society and cross‐sectoral collaboration. The formation of the Joint United Nations Team on HIV (JUTH) and the development of one unified work plan aligned to NSP II has resulted in a more focussed and coordinated effort by UN agencies. The United States Government support of the NSP II, through the United States Agency for International Development (USAID) and the Centres for Disease Control

16 Ibid. An orphan is defined as one parent having died. 17 Wolf, RC. Quantitative Secondary Data Analysis of DHS 2000 and DHS 2005 for Cambodia OVC Situation Analysis. 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update Global AIDS Program (CDC‐GAP), has been unified under the US President’s Emergency Plan for AIDS Relief (PEPFAR).

Multisectoral response NSP II has seen a greater focus on key ministries that have an essential role to play in the national response. These are MoI (both Police and the Department of Local Administration (DoLA)), MoND, MoSVY, MoEYS, MoLVT, MoPWT, MoWA, and MoCR, in addition to the core role of the health sector. This is an improvement on the approach taken under NSP I where there was lesser prioritisation on key ministries, and an emphasis on a broad‐based multisectoral approach. While most key sectors need an HIV strategic framework and operational plan, other sectors may only need to mainstream HIV into their existing sectoral plans. A positive sign is that a number of key ministries (MoND and MoEYS), with donor support, have developed new sectoral strategies to replace strategies coming to the end of their currency. This indicates a degree of sustainability in the work of these ministries. However, donor support for both these ministries has either declined or will decline in the near future. A key test of sustainability will be whether HIV work can be effectively mainstreamed within the work of these ministries, with support from the Government budget, and whether additional external funds can be mobilised. Sectoral, cross‐sectoral or population specific strategic plans have been developed for the first time by other ministries (MoSVY, MOWA and MoI) indicating a strengthening of the multisectoral response in key areas. The Universal Access indicator of 9 ministries actively implementing an HIV/AIDS sectoral strategy will probably not be fully met, largely due to difficulty in mobilising funding for implementation in some Ministries. The Leadership for Results Program (LRP) has provided support to NAA’s Technical Board and the MoEYS Inter‐Departmental Committee on HIV/AIDS. The 500 members of the LRP alumni have increased capacity for effective leadership in the HIV response across sectors.

Decentralisation NAA has established a good working relationship with DoLA in the MoI: a Working Group under the leadership of DoLA is developing a national “HIV/AIDS within Social Sector” curriculum for Commune Councils; and NAA will be a member of the Social Sector TWG under the National Council for Decentralisation and Deconcentration and the MoI. Operational research on HIV and decentralisation identified ways for NAA to share coordination responsibility with local government planning systems. NAA has also been conducting a pilot in 3 provinces to assess how HIV can be integrated within local government systems, and draft guidelines have been developed for the integration of HIV into the government’s decentralisation processes. It is unlikely that the 2008 Universal Access target of 25% of provincial and commune development strategies addressing HIV will be achieved. Work in this area is relatively new, requiring careful assessment of the best way to practically proceed. This has slowed progress, for understandable reasons.

Civil society Civil society has continued to make a strong and central contribution to the national response to HIV and AIDS in the areas of prevention, impact mitigation, care, support and treatment. Civil society continues to account for a significant proportion of services, especially in the areas of prevention and support of PLHIV. Overall, there has been a considerable improvement in communication and cooperation between government and civil society, which is reflected in joint planning. While coordination with government at the central level is reported to be good, coordination mechanisms at the provincial level are said to be less well developed. Civil society representatives reported that there is a greater understanding by ministries of the role that can be played by civil society and more interest in HIV by non‐health ministries. Civil society representatives identified the need to improve their own coordination and communication mechanisms. The HIV/AIDS Coordinating Committee (HACC) representing 90 NGOs/CBOs, has conducted a review and developed a new Strategic Plan which will provide the

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update opportunity for a stronger, unified civil society voice. There is also a need to increase the voice of community networks of PLHIV and most‐at‐risk populations such as, sex workers, MSM and IDU/DU, to supplement the voice of NGOs providing services. The Cambodian Network of People Living with HIV/AIDS (CPN+), which supports and coordinates a national network of local CBOs for people living with affected by HIV, has recently undertaken a situation and response assessment and developed a new Strategic Plan. CPN+ identified a lack of financial resources as the single most significant constraint to their work, as it limited their ability to develop their organisation’s capacity through employing skilled staff on long term contracts, and to fund capacity building activities for their staff and their member organisations. The Cambodian Community of Women Living with HIV(CCW), was established in 2007, under the umbrella of CPN+. This provides a mechanism for greater advocacy on the needs of female PLHIV. See section 3.3.4 below for a discussion of overall technical and organisational capacity needs.

Strategy 5: A supportive legal and public policy environment for the HIV/AIDS

response

Policy development An HIV/AIDS Policy Assessment and Audit commissioned by the NAA in 2006 concluded that there was a dynamic policy environment, evidenced by the number of new policies developed or existing policies under review. Policy development has been driven by the need for policies and guidelines to implement the AIDS Law; policy commitments in NSP II; Universal Access targets; a maturing national HIV response where policy is ‘catching‐up’ with program development; and a new trend for policy to drive program development. An outline of new and revised policies is provided in the relevant sub‐sections of 3.1.1. NAA has developed a training module on the AIDS Law and conducted training of core trainers at the national level. Public forums on the AIDS Law have been conducted in 3 provinces, plus a workshop for key officials in the Ministry of Justice.

Enabling environment Senior political leaders have continued their support for Cambodia’s response to HIV. The First Lady, Lok Chumteav Bun Rany Hun Sen, has been a leading advocate against stigma and discrimination against PLHIV. Stigma and discrimination results in abuses of human rights and is a significant impediment to HIV programs. It especially effects PLHIV and MARPs who are usually marginalised from society because of their work (e.g. sex work) or lifestyle (e.g. MSM and IDU). NGOs/CBOs and religious leaders have continued to play an active role in community education to reduce stigma and discrimination. Mass media produced by the BBC World Service Trust (BBCWST) has had a strong focus on stigma and discrimination. The commonly held view reported by a wide range of stakeholders of a reduction in HIV‐related stigma and discrimination in Cambodia is confirmed by attitudinal research by the BBCWST. Results from a baseline survey conducted in 2004 and end‐line survey in 2006 show a significant increase in respondents agreeing that HIV‐positive nurses, persons serving food and those sharing a meal should be able to continue their activities. 18 The 2005 CDHS found that 79% of women and 81% of men agree that an HIV‐positive teacher who is not sick should be allowed to continue teaching. 19

18 BBCWST, Cambodia Endline Results. HIV and AIDS Knowledge, Attitudes and Practice Trends and Impact of BBCWST Intervention. 2006. 19 CDHS, 2005.

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Strategy 6: Increased availability of information for policy makers and program planners

Leadership from NAA’s Department of Planning, Monitoring and Evaluation and Research and the M&E Advisory Group has resulted in the development of National HIV/AIDS Monitoring and Evaluation Guidelines. The Guidelines contain a national M&E framework, with 53 core indicators, and clarify the role of NAA and partners in M&E. For the first time, Cambodia has one unified national M&E framework, consistent with UNAIDS three one’s principles. Overall, more data is currently available and being shared between partners compared to NSP I. There is, however, more limited availability of program monitoring data to assess performance, effectiveness and impact. The M&E Guidelines provide a foundation for developing a good picture of progress in the national response in key areas. Progress has been made in strengthening the M&E capacity of NAA and partners. NCHADS has strengthened its M&E system, with the launch in 2007 of new guidelines and has implemented an information system, which has greatly improved the quality of program data. NCHADS also developed an HIV research agenda for 2007‐2008, to improve the use of evidence in program development.

Strategy 7: Increased, sustainable and equitably allocated resources for the national

response

DfID and USAID have agreed to jointly fund a US $27 million contract for social marketing of condoms over the next 5 years. This will enable an expansion of condom social marketing activities. AusAID and SIDA have separately committed funds for prevention of HIV among IDU/DU. The failure of Cambodia’s Global Fund round 6 proposal meant that planned scale‐up of key HIV programs in a number of areas has not occurred. DfID will cease funding of NAA and MoEYS at the end of 2007, although other donor funding of MoEYS for mainstream programs will continue. DfID Funding for NCHADS will continue in 2008. From 2009, these funds will be channelled into the funding mechanism that replaces the Health Sector Support Program. It is possible that NCHADS may lose some or all of this funding from 2009. The possibility of a significant reduction in USAID funding for HIV/AIDS programs in Cambodia has been averted following advocacy on resource needs and the fragility of the gains made to date. UNAIDS has been able to mobilise small amounts of money to foster planning work in a number of key priority areas in NSP II. A feature of all recent planning work in Cambodia is that Strategic Frameworks and Operational Plans are now costed. This did not commonly occur under NSP I.

3.2 Progress made under NSP II: Key conclusions

3.2 Progress made under NSP II: Key conclusions

In general, good progress has been made in the first 21 months of implementing NSP II. This has particularly been the case in the health sector with rapid scale‐up of the continuum of care. There has been less significant growth in prevention programs, but condom and lubricant sales and distribution have grown strongly. The national response has increasingly been focused on key priorities, assisted by the participatory Universal Access target setting process. Most Universal Access indicators for 2008 will be either met or exceeded, although some areas will fell well short of meeting targets. There has been extensive planning in prevention programs for MSM and IDU/DU and in impact mitigation programs for OVC. Implementation of these plans is dependent upon additional resources becoming available. Civil society has continued to make a strong and central contribution to the national response to HIV and AIDS in the areas of prevention, impact mitigation, care, support and treatment.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update The dynamic policy environment has seen new policies developed and existing policies revised. Some ministries have developed HIV policies for the first time. While most policies are HIV specific, there is an increasing number of mainstream policies with HIV content. Policy linkages within and between sectors are actively being developed. The inclusion in NSP II of a specific M&E strategy has paid dividends in fostering a greater focus in this area. Governance and coordination has improved, with significantly improved collaboration between partners, focused on priority issues.

3.2.1 Key areas which need to be addressed

While progress has been made in all of the following areas in the last 21 months, improving on current initiatives will be critical for the success of NSP II over the next 3 years, 2008‐2010: 1. Scaling up of prevention programs for MARPs: IFSWs in the entertainment industry, MSM and

IDU/DU, while sustaining and improving prevention programs for brothel based female sex workers.

2. Focussing prevention programs for larger populations of vulnerable groups to evidence of risk. 3. Improving the coverage and quality of PMTCT through strengthening of ANC. 4. Achieving higher coverage of HIV testing for pregnant women and TB patients. 5. Continuing to scale up health services to meet the growing care, support and treatment needs of

PLHIV. 6. Contributing to health system strengthening and developing stronger linkages between different

parts of the health system. 7. Implementing the OVC operational plan. 8. Mobilising additional resources. 9. Strengthening governance. 10. Improved collection and use of strategic information.

3.3 Challenges and threats in meeting NSP II targets

3.3 Challenges and threats in meeting NSP II targets

3.3.1 Resource needs

The cost of financing HIV programs in Cambodia is rising rapidly. The estimation of resource needs for NSP II, conducted in 2005, forecast resource needs increasing from $47.1m in 2006 to $69.9m in 2010. 20 In the light of recent planning work, this may be an underestimation. The increase in resource needs is primarily being driven by Universal Access targets for CoC scale‐up, the need to expand prevention programs to effectively reach IFSW, MSM and IDU/DU, and responding more effectively to impact mitigation. Sufficient funds have already been mobilised to meet existing and planned treatment needs through to 2010. Additional resources for treatment are needed from 2011. On a lesser scale, additional resources are needed for unmet prevention needs in the sex industry, MSM and IDU/DU and impact mitigation. The increase in resource needs to meet long‐term treatment obligations, coupled with the possibility of reduced donor funding, could result in competition for resources between treatment and prevention programs.

3.3.2 Resource mobilisation The government contribution to HIV programs is currently very limited, at 3% of annual expenditures. This has resulted in a dependence on donor funding. Unless government funding increases, there is a significant threat to the long‐term sustainability of HIV programs. HIV programs are heavily reliant on two sources of funding. The United States Government, (USAID and CDC‐GAP), and the Global Fund provide more than 70% of the financial resources. The dependence on two

20 Martin, G. Estimating Resource Requirements in Cambodia. POLICY Project Cambodia, 2006.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update main funding sources makes the national HIV response particularly vulnerable to any cuts in funding. The cost of ART is particularly dependent on the Global Fund. Donors see Cambodia’s success, but fail to recognise the fragility of that success. Cessation of major donor support for NAA, workplace programs and MoEYS will provide an initial test of sustainability. There is a possibility of a further reduction in donor funding for HIV in 2008 and beyond, but the picture is not yet clear. Even with the success of Cambodia’s Global Fund round 7 proposal , the funding will be insufficient to fully implement recently developed plans, including the OVC and MSM plans. Cambodia is becoming increasing reliant on Global Fund money. There is a need to mobilise additional resources from both the Royal Government of Cambodia (RGC) and donors to avoid the risk of over‐reliance on the Global Fund and the US Government. If HIV programs become mainstreamed in some sectors, there is the possibility of accessing non‐HIV funding from donors and the national budget.

3.3.3 Resource tracking and allocation Cambodia lacks an effective resource tracking system. There is no comprehensive picture of the total funds available for HIV work or how funds are allocated. If the funding gap widens, there will be an increasing need to set priorities. A fundamental starting point in priority setting is an accurate and comprehensive picture of total current funding and how it is being spent. The limited government financial contribution means resource allocation decisions are largely decided by donors, although government has a larger say in relation to Global Fund proposals. The NSP has some influence on how donors allocate money. Civil society representatives expressed the view that they had little influence in both donor and government priority setting processes. The terms of reference of the GDJTWG terms of reference include alignment of resource allocation decisions with NSP priorities. To date, there is no evidence of the GDJTWG substantively addressing this issue. The Cambodian Country Coordinating Mechanism (CCM) has set some reasonably broad priorities in Global Fund proposal preparation, but there is room for considerable improvement. While government has legitimate aspirations to increase its say in how funds are allocated, there is a need to demonstrate capacity to do so. This needs to be accompanied by development of fair and transparent processes where all partners can contribute to the complex task of priority setting being reflected in resource allocation. Development of an effective resource tracking system would be a first step in demonstrating capacity. There is also a need for greater accountability for the efficient and effective use of HIV funding by all recipients.

3.3.4 Key capacity constraints In 2007 the NAA conducted a Technical Needs Assessment and developed a Technical Support Plan covering key aspects of the HIV response. The Assessment found significant variability in the organisational capacity of both ministries and NGOs/CBOs. Weakness in organisational capacity limits the ability to make best use of technical skills. The leadership, coordination, strategic planning, monitoring and regulatory capacity of many government bodies needs considerable strengthening. Many NGOs/CBOs encounter impediments in implementing projects because of weak organisational capacity. The quality of HIV technical skills in Cambodia has improved considerably over time, especially in the health sector, although there is considerable variability. There is a pressing need to develop technical skills in some ministries, especially those becoming significantly involved in the response for the first time (e.g. MoSVY), NGOs/CBOs working with MARPs and PLHIV networks.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update Scaling‐up prevention, care, support and impact mitigation services in both government and civil society is facing limitations in terms of the quality and quantity of human resources. There are currently not enough good quality staff to ensure effective coverage to meet Universal Access targets. This is particularly the case in areas which have made less progress in achieving Universal Access indicators compared to the health sector. For example, the needed expansion of sex work prevention programs for IFSWs and their clients, and MSM and IDU/DU prevention programs.

3.3.5 Quality In recent years the focus of Cambodia’s HIV response has appropriately been to expand coverage. Stakeholders have expressed concern that the concentration on rapid growth in some services may have partially compromised quality. This has given rise to the need to place a greater emphasis on quality, while continuing to scale‐up.

3.3.6 Fragility of the gains? – Key risk areas An essential component of Cambodia’s response will continue to be effective prevention programs to keep incidence low. Key potential risks for prevention and treatment are: 1. Increasing HIV infections in populations most at risk driving a second wave of the epidemic. 2. Increasing (injecting) drug use by MARPs resulting in a difficult to control drug use driven

epidemic. 3. Increased incidence as a result of PLHIV living longer if positive prevention does not succeed

(which may be offset by reduced viral load, resulting from effective treatment). 4. The development of drug‐resistant HIV. 5. Organisational and human capacity not being enhanced quickly enough to facilitate scale‐up of

priority programs. 6. Additional funds to support scale‐up of under‐funded program areas not being mobilised. 7. Reduced donor funding of NAA. 8. Changes to the way donors fund the Cambodian health system resulting in reduced HIV funding

for the health sector.

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4. The situation analysis 4.1 The epidemiology of HIV in Cambodia: who is most at risk of HIV and why?

4. The situation analysis

4.1 The epidemiology of HIV in Cambodia: who is most at risk of HIV and why?

4.1.1 Reduced HIV prevalence in the general population Estimated HIV prevalence among the general adult population aged 15‐49 years has declined from a peak of 2.0% in 1998 to 0.9% in 2006. 21 This rapid decline in prevalence is a significant achievement. However, HIV prevalence in Cambodia is still high compared to the region as a whole. The total number of adults aged 15‐49 years living with HIV in 2006 was estimated to be 67,200. The estimated number of children aged 0‐14 years living with HIV in 2006 was 3,900. The total number of people living with HIV (PLHIV) (adults, plus children) in 2006 was 71,100 people. The significant decline in HIV prevalence has resulted from both: ‐ declining numbers of new infections due to effective prevention programs; and ‐ a large number of deaths among persons who were infected in the early years of the epidemic. 22 It is estimated that the number of new adult infections (incidence) declined from 12,700 in 1997 to 1,350 in 2006. In 1999, an estimated 132,300 Cambodian adults were living with HIV. AIDS‐related deaths are estimated to have exceeded 10,000 each year since 2000. By 2006 the number of adults living with HIV had fallen to 67,200. Females represent an increasing proportion of the number of people living with HIV. In 2006, 52% of PLHIV were female, up from 38% in 1997. The prevalence of HIV among females has, however, declined somewhat, as suggested by the reduction in HIV prevalence among ante‐natal care (ANC) women from 1.6% in 2003 to 1.1% in 2006. Asian Epidemic Model projections indicate that HIV incidence (new HIV cases), which has been declining among both men and women since its peak in the mid‐1990’s, will continue declining for the next several years. The increased proportion of female PLHIV is partially attributable to a high number of deaths among males, who represented the majority of infections in the earlier years of the epidemic. In addition, modelled estimates and projections suggest that since the year 2000, HIV incidence among women has been higher than that among men. 23 In general, adult HIV prevalence is higher in urban areas than in rural areas (2006: urban 1.1%, rural 0.8%). Of the 71,100 people aged 0‐49 years living with HIV in 2006, an estimated 33,100 were in need of antiretroviral therapy (ART). By 2010 the number in need of ART will increase to 38,600. Providing ART for all those in need will improve survival among persons living with HIV. The estimated number of deaths will decline from 10,000 in 2006 to 1,200 in 2009, based on provision of ART at current and planned levels. The reduction in deaths will slow the rapid decline in prevalence observed before ART became widely available in Cambodia. 21 NCHADS, Report of a Consensus Workshop. HIV Estimates and Projections for Cambodia 2006‐2012. 2007. All epidemiological data in this section are drawn from these estimates, unless otherwise indicated. 22 Neal, J. Overview of the HIV Epidemic in Cambodia. 2007. 23 Neal, J. Personal communication, 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update It is estimated that adult HIV prevalence will decline from 0.9% in 2006 to 0.6% by 2008 and remain at that level till 2010. The estimate of further reductions in incidence is based on the assumptions of sustained safe behaviour and the prevention benefit of lower viral load resulting from treatment. The estimate assumes condom use in most‐at‐risk populations (MARPs) remains at 95%.

4.1.2 HIV prevalence in most-at-risk populations

Sex workers and clients HIV prevalence among brothel‐based female sex workers (BBFSW) has declined from a peak of 45.8% in 1998 to 21.4% in 2003. 24 The 2006 HIV Sentinel Surveillance (HSS) data may show a further decline. HIV prevalence among non‐brothel based female sex workers (IFSW) declined from 19.3% in 1999 to 11.7% in 2003. 25 Consistent condom use by BBFSWs is high (80%) but has remained low with sweethearts (25%) and casual sex partners (34%). 26 STI prevalence among BBFSW did not change significantly between 2000 and 2005, possibly because they were re‐infected by their sweethearts, soon after treatment. Consistent condom use by indirect female sex workers (IFSW) with paying clients is high, but similar to BBFSW, is low with sweethearts. 27 The estimated number of BBFSWs has decreased significantly (2,977 in 2006 compared to 4,504 in 2004) while the number of IFSWs has increased dramatically (12,762 in 2006; up from 6,846 in 2004). 28 This change in the structure of the sex industry requires an enhancement of prevention programs for hard to reach IFSWs. However, the vast majority of commercial sex acts still take place in brothels, with a large number of new sex workers entering brothels each year. The median duration on the job for BBFSW is 14 months. 29 These factors point to the need for brothel‐based FSWs and their clients to remain the main priority for HIV prevention.

Men who have sex with men In 2005, HIV prevalence among men who have sex with men (MSM) in Phnom Penh was 8.7%, and in Battambang and Siem Reap cities was 0.7%. 30 Prevalence of any STI was 9.7% in Phnom Penh and 7.4% in Battambang and Siem Reap. Consistent condom use was low, especially in the provincial cities. Most MSM had a large number of male and female sexual partners. The large number of female sexual partners provides a potential bridge for transmission of HIV and STIs to a broader population. Regional experience demonstrates the possibility of rapid increases in HIV prevalence among MSM over short periods of time in the absence of comprehensive prevention programs. In Bangkok, HIV prevalence among MSM increased from 17.3% in 2003 to 28.3% in 2005. 31 Although the number of sexually active MSM is small compared to the whole population, MSM can account for a significant proportion of total HIV infections. It is estimated that MSM accounted for 30.3% of the total adult (male and female) HIV prevalence in Bangkok in 2005 (which is 1.4%). 32

24 NCHADS, HSS 2003 Report. 25 Ibid. 26 NCHADS, SSS, 2005. 27 PSI, Second Round HIV/AIDS Tracking Surveys, 2006. 28 NCHADS, Annual Report, 2006. 29 Guy Morineau, personal communication, 2007. 30 NCHADS, FHI, ADB and CDC‐GAP, Cambodian STI Survey 2005. September, 2006. 31 van Griensven, F, 2007. 32 Tim Brown, personal communication, 2007.

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Injecting and other drug users There is currently no reliable data on the extent of illicit drug use, the number of injecting and other drug users or HIV prevalence among drug users in Cambodia. Surveys are currently being conducted on HIV prevalence and related behaviours and amphetamine‐type stimulants (ATS) use and associated STI. A population size estimation survey is also being conducted. Limited data and the experience of NGOs indicates an increase in illicit drug use in Cambodia. ATS appears to be the most commonly used illicit drug, although injection is not the usual route of administration. ATS use may, however, have an effect on safer‐sex decision making. The number of injecting drug users is thought to be small, particularly compared to the number of ATS users. International evidence demonstrates that illicit drug use can increase rapidly, as can the number of injecting drug users, leading to the possibility of a rapid increase in HIV prevalence among injecting drug users (IDU) and their sexual partners. Evidence of high levels of alcohol and illicit drug use by MARPs (sex workers, MSM and street adolescents) is emerging. 33

Pregnant women HIV prevalence among pregnant women seeking antenatal care is estimated to be 1.1% in 2006, a decline from 1.6% in 2003. 34 In 2006 it is estimated that 1045 mother to child infections occurred. The limited coverage of the Prevention of Mother‐to‐Child Transmission (PMTCT) Program in Cambodia has resulted in a high number of mother‐to‐child infections still occurring.

Key conclusions A key conclusion of the 2007 Consensus Workshop on HIV Estimates and Projections is that prevalence in the general population has declined and will stabilise, if interventions are sustained. The primary driver of the HIV epidemic in Cambodia has been heterosexual transmission between sex workers and their clients and other sexual partners. HIV has also been passed on in significant numbers from the clients of sex workers to their female partners (wives and other sexual partners), and also to infants born to infected mothers. Because trends in prevalence among MSM and drug users have not been monitored over time, it is not known whether prevalence is declining, stable or increasing. Evidence has shown that HIV prevalence among MSM in Phnom Penh is quite high, and a very real potential exists for HIV epidemics among MSM in some provincial cities. Currently no reliable data on HIV prevalence among drug users are available, but will be in the near future. Population groups who may be especially vulnerable for HIV infection are female partners of high‐risk males, mobile populations (internal and external mobility), and youth, particularly urban youth and out‐of‐school youth. Gender power imbalance increases the HIV‐risk of married women whose partners have unprotected extra‐marital sex, as they are not empowered to insist on condom use with their husbands. These vulnerable population groups are much larger in size compared to the most‐at‐risk population groups of sex workers, MSM and drug users, but with a significantly lower overall risk. Prevention for these larger vulnerable groups should increasingly be targeted and linked to evidence of risk. The main risk of a second‐wave of HIV infections occurring in Cambodia (i.e., significantly increased HIV incidence), is from female sex workers, their clients and sweethearts. MSM and drug users are potential significant contributors to any second‐wave of HIV infections. Accordingly, prevention efforts under NSP II, 2008‐2010 should give highest priority to these MARPs, especially sex workers and their commercial and non‐commercial partners. There are three key conclusions to be drawn from the epidemiological and other risk assessment data, with implications for program development over the next three years and beyond:

33 PSI, Second Round HIV/AIDS Tracking Surveys, 2006; and Guy Morineau, personal communication, 2007. 34 NCHADS, Report of a Consensus Workshop. HIV Estimates and Projections for Cambodia 2006‐2012. 2007.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update 1. It cannot be assumed that incidence will remain low. Changes in the structure of the commercial

sex industry and the challenge of sustaining prevention programs in brothels, where there is a high turnover of sex workers, along with the possibility of significant epidemics among MSM and IDU/DU, mean that sustaining and improving prevention efforts to maintain the reduction in HIV incidence will need to attract high priority.

2. The maturing of the Cambodian epidemic means that there are a growing number of PLHIV in

need of ART. Delivering on the commitment to provide long‐term Universal Access to ART and associated care and support will need to be a continuing high priority.

3. The high death rate has resulted in many orphans and widows. PLHIV, especially those with

advanced stage HIV, have high social and economic support needs. Meeting the substantial impact mitigation needs for those already infected and affected needs to be a key priority.

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5. Opportunities for an Enhanced Response to HIV

5. Opportunities for an Enhanced Response to HIV

5.1 Policy implementation and enforcement

5.1 Policy implementation and enforcement

The high level of policy development indicates that the major focus of work needs to be on implementation and enforcement rather than further policy development. The recommendations of the Policy Audit and Assessment should be reviewed and implemented. Additional work to educate key sectors on the provisions of the AIDS Law should continue.

5.2 Continued scaling-up and quality improvement of key programs

5.2 Continued scaling-up and quality improvement of key programs

5.2.1 Prevention for most at risk populations The highest priority for prevention is most‐at‐risk populations to consolidate and improve on gains in reducing new infections and to avoid the possibility of a second‐wave of the HIV epidemic. The highest priority MARP continues to be sex workers and their clients. A priority for 2008 needs to be extending the reach of prevention programs to freelance sex workers and IFSW in entertainment establishments. The current limited availability of condoms in entertainment establishments and restricted access for prevention programs need to be addressed. The option of extending the 100% Condom use Program (CUP), by requiring all entertainment establishments to provide condoms, through a binding high level policy decision, needs to be actively explored. In addition, the currently limited access of prevention programs to entertainment establishments needs to be addressed. Comprehensive prevention programs for freelance and IFSWs need to be expanded to cope with the rapid increase in the number of non‐BBFSWs, including sexual health services. The TWG on Outreach and Peer Education and the 100% CUP for Sex Workers provides a mechanism to address these issues. Priority attention needs to remain focused on brothel based sex work prevention programs given the majority of commercial sex acts still take place in brothels. Greater priority needs to be given to prevention programs for clients of sex workers through developing a better understanding of the profile of clients and then developing strategies for targeting them through multi‐media male sexual health campaigns. The strategic planning work undertaken for MSM and IDU/DU populations provides a solid basis for scaling‐up prevention programs, providing funds are mobilised. The potential for explosive epidemics in these population groups, with spill‐over into the general population, cannot be ignored. The increase in drug use by MARPs will require prevention programs to develop expertise in drug‐related issues in addition to sexual transmission. Positive prevention programs for PLHIV, designed and delivered by PLHIV, will play an important role in maintaining low incidence rates. The scale‐up of prevention programs requires a better understanding of priority areas for improved coverage . In general, Phnom Penh, provincial capital cities and large district towns are of higher priority compared to rural areas, as prevalence is higher in urban locations. The focus of scale‐up

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update should not be extending the geographical scope of interventions to the whole country but rather ensuring high levels of coverage in areas where MARPs are concentrated.

5.2.2 Vulnerable populations

Given the large size of potentially vulnerable populations and the cost of programs with high coverage, there is a need to develop targeted and prioritised interventions based on evidence of vulnerability, rather than assumptions. For example, the proposed national sexual and drug use behavioural survey with adolescents and young people would provide valuable evidence for priority setting. There will, however, still be a need for reaching all youth with HIV life skills messages to enable them to make informed choices about their life and wellbeing. Reach to vulnerable populations can best be done by integrating HIV interventions within mainstream delivery mechanisms (e.g. effective use of the mass media in strategic behaviour communication, pre‐departure education of migrants, workplace education, etc). Interventions will be more effective if they address HIV in the context of broader social vulnerabilities such as gender, mobility and poverty. For example, limited use of condoms in marriages reflect gender power imbalances between men and women. This could be addressed through multi‐media education and promoting couple access to services (PMTCT, VCCT, ART). However, globally, condom use in marriage remains extremely low, with only very small increases following substantial promotion of condom use in marriages. 35 This suggests a more effective strategy may focus on condom use outside of marriage with extra‐marital sexual partners. In the area of mobility there is a need to develop effective mechanisms for inter‐country collaboration to address the vulnerabilities of the large number of undocumented migrant workers. Enforcement of the policy requiring 1% of the cost of large infrastructure projects be spent on HIV prevention programs will require strong advocacy to key ministries and the private sector.

5.2.3 Strategic behaviour change communication

The 2007 HIV/AIDS Technical Needs Assessment Report identified the need to give higher priority to developing skills in designing and delivering strategic behaviour change communication messages, informed by evidence on patterns of behaviour and related beliefs. This needs to be coupled with developing skills in how to segment audiences and define and deliver messages appropriate to different groups, using a variety of media and peer educators and outreach workers. Considerably greater use needs to be made of mass media communication strategies to access hard to reach populations such as clients of sex workers and hidden MSM and in addressing community‐wide issues such as stigma and discrimination.

5.2.4 Prevention of mother-to-child transmission Priority needs to be accorded to extending the coverage and effectiveness of the PMTCT Program to reduce the significant number of mother‐to‐child infections currently occurring. The key recommendation of the 2007 PMTCT Program Review was development of a comprehensive national scale‐up plan that is costed and time bound, with population targets. A key to the success of PMTCT scale‐up will be development of more effective linkages with VCCT and CoC services, and integration of PMTCT within the Maternal and Child Health Program. Steps to improve linkage and integration will need to address the points at which pregnant women either don’t access or drop‐out of the range

35 For example, African data shows an increase in condom use in marriage in Uganda from nil in the early 1990’s to 1.9% by the late 1990’s, despite substantial condom promotion campaigns. There is similar data for other African countries. ORC Macro, 2001.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update of services needed for effective PMTCT, including understanding why 50% of the pregnant women found to be HIV positive do not deliver at a PMTCT site.

5.2.5 Improving access to HIV testing

The percentage of the total population tested for HIV in Cambodia is high by international standards. However, routine testing of TB patients and pregnant women has proved difficult to achieve. The vast majority of patients attending VCCT (73%) are self‐referred. Only 15% are referred from health services. Two complementary strategies have been proposed to increase HIV testing of ANC and TB patients: ‐ The NCHADS Demonstration Project in Prey Veng will concentrate on improving referral to

VCCT sites. This will be achieved through a rational geographic distribution of VCCT sites to improve access and simplifying and strengthening referral lines and service linkages.

‐ CDC‐GAP is planning a demonstration project in 4 provinces where half the health centres will introduce HIV rapid testing for TB patients and pregnant women, with confirmation of all positive results at VCCT sites.

The outcomes of these two approaches should be carefully monitored for their wider application. The CoC Review noted the need to increase referral to VCCT by STI clinics and prevention programs for MARPs. VCCT and PMTCT services need to promote couple counselling and testing.

5.2.6 Continuum of Care

A principal objective should be to maintain one unified system of CoC for all PLHIV rather than the development of parallel systems for different sub‐populations. Over the next three years there will be continued emphasis on scale‐up. The most ambitious component of this scale‐up will be increasing the number of PLHIV on ART by 2010 to 95% of those in need. This is estimated to be approximately 36,500 people, which is an additional 10,000 people on ART compared to September 2007. In the near future the need for more expensive second‐line therapy is likely, as HIV drug resistance becomes more prevalent. There is also an opportunity to give increased emphasis to quality improvement and quality assurance, while continuing to scale‐up. The CoC review highlighted the need to improve access by MARPs. Other areas for improvement include improved supply management of drugs and HIV test kits, increased home based care coverage, and better operational links with other national programs such as Maternal and Child Health, Reproductive Health and TB.

5.2.7 Impact mitigation

In 2006‐2007 there has been a concentration on planning to meet the needs of OVC. Provided funds are mobilised, the next phase of work will be addressing the challenges of implementing a cross‐sectoral strategy. MoSVY will need to provide leadership to develop a coordinated and integrated approach by government and civil society. An essential component of this work will be social system strengthening, similar to the need for health system strengthening. The other 6 ministries with responsibilities for implementation will need technical support to operationalise their work. At the community level, sustainable community development models will need to be applied, to move away from a dependency model, working with local bodies such as pagodas, schools, health centres, Commune Councils and extended families. In addition to a focus on OVC, broader impact mitigation strategies need to be developed, including support for sustainable livelihoods, income generation and micro‐finance schemes.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update 5.2.8 Safe blood supply

The National Blood Transfusion Centre (NBTC) is well placed to improve blood safety through its plans to establish a quality assurance unit to provide for more regular supervision of provincial blood banks. Promulgation of draft regulations giving the NBTC a national coordination role in all aspects of public and private sector blood banking will also contribute to blood safety.

5.3 Contributing to health system strengthening

5.3 Contributing to health system strengthening

The recent Health Sector Review and the forthcoming design of the second phase of the Health Sector Support Program has resulted in an increased focus on donor funding modalities and the structure of the health system, including the relationship between national programs and the broader health system. The issues of how to achieve better linkages and/or integration between different parts of the health system are increasingly being discussed. Improved linkages and/or integration and new funding modalities have been proposed as necessary to ensure better health outcomes and program sustainability. A danger for NCHADS is that new funding modalities may result in a reduction in funding. There is a justifiable concern within the HIV program that the considerable achievement in scaling‐up HIV and AIDS health services could be put at risk from a rapid and poorly thought‐out move to integration. The recent CoC Review (draft report) concluded that integration of the CoC into the health system should be approached in an incremental and phased manner. Strengthening cross‐program linkages should be considered as the first step in any integration process. NCHADS should explore how to further its contribution to broader HSS. This should include examination of how vertical programs can result in diagonal system strengthening. The effect of AIDS paediatric care in strengthening general paediatric care is one example. However, examples of how HIV and AIDS health services can benefit the overall health system are few, anecdotal, and not well documented and analysed. The issue of how one annual operational plan at provincial and OD levels can provide a vehicle for integration also needs to be explored. Health system strengthening needs to address the whole health system from top to bottom and not just focus on national level structures. A key area for attention is how to strengthen community health systems. This provides an opportunity for close collaboration between government, civil society and the private sector in health system strengthening. The participation of civil society in this process would also allow for better linkages to be developed between health systems and social support systems, as the work of civil society often crosses this sectoral divide. The success of NCHADS is attributable to a range of factors, and not just funding. These include political commitment, a degree of autonomy from MoH systems, strong leadership and good management, a clear strategic vision, a culture of performance management coupled with a strong team approach, development of technical capacity, and a good relationship with civil society. Documentation of how these factors have strengthened NCHADS should occur to enable sharing of lessons with other parts of the health sector. Opportunities to develop the capacity of private health care providers with the aim of increasing their involvement in HIV care and treatment, should be explored. This could result in an overall improvement in the quality of care and assist with long‐term sustainability. However, the public sector will remain the main provider of HIV care, support and treatment for the foreseeable future.

5.4 Strengthening organisational and technical capacity to improve quality

5.4 Strengthening organisational and technical capacity to improve quality

Significantly greater priority will need to be given to strengthening organisational and technical capacity of ministries and civil society to meet scale‐up targets and ensure quality. For this to occur

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update TWGs will need to give greater priority to capacity building, in addition to their current primary focus on technical issues of a programmatic nature. The Technical Needs Assessment and Technical Support Plan developed by NAA in 2007 provides a foundation for TWGs to lead this process. Where sectors have developed strong technical expertise, there is the opportunity to share this with other less developed sectors through mentorship and training. There is a need to improve the quality and utility of training. Key priorities are focussing training on actual workplace needs and developing systems that maximise application of skills and knowledge on‐the‐job, post‐training.

5.5 Improving governance and coordination

5.5 Improving governance and coordination

The opportunity exists to build on recent improvements in governance and coordination. Political leadership, coupled with leadership from ministries, civil society, the private sector and development partners, has played a crucial role in the success of Cambodia’s response to HIV. Continued strong leadership by all partners will be essential in sustaining and building upon the achievements made.

5.5.1 GDJTWG

The GDJTWG on HIV/AIDS needs to strengthen its focus on addressing cross‐cutting key strategic issues (e.g. resource mobilisation, priority setting, key trends, etc), with a lesser emphasis on time‐consuming information sharing on specific technical issues that can be dealt with by lower level technical working groups.

5.5.2 Developing mechanisms to strengthen the participatory partnership approach Current governance arrangements do not sufficiently provide for broad‐based participation from the range of stakeholders that make up the HIV partnership in Cambodia. The high level strategic role of the GDJTWG means its membership is properly restricted to a limited number of high level representatives of the various elements of the partnership. The NAA Technical Board consists exclusively of the representatives of government ministries. There is no forum at the technical level which provides for broad based input from the range of key partners. Consideration should be given to the formation of a national partnership forum which would include technical staff from key government ministries, relevant civil society organisations, including those representing PLHIV and MARPs, bilateral and multilateral donors, and the private sector. The forum would facilitate greater participation by all key partners and promote harmonisation and alignment. It would also be a source of valuable advice on strategic and technical issues for the GDJTWG. The national partnership forum could be a newly established technical coordination body or an expanded NAA Technical Board. The establishment of such a forum would necessitate a review and re‐definition of the roles and responsibilities of various governance and coordination bodies, their membership, and inter‐relationships and linkages.

5.5.3 Priority setting and resource allocation The potential for competition for resources to become more intense will require an increased emphasis on priority setting in the next 3 years and beyond. Establishing an effective resource tracking system is a key first step. Improving the use of strategic information to guide priority setting is also needed. Aligning resource allocation to priorities is challenging and complex. Enhanced collaboration between government, donors and civil society on the alignment of resource allocation to NSP II priorities needs to occur. This will be an incremental process.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update 5.5.4 Mainstreaming

Mainstreaming of HIV into the core ongoing work of non‐health sectors can provide sustainability over the long term. However, most HIV work in ministries has occurred with significant levels of donor support. A challenge that needs to be addressed is to how to sustain HIV work in Ministries on a long‐term basis with limited or no donor support. Mainstreaming of HIV into non‐health sectors can also assist in addressing underlying vulnerability factors such as gender imbalance, poverty, and inequality in accessing public sector services. This too is challenging given the difficulty in addressing these complex social issues in a way that will result in significant change.

5.5.5 NAA

The focus of NAA on its core functions needs to be further strengthened. This could be achieved by NAA setting a limited number of key priorities on which to focus its work and ensuring that these are effectively undertaken. This needs to be accompanied by clear communication to all partners by NAA on its core functions and key priorities. It will be important for NAA to continue to give priority to developing the capacity and effectiveness of TWGs as these bodies are proving to be effective facilitators of coordination in priority areas. NAA has increasingly brought together a range of partners from ministries, civil society and technical assistance agencies to work collaboratively on a range of issues. This key facilitating aspect of coordination should continue to be prioritised by NAA. The recent NAA Sub‐Decree provides NAA with the opportunity to improve the capacity, efficiency and accountability of staff in line with RGC public administrative reforms.

5.5.6 Decentralisation

NAA’s and DoLA’s collaborative work to date indicates that the best approach to placing HIV on the agenda of local government organisations is to link HIV with other social sector issues such as gender, sexual and reproductive health, child protection and support, domestic violence, youth and drugs and mobility, rather than attempting a stand‐alone approach. The opportunity exists to develop capacity at national, provincial and local levels to mainstream HIV with other social issues in developing commune level investment plans. As a coordinating body, NAA does not have a vertical structure that links it to provincial and district levels. Consideration should be given to making use of existing mainstream structures at these levels in preference to stand‐alone, specialist HIV structures. For this approach to succeed, high level advocacy will be needed to gain support. Subsequently, HIV focal points within Provincial and District Facilitation Teams in priority provinces should be identified.

5. 6 Improving the collection and use of strategic information

5. 6 Improving the collection and use of strategic information

High priority needs to be given to the challenging task of implementing the National M&E Guidelines and collecting core indicator data. This will require continued capacity building in NAA and key partners in government and civil society. There is also a need to conduct evaluations of key programs to determine their impact. As part of the focus on quality improvement, systems to measure quality in all program areas need to be developed. Data needs to be collected, analysed and applied to ensure quality improvement takes place.

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update A greater emphasis also needs to be placed on the more effective use of existing and new strategic information, particularly analysis of data to set priorities, guide resource mobilisation and allocation and design and refine programs. Targets set in NSP II should be regularly reviewed. Where key strategic information is lacking, operational research needs to be commissioned. Research needs to be conducted to develop a profile of the clients of sex workers to assist with identifying ways of targeting this group with prevention messages. There is a diversity of views on the number of sexually active MSM in Cambodia. This is an impediment to determining the level of priority that should be accorded to prevention programs for MSM. There is a need for a population size estimation study to address this issue.

5.7 Critical success factors in the national response

5.7 Critical success factors in the national response

The key factors that will be critical to success in next phase of NSP II, 2008‐2010 are: 1. The priority accorded to prevention programs for MARPs needs to be enhanced. 2. Focussing prevention programs for larger populations of vulnerable groups to evidence of risk 3. The commitment to scale‐up care, support and treatment for PLHIV needs to be kept. 4. Impact mitigation services for orphans and vulnerable children need to be developed and broader

impact mitigation strategies need to be developed for all PLHIV and those affected by HIV. 5. Significantly higher priority needs to be accorded to developing organisational capacity in key

ministries and NGOs/CBOs and further development of technical capacity. 6. Rational and effective use of technical support to address capacity gaps in priority areas to ensure

improved and efficient absorption of resources. 7. Effectively responding to challenges in mitigating underlying determinants of the epidemic such

as gender inequality and stigma and discrimination. 8. Mainstreaming HIV into the work of key sectors and social sector planning and improved cross

program and sectoral linkages for related HIV programs 9. Resources need to be mobilised for under‐funded key priorities to achieve Universal Access

targets. 10. Improved resource tracking, priority setting and alignment of resource allocation to priorities. 11. An emphasis on quality improvement for all program areas. 12. Improved governance and coordination. 13. Better use of strategic information.

5.8 Key conclusions

5.8 Key conclusions

Overall, there has been good progress in implementing NSP II. Substantive work has been undertaken in all key areas identified in NSP II, although work in some areas has progressed further compared to others. Appropriately, there has been a major focus on scaling‐up care and treatment services and in particular on providing PLHIV with access to life‐saving ART. Further scale‐up of both care and treatment services and prevention programs is needed. It will be important to maintain an appropriate balance between the relative priority accorded to treatment and prevention. Apart from the impressive scale‐up of treatment services, the most significant development in the course of NSP II has been the release of the latest Cambodian estimates of HIV prevalence which indicate a further reduction in adult prevalence to 0.9%, with a projected further decline to 06.% by 2008, provided current interventions are sustained. Nonetheless, as this SRA has highlighted, the projected further decline in prevalence, followed by a plateauing in the number of PLHIV, will not be automatic. There is a degree of fragility in the gains made to date. The risk of a second wave of HIV infections cannot be ruled out. To avert this risk, there will need to be a greater focus on key

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A Situation and Response Analysis of HIV and AIDS in Cambodia: 2007 Update prevention priorities, especially with most at risk populations (i.e. sex workers, their clients, MSM, and IDU/DU). This is where the returns on investment will be greatest. More broadly, there is a need to be a focus on the key risk areas identified in this SRA to ensure that the gains are sustained and built upon.

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