HIV Counseling and Testing: Situation Analysis in Cambodia, Myanmar and Vietnam

HIV Counseling and Testing: a
Situation Analysis in Cambodia,

Myanmar and Viet Nam
January 2006
This document has been produced with the financial assistance of the European Union.
The contents of this document are the sole responsibility of Marie Stopes Cambodia, Marie
Stopes International Myanmar, Marie Stopes International Viet Nam and Marie Stopes
International Australia and can under no circumstances be regarded as reflecting the
position of the European Union.
ACKNOWLEDGEMENTS
Marie Stopes Cambodia (MSC), Marie Stopes International Myanmar (MSIM) and Marie Stopes
International Viet Nam (MSIVN) would like to extend their sincere thanks to the European Commission for
funding this literature review and publication as a part of the Mekong Integrated VCT project. Special thanks
to Dr. Douglas Shaw, HIV Technical Advisor, who conducted this comprehensive research, and for his
valuable input to this project over the first six months. Thanks also go to all members of the Regional Task
Force (RTF) who provided consistent encouragement and timely feedback. They were:
1. Ms. Jo Howard
2. Mr. Ros Thoeun
3. Dr. Khin Tar Tar
4. Ms. Nguyen Thi Bich Hang
Marie Stopes International Australia

Programme Director, MSC
Programme Director, MSIM
Programme Director, MSIVN
Our particular thanks go to Dr Om Chhorvoin the Regional Project Manager, also a member of the RTF, who
led this new project through the preparation phase with energy, enthusiasm and unfailing support. Special
thanks go to the Technical Teams in each country for their strong support, and especially for their gracious
hospitality and efficiency in arranging Key Informant Interviews. Our thanks go also to the staff of the
Medicam Library in Phnom Penh, who were both patient, and responsive, to requests for various
publications and reports.
Finally, our thanks go to the Key Informants themselves for setting aside some of their valuable time to
share their knowledge and insights which have added value to this report.
HIV Counseling and Testing: a situation analysis in Cambodia, Myanmar and Viet Nam
TABLE OF CONTENTS
EXECUTIVE SUMMARY
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1. PURPOSE OF THE SITUATION ANALYSIS
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2. METHODOLOGY FOR THE SITUATION ANALYSIS
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3. GLOBAL OVERVIEW OF HIV/AIDS AND HIV COUNSELING AND

TESTING
3.1 Global Overview of the HIV/AIDS pandemic
3.1.1 Global epidemiology and coverage of health services
3.1.2 Global impact of HIV/AIDS
3.1.3 Gender issues in the global response to HIV/AIDS
3.1.4 Human Rights and HIV/AIDS: the international situation
3.1.5 Global overview of HIV prevention
3.1.6 Global overview of HIV/AIDS treatment, care and support
3.1.7 Young people and HIV/AIDS
3.1.8 Sexually Transmitted Infections and HIV/AIDS
3.1.9 Tuberculosis and HIV/AIDS
3.2 Global Overview of HIV Counseling and Testing
3.2.1 Introduction and definition of HIV counseling and testing
3.2.2 HIV counseling and testing: the entry point or gateway to
HIV prevention, treatment, care and support
3.2.3 Guiding principles of HIV counseling and testing
3.2.4 Components of HIV counseling and testing
3.2.5 Impact of HIV counseling and testing
3.2.6 Lessons learned from international experience in HIV
counseling and testing
3.2.7 Training resources for HIV counseling and testing
3.3 HIV Counseling and Testing Service Models
3.3.1 Types of HIV counseling and testing service models
3.3.2 Ethical and legal considerations
3.4 Integration of HIV Counseling and Testing into Sexual and
Reproductive Health Settings: international experience
3.4.1 The rationale for providing integrated HIV counseling
and testing
3.4.2 Practical steps for integration
3.5 HIV Tests: Selection and Availability
3.5.1 Advantages of rapid tests
3.5.2 Types of rapid tests
3.5.3 Selection of rapid test kits
3.5.4 Quantification and availability of rapid test kits
3.6 Monitoring and Evaluation of HIV Counseling and Testing Services
4. MEKONG REGION OVERVIEW OF HIV/AIDS: FOCUS ON

CAMBODIA, MYANMAR AND VIET NAM
4.1 Key Indicators for Cambodia, Myanmar and Viet Nam
4.2 Regional Overview of HIV/AIDS Epidemiology
4.3 Regional Impact of HIV/AIDS and Responses
4.4 Gender and Human Rights Issues in the Regional Response to HIV/AIDS
4.5 Regional Overview of HIV Prevention
4.6 Young People and HIV/AIDS: Injecting Drug Use in the Region
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5. CAMBODIA SITUATION ANALYSIS

5.1 Key Indicators and Introduction for Cambodia
5.2 HIV/AIDS Epidemiology in Cambodia
5.2.1 National HIV Sentinel Surveillance
5.2.2 Incidence of HIV infection in Cambodia
5.2.3 National Behavioural Sentinel Surveillance and other
national Knowledge, Attitudes and Practices surveys
5.2.4 Sexually Transmitted Infections Sentinel Surveillance
5.3 Socio-economic Situation and Impact of HIV/AIDS in Cambodia
5.4 Cultural and Behavioural Determinants of HIV/AIDS in Cambodia
5.5 National Response, Policies and Strategic Plans in Cambodia
5.5.1 Response by Cambodian Government and its agencies
5.5.2 Response of International Organisations and International
Donors
5.5.3 Response of Non-Government Organisations
5.5.4 Response and involvement of PLHA
5.5.5 Response by business and employers: HIV/AIDS in the
workplace
5.5.6 Media response to HIV/AIDS
5.5.7 Key achievements and challenges (2001-mid 2004)
5.6 National Level HIV/AIDS networks
5.7 Human Rights and Legal Considerations in Cambodia related to
HIV/AIDS
5.7.1 Overview
5.7.2 HIV/AIDS legislation and human rights
5.8 Gender Analysis in Cambodia
5.9 Health Service Review in Cambodia
5.9.1 Overview of health sector: Ministry of Health, Health Sector
Strategic Plan 2003-2007
5.9.2 Sexual and Reproductive Health Services in Cambodia
5.10 HIV/AIDS Services Review in Cambodia
5.10.1 Prevention interventions
5.10.2 Care, treatment and support Interventions
5.11 Risk Behaviour Groups in Cambodia
5.11.1 Youth
5.11.2 Sex Workers
5.11.3 Uniformed Personnel
5.11.4 Mobile/migrant Workers
5.11.5 Men who have sex with men
5.11.6 Drug use and Injecting Drug Users (IDUs)
5.12 HIV Counseling and Testing Services Assessment in Cambodia
5.12.1 Overview of HIV counseling and testing in Cambodia
5.12.2 Costs of HIV counseling and testing services
5.12.3 Coverage of HIV counseling and testing services in
Cambodia
5.12.4 National Policies and Guidelines
5.12.5 Quality Assurance and Quality Control
5.12.6 Achievements
5.12.7 Challenges
5.12.8 Recommendations related to HIV counseling and testing
5.12.9 Key resource documents for HIV counseling and testing in
Cambodia
5.12.10 HIV testing protocol for Cambodia
5.13 Marie Stopes Clinics in Cambodia
5.14 Recommendations for Integration of VCT into Marie Stopes Clinics in
Cambodia
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6. MYANMAR SITUATION ANALYSIS

6.1 Key Indicators and Introduction for Myanmar
6.2 HIV/AIDS Epidemiology in Myanmar
6.2.2 National Behavioural Sentinel Surveillance
6.3 Socio-economic Situation and Impact of HIV/AIDS in Myanmar
6.4 Cultural and Behavioural Determinants of HIV/AIDS in Myanmar
6.5 National Response, Policies and Strategic Plans in Myanmar
6.5.1 Response by the Government of Myanmar
Donors
workplace
6.5.7 Key achievements
6.7 Legal Considerations in Myanmar related to HIV/AIDS
6.8 Gender Analysis in Myanmar
6.9 Health Services Review in Myanmar
6.9.1 Overview of Health Sector
6.9.2 Sexual and Reproductive Health Services in Myanmar
6.10 HIV/AIDS Services Review in Myanmar
6.10.2 Care, treatment and support interventions
6.11 Risk Behaviour Groups in Myanmar
6.11.1 Youth
6.11.2 Sex Workers
6.12 HIV counseling and Testing Services Assessment in Myanmar
6.12.1 Overview of HIV counseling and testing in Myanmar
Myanmar
6.12.5 Achievements, challenges and recommendations
6.13 Marie Stopes Clinics in Myanmar
6.14 Recommendations for Integration of VCT into Marie Stopes Clinics
in Myanmar
7. VIET NAM SITUATION ANALYSIS

7.1 Key Indicators and Introduction for Viet Nam
7.2 HIV/AIDS Epidemiology in Viet Nam
7.2.2 National Behavioural Sentinel Surveillance and other
national Knowledge, Attitudes and Practices surveys
7.3 Socio-economic Situation and Impact of HIV/AIDS in Viet Nam
7.4 Cultural and Behavioural Determinants of HIV/AIDS in Viet Nam
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7.5 National Response, Policies and Strategic Plans in Viet Nam

7.5.1 Response by Vietnamese Government and its agencies
Donors
workplace and Media response to HIV/AIDS
7.7 Human Rights and Legal Considerations in Viet Nam related to
HIV/AIDS
7.8 Gender Analysis in Viet Nam
7.9 Health Services Review in Viet Nam
7.9.1 Overview of health sector
7.9.2 Sexual and reproductive health services in Viet Nam
7.10 HIV/AIDS Services Review in Viet Nam
7.11 Risk Behaviour Groups in Viet Nam
7.11.1 Youth
7.11.2 Female Sex Workers
7.11.3 Female Sex Workers who also inject drugs
7.11.4 Injecting Drug Users (IDUs)
7.12 HIV Counseling and Testing Services Assessment in Viet Nam
7.12.1 Overview of HIV counseling and testing in Viet Nam
Viet Nam
7.12.4 Profile of clients attending VCT Centres in Viet Nam
7.12.5 National Policies and Guidelines and key resource
documents for HIV counseling and testing in Viet Nam
7.12.6 Laboratory services for VCT in Viet Nam
7.12.7 Achievements and challenges
7.13 Marie Stopes Clinics in Viet Nam
7.14 Recommendations for Integration of VCT into Marie Stopes Clinics
in Viet Nam
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8. COMMON THEMES AND TRENDS
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9. REFERENCES
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10. ANNEXES
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1.
2.
3.
4.
5.
List of key web-sites and resource centres

List of Key Informants for Cambodia
List of Key Informants for Myanmar
List of Key Informants for Viet Nam
Generic Questionnaire for Key Informants
LIST OF ACRONYMS
GENERAL
Asian Development Bank
ADB
Adolescent and Reproductive
ARH
Health
Anti-Retroviral Therapy
ART
Anti-Retro Viral
ARV
AusAID Australian Agency for International
Development
British Broadcasting Commission
BBC
(World Service Trust)
Behaviour Change Communication
BCC
Behavioural Sentinel Surveillance
BSS
MDG
MSIA
Millennium Development Goals

Marie Stopes International Australia
MSM
MSF
MTCT
Men who have Sex with Men

Medicines Sans Frontieres
Mother To Child Transmission
NGO
Non-Government Organisation
OI
PEPFAR
Community Based Organisation

Centre for Disease Control (USA)
Commercial Sex Worker
Department for International
Development (United Kingdom)
Directly Observed Therapy Short
course
Direct Sex Worker
Enzyme Linked Immunosorbent
Assay
Family Health International
PLHA
PLWHA
PSI
SRH
Opportunistic Infection
President's Emergency Plan for
AIDS Relief
People Living with HIV/AIDS
People Living With HIV/AIDS
Population Services International
Sexual and Reproductive Health
STD
Sexually Transmitted Disease
STI
TB
Sexually Transmitted Infection

Tuberculosis
UNAIDS
Global Fund for AIDS, TB and

malaria
Greater Involvement of People
lining with HIV/AIDS
Human Development Indicators
HIV Sentinel Surveillance
Injecting Drug Use or User
UNDP
Indirect Sex Worker
UNHCR
Information, Education and

Communication
International Labour Organisation
UNICEF
Joint United Nations Programme on

HIV/AIDS
United Nations Development
Programme
United Nations Educational,
Scientific and Cultural Organisation
United Nations Population Fund
United Nations General Assembly
United Nations High Commissioner
for Human Rights
United Nations High Commissioner
for Refugees
United Nations Children's Fund
UNV
USAID
KAP
International Organisation
International Planned Parenthood
Federation
Japan International Cooperation
Agency
Knowledge, Attitudes and Practice
KII
MARPS
Key Informant Interview

Most At Risk Population Groups
WB
WHO
CBO
CDC
CSW
DFID
DOTS
DSW
ELISA
FHI
GFATM
GIPA
HDI
HSS
IDU or
IDUs
IDSW
IEC
ILO
IO
IPPF
JICA
UNESCO
UNFPA
UNGASS
UNHCHR
UNODC
VCT
VCCT
United Nations Office on Drugs and

Crime
United Nations Volunteers
United States Agency for
International Development
Voluntary Counseling and Testing
Voluntary, Confidential Counseling
and Testing
World Bank
World Health Organisation
CAMBODIA
Cambodian Demographic and
CDHS
Health Survey, 2000
CHRHAN Cambodian Human Rights and
HIV/AIDS Network
Cambodia Millennium
CMDG
Development Goals
Continuum of Care
CoC
Complementary Package of
CPA
Activities
Cambodian Network of People
CPN+
Living with HIV/AIDS
(100%) Condom Use Program
CUP
MPA
Ministry of Women's and Veteran's

Affairs
Minimum Package of Activities
MSC
Marie Stopes Cambodia
NAA
NACD
National AIDS Authority

National Authority for Combating
Drugs
National Centre for HIV/AIDS,
Dermatology and STD
National Centre for Health
Promotion
National Maternal and Child Health
Centre
National Strategic Plan for a
Comprehensive and Multi-sectoral
Response to HIV/AIDS, 2006-2010
Reproductive Health Association of
Cambodia
MoWVA
NCHADS
NCHP
HACC
HIV/AIDS Coordinating Committee
NMCHC
KHANA
Khmer HIV/AIDS NGO Alliance
NSP II
MoH
Ministry of Health
RHAC
MYANMAR
Drug Detoxification/ Treatment and
DDTRU
Rehabilitation Unit, Ministry of
Health
Central Committee for Drug Abuse
CCDAC
Control
Fund for HIV/AIDS for Myanmar
FHAM
VIET NAM
Community-based Counseling and
CCSC
Support Centre
Marie Stopes International
MSIVN
Viet Nam
NAP
National AIDS (Control)

Programme
MSIM
Marie Stopes International

Myanmar
PAC
Provincial AIDS Committee
SAVY
Survey of Vietnamese Youth
EXECUTIVE SUMMARY
This document is a situation analysis of HIV/AIDS in Cambodia, Myanmar and Viet Nam, with
specific reference to voluntary counseling and testing (VCT). The main purpose of this analysis is
to provide sufficient detail to effectively plan integrated VCT services, tailored to the
epidemiological, cultural, behavioural and economic context of each country. A comprehensive
literature review, supplemented by Key Informant Interviews in all three countries was used to
prepare this report. A selection of the most important findings is presented here.
Global Overview
HIV counseling and testing is the "entry point" or "gateway" to the Continuum of Care.
Globally, there is low coverage of HIV counseling and testing services.
A human-rights based approach to HIV counseling and testing contributes to reducing
stigma and discrimination.
Studies confirm that VCT is cost-effective and promotes positive behaviour change.
Community outreach to raise HIV/AIDS awareness and the provision of treatment, care
and support services, are strong motivators to increase uptake of VCT services.
VCT services integrated into existing sexual and reproductive health settings is a model
that is strongly supported in the international literature.
Challenges include reaching the partners of VCT clients and encouraging voluntary
disclosure of results to partners while preventing the possibility of gender-based violence.
Regional Overview
There is extreme geographical and temporal diversity in the HIV epidemics in Asia.
The contributing factors that fuel these epidemics are: poverty; other sexually transmitted
infections; the sex industry; human trafficking; mobility; stigma and discrimination; the
vulnerability of women; and high risk behaviours among Injecting Drug Users (IDUs) and
men who have sex with men (MSM).
Cambodia
Cambodia has demonstrated strong political commitment to a national multi-sectoral
response, resulting in a consistent fall in HIV prevalence (1.9% in 2003).
There is increased condom use by sex workers and fewer sexual partners for male
sentinel groups, but condom use in sweetheart relationships is still relatively low.
There are significant gender and cultural barriers that limit a more effective response:
young women are expected to remain virgins until marriage and not to know about sexual
matters, while male promiscuity is tolerated.
Most HIV transmission in Cambodia is now husband-to-wife and mother-to-child.
The HIV/AIDS Law in Cambodia is considered best practice in Asia.
The National Strategic Plan 2006-2010 recognizes the need to include IDUs and MSM as
population groups for HIV prevention.
Cambodia has received significant support from the international donor community,
including the Global Fund for HIV/AIDS, Tuberculosis and Malaria.
There are well developed and active networks of International and Non-Government
Organisations (NGOs), and of People Living with HIV/AIDS (PLHA) in Cambodia.
There is evidence of reducing levels of stigma and discrimination in Cambodia.
There are rapidly increasing numbers of PLHA receiving antiretroviral therapy and well
developed home based care and support services, at least in urban areas.
There is an urgent need for youth-friendly sexual and reproductive health.
There is a strong demand for HIV counseling and testing services.
There are over 109 licensed VCT sites using rapid tests and a comprehensive set of
national policies, guidelines and training curricula is available.
Couple's counseling and testing, is increasing but there is still low uptake VCT for the
Prevention of Mother-To-Child Transmission of HIV.
Myanmar
The HIV epidemic in Myanmar is moving from a concentrated form, with high prevalence
among IDUs, to a more generalized form. The national prevalence in 2004 was 1.3%.
There is an urgent need to promote wider discussion on sexual, cultural and behavioural
practices to increase awareness of HIV/AIDS.
The National AIDS Programme is located within the Ministry of Health which limits the
ability to plan a multi-sectoral response. The current context also limits the ability to form
effective partnerships to allow scale-up of critical interventions.
The United Nations Expanded Theme Group is implementing the Joint Programme for
HIV/AIDS in partnership with the government and International and local NGOs, but with
limited resources. The Global Fund withdrew from Myanmar in late 2005.
There are a few small groups of PLHA which are becoming active in responding to
HIV/AIDS in partnership with the government.
Capacity building for all sectors involved in the HIV/AIDS response is urgently needed.
High levels of stigma and discrimination towards PLHA and IDUs are a barrier to HIV
prevention efforts.
Harm reduction initiatives for IDUs are starting to be implemented as pilot activities.
There is strong community demand for VCT services, despite low levels of treatment,
care and support services. Coverage of VCT services for high risk behaviour groups is
expanding, but coverage for the general population remains low. Population Services
International have been given approval to conduct screening and confirmatory testing.
Most VCT in Myanmar is in the context of the PMTCT program.
Technical resources for VCT are at various stages of development with detailed
Operational Guidelines in draft form.
Viet Nam
The HIV epidemic in Viet Nam is moving from a concentrated to a more generalized form
with wide variations in prevalence among target groups in different Provinces (high rates
among IDUs and increasing rates among sex workers). The national prevalence in 2004
was 0.4%. There are a significant number of female sex workers who are injecting drugs.
Levels of stigma and discrimination towards PLHA and towards IDUs and sex workers,
remain high.
There is increased political commitment to addressing HIV/AIDS with a move from a
"social evils" approach to a harm reduction approach. A new Law which should
contribute to reducing stigma and discrimination awaits endorsement
While the Greater Involvement of PLHA principle is endorsed, in practice there is limited
involvement in responding to HIV/AIDS at present.
Women in Viet Nam have relatively high levels of health, education and gender equity,
but there are persisting cultural and social norms that limit HIV prevention efforts, such as
the expectation that women will remain virgins until marriage and taboos on discussing
sexual issues.
There is limited recognition of MSM as an important population group for HIV prevention.
There is an urgent need to expand access to treatment, care and support services.
There is a strong need for youth-friendly sexual and reproductive health services.
There is a national plan to expand VCT services but currently NGOs are not allowed to
do confirmatory testing. Current protocols use non-rapid tests with resultant delays in
informing clients of results.
There are comprehensive Vietnamese and English language training resources for VCT
available from International and NGOs working in partnership with the government.
Mass organizations in Viet Nam have the potential to widely promote VCT services.
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1. PURPOSE OF THE SITUATION ANALYSIS

This document presents a situation analysis of the HIV/AIDS epidemic in Cambodia, Myanmar
and Viet Nam with specific reference to the provision of voluntary counseling and testing services
(VCTi) integrated into the existing sexual and reproductive health (SRH) clinics managed by
Marie Stopes Cambodia (MSC), Marie Stopes International Myanmar (MSIM) and Marie Stopes
International Viet Nam (MSIVN). The main purpose of this analysis is to describe and analyse
the national situation in sufficient detail to allow for the effective planning of integrated VCT
services tailored to the epidemiological, cultural, behavioural and economic context of each
country and specific target groups. In addition, this analysis contributes to the development of
supportive policies in relation to HIV counseling and testing and helps each Marie Stopes Clinic,
health service partners and communities to understand their specific roles and responsibilities.
This analysis reviews the considerable body of literature already available and provides detailed
references to allow access to the original material. The review attempts to achieve a balance by
presenting brief overviews of the overall epidemiological, cultural, behavioural and socioeconomic situation, a more detailed analysis of the response to HIV/AIDS in each country and a
comprehensive review of issues directly and indirectly related to HIV counseling and testing. The
literature review is complemented by Key Informant Interviews (KII) at the national level in each
country.
Following the completion of this national Situation Analysis, a Baseline Survey will be conducted
leading to a detailed district level assessment for each implementing Clinic site. This assessment
will draw on the information in the national level Situation Analysis and Baseline Survey and
include more community and partner consultation and participation to effectively tailor the VCT
interventions for each geographical location and target group.
2. METHODOLOGY FOR THE SITUATION ANALYSIS

This national level situation analysis uses data from two main sources: published literature and
Key Informant Interviews. The literature review was conducted by accessing the web-sites of
major international HIV/AIDS organizations and country-specific resources. In addition, further
literature was obtained from national resource centres and from persons contacted for the Key
Informant Interviews. A list of the key web-sites and resource centres is provided in Annex 1 and
full referencing for all cited sources is given using the Vancouver system in Section 9.
A list of Key Informants was compiled based on the knowledge, experience and
recommendations of the Marie Stopes Program Directors in each country. These Key Informants
included government authorities from the health and non-health sectors and representatives of
international organizations (IO), donors and major community and Non-Government
Organizations (NGO). An open-ended questionnaire was developed with core or common
questions, with additional questions specific for each Key Informant in order to maximize the
unique insights that each person was able to provide. A total of 21 Key Informant Interviews were
conducted with 29 Key Informants from government, International Organisations and NonGovernment Organisations. The List of Key Informants for each country and the Questionnaires
used are provided in Annexes 2-4 and Annex 5.
This review will use the acronym VCT to refer specifically to the type of HIV counseling and testing service that the Marie
Stopes Clinics plan to provide. For more general discussion, the term "HIV counseling and testing" will be used.
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3. GLOBAL OVERVIEW OF HIV/AIDS AND HIV COUNSELING

AND TESTING
3.1 Global Overview of the HIV/AIDS pandemic
3.1.1 Global epidemiology and coverage of health services
"AIDS is an extraordinary kind of crisis. To stand any chance of effectively responding to the
epidemic we have to treat it both as an emergency and a long-term development issue"1.
The global situation in December 2005 is shown below2.
____________________________________________________________________
Number of people living with HIV in 2005
Total
40.3 million
Adults
38.0 million
Women
17.5 million
Children under 15 yrs
2.3 million
____________________________________________________________________
People newly infected with HIV in 2005
Total
4.9 million
Adults
4.2 million
700,000
____________________________________________________________________
AIDS deaths in 2005
Total
3.1 million
Adults
2.6 million
570,000
____________________________________________________________________
The required coverage of health and other services to meet the huge numbers of people infected
and affected by HIV/AIDS is much less than required. In 2001, WHO initiated a study to measure
the coverage of important health services, which was repeated in 20033, 4. The services
assessed were: voluntary counseling and testing; prevention of mother-to-child transmission of
HIV; antiretroviral therapy; care and treatment; and blood safety. The global results are presented
here, with country-specific results for Cambodia, Myanmar and Viet Nam given in the later
sections for each country.
Globally, VCT was available to only about 12% of the people needing it in 2001, with an estimate
that 14 million people would use the service if it were available to everyone. In 2003, the
estimate of the number of persons receiving VCT had doubled to 4.2 million clients in 88 reporting
countries. Prevention of Mother to Child Transmission (PMTCT) coverage was estimated to be
5% in 2001, and increased to 8% in 2003. Antiretroviral therapy (ART) coverage was only 2% of
those who needed treatment in 2001, but had increased to 7% in 2003. UNAIDS states that "at
bestone in 10 Africans and one in seven Asians in need of antiretroviral treatment received it in
20052. More encouraging results were that there was 96% coverage for the screening of donated
blood in 2001 and that coverage for essential, or better, care and treatment increased from 31%
in 2001 to 60% in 2003.
These trends are reflected in the UN General Assembly Report of 25 July 2003 on Progress
towards Implementation of the Declaration of Commitment on HIV/AIDS, which reported
significant progress in the global response to HIV/AIDS since the previous report in August 2002.
However, the report stated that less than one in four people at risk of infection were able to obtain
basic information about HIV/AIDS; only one in nine persons seeking to know their HIV serostatus
had access to VCT; and less than one in 20 pregnant women presenting for antenatal care were
able to access services to prevent mother-to-child transmission of HIV5.
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The global efforts to scale-up critical interventions in response to HIVAIDS require a strong
monitoring and evaluation framework with accurate, timely and comparable data to assess
progress, strengthen local programs and demonstrate accountability. There are a number of
international resources available with detailed indicators and tools for monitoring and evaluation
of the whole spectrum of HIV/AIDS interventions6, 7.
3.1.2 Global impact of HIV/AIDS

The following brief summary is extracted from the UNAIDS 2004 report on the global AIDS
epidemic1. For the purposes of this literature review, this summary serves to highlight the
widespread impact of HIV on people and the environment.
impact on the demographic population structure with young adult deaths
impact on women who are affected more than men
impact on young people who are disproportionately affected
impact on children: physical and emotional health, nutrition, shelter and material
needs, legal status, access to health and education services, discrimination and
exploitation
impact on poverty and hunger: lost income, food insecurity and increased spending
needs
impact on agriculture and rural development
impact on the supply, demand and quality of education: supply of teachers, school
attendance, student enrolment and the quality of education
impact on the health sector: staff losses and absenteeism
impact on public sector capacity
impact on workers and the workplace: increased cost of doing business
macroeconomic impact.
3.1.3 Gender issues in the global response to HIV/AIDS

Gender is defined as "an array of societal beliefs, norms, customs and practices that define
'masculine' and 'feminine' attributes and behaviours". In every society there are many kinds of
masculinity and femininity that vary with social class, ethnicity, sexuality and age8.
Women are more physically susceptible to HIV infection than men, and young women are
biologically more susceptible to infection than older women before menopause. When combined
with gender inequalities, this means that for many women, including married women, their male
partner's sexual behaviour is the most important HIV risk factor. The result is that, in 2005,
almost half of all People Living with HIV/AIDS (PLHA) were women and over 60% of 15 to 24
years olds with HIV were young women. The HIV epidemic also has a disproportionate impact on
women in their socially defined roles as carers, wives, mothers and grandmothers, and the stigma
associated with HIV may prevent many women (and men) from accessing health services1, 2, 8.
"Women may hesitate to receive HIV testing or fail to return for their results because they
are afraid that disclosing their HIV-positive status may result in physical violence,
expulsion from their home or social ostracism. Young girls may drop out of school to look
after ailing parents, look after household duties or care for younger siblings. Older
women often shoulder the burden of care when their adult children fall ill, and later may
have to become surrogate parents to their bereaved grandchildren. When their partners
or fathers die of AIDS, women may be left without land, housing or other assets. The
denial of these basic rights increases women's and girl's vulnerability to sexual
exploitation, abuse and HIV" 1.
13
In summary, the key gender issues in responding to HIV/AIDS are8:

Sociocultural factors
knowledge of sex and HIV risk
fidelity and multiple partners
motherhood as the ideal
dependence versus self-reliance
sexual dominance, homophobia and violence against women
access to services
Economic factors
sex as a marketable commodity
lack of economic leverage
lack of access to information
impact of migration
impact of ethnicity, caste and race
coping with the socioeconomic impacts of HIV
access to, and use of, services.
UNAIDS recommend the following key actions to respond to gender inequity in addressing
HIV/AIDS1, 9.
support HIV positive women and their organizations and networks
make HIV/AIDS money work for women
ensure adolescent girls and women have the knowledge and means to prevent
HIV infection
ensure equal and universal access to treatment, care and support services
promote girls' primary and secondary education and women's literacy
recognize and support home based caregivers of AIDS patients and orphans
promote zero tolerance of all forms of gender based violence
promote and protect the human rights of women and girls, including
strengthening the legal protection for women's property and inheritance rights.
The most recent UNAIDS Epidemic Update, 20052, recognizes the importance of engaging men
and boys in HIV/AIDS prevention efforts for a long-standing impact on gender inequality, with
specific attention needed for boys in terms of their socialization towards gender norms.
Violence against women deserves separate mention. Violence against women takes many forms
including physical, sexual and psychological abuse. Research shows that violence against
women is associated with increased risk for acquiring Sexually Transmitted Infections (STI) and
HIV infections. In many countries, inequitable divorce and property laws make it difficult for
women to leave abusive relationships. Even where there are laws against gender-based
violence, there may be insufficient resources, discriminatory practices by police and law courts,
and lack of institutional support to adequately protect women against violence10.
Intimate partner violence is the most common form of violence against women and contributes
directly and indirectly to HIV transmission. Violence against women, particularly sexual violence,
is widespread in conflict settings where there is a high risk of acquiring STI and HIV by direct
transmission through rape; by being placed in situations where women may be forced to
exchange sex for survival; and through experiencing increased levels of overall violence,
including intimate partner violence, which makes it more difficult to negotiate safe sex in
relationships11. Violence against women following disclosure of results from voluntary counseling
and testing is discussed in Section 3.2.5: Impact of HIV counseling and testing.
14
3.1.4 Human Rights and HIV/AIDS: the international situation

"Human rights are a set of universal entitlements that individuals enjoy irrespective of their sex,
nationality, religion, culture or other status, that are inherent to human beings and that are
proclaimed and protected by international law"12. Human rights law provides a useful framework
for countries to formulate laws and policies that integrate public health objectives with human
rights standards. Human rights laws also provide Non-Government Organizations and advocacy
groups with tools to monitor the performance of States and describe the obligations and
responsibilities of public health practitioners to protect and promote population health12.
A human rights approach to HIV/AIDS policies and programs has been strongly endorsed by
most United Nations States and documented in International Guidelines published in 199613. The
12 Guidelines are summarized here:
Guideline 1 relates to a national framework to address HIV/AIDS through
coordination, participation, transparency, accountability and integration
Guideline 2 refers to the importance of community consultation
Guideline 3 refers to reform of public health laws
Guideline 4 refers to review and reform of criminal law
Guideline 5 relates to strengthening anti-discrimination and other protective laws
Guideline 6 refers to the regulation of HIV-related goods, services and information
and the widespread availability of services
Guideline 7 refers to strengthening legal support services
Guideline 8 stresses the importance of a supportive and enabling environment for
women, children and other vulnerable groups
Guideline 9 refers to changes in attitudes of stigma and discrimination through
education, training and the media
Guideline 10 refers to the development of codes of conduct for professional
responsibilities and practices
Guideline 11 refers to monitoring and enforcement mechanisms
Guideline 12 requests coordination through the United Nations system.
In response to the scale-up of the global response to HIV, in particular to the increased
availability of antiretroviral therapy, Guideline 6: Access to prevention, treatment, care and
support, was revised in August 200214. This revision noted the need "to ensure widespread
availability of quality preventive measures and services, adequate HIV prevention and care
information, and safe and effective medication at an affordable pricewith particular attention to
vulnerable individuals and populations". In specific reference to HIV counseling and testing, one
recommendation states that:
"laws and regulations should be enacted to ensure the quality and availability of HIV tests
and counseling. If home tests and/or rapid HIV test kits are permitted on the market, they
should be strictly regulated to ensure quality and accuracyStates should also ensure
supervision of the quality of delivery of voluntary counseling and testing services".
The UN Convention on the Rights of the Child (1989) has been reviewed in the context of the
global HIV/AIDS epidemic15. Prevention, care, treatment and support for children infected or
affected by HIV/AIDS form a continuum along which all the Rights of the Child have relevance.
Specific reference to HIV counseling and testing is made in paragraphs 19-23 of this document.
These refer to the accessibility of voluntary, confidential HIV counseling and testing services as a
fundamental right of children (19); that mandatory testing of children should not be imposed and
that the risks and benefits of testing are sufficiently conveyed to allow informed choice by the
child or parents/ guardian as appropriate (20); that the role of States is to protect the
confidentiality of HIV test results which should not be disclosed to third parties, including parents,
without consent (21); and making HIV counseling and testing services available to pregnant
women and their partners (23).
15
In reviewing the progress that member States have made in implementing the Declaration of
Commitment on HIV/AIDS, the UN Report noted that only 62% of responding States had laws
and policies in place to protect against discrimination towards people living with, or affected by,
HIV/AIDS, and that many of these were general, rather than HIV specific, laws and policies.
There were far fewer States (38%) with policies that prohibited discrimination against specific
vulnerable population groups5.
Because human rights issues are strongly linked to stigma and discrimination, a short discussion
of this important issue is included in this literature review. A recent study by Ogden and Nyblade
in 200516, in Ethiopia, Tanzania, Viet Nam and Zambia, described stigma as "a process of
devaluation" of people either living with, or associated with, HIV and AIDS. Discrimination, which
follows stigma, was defined as the unfair or unjust treatment of an individual based on his or her
real or perceived HIV status (citing a UNAIDS December 2003 Fact Sheet). A short summary of
this study is presented here with more details of the results from Viet Nam given in Section 7.7.
The key finding was that HIV/AIDS stigma and discrimination was "remarkably consistent" across
the four countries studied. The country contexts were very different, with the three African
countries experiencing generalized HIV epidemics, while in Viet Nam the epidemic was
concentrated among injecting drug users and strongly linked in policies and programs to illegal
drug use and prostitution, both considered as "social evils". A detailed analysis of the results
indicated that in all four study locations a process of fear related to unlikely casual modes of
transmission, combined with fear-based public messages and underlying moral judgments, led to
a division between "them" and "us". People living with HIV/AIDS tended to be placed on a
continuum from innocence (children) to guilt (sex workers and injecting drug users). Stigma was
found to be greater towards women than men, perhaps because women are expected to uphold
the moral traditions of society.
Four broad types of stigma were found in all four countries, although with varied specific
expression:
physical stigma: isolation and violence
social stigma: isolation, voyeurism, loss of identity and role
verbal stigma: gossip, taunting, experience of blame and shame, labeling and use of
derogatory words
institutional stigma: loss of livelihood and housing and differential treatment in school,
health care, public spaces and in the media.
The consequences for individuals with HIV infection were: loss of marriage and child-bearing as
life options; loss of livelihood; poor care in the health sector; withdrawal of care-giving in the
home; and internalized or "self-stigma", with effects on mental health including loss of hope,
feeling worthless, having no future, anxiety and depression.
Stigma has an impact on treatment programs for HIV, with those experiencing stigma less able or
willing to access and use treatment services. Stigma also has an impact on prevention programs,
as fear of stigma may lead to some people with HIV denying their infection as a self-protective
response. This could lead to further transmission of HIV. Stigma also was found to have an
impact on HIV testing services, preventing people from accessing testing services, or not
returning for the results of tests.
Of importance to this literature review was the finding that people experiencing stigma and
discrimination avoided clinics known as HIV testing sites and expressed fears that test results
may not be kept confidential. The impact of stigma on disclosure of results is discussed in more
detail in Section 3.2.5: Impact of HIV counseling and testing.
16
3.1.5 Global overview of HIV prevention

This particular section on global approaches to prevention of HIV infection is intentionally brief.
The country-specific sections that follow will provide more information on HIV prevention
interventions in Cambodia, Myanmar and Viet Nam.
An international review in May 2003 of access to HIV prevention concluded that proven
interventions should be used in combination to target the many diverse populations affected by
HIV and the various routes of HIV transmission17. The review stated that interventions should be
science-based and tailored to address national and local needs. The key interventions
recommended were:
behaviour change, both broad-based and targeted, focusing on delayed initiation of
sexual activity, mutual monogamy and consistent and correct condom use
Sexually Transmitted Infection (STI) management and control
voluntary counseling and testing
harm reduction for injecting drug users
prevention of mother-to-child transmission with a package of interventions, including
VCT
blood safety
infection control in health care settings
structural interventions such as policy reform related to gender inequity and
education
programs for people living with HIV/AIDS.
The central role of the male condom in prevention has been clearly re-affirmed despite continuing
controversy.
"The male latex condom is the single, most efficient, available technology to reduce the
sexual transmission of HIV and other sexually transmitted infectionsCondom use is a
critical element in a comprehensive, effective and sustainable approach to HIV
prevention and treatment...Condoms must be readily available universally, either free or
at low cost, and promoted in ways that help overcome social and personal obstacles to
their useHIV prevention education and condom promotion must overcome the
challenges of complex gender and social factors, in particular the need for young girls
and women to have information about and access to condoms"18.
Reproductive health service providers can make a significant contribution in closing gaps in HIV
prevention. Reproductive health interventions include: family planning information, education and
communication; contraceptive counseling and the provision of contraceptives; basic screening for
sexually transmitted infections; prenatal and newborn care; and breast feeding support, all of
which can be readily linked with HIV prevention activities. Reproductive health service providers
also have the opportunity to develop services, including HIV counseling and testing, to attract
young people, a critical population group for HIV prevention19.
The prevention of mother to child transmission of HIV infection is now firmly established as a
cost-effective intervention that requires rapid scale-up. There are four key strategies to prevent
mother-to-child transmission20:
preventing the spread of HIV (primary prevention)
preventing unintended pregnancies
preventing mother-to-child transmission during pregnancy, delivery and breastfeeding
providing care, support and treatment to HIV+ mothers and their families.
17
The World Health Organisation (WHO) and the United States Centre for Disease Control (CDC)
have produced a Generic Training Package for the Prevention of Mother-to-Child Transmission of
HIV with modules on specific interventions to prevent transmission; infant feeding options; stigma
and discrimination in relation to PMTCT; HIV counseling and testing for PMTCT; linkages to
treatment, care and support for mothers and families with HIV infection; safety and supportive
care in the work environment; and PMTCT program monitoring20.
3.1.6 Global overview of HIV/AIDS treatment, care and support

This literature review cannot address the huge area of HIV treatment, care and support in any
detail. The main purpose of this brief paragraph is to highlight that international experience
emphasizes HIV counseling and testing as the "entry point" or "gateway" to the Continuum of
Care from prevention through to treatment, care and support. Some key resources include the
WHO Regional Office for the Western Pacific, HIV/AIDS Care and Treatment Guide for
Implementation, 200421; the WHO Community home-based care in resource limited settings,
200222, which provides a framework to establish and maintain community home-based care for
people living with HIV/AIDS and other chronic illnesses and disabilities; and the joint UNICEF,
UNAIDS, WHO, Medicines Sans Frontieres (MSF) publication, Sources and prices of selected
medicines and diagnostics for people living with HIV/AIDS, 200423, which focuses on antiretroviral
drugs, medicines for treatment and prophylaxis of opportunistic infection, medication for
symptomatic treatment and palliative care, as well as a list of HIV diagnostic tests evaluated by
WHO.
3.1.7 Young people and HIV/AIDS

This literature review is written to provide the context for integrated VCT services into sexual and
reproductive health settings, with youth identified as a priority target group. A brief overview of
the international literature related to youth and HIV/AIDS is therefore presented here. "Nearly
half the global population is less than 25 years and they have not known a world without
AIDSthey are the most threatenedand the greatest hope for turning the tide against AIDS"1.
Every day an estimated 5,000 to 6,000 young people aged 15-24 become infected with HIV and
almost 1 in 4 of those living with AIDS are under age 2524. While there is growing evidence that
comprehensive prevention programs can reduce the rate of infection among young people, there
is recognition that too few young people are currently receiving the services they need to avoid
transmission5.
While there are many similarities among young people, they are not an homogenous group and
there are significant differences that must be recognized related to gender, ethnicity, urban or
rural residence, education and school attendance, injecting drug use, sex work and male to male
sex. For many young people these are overlapping categories and HIV prevention interventions
need to be adapted for each context25. Ten steps have been listed to respond to youth and
HIV/AIDS issues 24, 26.
1. end silence, stigma and shame
2. provide young people with knowledge and information through schools, communities
and the media
3. equip young people with life skills to put knowledge into practice, including access to
condoms
4. provide youth friendly health services
5. promote voluntary and confidential HIV counseling and testing
6. work with young people and promote their participation (including peer education)
7. engage with young people who are living with HIV/AIDS
8. create safe and supportive environments
9. reach out to young people most at risk
10. strengthen partnerships and monitor progress.
18
The role of health services in protecting young people from HIV and AIDS has been specifically
addressed in a recent WHO publication27. Health services have a key role in providing accurate
and up-to-date information, in implementing interventions such as condom promotion and harm
reduction for IDUs, and in the provision of diagnosis, treatment and care, with counseling and
testing for HIV being an important health service responsibility.
In addressing gender issues among young people, there has been an understandable focus on
girls and women. However, the role of young men in promoting sexual and reproductive health,
including their role in HIV prevention, needs to be addressed. There are some successful small
scale initiatives working with young men to encourage them to take increasing responsibility for
their own, and their partners, sexual health, but such interventions remain limited in their scope28.
Useful practical resources have been developed by WHO. A Rapid Assessment and Response
guide for especially vulnerable young people (defined as those who sell sex or inject drugs,
young migrants and refugees, young men who have sex with men and groups such as homeless
youth and orphans) was published in 200429. WHO has also developed a guide for monitoring
and evaluating HIV prevention programs for young people in recognition that there is limited data
specific for young people7. Most national HIV surveillance systems only include a small subsample of youth aged 15-24 years which makes it difficult to accurately assess the magnitude of
some indicators and to assess trends in prevalence and behaviours30. Even among youth, data
needs to be disaggregated by age, gender, school attendance, marital status, urban or rural
residence, as well as for specific risk behaviours such as needle sharing during injecting drug
use, unprotected commercial sex work and unprotected sex among men who have sex with men.
Injecting drug use is a behaviour mostly practiced by youth, and directly relevant to Myanmar,
Viet Nam and Cambodia. Among Injecting Drug Users (IDUs), HIV infection can be transmitted
by needle sharing and unprotected sex. The following comments provide a brief global overview,
with the Regional Overview (Section 4.6) and country-specific sections adding more detail. WHO
notes that injecting drug use continues to spread around the world "regardless of religious
persuasion, stage of economic development, social class, environment (urban or rural) or political
system"31. It is estimated that IDUs account directly for 10% of all reported AIDS cases globally.
In Asia, explosive epidemics among IDUs have been reported in Myanmar and Viet Nam as well
as in China, Nepal, Thailand, Malaysia and north-east India. Within 6 to 12 months of the
appearance of the first case, 60-90% of the IDUs in a particular location can be infected. The
infection spreads from drug distribution epicenters and along drug distribution routes. Sexual
transmission to non-IDU sexual partners can fuel a more generalized HIV epidemic, particularly if
significant proportions of IDUs are also engaged in commercial sex work31.
WHO has commissioned a comprehensive literature and program review to assess the
effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users32.
Outreach is one component of a comprehensive approach to prevent HIV infection among IDUs,
along with the provision of clean needles and syringes, drug dependency treatment options,
condom promotion and HIV counseling and testing. The conclusion of the review was that there
was strong evidence of reduced risk behaviour, lowered exposure to HIV and increased use of
voluntary counseling and testing and drug dependency services as a result of outreach:
"Outreach is an effective strategy for reachingIDUs and provides the means for enabling IDUs
to reduce their risk behavioursHIV transmission in IDUs is preventable"32, 33. Based on this
evidence, WHO have produced a Training Guide for HIV prevention outreach to IDUs which
contains details of the planning and content for an orientation workshop, a program development
workshop, a program management workshop and field worker training in core outreach skills34.
However, the cultural and legal situation in some countries limits a harm reduction approach to
injecting drug use, with needle and syringe exchange programs and drug substitution programs
not officially approved. Details specific to Cambodia, and especially to Myanmar and Viet Nam,
are presented in the country-specific sections that follow. Section 7.11 describes the important
link between injecting drug use and sex work in Viet Nam, a situation that is common in many
other countries to varying extents.
19
3.1.8 Sexually Transmitted Infections and HIV/AIDS

There is "compelling [epidemiological and biological] evidence that STD is a co-factor for HIV
transmission"35. In response to this evidence, STD control has been recognized as having a
critical role in the reduction of sexually acquired HIV transmission, and is therefore a key
intervention in all national HIV/AIDS control programs. To have the maximum impact on HIV
incidence, a combination of primary prevention of STDs as well as effective case management is
required.
3.1.9 Tuberculosis and HIV/AIDS

Tuberculosis (TB) is a largely treatable infection, but remains one of the most common causes of
HIV-related illness and death. It is estimated that 11 million adults living with HIV are co-infected
with TB (71% in sub-Saharan Africa and 22% in South East Asia). HIV infection increases the
number of TB cases and alters the clinical course of TB so that the infection is more likely to be
disseminated and more difficult to diagnose with increasing immunosuppression. This, combined
with increased morbidity from other HIV-related diseases, had led to an increase in the TB casefatality rate36. HIV infection therefore impacts directly on TB control programs, and in turn, TB
infection impacts directly on HIV control programs. DOTS (Directly Observed Therapy, Shortcourse) is the recommended core activity for TB control.
WHO has published a series of booklets to strengthen collaborative HIV/TB interventions. A
booklet on a Strategic Framework describes what could be done; an Interim Policy describes
what should be done; Guidelines for Collaborative Activities describes how these things can be
done; and there is a separate booklet on monitoring and evaluation36, 37, 38, 39. The recommended
collaborative activities are:
To decrease the burden of TB in People Living with HIV/AIDS
intensify TB case-finding by including screening questions asked by trained
counselors of all clients testing HIV+ in HIV counseling and testing settings, and
promoting referral systems between HIV counseling and testing services and TB
diagnosis and treatment services
introduce isoniazid preventive therapy
ensure TB infection control in health care settings
To decrease the burden of HIV in TB patients
provide HIV counseling and testing to all TB patients in settings where the HIV
prevalence among TB patients exceeds 5%
introduce HIV prevention methods
introduce co-trimoxazole preventive therapy
ensure HIV/AIDS care and support
introduce anti-retroviral therapy (ART).
These key documents make specific reference to the importance of VCT, and recommend that
centres providing VCT and sexual and reproductive health services should consider the addition
of the following services (listed in order of increasing additional resources and planning). VCT is
considered as an entry point for a range of HIV/TB care and prevention interventions.
client education on TB
referral of HIV+ clients to clinical care
screening checks for TB among persons testing HIV positive
PMTCT services with antiretroviral drugs
sputum collection points
TB diagnosis
TB treatment centre and Isoniazid preventive treatment
20
Key indicators for these interventions, selected for this literature review are6
HIV sero-prevalence among all TB patients
intensified case finding for TB among PLHA
rate of new cases of TB diagnosed clients attending HIV counseling and testing
services or HIV treatment and care services
proportion of all registered TB patients who are tested for HIV
proportion of these who are HIV+
proportion of HIV+ TB patients who receive post-test counseling.
3.2 Global Overview of HIV Counseling and Testing

3.2.1 Introduction and definition of HIV counseling and testing
Until recently, HIV counseling and testing was mostly discussed using the term "voluntary
counseling and testing" (VCT) or "voluntary, confidential counseling and testing" (VCCT).
However, the World Health Organization (WHO) and other authorities now prefer to use the term
"HIV counseling and testingii" to refer to a variety of interventions in different services settings,
one of which is the provision of VCT40. UNAIDS and WHO therefore recommend making a clear
distinction between voluntary counseling and testing (VCT); diagnostic HIV testing; the routine
offer of HIV testing by health care providers (for example, in all patients being assessed in a
sexually transmitted infection clinic and among antenatal clinic clients); and mandatory HIV
screening41. In this review, the term "HIV counseling and testing" will be used to refer to the
variety of interventions, while VCT will have the more limited and specific definition.
3.2.2 HIV counseling and testing: the entry point or gateway to HIV
prevention, treatment, care and support
Over the past 20 years, HIV testing has clearly moved from a diagnostic tool to an essential
component of HIV prevention, treatment, care and support, best summarized in the diagram
below. HIV counseling and testing is now considered as the "entry point" or "gateway" to a
Continuum of Care. "Among interventions which play a pivotal role both in treatment and
prevention, HIV counseling and testing stands out as paramount"41.
3.2.3 Guiding principles of HIV counseling and testing
To be successful, HIV counseling and testing services must40:

build and sustain political commitment to scale-up of counseling and testing
improve awareness of the benefits of HIV counseling and testing to contribute to the
normalization of HIV and the reduction of stigma and discrimination
involve PLHA, communities and other key stakeholders in the design,
implementation, monitoring and evaluation of the services
develop and use standardized HIV counseling and testing protocols
be client-centered with effective links to post-test services and support
must be ethical: HIV tests must be voluntary and ensure confidentiality with the
provision of, or referral to, post-test support and services considered crucial.
ii
WHO uses the term "HIV testing and counseling". In this review, the order is reversed as "HIV counseling and testing"
to highlight the importance of counseling and to put the steps in the preferred order.
21
3.2.4 Components of HIV counseling and testing

HIV counseling and testing is more than just the provision of counseling and testing services. A
comprehensive package of components for HIV counseling and testing includes40:
policy, advocacy and stakeholder mobilization
community mobilization
supply and management of commodities
service delivery
capacity building and training
management and coordination
costs and financing.
3.2.5 Impact of HIV counseling and testing

Many studies have now been done to assess the feasibility and effectiveness of HIV counseling
and testing, particularly VCT. There is now consensus regarding the efficacy and costeffectiveness of VCT interventions for HIV prevention and care42. Among adults in developing
countries, there have been significant behaviour changes in terms of increased condom use,
reduced number of sexual partners and reduced STI incidence. In many of these studies the
sample includes youth, but data has not been disaggregated. So, while it is probable that youth
do reduce risk behaviour as a result of having VCT, there is a need to study youth sub-groups to
reach a more definite conclusion43. There is a low uptake of VCT by youth, and an important
intervention is therefore encouraging youth to utilize VCT.
Violence against women may result from disclosure of HIV status following HIV counseling and
testing, and is therefore of particular relevance to this literature review. HIV counseling and
testing promotes the importance of HIV status disclosure, particularly to the sexual partners of
those testing positive. This has many individual and public health benefits: disclosure may
22
motivate partners to seek testing, change behaviour and ultimately reduce transmission; it
provides increased opportunities for social support; improved access to medical care, including
antiretroviral therapy; and increased opportunities to discuss and implement risk reduction with
partners and plan for the future. However there are some potential risks for the individual,
including loss of economic support, blame, abandonment, physical and emotional abuse,
discrimination, and disruption of family relationships.
A detailed review of the impact of disclosure of HIV status by WHO44 found that:
rates of disclosure in developing countries were notably lower than rates in
developed countries
larger proportions of studies in developing countries reported women that did not
share results with anyone (10-78%), compared to women in developed countries (310%)
the most common barriers to disclosure were fear of abandonment, loss of economic
support from partners, rejection/discrimination, violence and accusations of infidelity
motivating factors for disclosure were a sense of ethical responsibility for the
partner's health and the need for social support to cope with the diagnosis
the outcomes of HIV status disclosure were generally positive in both developed and
developing countries, but the review noted that those who chose not to disclose may
be those more likely to have negative outcomes.
The key relevant recommendations from this study were:
develop and test different models of VCT to ensure that people, particularly women,
are not put at risk
assess issues of disclosure among youth, including injecting drug users
develop effective ways to involve men in HIV counseling and testing and promote
couples' counseling
develop '"screening tools" to help counselors identify women least likely to disclose
and most likely to experience negative outcomes from disclosure
assess whether community-based stigma reduction interventions increase uptake of
HIV testing and disclosure rates
test models to incorporate interventions to address violence against women in HIV
counseling and testing settings
consider cross-training of HIV and domestic violence staff and promote referral
between these services
consider culturally appropriate mediated forms of disclosure, for example through the
counselor or a trusted family member or friend.
3.2.6 Lessons learned from international experience in HIV counseling and

testing
Many lessons have been learned from international experience with HIV counseling and testing.
For this literature review, the following lessons have been selected from VCT experiences in subSaharan Africa as being relevant to the situation in Cambodia, Myanmar and Viet Nam45.
the partners of clients require encouragement to utilize VCT services
there is increasing emphasis on VCT for couples
community outreach strongly influences VCT service utilization
additional VCT staff can be required to complement existing health staff
lay counselors can make a significant contribution
health workers should be prepared for the increased workload of VCT in integrated
settings
training of all health workers is recommended in clinics where VCT is introduced
the overall quality of counseling in other clinical settings is improved in clinics
following the introduction of VCT
23
referral to peer-support networks can help HIV+ persons come to terms with their
status
it is important to involve the community in the development of new services
sustainable funding for VCT services must be ensured.
3.2.7 Training resources for HIV counseling and testing

There are well developed, tried and tested resources available from international organizations to
support HIV counseling and testing services. Some of these training packages have been
adapted to the specific needs of various countries. Two key resources are summarized here.
WHO Voluntary Counseling and Testing Manual for Training of Trainers46. This Manual
comprises two Parts with a total of six modules covering:
basic Information on HIV/AIDS and HIV counseling and testing
basic counseling techniques
counseling for specific target groups, including injecting drug users, sex workers,
youth and children, men who have sex with men, prevention of mother-child
transmission, and mobile and prison populations
counseling and care, including antiretroviral treatment
VCT service delivery and program management. In particular, Sub-Module 2 deals
with Models of VCT service delivery; Sub-Module 6 with Monitoring and Evaluation;
and Sub-Module 7 with Counselor records and data management
Adult learning, training and presentation skills and a range of related issues.
In addition, WHO have produced a toolkit for HIV counseling and testing which includes a
detailed annotated bibliography of peer reviewed resources40.
Family Health International (FHI) have also produced a Voluntary Counseling and Testing Toolkit
comprising the following components:
Voluntary Counseling and Testing for HIV: a strategic framework42
A Guide to Establishing Voluntary Counseling and Testing Services for HIV47. This
short Manual describes three phases of assessment, design and implementation with
details for each phase divided into the national level and the district/ facility leveliii.
Skills Training Curriculum: Facilitator's Guide and Participant's Manual48, 49. These
complementary Manuals provide a curriculum for 27 training sessions covering core
skills, practicum and advanced skills.
Voluntary Counseling and Testing and Young People: a summary overview50. This
Manual discusses the relevance of VCT to young people (defined as 15-24 years)
and stresses that the diversity among young people means that appropriate service
models are needed, but that there is no ideal model.
Trainer's Manual: Counseling Supervision and Training51. The purpose of this
Manual is to train counseling supervisors to supervise other counselors, provide
emotional support and guide professional development. Of the 10 modules, there is
one focusing on ethical issues, another on stress management with a field-based
practicum.
Commodity Management in VCT Programs: a planning guide52. This Manual provides
practical guidance on commodity management for VCT. There is a detailed list of all
commodities required for VCT and steps for selection, procurement, distribution and
use of these commodities. Key issues addressed include any national policies and
legal frameworks, financing, management information system, human resources,
monitoring and evaluation, quality assurance and scale-up and linkages to other
prevention and care services. An Appendix provides details on the quantification of
HIV test kit requirements.
iii
This Manual was a key reference document for the Marie Stopes Mekong VCT Project Proposal as the national level
situation analysis outline described in this Manual is reproduced in the Project Proposal.
24
A Reference Guide for Counselors and Trainers53. This Manual contains 11 chapters
covering a wide range of HIV/AIDS issues in relation to counseling and testing.
Chapter 2 discusses various HIV testing strategies and protocols, types of HIV tests,
the interpretation of HIV tests and confidentiality.
Counseling and Testing for Youth: a manual for providers54. This Manual covers most
aspects of HIV counseling, but with a focus on youth.
3.3 HIV Counseling and Testing Service Models

3.3.1 Types of HIV counseling and testing service models
The international literature refers to a number of different characteristics that have been used to
define different types of HIV counseling and testing service models.
Client-initiated or provider-initiated
The primary model for HIV testing in many low and middle income countries has been clientinitiated voluntary counseling and testing services. However, there is increasing promotion of
provider-initiated approaches to HIV counseling and testing in clinical settings41.
Opting in or Opting out
Clients may "opt-in" for HIV testing after giving informed consent and making a specific request
for a HIV test. This closely corresponds to the client-initiated VCT model noted above.
Alternatively, clients may be given the opportunity to "opt-out" when a HIV test is part of a
standard package of care, particularly in the setting of antenatal care. The client must still be
given information on HIV testing, including risks and benefits, but is told that a HIV test will be
done along with other tests and that she/he has the right to refuse this test. Usually a signed
statement of refusal is required. Opt-out strategies usually have a higher percentage of clients
accepting tests. However, the decision about whether clients can opt-in or opt-out is mostly
determined by government policy in individual countries.
Site location and management
Service delivery models are also commonly classified by site location and management47. There
are a number of different VCT service models that have been used to date which are briefly
described here.
Stand-alone or free-standing sites are usually separate from other medical
facilities with staff dedicated to VCT services. The advantages are that coverage
and quality are maximized, accessibility usually improved and linkages readily
made with support groups of PLHA. The sites are usually located in areas of high
population which limits geographical accessibility. Other disadvantages are that
medical follow-up may be difficult, the sites may initially been seen as
stigmatizing and there are high establishment and operating costs.
Integrated models are often found in public health care services, such as
hospitals, STI Clinics, Tuberculosis Clinics, Family Planning Clinics or Antenatal
Clinics. The advantages are that VCT is seen as part of general health care with
normalization of HIV/AIDS, health workers are directly involved in HIV prevention
activities, direct referral to other health providers is facilitated and there is a high
volume of potential clients and high potential for replication and scale-up
contributing to cost-effectiveness. Disadvantages are that the quality of other
services may be diluted and VCT quality itself may be lower, low motivation of
some public health sector staff, difficulty in achieving quality assurance, limited
management capacity, long waiting times and inconvenient hours of operation.
NGO models may be integrated or stand-alone. Benefits include improved
management, capacity to provide confidential VCT, more responsive waiting
times and clinic hours, and improved ability to ensure quality services. Donor
dependency and limited scale-up potential are some challenges.
25
Private Sector models can provide high quality services, are seen as private and
confidential and responsive to client needs, but with limited access to the poor.
For these models it may be more difficult to ensure national standards are
followed.
Public sector and NGO partnerships can build on the strengths of both these
models.
Mobile/ outreach VCT service models. There is currently limited international
experience of these models, most of which have operated as pilot activities. A
potential advantage is the ability to serve hard to reach groups, such as injecting
drug users and sex workers. However, these services are expensive and
confidentiality may be difficult to maintain.
Types of HIV testing based on methods to ensure confidentiality

Linked testing. Each blood sample is given an identifier (for example a Clinic
number) to link the sample to individual clients.
Linked anonymous testing. The client is given a unique number not linked to the
medical records but matched to the blood sample. The client must therefore
return to the Clinic and present the correct number to get the result. No record is
kept of clients, so there is no way to find a client if he/she does not return for
results.
Unlinked anonymous testing. This is often done on blood collected for other
reasons where all identifying features are removed so the results cannot be
traced to individual clients. No records are kept of clients. This method is usually
used to monitor HIV trends, for example during a national HIV Sentinel
Surveillance Survey53.
Types of HIV counseling and testing services provided
WHO uses the types of services provided to outline seven different HIV counseling and
testing service models40.
Model 1. Individual pre-test and post-test counseling and HIV testing (the classic
model used by most free-standing VCT sites)
Model 2. Group information, opt-in individual pre-test counseling and individual
post-test counseling
Model 3. Group information, opt-out individual testing, individual post-test
counseling for HIV+ persons with HIV negative persons informed of their status.
Model 4. Group information, opt-in couple/family pre-test counseling,
individual/couple/family post-test counseling (shared confidentiality model)
Model 5. No pre-test information, screening/testing (with possibility of opting out),
individual post-test counseling for HIV+ persons (for example, screening of STI
clinic attendees, drug treatment program attendees and women at antenatal
clinics)
Model 6. Mandatory HIV testing
Model 7.Counseling without testing.
VCT Service Models for Young People
There is no ideal model for VCT services for young people. A variety of models, including
variations on those listed above, have been proposed and tested. Models integrated into primary
health care, for example, youth-friendly corners in clinics, may be effective but young people are
often reluctant to attend formal health services. VCT services may also be integrated into school
and college health services, but there is very little experience of this approach from a developing
country context. VCT can be integrated with TB and Antiretroviral therapy services, but again,
this may not attract youth. Similarly, unless VCT services are truly "youth-friendly", integration
into clinics providing STI and family planning services may have low uptake. Youth centres for
counseling and testing have potential but may be limited by concerns of confidentiality, quality of
testing and adequate referral networks for HIV positive young people. Mobile services for hard-
26
to-reach-youth have limited experience in developing countries and are expensive. Private sector
VCT services can reach some youth, but pre-test counseling, informed consent and testing may
not be of adequate quality. Home testing is becoming available in some countries, but this not
VCT as such, and not a desirable model as results may be inaccurate or misinterpreted, pre-test
counseling not provided, and there is no referral mechanism to other services50.
Issues to consider in choosing models
Several key criteria help to decide the most appropriate service model(s) in the unique
epidemiological, behavioural and economic context of each country42, 47. These include:
program goals
choice of local authorities
target populations
level of stigma and discrimination in the community
management and administrative ease
potential for linkages
existing demand and likelihood of service utilization
equity issues
cost of the service model
cost-effectiveness of the service model
feasibility
ability to be replicated
sustainability
ethical and legal considerations (see below).
3.3.2 Ethical and legal considerations

Several important ethical and legal issues need to be considered in deciding on appropriate
service models. Some of these issues are covered in more detail in the discussions on Gender
Issues (3.1.3) and Human Rights and HIV/AIDS (3.1.4).
One important current debate relates to the global situation where there is inadequate scale-up of
VCT in the context of increased availability of treatment and care. Since persisting stigma is
believed to contribute to this low testing coverage, there have been suggestions to enforce testing
in more stringent ways than the current voluntary form so that care and treatment are more widely
used and stigma minimized. There is increasing reference to "routine" HIV testing, especially the
routine offer of a HIV test within health care services. There is a tension between this "public
health approach" and a "human rights" approach to testing. UNAIDS and WHO have concluded
that, in light of initiatives to scale-up HIV testing, "there must be a methodical human rights and
public health analysis of HIV counseling and testing55".
A related debate is the argument that it is not ethical to promote VCT if there are inadequate
treatment, care and support services available. In particular, any provider-initiated HIV testing
must ensure and promote referral to post-test counseling services for all those being tested and
to medical and psychological support for those testing positive41.
3.4 Integration of HIV Counseling and Testing into Sexual and

Reproductive Health Settings: international experience.
3.4.1 The rationale for providing integrated HIV counseling and testing
A review of the international literature on the integration of HIV counseling and testing into sexual
and reproductive health settings demonstrates a strong consensus that this approach is urgently
required and practical. To support advocacy efforts in obtaining approval for this approach to HIV
counseling and testing, a series of selected quotations from authoritative sources is presented.
27
"Central to making the "3 by 5"iv initiative work at the local level will be civil society
leadership and involvement with HIV testing. Community groupswould be involved in
all aspects of HIV testing, from education to providing the testing itself (in a secure,
friendly, non-judgmental environment). It makes more sense to invest in these
communities and their organizations to deliver because there is very little hope that
scaling up with a focus on government doctors and labs can take place in the short term.
It simply takes too long, is too expensive, and can not even begin to deal with the
numbers of people needing to access HIV testing and treatment services that currently
exist in the highly affected regions, much less will be able to scale up56".
"The time has now come to implement HIV counseling and testing more widely using
existing health care settings, moving beyond the model of provision that relies entirely
upon concerned individuals seeking out help for themselves to permit broader access for
all. In this new approach, such services will become a routine part of health care, for
example during attendance at antenatal clinics or at diagnosis and treatment
forsexually transmitted infectionsThese innovations cannot come quickly
enoughthe lost opportunities for providing care and for strengthening prevention efforts
are enormous57, 58".
"To achieve large scale implementation of HIV VCT, Family Health International supports
the notion espoused by WHO and other international organizations that it is critical to
move beyond the idea of VCT as a package always to be provided in the exact way in all
circumstances42".
"Yet, all too often, VCT has been introduced in isolation from services meeting people's
overall sexual and reproductive health needs59".
"VCT services may have to be general or targeted depending on a range of factors
including HIV prevalence, health-seeking behaviour, levels of stigma, access to hard to
reach groups and supportive legal and policy environmentFew services have been
developed to help young people in developing countries who are at increased
vulnerability to HIV/AIDS as a result of risk practice or experience" (italics in original)50.
"VCT initiatives have been slower to develop in Asiaand have not been adequately
prioritized in the past, resulting in a shortage of a broad range of good practice models
from the regionless attention has been given to developing models for integrated
community-based VCT programs" (p2). "In a relatively low prevalence setting such as
Asiaintegrating services could not be more important, particularly in the fight against
stigma and discrimination" (p4). "VCT is best placed and more likely to be a valuable
service if integrated and mainstreamed within existing community servicesit is
imperative that the test is accessible, available and suitable for specific client
populations" (p23-24)60.
The United States Agency for International Development (USAID) Regional Strategy for
Asia supports the expansion of VCT services through NGOs and community based
groups for vulnerable populations.
"Since it is especially difficult for those most at risk for HIV to access VCT in
government clinics and other institutions, it is especially important that NGOs and
other organizations that can reach MARPs [Most At Risk Population groups],
have the ability to provide VCT, or at least counseling with referral to testing"61.
iv
The 3 by 5 initiative is a program led by WHO to have 3 million People Living with HIV/AIDS on antiretroviral therapy by
the year 2005.
28
Family planning settings offer specific opportunities for reaching women with an
integrated VCT service, in particular:
this approach helps to meet the demand for knowing HIV status, as VCT services
are currently not available to many people, especially women, who want to know
their HIV status
VCT and Sexual and Reproductive Health (SRH) services have similar aims
integration makes it easier for some clients to use VCT servicesmany people
are not comfortable attending free-standing sites because of the stigma and
discrimination associated with HIV testing
this approach provides opportunities to reach young people, men and couples
groups who might not otherwise access VCT services
the costs of integration are lower because of the similarities between VCT and
SRH services lower start-up costs, minimal changes to existing infrastructure,
many service providers already with basic counseling skills, logistical
management systems for SRH services that can manage VCT commodities,
SRH service providers already familiar with referrals, and existing SRH outreach
can be expanded to include VCT promotion62.
3.4.2 Practical steps for integration

The International Planned Parenthood Federation (IPPF) has produced a practical stepwise guide
to integrating HIV counseling and testing services into SRH settings62. The steps are
summarized herev.
Analyse community needs.
What is the scale of the HIV/AIDS and STI in both the client population and the community? What
are the views of clients and the community on HIV/AIDS and VCT? What level of knowledge and
understanding? Is there interest in knowing HIV status? Will the community accept integrated
VCT services? What are the social, economic, cultural and political factors influencing rates of
HIV? What other HIV/AIDS and STI services are available? Will new services duplicate existing
services? Who uses the services now and what changes in clientele, if any, will result from
integrating VCT? One implication of integrating VCT into SRH settings may be that more male
clients attend the clinics. Each site therefore needs to be aware of, and assess, the implications
of this change in profile of the service users.
Assess organizational capacity.
Is the organization's mission and strategic plan supportive of integrated service provision?
Assess staff readiness and training needs, existing and required infrastructure and resources,
monitoring and evaluation resources and national laws or policies.
Operational assessment of integrated services.
What are the similarities and differences between existing services and VCT? Which
components of VCT can be delivered in the settings where the site offers services? Who should
the VCT services target? Which VCT services are appropriate to integrate into existing services?
What additional resources are needed to integrate VCT?
Special consideration needs to be given to youth. Barriers to VCT for young people include:
availability and acceptability of VCT services, including legal issues
waiting time
cost and pressure from health staff to notify partner(s)
worries about confidentiality fear that results may be shared with parents and
partners without consent
inaccurate risk perception
fear of being labeled, and stigma from family, friends and community
v
Appendices include checklists for counseling and testing and sample monitoring forms
29
perception of the consequences of living with HIV

inadequate response from health care providers to young people's HIV/AIDS related
needs50.
In response to these barriers, youth-friendly VCT services have been suggested as a way to
encourage youth to present for HIV testing with the opportunity to provide HIV prevention,
treatment, care and support education.
The components of VCT are more than pre-test counseling, testing and post-test counseling (see
3.2.4: Components of HIV counseling and testing). Each sexual and reproductive health service
site needs to decide which components of a comprehensive HIV counseling and testing service
are able to be integrated into existing clinic services, and which are best done by other groups or
organizations62.
3.5 HIV tests: Selection and Availability

3.5.1 Advantages of rapid tests
This section focuses on rapid tests for HIV which, at the field level, have largely replaced the
ELISA test (enzyme linked immunosorbent assay) which requires a laboratory, skilled
technicians, equipment that needs to be maintained, disposable supplies, refrigeration and clean
water. Similarly, until recently, the most commonly used confirmatory test was the Western Blot
test, but this is very expensive, and in some conditions, has given a relatively large number of
indeterminate results63.
The following list of the advantages of rapid tests is complied from several references 42, 63, 64
feasibility
short time for results (10-30 minutes): clients informed of results at the same visit
accuracy with high sensitivity and specificity (>99%)
acceptability of HIV testing to clients
decentralization of HIV counseling and testing
low cost: mostly <$US1.00 for initial screening
ease of performance: minimal technical training for non-laboratory staff and few steps
ease of interpretation: visual interpretation without equipment and a stable endreading point
flexibility in number of tests performed
reduction in occupational risk from finger-prick specimen compared to venepuncture
little lab equipment required
no constant electricity or water supply required
easy to store: at room temperature for several weeks (provided there are no
significant temperature fluctuations) for many test kits
shelf life of 12 months or more
number of tests: can do individual or small volume testing (1-40 tests/day)
minimal waste and waste disposal
emerging technologies for testing urine and saliva.
3.5.2 Types of rapid tests

1. Particle Agglutination tests which needs serum or plasma and more staff training and
which can be more difficult to interpret if agglutination is weak.
2. Membrane Immunoconcentration (flow-through) tests where results are easy to
interpret and test kits have a built-in control site.
3. Immunochromatographic (lateral-flow) tests where results are also easy to interpret
and test kits have built-in control site64.
30
3.5.3 Selection of rapid test kits

While rapid tests have many advantages, the proliferation in the number of brands of test kits in
countries can lead to a lower overall quality of testing unless there are national HIV testing
guidelines, protocols and quality assurance mechanisms in place64.
In deciding which rapid test kit to use in a particular situation, the following criteria are
used 52, 63, 64
government recommendations (or, in the absence of this, WHO recommendations)
reliable data on sensitivity and specificity
availability of reliable pre-qualified supplies (approved by governments and/or WHO)
the need for any additional equipment and consumables
the need for any additional training for staff performing the tests
packaging (individually packaged or not), shelf-life and storage conditions
cost, which should not be the sole determining criteria. Prices can vary significantly
as new test kits are marketed. Hidden costs, such as equipment, reagents, training
for staff and consumables, must be considered. The quoted price should be
competitive within the region and internationally.
the ability for detect both HIV1 and HIV 2 may be important, or become important in
the near future in some countries.
type of specimen required: finger-prick or whole blood? HIV test kits for saliva are
already available and, when the cost per test is competitive with tests using blood,
they may become the test of choice in some settings.
The selection of rapid test kits also depends on whether parallel or serial testing protocols are
followed. Serial testing is currently recommended by the WHO. All clients are tested with one
rapid HIV test, and, if this test is positive, a second and different type of rapid test is used to
confirm the result. For discordant results, a third, different rapid test is again recommended. In
parallel testing all clients are tested using two different rapid tests at the same time (in parallel).
For discordant results a third rapid test is used as a tiebreaker42 (p16 of this reference has a
detailed Table of Pros and Cons of the two protocols).
A useful objective resource to help choose a rapid test kit is the WHO HIV Assays: Operational
Characteristics Report 14, which provides a cumulative list of assays evaluated and currently
commercially available65. In addition, the following website gives links to the websites of
individual manufacturers of rapid tests: www.rapid-diagnostics.org/rti-hiv-com.htm 66.
3.5.4 Quantification and availability of rapid test kits

There are several resources that give guidance to calculating the requirements for the number of
HIV test kits and related commodities for specific programs. These resources are especially
relevant during any scale-up phase where increased commodities, including test kits, will be
required52, 67.
The WHO Bulk Procurement Scheme68 is a further useful resource. This Scheme was
established 1998 to facilitate access to high quality test kits, all evaluated by WHO, at low cost
through an easy purchase procedure. The Scheme provides additional information and
assistance to ensure chosen kits will be appropriate for the conditions in which they will be used,
and supports National AIDS programs, blood transfusion services, UN agencies, NGOs and
donor supported HIV/AIDS projects. WHO negotiates prices directly with manufacturers which
results in per test costs approximately half the open market prices. Requests are accepted in
three categories.
A WHO programmes and UN agencies
B WHO member states and NGOs in official relations with WHO and
C - other clients.
31
3.6 Monitoring and Evaluation of HIV Counseling and Testing

Services
This section presents a very brief overview of monitoring and evaluation with further details given
with each country's national situation analysis. There are two main areas for monitoring and
evaluation69:
1. Service delivery (how well the VCT services are provided, including both counseling and
testing services) which is usually assessed through:
counseling protocol adequacy
testing protocol adequacy (on site audits with standard checklists, proficiency
testing or external quality assessment and blinded re-checking)
staff performance
service assessment and barriers: travel time, public transport, cost to receive
services, who is being reached and not being reached
service use: who uses the services, client numbers, reasons for seeking service.
2. Program effectiveness (outcomes and impacts of VCT on the population receiving services)
Outcome indicators measure the extent to which VCT has encouraged behaviour
change among clients and partners, changes in STI rates as a biological proxy
indicator for adopting preventive behaviours, and reduced stigma and
discrimination.
Impact indicators measure the rate of HIV transmission, including mother-to-child
transmission of HIV.
There are a number of international resources with detailed indicators and tools for monitoring
and evaluation the whole spectrum of HIV/AIDS. These references also contain indicators
specific for monitoring and evaluating HIV counseling and testing 6, 7, 63, 69, 70.
32
4. MEKONG REGION OVERVIEW OF HIV/AIDS: FOCUS ON

CAMBODIA, MYANMAR AND VIET NAM
This section aims to fill any important gaps between the global review above and the countryspecific situation analyses that follow. There is some inconsistency in defining the word "Region",
with most authorities including Myanmar, Cambodia and Viet Nam in South East Asia (or a
combined South and South East Asia Region). However, the WHO coverage areas place
Myanmar in the South East Asia Region, and Cambodia and Viet Nam in the Asia and Pacific
Region. The Greater Mekong Sub-Region is also sometimes used, referring to Myanmar,
Thailand, Laos, southern China, Cambodia and Viet Nam. Much of the global overview above
applies directly to this regional overview and is not repeated here. Many of the documents
covering the Region also give country specific information, which is presented and discussed in
the country-specific sections that follow.
The following Table shows selected key indicators for Cambodia, Myanmar and Viet Nam using
the most recent available data. The data does not show trends within each country, and for
HIV/AIDS, such trends are detailed in each country-specific section. While the Table allows
some comparison between the three countries, this should be done with care, as some data are
from different years and using different survey methodologies. The key reference sources are
given at the end of the Table, but these are mostly secondary reference sources which give full
details of the primary sources.
33
4.1 Key Indicators for Cambodia, Myanmar and Viet Nam

Indicator
Demographic Indicators
Total population (1)(4)
Population under 15 (2)
Annual population growth rate, 1990-2004 (1)
Total Fertility Rate (1)
Urban population (1)
Maternal mortality ratio/ 100000 live births, 2000
adjusted (1)vi
Infant Mortality Rate/ 1000 live births (1)
Under 5 child mortality rate/ 1000 live births (1)
Life expectancy at birth (years) (1)
HDI rank (2)
Gender related development index rank (2)
Human Poverty Index rank (2)
Total adult literacy rate (1)
Adult female literacy rate (1)
Population using improved drinking water
sources, 2002 (1)
Parliament seats held by women, 2002 (2)
Economic
Per capita Goss National Income (1)
Per capita total health expenditure, 2002 (2)
Population living on less than $US1 per day,
1993-2003 (1)
HIV/AIDS specific (3)
Adult HIV prevalence, 2003
Total population with HIV/AIDS, 2003
HIV prevalence in female commercial sex
workers, 2003, 2004, 2004
HIV prevalence in injecting drug users, 2004
HIV prevalence in women in antenatal clinics,
2003, 2004, 2004
Number of people on ART, 2005, 2005, 2004
Adult TB cases that are HIV+, 2003, 2003, 2002
Health specific indicators
Contraceptive prevalence rate, 1996-2004 (1)
Births with skilled birth attendant, 1996-2004 (1)
Pregnant women receiving antenatal care (1)
Children under 5 moderate underweight (for
age), 1996-2004 (1)
Cambodia
Myanmar
Viet Nam
13,798,000
38%
2.5%
4.1
19%
450
52,170,000
31%
1.5%
2.3
30%
360
83,123,000
31%
1.6%
2.3
26%
130
97
140
56
76
106
61
17
23
71
130
99
81
74%
64%
34%
129
50
90%
86%
80%
108
83
47
90%
87%
73%
10.9%
na
27.3%
$US 320
$US 192
34%
$US 220
$US 30
-
$US 550
$US 148
<2%
1.9%
123,000
20.8%
1.2%
[0.6-2.2]
330,000
27.5%
0.4%
[0.2-0.8]
220,000
4.4%
not known
2.2%
34.4%
1.8%
29.3%
0.35%
10,000
11.8%
955
6.8%
1,000+
1.8-3.0%
24%
32%
38%
45%
34%
57%
76%
32%
79%
85%
86%
28%
(1) UNICEF website www.unicef.org/ accessed 20 December 2005. Unless indicated, data is for 2004.
71
(2) Human Development Indicators, 2005 from http://hdr.undp.org/reports/global/pdf/HR05_HDI.pdf (HDI
is a composite measure of longevity, educational attainment and standard of living). (3) HIV/AIDS data from
most recent national sources: see country-specific Sections 5, 6 and 7. (4) Statistical Year Book 2003,
Central Statistical Organisation, Yangon, Myanmar which states the Annual Population growth rate to be
2.02%.
vi
The unadjusted MMR for Cambodia is 437, based on the Cambodian Demographic and Health Survey 2000 and widely
cited in national and international references. This table shows the adjusted MMR for all three countries from the UNICEF
website.
34
4.2 Regional Overview of HIV/AIDS Epidemiology

"With almost half the world's population, Asia will determine the future of the global HIV/AIDS
pandemic"72. The reason for this statement is that, while the Asia region does not have the high
HIV prevalence rates of sub-Saharan African countries, because of the huge populations in India
and China, even low prevalence translates into large numbers of people living with HIV/AIDS.
____________________________________________________________
HIV/AIDS in Asia, in 2003 and 20052
2003
2005
Adult prevalence (%)
0.4
0.4
Adults and children living with HIV
7.1 million
8.3 million
Number of women living with HIV
1.7 million
2.0 million
Adults and children newly infected with HIV
940,000
1.1 million
Adult and child deaths due to AIDS
420,000
520,000
_____________________________________________________________
For South and South East Asia, there were estimated to be 7.4 million [4.5-11.0] adults and
children with HIV/AIDS in 2005 of which 1.9 million [1.1-2.8] were women. In 2005, 990,000
[480,000-2.4 million] adults and children were newly infected with HIV and there were 480,000
[290,000-740,000] deaths from AIDS2.
Asia shows extreme diversity in its HIV epidemics, both geographically and temporally73. Five
different epidemic types are described for Asia74:
1. Recent sharp rises in HIV among people with identified risky behaviour (injecting
drug users, men who have sex with men, sex workers and their clients): in parts
of China, Indonesia and Viet Nam
2. Continued high prevalence that seeps into the lower-risk segments of the
population: in parts of India and in Myanmar
3. Massive preventive efforts addressing risk behaviour and bringing the epidemic
under control: in Thailand and Cambodia
4. Low prevalence with some prevention success and great prevention
opportunities: in Bangladesh, Pakistan, Sri Lanka, Laos, the Philippines and East
Timor
5. A sub-Saharan pattern in the Pacific region, especially in Papua New Guinea.
One of the most important factors determining the severity of these Asian epidemics is the size of
the adult male population visiting sex workers and the number of sex worker clients per night.
This hypothesis has been proposed and accurately modeled by Chin and colleagues (cited by
Ruxrungtham, Brown and Phanuphak, 200473). The nature of these different epidemics is
depicted in the following two diagrams75. The first shows the typical, or historical, pattern of the
HIV epidemic by the population groups experiencing the highest rates of infection. The second
shows where countries in the Region are currently placed on this epidemic curve, with Cambodia,
Myanmar and Viet Nam highlighted in black.
The most important contributing factors fueling these multiple HIV epidemics are: poverty; other
sexually transmitted infections; the sex industry; human trafficking and sexual exploitation;
mobility within and between countries; stigma and discrimination; the vulnerability of women;
substance use as a precursor to injecting drug use and other high risk behaviours; and alternative
sexualities such as transgender and men who have sex with both males and females76. In all
countries in the region, the major risk behaviour groups (sex workers, injecting drug uses and
men who have sex with men) are characterized by social marginalization and engagement in
socially unacceptable and often illegal behaviours77. Further, these groups overlap, particularly in
the case of sex workers who also inject drugs. Mobile population groups in the region include
seasonal agricultural workers, fishermen, truck drivers, construction workers, uniformed
personnel, refugees and other displaced groups, sex workers, businesspeople and tourists76.
35
A familiar pattern emerging need to prioritise and scale

160000
New HIV infections

(number of people)
140000
50% Spouse
SW 15%
IDU 20%
MTCT 15%
120000
100000
90% SW
Spouse 5%
IDU 5%
80000
60000
40000
20000
70% IDU
SW 26 %
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
Year
UN Theme Group 2002
A familiar pattern emerging need to prioritise and scale

India, China,
Nepal, Vietnam
Myanmar,
Malaysia,
Indonesia,
Lao, Philippines,
Bangladesh,
Pakistan,
Afghanistan,
Bhutan, Maldives
Cambodia,
Thailand
Year
Source: Thai Working Group on HIV/AIDS Projections, 2001)
36
4.3 Regional Impact of HIV/AIDS and Responses

The broad impact of HIV/AIDS on people and the environment listed in Section 3.1.2 applies
directly to the Asian region. The impact is and will be particularly evident in the region in the
clinical burden of HIV infection; pediatric AIDS and maternal AIDS orphans; the HIV/ TB coepidemic; and AIDS deaths and HIV care, including antiretroviral therapy77. The Mekong Region
contains five of the 22 high tuberculosis prevalence countries in the world: Cambodia, Myanmar,
Viet Nam, China and Thailand. Cambodia and Thailand are already experiencing an increased
TB epidemic due to HIV. Many regional organizations are responding to HIV/AIDS, and four
representative examples are presented here.
The WHO South East Asia Strategic Framework (2002-2006)78
This framework has the following objectives:
1. To prevent HIV transmission by promoting healthy life styles and interventions for
disease prevention (listed as safer sex, including condoms, prevention and treatment
of other STIs, PMTCT and preventing HIV transmission through injecting drug use)
2. To improve the quality of life of PLHA through treatment and care, including VCT,
psychosocial support, treatment of HIV/AIDS related disease and, where possible,
antiretroviral therapy
3. To alleviate the impact of HIV/AIDS on individual households and local communities
by adopting enabling health sector policies and institutional environments as part of
wider social and economic development policies.
The main strategies of this Framework mention the need to improve access to VCT services for
pregnant women and to establish special VCT services for pregnant women for PMTCT. VCT is
recognized as an entry point for care interventions. The Framework commits WHO to work to
establish and expand VCT services, to train human resources for VCT services and to provide
guidelines for VCT introduction and implementation.
United States Agency for International Development (USAID)
In June 2003, USAID opened a Regional Development Mission for Asia in Bangkok with a
HIV/AIDS and Health Office to draft a HIV/AIDS Strategic Plan for the Greater Mekong Region61.
This includes Burmavii, Laos, Viet Nam, Thailand, and Yunnan and Guangxi Provinces in the
south of China. Cambodia, as a USAID Rapid Scale-Up country, has its own bilateral USAID
mission, but is included in the regional activities. The Strategy focuses on Most At Risk
Population groups (MARPs): injecting drug users, men who have sex with men, male and female
sex workers, clients of sex workers, migrant and mobile populations, people living with HIV/AIDS,
ethnic minorities and hill tribes and youth in high prevalence groups. The strategy supports the
expansion of VCT services through NGOs and community based groups for these vulnerable
populations.
Stressing the multi-sectoral response needed to address HIV/AIDS in the Region, the Asian
Development Bank (ADB) has stated that its role is to build on its comparative strengths in the
interaction of HIV/AIDS with economic development and poverty alleviation. The ADB priorities
are for leadership support, capacity building and targeting programs to expand HIV/AIDS
interventions that mitigate risk among poor, vulnerable and high-risk groups79. The ADB supports
the increased availability and use of VCT services. UNAIDS and ADB have produced costing
guidelines to estimate resource needs for scaling up responses to HIV/AIDS in the Asia Pacific
Region80. This document notes that financial and human resources are major barriers for scaleup of VCT interventions and gives details for costing VCT services, including behaviour change,
commodities and services, program management and monitoring and evaluation (p34-35). The
report notes that at the start of service provision, the demand may be low and unit costs therefore
vii
United States government documents usually use the former country name of Burma in preference to Myanmar.
37
high. The variables that have the greatest impact on unit costs are: the number of counselors
and their remuneration; number of clients counseled; whether the VCT service is delivered in a
free-standing facility or integrated into existing structures; and program management.
CARE International
CARE International, a major international NGO, has a Regional Strategy for the Asia Region
(2003) with four strategic objectives which aim to reduce the vulnerability of mobile populations;
reduce the vulnerability of sex workers; promote meaningful involvement of PLHA; and promote
recognition of IDUs as stakeholders in policy and program development. The strategy has an
intentional gender and human rights based focus81.
4.4 Gender and Human Rights Issues in the Regional Response

to HIV/AIDS
The United Nationals Population Fund (UNFPA) notes that while there has been significant
progress in reproductive health in the Region there remain challenges to be faced in many
countries. These include high maternal mortality and population growth rates; persisting gender
inequity, gender based violence and human trafficking; extreme poverty; illiteracy, especially for
women and girls; and a rising HIV incidence82. Key factors in the spread of HIV/AIDS among
young women in the Asia Pacific Region are identified as poverty, early marriage, trafficking, sex
work, migration, lack of education and gender discrimination and violence9.
In addition to the discussion on Human Rights in Section 3.1.4, the United Nations Office of the
High Commissioner for Human Rights (UNOHCHR) and UNAIDS have published specific
recommendations on integrating human rights into HIV/AIDS responses in the Asia-Pacific
Region83. Specific issues for PLHA are to support the Greater Involvement of People with
HIV/AIDS (GIPA) principle, freedom of movement and the right to privacy in personal
relationships. Specific issues to promote human rights among vulnerable populations are also
detailed for injecting drug users, sex workers, women, youth/children, men who have sex with
men (MSM), prisoners and mobile populations. The document also recommends that human
rights can and should be integrated into various sectoral responses to HIV/AIDS, with the health
sector recommendations noting the need to expand access to VCT for vulnerable populations.
4.5 Regional Overview of HIV Prevention

The Global Working Group on HIV prevention report, cited in Section 3.1.5 above, also provides
data on gaps in prevention services for the combined South and South East Asia region17. The
report notes that the key population groups for prevention are women, sex workers, MSM, young
people and migrant populations. Key findings are presented here:
behavioural interventions currently reach only 5% of sex workers, 3% of out-of-school
youth and 10% of MSM
condoms are accessible to only 24% of people who need them in the Region
harm reduction programs are available for only 10% of injecting drug users
STD services are available to only 14% of those who need them
PMTCT services are accessible for only 3-6% of [pregnant] women
safe medical injection is available for 20% of people, but less than 20% of health care
settings adhere to universal precautions
broad based HIV awareness programs delivered by the mass media are received by
22% of people at risk
VCT services are accessible to 69% of people in South and South East Asia who
want to learn their HIV sero-status
38
4.6 Young People and HIV/AIDS: Injecting Drug Use in the

Region
Molecular epidemiology has been helpful in mapping the spread of different HIV sub-types along
heroin routes in Asia. This reveals a diversity of mixing of subtypes and highlights the need for a
regional response to the movement of drugs73. There are a number of comprehensive reviews of
drug use and HIV vulnerability in Asia, although, as the situation is rapidly evolving, up-to-date
data is required to plan timely responses84, 85, 86, 87. The estimated number of Injecting Drug
Users (IDUs) in the Region in 2003 was between 2 to 4 million, of which 750,000 were HIV
positive. This was projected to increase to over 2 million IDUs and their sexual partners by 2010
and fuel generalized epidemics in the non-drug using population77.
Re-visiting the Hidden Epidemic87 is a rapid situation assessment conducted in 2001 to follow-up
a similar study in 1997. Key findings were:
Myanmar was the second largest global producer of illicit opium and heroin in 2001
(after Afghanistan)
while heroin and opium use continued, use of methamphetamine had skyrocketed,
becoming the drug of choice in some countries (including Cambodia)
use of ecstasy was growing in popularity
injecting drug use appeared to be increasing, with the use of professional injectors in
Viet Nam and Myanmar noted with concern
the estimated number of drug users and injectors were both increasing
the confirmed number of cases of HIV infection and AIDS was increasing in drug
users, with high prevalence rates in IDUs in Myanmar and Viet Nam
the majority of drug users were male, but there were increasing numbers of Asian
women using drugs, including sex workers
the age of initiation into drug use was becoming lower
there were insufficient treatment and rehabilitation centres in most countries
treatment recidivism (relapse) rates were between 70-90%.
A review using 1999 data from China, India, Malaysia, Myanmar, Nepal, Thailand and Viet Nam
concluded that overall there were many serious legal and political barriers to the implementation
of effective prevention interventions for HIV among IDUs, with most national drug policies paying
little attention to HIV prevention84. Harm reduction programs were limited by the illegal status of
drug use. However, there have been successful interventions and, in 2001, UNAIDS published a
review of a series of case studies highlighting some successes in the prevention of HIV/AIDS
among drug users in Asia85. The range of interventions included community based responses,
care and support, outreach, substitution therapy and advocacy. One case report among street
children in Cambodia is described in the Cambodia country section that follows. An additional
useful resource is the Manual for Reducing Drug Related Harm in Asia86 which contains a section
covering VCT in general, but with additional guidance for counselors on addressing drug related
issues (p274-293).
39
5. CAMBODIA SITUATION ANALYSIS

5.1 Key Indicators and Introduction for Cambodia
Indicator
Total population (1)
Maternal mortality ratio/ 100000 live births, 2000 adjusted (1)viii
HDI rank (2)
Population using improved drinking water sources, 2002 (1)
Economic
Population living on less than $US1 per day, 1993-2003 (1)
HIV prevalence in female commercial sex workers, 2003
HIV prevalence in injecting drug users
HIV prevalence in women in antenatal clinics, 2003
Number of people on ART, 2005
Adult TB cases that are HIV+, 2003
Children under 5 moderate underweight (for age), 1996-2004 (1)
13,798,000
38%
2.5%
4.1
19%
450
97
140
56
130
99
81
74%
64%
34%
10.9%
$US 320
$US 192
34%
1.9%
123,000
20.8%
not known
2.2%
10,000
11.8%
24%
32%
38%
45%
(1) UNICEF, unless indicated, data is for 2004. (2) Human Development Indicators, 2005
(3) HIV/AIDS data from most recent national sources
There is a large and growing literature related to HIV/AIDS in Cambodia. Much of this is countryspecific, but reference to HIV/AIDS in Cambodia is also found in many regional and international
articles and publications. All this literature can be broadly classified into two main categories.
The first are primary source documents, studies, articles and other publications. The second are
review or summary documents which bring together many of the primary sources. This Section
of the literature review uses both categories: key review articles are summarized and additional
viii
The unadjusted MMR is 437 and is based on the Cambodian Demographic and Health Survey 2000 and widely cited in
national and international references. This table shows the adjusted MMR for Cambodia from the UNICEF website.
40
details on relevant issues, especially for HIV counseling and testing, are provided from the
primary sources. There are two key review publications that have been extensively used for this
Cambodia country-specific section:
The UNAIDS Country Profile: an overview of the HIV/AIDS/STI Situation and the
National Response in Cambodia, 5th Edition, December 200488. Several sections of
this document are now out-of-date and this literature review provides updated
information, where available.
The National AIDS Authority, National Strategic Plan for a Comprehensive and
Multisectoral Response to HIV/AIDS 2006-2010 which was released in November
200589.
At the time of completing this review (January 2006), an important document was in the process
of being finalized: Scaling Up Voluntary Counseling and Testing Services: lessons learned from
Cambodia, prepared on behalf of UNICEF90. This will be an additional key reference for the
Marie Stopes Mekong Regional VCT Project.
In addition to a review of publications and reports, a total of eight Key Informant Interviews (KII)
were conducted with representatives from the government, International Organisations and
NGOs in Cambodia. A further three less structured meetings were held with representatives of
three other organizations, prior to the development of the KII questionnaire (Annex 2).
The key issues related to HIV/AIDS in Cambodia that were identified by the Key Informants were
as follows (in no particular order):
the Cambodian government has demonstrated continuing high political commitment
to addressing HIV/AIDS, reflected in a strong health sector response with increased
regulation and coordination with International Organisations (IOs) and NGOs.
there have been significant changes in awareness of HIV/AIDS in Cambodia with
almost all people now having heard of HIV/AIDS
increased resources have allowed increased and expanded responses to HIV/AIDS
compared to limited resources in the past
there is now increased transmission from husband to wife and mother to child
possible epidemic among IDUs in the near future
need to intensify prevention among students and migrant workers
many people still don't speak openly about sexual matters, but there are signs of
positive changes in this practice
there is a need to increase motivation among community leaders, especially at the
commune level, to address HIV/AIDS in their communities
globalization, with related population mobility and changed economic circumstances,
has placed some population groups in Cambodia at increased risk of infection
condom use in non-commercial sexual relationships remains low due to issues
related to trust.
5.2 HIV/AIDS Epidemiology in Cambodia

A National HIV Sentinel Surveillance Survey (HSS) has been conducted in Cambodia every year
from 1995 to 2003, except for 2001. The 2003 HSS91 was conducted in 22 of the 24 Provinces/
Municipalities among Direct Sex Workers (DSW), Indirect Sex Workers (IDSW), police and
pregnant women attending antenatal clinics. The quality of these surveys has been consistently
high and Cambodia has been credited with having one of the most advanced surveillance
systems for HIV/AIDS among less developed countries.
41
For the 2003 HSS there were changes in quality assurance testing where samples from 1999 to
2003 were re-analysed to assess the rate of false positive and negative results. The prevalence
rates from these years were then retrospectively adjusted. The adjusted 2003 HSS results are
summarized here, together with trends from comparison with earlier HSS:
Direct Female Sex Workers 20.8%, with a consistent trend down from 42.8% in 1998
Indirect Female Sex Workers 11.7%, with a less marked but downward trend from
18.4% in 1998
Police 2.5%, reduced from a high of 4.5% in 1997
Antenatal women 2.2%, rising from 1.9% in 1996, leveling at 2.5% from 1998-2000,
then followed by a small reduction to 2.2% in 2003
The national prevalence for adults aged 15-49 years, using the adjusted methodology, was
calculated to be 1.9%, with a consistent reduction in prevalence from a high in 1997 of 3.0%
shown in the diagram below. This national prevalence decrease cannot be explained by
increased deaths from AIDS alone and therefore means that the incidence must be declining.
Estimated National HIV Prevalence among adults

15-49, 1995-2003, Cambodia
Percentage
3.5
3
2.5
2
1.5
1
2.9
3.0
2.8
2.7
2.5
2.1
2.2
2.1
1.9
2002
2003
0.5
0
1995
1996
1997
1998
1999
2000
2001
Year
Based on this HSS 2003 prevalence data, there were an estimated 123,000 PLHA in 2003
(65,600 men and 57,000 women). The proportion of female PLHA has been consistently
increasing to reach almost 50% in 2003. The estimated number of AIDS cases in 2004 was
19,814 (11,470 men and 8,344 women). These numbers represent a considerable reduction
from calculations using earlier unadjusted data. For example, the UNAIDS December 2004
Update92 uses data from the US Bureau of Census database which combines data from different
sources. At the end of 2003, it was estimated that 170,000 adults and children were living with
HIV/AIDS (51,000 women), with 15,000 AIDS deaths in 2003. The adult prevalence for 2002
using the unadjusted data was 2.6% [1.4-4.4], a figure widely quoted in many recent references.
The HSS provides province-specific data, but the sample size is too small for district level
analysis. In Cambodia, the highest HIV prevalence rates are found in the south-east and central
provinces and along the Thai border.
Using the Asian Epidemic Model and data from the 2002 HSS, transmission between married
couples now accounts for about half of all new infections, while about one-third are due to
mother-to-child transmission88.
42
5.2.2 Incidence of HIV infection in Cambodia

In 2004, a study was reported assessing the prevalence of recent infection among the different
sentinel groups using newly developed techniques to measure IgG BED-CEIA, a marker of early
infection and therefore an approximation of the incidence of HIV infection93. Specimens from
1999, 2000 and the 2002 HIV Sentinel Surveillance were sampled for all four sentinel groups.
The results were:
HIV Incidence estimates among sentinel populations 1999-2002
1999
2000
antenatal women
0.72
1.11
direct sex workers
13.9
9.02
indirect sex workers
5.08
5.08
police
1.74
1.30
2002
0.59
6.45
2.87
0.26
The conclusion was that there was a reduced incidence of HIV infection in all groups except
pregnant women attending antenatal clinics. This was considered to be consistent with reduced
transmission among the high risk population, but with more constant transmission among the
general population. Further recently published research by Saphonn et al (cited by UNAIDS2)
has shown that there has been a significant increase in HIV incidence among pregnant women
along the Thai-Cambodian border from 0.35% in 1999 to 1.48% in 2002.
5.2.3 National Behavioural Sentinel Surveillance and other national

Knowledge, Attitudes and Practices surveys
National Behavioural Sentinel Surveillance
Behavioural Sentinel Surveillance (BSS) provides specific year information on sociodemographic
characteristics and risk behaviours related to HIV/AIDS and STIs and monitors the sexual
behaviour of risk groups year to year to assess trends. BSS has been conducted since 1997,
mostly assessing the same high risk groups, but on alternate years medium or low risk groups
are included. The BSS 200394 report includes an assessment of trends in all BSS studies from
1997-2003. A separate report on sexual behaviour among urban sentinel groups was published
in 2003, based on BSS V data from 200195.
Key Findings from BSS 2003:
Female sentinel groups (DSW and IDSW)
Consistent condom use with partner
sweetheart
client
Beer girls
65.8%
81.7%
Karaoke workers
41.7%
81.0%
Direct sex worker
55.6%
95.1%
Trust in the relationship was the main reason for not using condoms with sweethearts for
all three sub-groups.
Last HIV test
VCT
Private clinic/lab
Public clinic
Beer girls
32.5%
32.1%
35.3%
Karaoke workers
51.0%
33.9%
15.8%
Direct sex worker
51.0%
22.3%
25.4%
(Note: many VCT centres in Cambodia are located in public health facilities)
There were high levels of abnormal vaginal discharge in the last 12 months (31.4% for
karaoke workers, 43.6% for DSW and 47.4% for beer girls). Drug use was low but 7% of
the DSW and 2.9% of the karaoke workers had used yama (amphetamines).
43
Male sentinel groups

First sexual partner
wife
DFSW
sweetheart
Military
33.4%
34.8%
28.8%
Police
42.7%
22.7%
31.5%
Moto-taxi driver
43.6%
26.9%
27.8%
A high proportion in all three groups (range 65.5 to 78.5%) had ever had sex with a
sweetheart, but a lower proportion had a sweetheart in the last year (range 7.2 to 11.1%).
A higher proportion of younger men had sex with a sex worker in the last year: 68.2% of
20-24 year military personnel had sex with a sex worker (and 49.9% in the last month).
Overall percentages of the sample who had sex with a direct sex worker in the last year
were: 37.5% for the military, 24.4% for police and 31.6% for moto-taxi drivers.
Consistent condom use with direct sex workers in last 3 months were high (between 88.9
to 95.5%) for all three groups but low for sex with a sweetheart (between 26.4 to 37.6%).
The main reasons for not using condoms with sweethearts were trust with a "virgin" and
being "extremely in love" (a common reason for military personnel). There was a low
proportion of urethral discharge in the last year for all three groups (2.3 to 4.3%).
Reported drug use was low: 8.4% of motor-taxi drivers had used marijuana and 3.4%
used yama; while 5.7% of the combined military and police sample had used marijuana
and 1.4% had used yama.
Last HIV test
VCT
Private clinic/lab
Public
Military
30.7%
20.5%
46.8%
Police
10.7%
19.7%
67.2%
Moto-taxi driver
12.2%
31.7%
54.3%
(Note: many VCT centres in Cambodia are located in public health facilities)
BSS Trends 1997-2003
DSW and IDSW are mobile populations and changes between the two categories
are common
there is increased consistent condom use with clients by DSW (42% in 1997 to
96% in 2003) and beer girls (14.8% in 1997 to 84.4% in 2003)
STI care seeking at public facilities/ STD clinics increased for both DSW and
beer girls
HIV testing at VCT increased for DSW (from 13.7% in 1997 to 56.3% in 2003)
and beer girls (10.7% in 1997 to 48% in 2003)
consistent condom use with sex workers in the last three months increased for all
3 male sentinel groups
commercial sex in the past year decreased for all three male sentinel groups
from 1997 to 2001, but there was a small increase in 2003
there was some increase in consistent condom use with sweethearts from 1997
to 2003, but the rate of use is much lower than for sex with DSW
HIV testing at VCT has increased for military personnel and moto-taxi drivers but
is still the least reported site for having the last HIV test for male sentinel groups.
Household males in BSSIV 2000
The BSSIV in 200096 included household males for the first and only time to date as a
sentinel group. Household males aged 15-49 years in the five BSS Provinces were
sampled with results disaggregated for rural and urban areas. Key findings were:
66.6% had ever had a sweetheart with 9.2% having a sweetheart in the last year
40.1% of those who ever had a sweetheart had sex with the sweetheart
there were low levels of drug use but regular alcohol consumption was high
44
12.8% of the men had more than one sex partner in the last year
13% had sex with a sex worker in the last year.
men, both urban and rural, who traveled away from home for more than one
month in total in the last year were more likely to purchase sex
consistent condom use in the last three months with a DSW was 70.1% for rural
men and 81% for urban men, while with a sweetheart, the rates were 17.7% and
42.1% respectively
there was a low reported rate of urethral discharge (3.8%)
12% of men had ever been tested for HIV (7.7% rural and 25.2% urban) with
40% of the total tests occurring in public clinics and 36% in private clinics. Only
18.6% of urban men and 8.5% of rural men were tested at a VCT.
Other National level KAP Surveys

The national BSS results presented above are complemented by other national surveys
conducted by various organisations. In particular, because the HSS and BSS only focus on a
limited number of selected sentinel groups, national surveys representative of the general
population give additional important data.
Cambodia National Youth Risk Behaviour Survey.
Given the scarcity of data for young people, the Cambodia National Youth Risk Behaviour
Survey in 2004 of 11-18 year olds is especially valuable97. The survey covered 9,388 young
people in all 24 provinces and municipalities, including 4,284 students in 319 schools and
5,104 young people out of school in 319 villages. Seventy percent of the sample were rural,
27% urban and 3% from remote locations. The key findings relevant to this review are:
50% of young people out of school are illiterate
more than 90% knew ways to avoid HIV/AIDS but only 53% had ever received
education on HIV/AIDS at school
less than 2% of the sample reported sexual activity, but 44% of these had more than
two sexual partners over the previous year
one third of sexually active youth never use condoms, one third state they always use
them and the other third use condoms sometimes
24% of sexually active youth are not aware of STIs
63% of those sexually active use contraception to avoid pregnancy
STI prevalence is very low with only 12 cases recorded
23 of the 148 sexually active youth said they had forced someone else to have sex
33% personally knew young men who had taken part in gang rape
14% of the sample said they drink alcohol, with 66% of these being male, and 60%
not attending school
among those having sex, 40% did so after drinking alcohol
less than one percent of the sample said they used drugs, with glue or spray,
amphetamines (yama), marijuana and heroin mentioned. Most (95%) had used
drugs in the last 12 months. More than 2% of the urban sample had used drugs and
most drug users were taking drugs by the age of 12 years.
Population Services International/ Cambodia
A national HIV/AIDS Knowledge, Attitudes and Practices (KAP) survey was conducted in
2003, as a baseline for behaviours targeted by PSI/Cambodia98. A total of 3,643 men and
women aged 15-49 were selected from five Provinces as well as Phnom Penh. Key relevant
findings were:
generally good knowledge of HIV routes of transmission (more than 90% correct, with
the exceptions of anal sex: men 66% and women 57% correct)
88% believed that a "good looking person" could have HIV
major misconceptions about transmission were higher in rural than urban areas with
10% of the Phnom Penh sample stating that mosquito bites could transmit HIV
compared to 48% of the rural respondents
45
knowledge of prevention varied, with condoms cited by 84% of men and 89% of
women, but abstinence by only 26% of men and 17% of women
knowledge of where HIV testing could be done varied by urban or rural location, with
urban respondents listing health centres/ hospitals, VCT centres or the Pasteur
Institute in Phnom Penh, and rural respondents listing health centres/ hospitals. Most
(89%) urban respondents knew at least one location for HIV testing compared to
71.4% of rural respondents
86% of men and 80% of women assessed that they were at "no risk" of HIV infection
issues related to condom use were embarrassment in buying a condom (77% of men
and 81% of women), embarrassment in carrying a condom (70% men, 78% women),
low acceptance that unmarried women could buy condoms (18% men, 10% women),
higher acceptance that married women could buy condoms (68% men, 79% women)
and high levels of belief that condom use implied mistrust (92% men, 82% women).
only 48.5% of men and 33.2% of women had ever discussed condom use with
another person (family, friend or sexual partner)
attitudes towards PLHA were varied with most men (73%) and women (88%) willing
to care for a relative with AIDS; most men (63%) and women (91%) agreeing that a
HIV positive female teacher who is not sick can continue teaching; but only 21% of
men and 45% of women would buy food from a HIV infected food seller.
only 5% of the sample (29% in Phnom Penh) had ever been tested for HIV, but 98%
of the urban sample and 86% of the rural sample were interested in having a test
for men, condom use in last sex with a sex worker was high at 98%, but lower for last
sex with any non-spousal partner (79%) and only 50% with a regular non-spousal
partner.
British Broadcasting Commission (BBC) World Service Trust

A survey of HIV/AIDS knowledge, attitudes and self-reported behaviour was conducted
among media consumers in July 200399. This was a cross sectional household survey in 21
provinces with a sample of 2,215 adults aged 18-35 years. Key findings were:
TV 5 was the most watched TV channel and FM 103 the most listened to radio,
followed by AM 918 and FM 102
recall of messages related to condoms was high for TV and radio
54% of the sample never talk about sex
41% never talk about having only one partner
while more than 80% know that anyone can get HIV, 75% believe they are at no, or
low, risk
47% never talk about condoms
20% do not think it is acceptable for a woman to tell a man to use a condom
only about 50% know that condoms can be used for birth control
87% of the sample have never bought a condom
only 24% of those sexually active have ever used a condom (mostly men)
half the sample would be embarrassed to buy a condom, but there was widespread
acceptance of the idea of a woman making the purchase
87% had never been tested for HIV, with 43% wanting a test
while 90% would help care for a sick relative with AIDS, most, especially women,
would want to keep their HIV status secret
Cambodian Demographic and Health Survey 2000 (CHDS 2000)
By early 2006, Cambodia should have completed the latest Demographic and Health Survey,
although a report is not expected until later in 2006. Until then, the CDHS 2000100 provides
data on some key HIV/AIDS indicators for the sample population of women aged 15-49
years.
57% would be willing to care for a family member sick with AIDS (75% for those with
secondary education or higher)
46
37% state that a female teacher who is HIV+ should be able to continue to teach
(53% for those with higher education)
only 30% have positive attitudes towards PLHA: a combination of the two indicators
above (46% for those with higher education)
24% believe that a patient should be allowed to keep their HIV status private
66% state that correct use of condoms can provide protection from HIV infection
66% also state that having one faithful sexual partner is protective
40% have no incorrect beliefs about AIDS: a composite variable of those stating that
a healthy looking person can have AIDS and that HIV is not transmitted by mosquito
bites or sharing meal with a HIV+ person (68% for those with higher education)
overall knowledge about mother to child transmission of HIV was 73% with separate
results for transmission during pregnancy at 70%, during delivery, 62% and during
breast feeding, 67% (all higher for women with higher education). When all three subvariables are combined, 59% of the women have correct knowledge about MTCT
(75% for those with higher education).
36% know two ways to prevent HIV infection and reject 3 misconceptions (61% for
those with higher education)
only 14% know three ways to prevent HIV and reject 3 misconceptions (23% for
those with higher education)
only 3% had ever received HIV testing (8% in urban areas and 8% for those with
higher education)
64% believe that a woman can negotiate safer sex with her husband (refuse sex or
use a condom if husband has an STI)
none of the women in this sample had higher risk sex in last 12 months
the median age for first sex for those aged 15-24 years was 21.6 years
no young women (15-24 years) were recorded as having had pre-marital sex in the
last 12 months.
An STI Prevalence study was conducted in 2001101. This used cross sectional cluster sampling
in seven provinces to determine the prevalence of the most common STIs in priority populations:
brothel based sex workers, police and women attending antenatal clinics. The study included
diagnostic tests for symptomatic and asymptomatic STI. Key findings were:
low rates of ulcerative and non-ulcerative STI for all groups except sex workers
high level of sensitivity to currently used antibiotics
evidence of behaviour change with fewer partners and more condom use
STI prevalence consistently lower than in 1996
The survey report concluded that "the low STI prevalence rates add biological evidence that
strengthens the credibility of reported behaviour change and helps explain recent declining HIV
trends".
5.3 Socio-economic Situation and Impact of HIV/AIDS in

Cambodia
There are many publications that examine the impact of HIV/AIDS on society in general terms.
This section describes key documents specific for the Cambodian context. The 2001 Human
Development Report for Cambodia102 explicitly recognises HIV/AIDS as a development issue and
highlights the key concept of social vulnerability. HIV/AIDS is noted to be impacting human
development achievements in three key areas: the impoverishment of households; the increased
vulnerability of children; and setbacks in human rights achievements. Sex is recognized as a
social issue, with acknowledgment that individual behaviour cannot be separated from the social
context.
47
The report notes that poverty in Cambodia fuels the HIV epidemic through:
gender inequalities with strict division of roles between men and women inside
society and inside families, with strong hierarchies leading to rigid stratification
commercial sex consumption by young men that is socially tolerated, making married
women vulnerable to infection from their husbands
a weak public sector, including health and education, that hinders a multi-sectoral
response
migration and mobility for economic reasons
disempowering the poor from claiming their rights.
It is estimated that from 2004, 20,000 Cambodian people will die each year from AIDS, with 70%
of these deaths in people aged 20-44 years. In addition to the burden this will place on the health
system, there will be a need to strengthen social safety nets to support the families affected88. A
recent study by Allenbrack et al in 2004103 provides evidence for this claim. The study aimed to
identify the social and economic impact of HIV/AIDS on children, adolescents and their guardians
through a case-comparison study design of two groups of 500 households. Each case group
household had at least one adult living with HIV, while control households were those in close
proximity to the case household. Interviews were conducted with the guardian and at least one
child aged 6-12 or adolescent aged 13-18 years. Key results relevant to this review were:
case households had a higher percentage of widows
case households had lower income, higher health expenditure and fewer household
assets
stigma and discrimination was reported more often by women in case households
children in case households had fewer meals per day
adolescents in case households were less likely to be enrolled in school and more
likely to work for income and take on additional household responsibilities
using a specially adapted Quality of Life assessment tool, the quality of life in case
households was significantly lower than in control households.
Another study assessed the impact on HIV/AIDS on older people in Cambodia104. Case studies
in 15 rural villages in Battambang Province showed that HIV/AIDS resulted in significant changes
in the responsibilities and needs of older people. There were substantial increases in workload
as older people, especially women, assumed the role of primary carer for sick relatives and
orphaned children. With the added responsibilities of income generation and domestic duties,
older people were found to be vulnerable to extreme poverty. This finding is further compounded
by a unique situation in the population demography of Cambodia. As a result of war and civil
unrest, there were fewer births between 1970 and 1980. Many of those born during that time
were denied basic health and education and now, as adults, have limited skills. This, combined
with the reduced population of males over 45, means that there are fewer grandparents in
Cambodia to care for sick relative and orphans105.
5.4 Cultural and Behavioural Determinants of HIV/AIDS in

Cambodia
This section presents the findings of several studies examining the cultural and behavioural
determinants of HIV/AIDS in Cambodia. There are a limited number of in-depth qualitative
research studies and much remains to be explored regarding issues of sexuality in Cambodia.
The findings presented here underlie and overlap with Section 5.8 on Gender Analysis and
Section 5.11 on Risk Behaviour Groups in Cambodia.
The women's code of conduct (chbap srey) dominates the behaviour of women in Cambodia.
This code suggests that women should be "demure and obedient, intelligent enough to hold a
conversation but not too intelligent to argue with their husbands, and they should be fulfilled
completely by housework and caring for husband and family"88.
48
A study by Phan and Patterson in 1994106 is widely cited, as the study title uses a Cambodian
saying: "Men are gold, women are cloth". Some key cultural and behavioural findings are
presented here:
Cambodian men are able to seek sexual pleasure with beautiful women at whim
The concept of beauty is superficial and out of the reach of the majority of
housewives as it is equated with youth and virginity
Men believe they are in control of their futures, while women believe they are subject
to men's inability to curb sexual desire, but are unable to give them the sexual
gratification they need. Men visiting sex workers is a normal part of the culture
Men dominate women in Cambodian society. "Love, affection and trust in marriage
is rarewives are expected to take the traditional role of respectable women quiet
and submissive"
Wives are generally not considered to have good sexual techniques so men go to
sex workers who have such skills
Single women have little opportunity to learn about sex. They are considered "bad
women" if they reveal too much knowledge of sexual issues.
The 1994 findings related to HIV/AIDS knowledge can be contrasted with current levels of
knowledge. In 1994, levels of knowledge and awareness about HIV in Phnom Penh were
relatively high in men and a little less in women, but there were many misconceptions. One of
these was that specific groups, including Vietnamese sex workers and foreigners, were most
likely to contract HIV infection. Interestingly this study noted that even in 1994 there were signs
of changes in traditional values, with mothers wanting young couples to be tested for HIV before
marriage - at a time when there were no HIV counseling and testing services in Cambodia.
In 1999, Tarr and Aggleton published a study of young people in Cambodia which explored risks,,
but also sought to understand the meanings that underpin behaviours and related sexual
identities and cultures107. The key finding was that the dominant discourses about sexuality and
their consequences for young men and women are best characterized by "contradiction". Young
women are expected to do everything in their power to resist the sexual advances of young men,
while the latter, regardless of what they do, avoid condemnation for their actions. The study was
based on fieldwork among 281 young people and 62 older informants in 1995 and 1996 in Phnom
Penh and one rural location near the city. Key findings are summarized here:
none of the sexually active young women practiced any form of safe sex
young men stated they would never use a condom with a woman their own age with
whom they were romantically involved
young male's early sexual contacts were motivated by "sex for pleasure" and the
"release of semen"
male respondents described a variety of forms of oral sex, all of which were more
popular than anal sex, which was often portrayed as something dirty
paying for sex with sex workers, often in groups, was considered an integral part of
peer group socializing for young men
beer promotion using young and glamorous women symbolizes what alcohol
consumption could, in theory, do for men
nearly all young people interviewed agreed that the family reputation was an
important consideration in making decisions about sexual activity.
This study criticized the superficial understandings of sexuality described using external
categories in most epidemiological and behavioural surveys where there are convenient divisions
of people into separate groups that can be targeted for prevention efforts. This study noted that a
more complex interplay of what is socially respectable and socially illicit is present and this needs
to be considered in designing interventions for HIV prevention.
49
A qualitative study by Population Services International/Cambodia in 2002 explored "sweetheart"

relationships in Cambodia108. The study was prompted by the Behavioural Sentinel Surveillance
finding that, while fewer men were visiting sex workers and with high levels of condom use, many
men in the sample (73%) also had sweetheart relationships where condom use was much lower
(20%). The PSI study used Focus Group Discussions and peer ethnographic techniques, where
male university students and indirect sex workers were trained to use ethnographic approaches
among their peers. The major findings from this study were:
There are a wide variety of terms used for non-commercial relationships, reflecting a
range of emotional involvement, social acceptability and degree of economic
exchange. Three broad categories were found:
o affectionate terms that imply emotional involvement
o terms that involve some affection but also denote that sex is the primary
motivation for men and sex and/or money for women
o terms that imply the relationship exists only for sexual gratification of men
and sexual pleasure and/or money for women.
The higher the degree of affection in the relationship, the less likely that condoms
would be used in that relationship
Condoms may be used early in a relationship but then discontinued, sometimes
following a HIV test
One effective way of introducing condoms into trusted partner relationships is to
justify condom use through fear of pregnancy
Participants felt it was acceptable for women to initiate discussion of condom use but
most also said it was not socially acceptable for women to carry condoms or provide
them for the couple such women would be seen as "bad women"
Many of the waitresses studied reported having paying sex partners to supplement
income. Some had a ta-ta, an older man who has evolved from a client to a
caretaker in financial and material terms. Many also had a "sweetheart", a young
man close to their own age. Most waitresses did not use condoms with the ta-ta or
sweetheart.
Some clients pay extra to forgo condom use, and alcohol use by clients makes the
negotiation of condom use difficult, with widespread reports of violence
Male university students reported simultaneous multiple partners with inconsistent
condom use, but low self-risk assessment for HIV/AIDS.
The most "striking finding" was the frequent occurrence of coerced sex in noncommercial sexual relationships, as well as the prevalence of gang rapeix, almost
always associated with alcohol use and inconsistent condom use. Women report
gang rape as their second greatest fear, after an unwanted pregnancy out of
wedlock88.
There is still much that is not known about patterns of sexual relationships in Cambodia. Other
important findings from other primary and secondary sources are summarized here:
There are many cultural assumptions that are contradicted by emerging evidence.
For example male-to-male sexual relationships appear to be more common than
originally thought (see Section 5.11.5)
Sexual norms are changing, especially among urban youth. Young males do not
seem to visit as many sex workers as their fathers but have more casual sex with
sweethearts88
For both in-school and out-of-school youth there is a lack of sexual experience and a
desire to experiment. It is virtually impossible to ask an adult for information about
sexual and reproductive health, and admitting to having sex would be too shameful88
(citing a study by Perry, 2002)
ix
This refers to a situation where a woman, usually but not always a sex worker, is coerced to a venue where a number of
young men are waiting for sex. Studies suggest this is a form of male bonding and is known as bauk in slang terms.
50
In the uniformed services there is a culture of masculinity and risk taking, working
away from family, additional income, feelings of invulnerability, peer pressure and
excessive alcohol consumption (See Section 5.11.3).
5.5 National Response, Policies and Strategic Plans in Cambodia

5.5.1 Response by Cambodian Government and its agencies
National Strategic Plan for a Comprehensive and Multi-sectoral Response to HIV/AIDS,
2001-2005109
During the time taken to prepare this literature review, a new National Strategic Plan 2006-2010
was released and is summarized below. The key features of the earlier National Strategic Plan
2001-2005 are presented first.
In Cambodia, the National AIDS Authority (NAA) has the legal mandate and broad representation
to lead and coordinate the national multisectoral response. The NAA comprises a Secretariat, 26
line Ministries, the Cambodian Red Cross and 24 Provincial AIDS Committees (PAC). The 20012005 Strategic Plan was based on a Situation and Response Analysis110 identifying vulnerable
populations in Cambodia, considering why they are vulnerable, assessing what has been done so
far, identifying the most serious obstacles to expanding the national response and highlighting the
most promising opportunities.
The 2001-2005 Strategic Plan outlined a "paradigm shift" in the national response:
from segmented and sectoral to an approach that is holistic and developmental
from health centered to people centered and gender sensitive
from top down to bottom up and participatory
from a linear to a cyclical process
from administering and managing others to leading and empowering them.
The guiding principles of this paradigm shift were listed as: holistic, empowerment (including the
greater involvement of PLHA), community development, gender equality and human-rights
based. The Plan had seven Key Strategies
1. Empowering the individual, family and community to prevent HIV and deal with the
consequences of HIV/AIDS
2. Enhancing legislative measures and policy development
3. Strengthening managerial structures, processes and mechanisms
4. Strengthening and expanding effective preventive measures and piloting other
interventions
5. Strengthening and expanding effective actions for care and support and piloting other
interventions
6. Strengthening national capacity for monitoring, evaluation and research
7. Mobilizing resources to ensure adequate human capacity and funding at all levels.
The resource requirements for this Plan were calculated in a POLICY Project study in September
2002111. The overall cost for the year 2005 was estimated to be $54.7 million. Reaching 90% of
sex workers with peer education and achieving 90% condom use was estimated to cost $4.4
million; treating 53,000 clients for STI, $9.2 million; screening 47,000 clients for HIV, $2.2 million
(full cost of $47 per client); reducing mother to child transmission, $0.6 million; and expanding
behaviour change outreach activities, $4.5 million.
51
National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS,

2006-2010.
This document (NSP-II) was officially launched in November 2005 and builds on the first National
Strategic Plan. The overall goals of the NSP-II are:
1. To reduce new infections of HIV
2. To provide care and support to people living with and affected by HIV/AIDS
3. To alleviate the socio-economic and human impact of AIDS on the individual, family,
community and society.
The Strategies are similar to the first NSP but more specific:
1. Increase coverage of effective prevention interventions with additional interventions
developed. The emphasis on commercial and casual sex networks will continue, with
other priorities including mobile men, garment factory workers, MSM and drug users.
2. Increase coverage of effective interventions for comprehensive care and support with
additional interventions developed. This Strategy states that "VCT needs to be
scaled up, as the majority of people with HIV/AIDS are not aware of their serostatus".
One activity is that "NCHADS and NGOs will continue to scale-up coverage and
quality of VCT services in the public, commercial and non-profit health sectors".
3. Increase coverage of effective interventions for impact mitigation with additional
interventions developed. This will target individuals (PLHA, Orphans and Vulnerable
Children and widows) and families.
4. Increase capacity of government sectors and civil society, at central and local levels,
to respond to HIV/AIDS. Line Ministries will be encouraged to translate Plans and
Policies into activities and allocate resources for implementation.
5. A supportive legal and public policy environment. The new National Strategic
Development Plan will include HIV/AIDS as a cross-cutting issue.
6. Increase the availability of information for policy makers and program planners
through monitoring, evaluation and research. The current surveillance system will
remain the "backbone" of the national multi-sectoral M&E system.
7. Increased, sustainable and equitably allocated resources for the national response.
The NAA, with support from UNAIDS, have developed a National Monitoring and Evaluation
Framework. In relation to counseling and testing, the main indicator is the number and
percentage of adults 15-49 years who receive a HIV test at licensed VCT services in the past 12
months. The Baseline for 2005 is set at 2.5% and the target for 2010 at 2.8%. More details
about activities for HIV counseling and testing are given in a Matrix of Activities for each Strategy
included in the NSP-II document. Strategy 2, Objective 4 aims to increase demand for, coverage
and quality of, VCT services. The five year target is to have 132 health facilities offering VCT.
The main activities for this Objective are:
to increase the number of public and private sector VCT sites
to ensure quality of HIV counseling and lab testing in public and private sectors
to promote quality VCT services
to ensure continuity of HIV test kits and supplies
to integrate VCT into the Complementary Package of Activities (CPA).
Additional activities for other Strategies are to increase VCT services for married couples,
strengthen linkages between VCT and PMTCT services and between VCT and TB services.
Cambodia Millennium Development Goals (CMDG)
This sub-section describes the 3 MDGs most relevant to HIV/AIDS and assesses progress
towards achieving these goals in Cambodia in 2003112.
MDG3: Promote gender equality and empower women. This includes secondary and
tertiary education enrolment by gender, literacy for males and females 15-24 years, wage
employment, representation of women in public institutions and reductions in violence
against women and children. The 2003 Cambodian MDG Report indicates progress
towards some, but not all, these targets.
52
MDG5: Improve maternal health. The targets for Cambodia for 2015 are to:
reduce the Maternal Mortality Ratio from 437 (1997) to 140
reduce Total Fertility Rate from 4 (1998) to 3
increase births attended by trained persons from 32% (2000) to 80%
increase use of modern methods of birth spacing from 18.5% (2000) to 60%
increase antenatal visits to at least two for each pregnancy from 30.5% (2000) to
90%.
Other specific targets relate to malnutrition and micronutrient deficiencies in women. The
2003 Report suggests that Cambodia will fall short of most targets with the exception of
the Total Fertility Rate.
MDG6: Combat HIV/AIDS, malaria and other diseases: The HIV/AIDS targets for
Cambodia for 2015 are:
reduce HIV prevalence among persons 15-49 from 2.6% (2002) to 1.8%
reduce HIV prevalence among pregnant women from 2.7% (2002) to 1.5%
increase condom use during last commercial sex from 91% (2002) to 98%
increase youth using condoms with non-regular partner from 82% (2000) to 95%
increase condom use in married "at risk" women from 1% (2000) to 10%
increase antiretroviral therapy (ART) for PMTCT from 2.7% (2002) to 50%
increase ART for people with advanced AIDS from 3% (2002) to 75%.
The 2003 report suggests that Cambodia will meet the prevalence goal for the
general population but may fall short in reducing prevalence among pregnant
women. For many of the other indicators, there is insufficient data at present to
anticipate trends.
National Poverty Reduction Strategy 2003-2005
This official document is produced by the Council for Social Development and endorsed by the
Prime Minister113. The priority poverty reduction actions are: to maintain macroeconomic stability;
improve rural livelihoods; expand job opportunities; improve capabilities; strengthen institutions
and improve governance; reduce vulnerabilities and strengthen social inclusion; and promote
gender equity. The document makes multiple references to HIV/AIDS, particularly in the sections
on vulnerability and gender (see also Section 5.8: Gender Analysis in Cambodia). One key quote
states: "HIV/AIDS has stripped most of the victims of their future and hope, and their ability to live
in equal stance as ordinary citizens" (p22).
National Centre for HIV/AIDS, Dermatology and STDs (NCHADS) Strategic Plan for
HIV/AIDS, 2001-2005
NCHADS are the lead agency in the Ministry of Health for responding to HIV/AIDS. This plan
was prepared to complement the National Strategic Plan 2001-2005 and to outline the roles and
responsibilities of the Ministry of Health114. The plan has three main elements:
to reduce transmission in high risk situations through targeted STI care and
increased condom use
to provide awareness raising, counseling and testing services to the general
population
to equip the health system to cope with increased demand.
There are eight strategies:
1. HIV/AIDS and STI awareness and education, including IEC and outreach
2. 100% condom use for brothel-based sex workers
3. STI services
4. Blood safety
5. PMTCT
6. AIDS care, including institutional and home based care, hospices and self-help
groups, counseling, testing and universal precautions
53
7. HIV/AIDS and STI surveillance and research

8. Strengthening the planning and coordination of program management.
Strategy 5 for PMTCT refers to VCT in the context of antenatal care where other care and
support services are available. Strategy 6 has the goal to strengthen and expand HIV counseling
and testing services in both government and private sectors. The requested budget for HIV
counseling and testing was $2.84 million over the three years 2001-2003, of a total NCHADS
requested budget of $30 million.
NCHADS, with some external technical support, has produced a comprehensive set of policies,
guidelines and protocols related to HIV/AIDS detailed in Sections 5.10 and 5.12.
Response of other Government Ministries88
Ministry of Cults and Religion (MoCR) has prepared modules for teaching life skills at
pagoda schools and monk's trainings and passed a Policy on Religious Response to
HIV/AIDS Epidemic in Cambodia in May 2002.
Ministry of Culture and Fine Arts has developed cultural performances on HIV/AIDS.
Ministry of Education, Youth and Sports (MoEYS) has a Priority Action Plan to
mainstream HIV/AIDS activities into various networks, including schools. The Ministry
has piloted and evaluated prevention education in schools using a training curriculum
developed using UNESCO, WHO and UNAIDS resources. The training curriculum
comprises four Units: Basic knowledge on HIV/AIDS; Responsible Behaviour- delaying
sex; Responsible Behaviour protected sex; and Care and Support. The findings of one
evaluation of Grade 9 students in 2002 found improved knowledge of HIV/AIDS on posttest assessment, especially related to life skills, with girls having greater improvement
than boys115.
Ministry of Interior (MoI) conducts staff training for police and has developed a HIV
Prevention and Care Plan.
Ministry of National Defence (MoND) has its own Strategic Plan based on peer education
that currently reaches over 80% of the military. This Ministry is also a Global Fund subrecipient. The MoND response to HIV/AIDS has been documented in a UNDP
publication116.
Ministry of Planning (MoP) has addressed HIV/AIDS in the Cambodian Human
Development Report, the Cambodian Millennium Development Goals process, and the
Social and Economic Development Plan (SEDP2), which has separate Chapters on
HIV/AIDS and on health101, 112, 117. The Ministry of Planning is also responsible for
developing the National Population Policy. The documents related to this Policy make
specific reference to HIV/AIDS as one of 10 key population issues118. HIV/AIDS "is
potentially such an enormous threat to Cambodia's development effortsit deserves a
section of its own (p16-17)." Another document119 of June 2003 notes that the two
largest cohorts in the population pyramid are children 5-9 and 10-14 years and therefore:
"the need for sexual and reproductive health is dramatically on the increase
because of the huge number of adolescents entering the reproductive and
sexually active age[who must be] targets of massive life skill education
empowering them to protect themselves".
Ministry of Public Works and Transport has an AIDS Committee and plans to integrate
HIV awareness into driving schools; training for staff; condom distribution messages on
public transport; and HIV awareness for road builders and highway communities. The
UNAIDS Overview notes that only the first three interventions were partly achieved by
2004.
54
Ministry of Rural Development (MRD) aims to integrate HIV/AIDS issues into all
programs to mitigate the impact on rural communities through a five-year strategic plan
2002-2006.
Ministry of Social Affairs, Labor, Vocational Training and Youth Rehabilitation
(MoSALVY) aims to improve the social environment of vulnerable groups and support
PLHA and other vulnerable groups. This Ministry is in the process of being reorganised
into a Ministry of Labor and Vocational Training and a separate Ministry of Social Affairs
and Youth Rehabilitation. A Strategic Plan 2002-2006 was developed and funds from the
Global Fund awarded, but poor infrastructure and a shortage of skilled staff have meant
that little of these funds have been disbursed.
Ministry of Women's and Veteran's Affairs (MoWVA) has its own strategic plan for a
comprehensive response to HIV/AIDS and has also published a Policy on Women, the
Girl Child and STI/HIV/AIDS in 2003120. The key objectives of this policy are to work in a
multi-sectoral way to prevent STI and HIV/AIDS infections, reduce the impact of STI and
HIV on women and girls, and to ensure access to care for women and girls with STI and
HIV/AIDS.
National Authority for Combating Drugs (NACD) has developed a Drug Control Master
Plan 2004-2009 that refers to harm reduction for HIV/AIDS prevention.
Government Response at the Provincial Level includes Provincial AIDS Committees
(multi-sectoral), Provincial AIDS Secretariats which support the PAC, and Provincial
AIDS Offices (PAO) which address the health sector response to HIV/AIDS.
5.5.2 Response of International Organizations and international Donors

The United Nations
The UN response is coordinated through the UN Theme Group on HIV/AIDS comprising
representatives of UNESCO, World Food Program, World Bank, ILO, UNHCHR, UNDP, UNFPA,
UNHCR, UNICEF, UNDOC, UNV, WHO and UNAIDS. The Group oversees a coordinated
response with each agency having specific roles and responsibilities88.
Multilateral and Bilateral Agencies
These include the Asian Development Bank (ADB), AusAID, Centre for Disease Control (USA),
Department for International Development (DFID-UK), European Commission, French
Cooperation, Institute of Tropical Medicine, Japan International Cooperation Agency and
USAID88. Cambodia is a USAID Rapid-Scale Up country with a $US 13.8 million budget for 2002.
The USAID Strategy121 is designed to respond to the shift in HIV epidemiology into the general
population and address the underlying factors of poverty, commercial sex and the acceptance of
male promiscuity with the power imbalance between men and women. The Strategy targets
direct and indirect female sex workers, their male clients, migrant workers, men who have sex
with men, sweetheart relationships, youth, pregnant women, women of reproductive age and the
general population. The Strategy is focused on prevention, with specific mention of VCT, but
some resources are allocated to care and support, HIV/TB co-infection, technical support for ART
and support for PLHA networks, faith-based responses, surveillance and research.
Global Fund for HIV/AIDS, TB and Malaria
The Cambodia Country Coordinating Committee comprises representatives of the Government,
UN Agencies, Multilateral and Bilateral Donors, NGOs and International Organisations, Civil
Society, the Private Sector and the Academic and Scientific community.
55
Round 1: Partnerships for going to scale with proven interventions for HIV/AIDS, TB
and malaria, was approved for peer education among garment factory workers,
youth, military and police; STI case management; treatment and care for PLHA;
impact mitigation; and social marketing of condoms. The requested and approved
funding was $US 15.7 million with $ 9.7 million disbursed by September 2005. The
Grant agreement was signed on 27 January 2003 and Grant Start Date recorded as
01 September 2003122.
Round 2: Partnerships for going to scale with proven interventions for HIV/AIDS. A
total of $14.9 million was requested with $5.3 million approved and $4.7 million
disbursed by September 2005. The Grant Agreement was signed on 14 October
2003 with the Grant Start date of 1 January 2004123. The goal of this proposal is to
reduce the mortality and morbidity resulting from HIV/AIDS through the
implementation of the National Strategic Plan for HIV/AIDS. The objectives are:
o to expand coverage and enhance quality prevention activities to include
vulnerable populations not adequately addressed so far, including increasing
the availability of VCT
o to improve access to quality comprehensive care interventions including
Highly Active Anti-Retroviral Therapy (HAART), and promoting GIPA
o to secure reliable and adequate drug supplies in order to improve access to
quality comprehensive care interventions, including Opportunistic Infections,
STI, PMTCT and ART.
Round 4: Continuum of Care, requested $US 36.5 million of which $8.8 million had
been approved and $2.8 million disbursed by September 2005124. The Grant
Agreement was signed on 24 June 2005 with start date of 01 September 2005. The
goal of the Round 4 proposal is to increase the survival of PLHA in Cambodia and
reduce the percentage of infected infants born to HIV infected mothers. The three
objectives are:
o to increase the number of PLHA receiving ART; support capacity of health
care professionals; and build partnerships with PLHA. One target is to have
26,715 patients with advanced HIV on ART by the end of 2009, representing
75% of those in need of treatment
o to increase the capacity of health care facilities to support comprehensive
HIV care and fill gaps in the continuum of care
o to increase the percentage of HIV infected pregnant women and their
newborn who receive ARV prophylaxis to prevent MTCT of HIV.
5.5.3 Response of Non-Government Organizations

Medicam is a local NGO representing over 100 health and health-related international and local
NGOs, many of which implement HIV/AIDS interventions. The HIV/AIDS Coordinating
Committee (HACC) is a local NGO representing over 80 international and local NGOs involved
in responding to HIV/AIDS in Cambodia (many are also members of Medicam). The Khmer
HIV/AIDS NGO Alliance (KHANA) supports 39 local NGOs and community based organizations
in responding to HIV/AIDS. KHANA's Strategic Directions 2004-2008125 are to: scale-up a civil
society response to HIV/AIDS; strengthen organizational capacity; and foster and strengthen
strategic alliances to promote access to comprehensive HIV/AIDS/STI services (with mention of
KHANA's participation in Technical Working Groups on VCT and PMTCT).
World Vision Cambodia's HIV/AIDS Strategic Plan 2004-2006126 addresses prevention, with a
focus on children aged 5-15 years; PMTCT; peer education for high-risk behavior; community
outreach; and access to VCT and STI services. Care and support is addressed through home
and community based care, self-support groups and community care networks. Additional
strategies include advocacy to reduce stigma and discrimination and staff awareness training.
56
Other NGOs with major investments in Cambodia's HIV/AIDS response are CARE Cambodia,
Family Health International and Population Services International (see Section 5.6: National Level
HIV/AIDS Networks).
NGOs play important roles in behaviour change communication, empowerment interventions,
peer education, community awareness and outreach, advocacy, providing counseling and testing
services, resource mobilization and in care and support services for PLHA and their families88.

The National AIDS Authority, UN Theme Group members and other partners actively promote the
Greater Involvement of People Living with HIV/AIDS (GIPA) principle. The Cambodian Network
of PLHA (CPN+) has 36 support groups and 215 sub-support groups with a total of 9,261 PLHA
registered as members in October 2004. The majority of members are women (6,097)88. CPN+
advocates at all levels, including the national level, for the rights of PLHA and to reduce stigma
and discrimination. The organization seeks to mobilize PLHA to become involved in all aspects
of the HIV/AIDS response, including the development of national policies and guidelines.
A qualitative research study, based on the GIPA principle, examined the meaningful involvement
of HIV positive persons in the design, implementation and AIDS policies and programs in
Cambodia in 2005127. Key findings were:
PLHA, especially women, can play a valuable role in counseling, treatment literacy
and community education. Many widows with dependent children are highly
motivated to eliminate AIDS related stigma and discrimination and reduce HIV
infection among youth. "HIV+ people make 'extraordinarily good' counselors and are
ideally placed to provide treatment education" (p17). However, the report notes that
to date, few PLHA have been employed in these capacities.
Peer support groups and the Mondul Mith Chuoy Mith (MMM) centres (Friends
helping Friends) are good structures for greater involvement of PLHA
There is currently no process for the election of PLHA representatives onto national
and regional bodies. CPN+ has no structure to allow PLHA to elect representatives.
Many Working Groups, Stakeholder Forums and Program Monitoring Groups have
designated positions for PLHA, but there is no mechanism to ensure that these
positions are elected and endorsed by peers as their representatives.
5.5.5 Response by business and employers: HIV/AIDS in the workplace

The International Labor Organisation (ILO) is working with the Cambodian Federation of
Employers and Business Associations, including the Garment Manufacturer's Association of
Cambodia, and has launched a HIV/AIDS Workplace Education Program. The ILO Code of
Practice on HIV/AIDS is an important resource for these activities88. Further details of workplace
based interventions for garment factory workers are given in Section 5.11.4.
The media response to HIV/AIDS has been reviewed in a 2003 POLICY Project study128 which
assessed the thematic content of selected print media over three months in late 2002. The study
recognized that the media is a central actor in disseminating information on HIV/AIDS and
shaping community attitudes towards those most affected. The key findings were:
Reaksmey Kampuchea and Popular Magazine were the most read publications
English language materials represented 77% of the total number of relevant materials
the theme of prevention and infection by HIV/AIDS was dominant
attitudes towards PLHA, discrimination and the lives of infected women were scarcely
reported
women are perceived as vectors of contamination, contributing to stigma, especially
for women who work in the entertainment sector
PLHAs are reported objectively in only one-third of materials analyzed. They tend to
be excessively dramatized, sensationalised or romanticized
57
the local media also place an exaggerated emphasis on charlatanism related to the
treatment and cure of PLHAs through traditional medicines
recommendations relate to the diversification of themes covered and training for
journalists in identifying key themes and reflecting on appropriate reporting styles.
5.5.7 Key achievements and challenges (2001 to mid 2004)

The following achievements are selected from the UNAIDS Cambodia, Country Profile: Overview
of December 200488.
reduced prevalence of HIV/AIDS from 3.3% in 1997 to 2.6% in 2002 (the adjusted
2003 prevalence of 1.9% was not available at the time this report was finalised)
Law on the Prevention and Control of HIV/AIDS, 2002
Policy on Women, the Girl Child and STI/HIV/AIDS by the Ministry of Women's and
Veteran's Affairs
National AIDS Authority (NAA) National Strategic Plan 2001-2005
Health Sector Strategic Plan 2003-2007, with HIV/AIDS and STI listed as priority
health interventions (see Section 5.9)
National Poverty Reduction Strategy 2003-2007, stating that HIV/AIDS is a priority
issue to reduce vulnerability and strengthen social inclusion
National Population Policy 2004, which identified HIV/AIDS as one of 10 priority
population related issues
National Blood Policy in 2002, increasing the coverage of quality services. The HIV
prevalence in screened blood dropped from 4.2% in 1998 to 1.8% in 2002.
National Policy on the Prevention of Mother-to-Child Transmission, 2002 and
Guidelines for PMTCT Expansion in 2003
A Voluntary Counseling and Testing (VCT) sub-working group established in 2003
(see Section 5.12 for a comprehensive review of VCT in Cambodia)
Guidelines for Medical Institution Universal Precautions finalized in 2002
National Policy on STI Case Management
Continuum of Care Operational Framework completed in May 2003
Several line Ministries developed HIV/AIDS Strategic Plans (see 5.5.1 above)
Increasing involvement of PLHA
Increasing resources for HIV/AIDS, including GFATM Rounds 1, 2 and 4.
The key challenges faced are:
limited coordination mechanisms and linkages within and among various technical
and operational units
need for improved coordination for monitoring and evaluation
increasing need for medical care, psychosocial and economic support for PLHA and
for children and families affected by HIV/AIDS
need for increased capacity of the NAA in leadership and coordination
need to scale-up and replicate successful interventions
need to increase national technical expertise in some areas
need to increase numbers and quality training of care and support workers
strengthen the strategic role of the Ministry of Social Affairs, Labour and Vocational
Training and Youth to provide social safety nets to mitigate the impact of HIV
need for increased decentralization of resources
need to support capacity development for the Cambodia Country Coordinating
Committee for Global Fund
need to address the slow integration of HIV/AIDS in the education system
58

The Section above gives details of the major national level HIV/AIDS networks including the UN
Theme Group, the HIV/AIDS Coordinating Committee (HACC) and Medicam. In July 2004, a
comprehensive list of all government Ministries and agencies, United Nations, International
Organisations and Donors, International and Local NGOs and current HIV/AIDS Networks active
in responding to HIV/AIDS was prepared ahead of the XV International AIDS Conference in
Bangkok129. This document gives a synopsis of HIV/AIDS activities implemented by each body
together with contact details, some of which are now out-of-date. Annex 3 of the NSP-II
published in November 2005 lists 166 NGOs active in the national HIV/AIDS response, along with
contact details, geographical area of operation and type of programs, but with limited detail. The
HIV/AIDS Coordinating Committee (HACC) has produced a Membership Directory which serves
as a useful resource for referral. The HACC Executive Officer advised during the Key Informant
Interview that an updated Directory was sent to the printers in late 2005 and will probably be
available as this report is being finalized (January 2006).
5.7 Human Rights and Legal Considerations in Cambodia related

to HIV/AIDS
5.7.1 Overview
The government of Cambodia has ratified almost all of the key international human rights
instruments and other international conventions, treaties and ILO conventions. A list of 27 such
documents is given in the MoWVA Policy on Women, the Girl Child and STI/HIV/AIDS120. Those
of most relevance for this review, with the year of ratification, are:
The Convention on the Rights of the Child (1992)
Convention of the Elimination of all forms of Discrimination Against Women
(CEDAW) (1992)
ILO Conventions related to Forced Labor, Freedom of Association, Collective
Bargaining, Equal Remuneration, Minimum Age and Discrimination (1999).
5.7.2 HIV/AIDS legislation and human rights

This section is compiled from a variety of primary and secondary sources. The key primary
references are:
Law on Prevention and Control of HIV/AIDS, 2002130
Implementing Guidelines for the Law, 2005131
Cambodian HIV/AIDS and Human Rights Legislative Audit, The POLICY Project and
USAID by Watchirs and Ward, 2003132
HIV/AIDS and Human Rights in Cambodia: a situation report, The POLICY Project,
June 2005133, updated from an earlier briefing paper prepared for the HIV/AIDS and
Human Rights in Asia-Pacific Expert Meeting, 23-24 March, 2004 in Bangkok134
The Law on Prevention and Control of HIV/AIDS
The Law on Prevention and Control of HIV/AIDS was passed by National Assembly in July 2002
and endorsed by the government in September 2002. The law recognizes the need for a multisectoral response by the state to:
promote nationwide public awareness
prohibit all kinds of discrimination
promote universal precautions
promote greater involvement of PLHA
promote VCT
ensure the confidentiality of personal HIV status
promote access to primary health care for all PLHA
promote legislative actions and policy response
59
Key areas of this law are:

Public health: with a legal duty to implement universal infection control procedures,
the prohibition of mandatory testing, accreditation of HIV testing centres and a
requirement to provide pre and post-test counseling.
Anti-discrimination and privacy: prohibits discrimination on the basis of HIV status for
employment, education, accommodation, finances and travel and health care, with
penalties for non-compliance. There are also penalties for non-compliance with
breaches of confidentiality.
Employment law: prohibits HIV screening and employment discrimination on basis of
HIV status with penalties for non-compliance
Therapeutic goods, access to health care and ethical research: all PLHA are entitled
to free primary health care, but in reality there are barriers to this, for example
through the unauthorized collection of fees by health workers. The Law also bans
misleading advertisements with penalties.
Transmission offences, quarantine and isolation: The Law penalizes the intentional
transmission of HIV but there is no defence for partner consent. The Law also
prohibits quarantine or isolation on the basis of HIV status, with penalties.
The conclusion of this Audit was that"Many features of the law are regarded as best practice in
Asia, particularly in relation to anti-discrimination, privacy and confidentiality, and voluntary
counseling and testing protectionsbut further steps must be taken to ensure the law is
implemented". There is a need for operational policies for accreditation of HIV testing centres;
clarification on partner notification procedures; a code of practice for health workers providing
HIV/AIDS related services; procedures for dealing with complaints of discrimination and breaches
of confidentiality; and regulation of advertising of products for HIV prevention and treatment. In
addition, some sections do not have penalties for breaching the law, such as the prohibition
against mandatory testing and the requirement to provide pre and post-test counseling, where
compliance is essentially voluntary. Some of these concerns are addressed in the Implementing
Guidelines published in 2005.
In addition to the Law on Prevention and Control of HIV/AIDS, the Audit Report noted that the
amendment of other relevant laws could contribute to a more effective response to HIV/AIDS.
Law on the Control of Drugs needs review to clarify that needle and syringe programs
and other harm reduction initiatives do not constitute an incitement to take illegal
drugs. This law allows the diversion of drug offenders from the criminal justice
system to treatment and rehabilitation, but there is an urgent need for resources for
drug rehabilitation facilities.
Sexual offences and the sex industry: Sex work is prohibited under the Constitution
but widely tolerated by police and the community. There are protections against
sexual exploitation of minors but problems with enforcement of these laws. The 100%
Condom Use Program has given quasi-legal status to the sex industry and has
demonstrated success, but there have been reports of police, brothel owners and
clinic staff taking bribes and the mandatory registration of sex workers violates
human rights. Other human rights violations against sex workers in Cambodia are
reported to be common, particularly with police as the perpetuators through violence,
assault, forced sex, extortion, intimidation and threats135 (citing a 2002 report).
Prisons and correction laws: The United Nations Transitional Authority in Cambodia
(UNTAC) Penal Code guarantees a prisoner's access to medical care but this is
generally not met in practice. Involuntary HIV testing and the segregation of HIV+
prisoners is not yet considered a major issue in Cambodian prisons. Cambodian
prisoners with a serious medical condition, such as an AIDS-related illness, are
entitled to apply for a royal amnesty which permits early release but there are
concerns about maintaining confidentiality of HIV status for this process.
60
Equal status of vulnerable populations: Women have formal equal legal status under
the Constitution and the Law on Marriage and the Family, "but the reality is that they
are less equal than men in many respects, including property, finances, work and
domestic relationships".
Therapeutic Goods: Cambodia became a member of the World Trade Organisation in
October 2003. The Law on Patents, Utility Model Certificates and Industrial Design
(January 2003) allows Cambodia to take advantage of the special conditions for least
developed countries and exempts pharmaceutical products, including anti-retroviral
drugs, from patent protection until 1 January 2016. The safety of therapeutic goods is
dealt with under the Law on the Management of Pharmaceuticals, 1996, but in
practice, pharmaceutical products are widely available and largely unregulated, with
resultant concerns about drug-resistance to antiretroviral and other antibiotics used
for HIV/AIDS management. No legal barriers exist for accessing condoms and the
quality and safety of condoms is regulated under the Law on the Management of
Quality and Safety of Products and Services 2000.
Ethical research: Cambodia has a functioning national ethical review committee
based at the National institute of Public Health.
In the context of the current legal and human rights situation for HIV/AIDS in Cambodia, it is
interesting to reflect on the findings of a hospital based survey of medical staff and AIDS patients
receiving treatment in Phnom Penh in 2001, before the Law was enacted136. At that time there
was
"little awareness, much less compliance, with national policies for HIV testing in public
facilitiesThe procedure for informing, counseling and obtaining consent from patients
seems to be determined by the staff or institution with little regard for national policies
and guidelines. Medical staff routinely test patients without informing them or obtaining
consent, results are sometimes withheld from the patient despite their request to be told,
test results are given to relatives and other medical staff without patient authorization, pre
and post-test counseling are often skipped and of poor quality".
More recent monitoring of HIV/AIDS related human rights by the Cambodian Human Rights and
HIV/AIDS Network (CHRHAN), cited by the NAA Technical Working Group135, has shown that
breaches of human rights are most likely to occur in health care, family and community settings.
Of 83 recorded cases on the CHRHAN database there were:
5 cases (2 females) of testing a person without their voluntary informed consent
11 cases (6 females) of failing to provide adequate pre-and post-test counseling
15 cases (10 females) of breaching confidentiality with HIV/AIDS related information
6 cases (4 females) of discrimination in employment
5 cases (all females) of discrimination in education
49 cases (35 females) of restrictions on the freedom of movement or residence, with
the majority of these related to isolation of a person because of their HIV status or
restricting a person's right to choose where to live because of their HIV status.
Of relevance to this literature review is the fact that 72% of all recorded cases involve alleged
breaches of the law by workers and institutions in the health sector.
Implementing Guidelines of the Law on the Prevention and Control of HIV/AIDS, 2005
In 2005 the NAA published Implementing Guidelines in English and Khmer in order to explain the
provisions of the Law in plain language; to identify duties and responsibilities under the law; to
explain how these responsibilities will be fulfilled; and to increase awareness and understanding
of the Law. Each of the chapters of these Guidelines is summarized here, with more details
provided in Section 5.12 on HIV counseling and testing.
61
Chapter 1 explains why the Law was needed and why the Guidelines were prepared.
Respecting the human rights of PLHA, dealing with discrimination, recognizing rights of
privacy and confidentiality and encouraging the involvement of PLHA are stressed.
Penalties, including fines and imprisonment, may be imposed for breaches of some
sections of the Law.
Chapter 2 notes that HIV education should provide "timely, accurate, specific and
relevant HIV information that will empower people to think and act in ways to protect
them from HIV infection, to minimize transmission and mitigate the personal and social
consequences of infection". The content of all education initiatives should be guided by:
accuracy, clarity, culturally appropriate, detailed, gender-sensitive, affirmative and
demonstrating a respect for human rights. School-based HIV education, education for
health care workers, for women and girls, for other vulnerable populations, for tourists
and travelers and HIV/AIDS in the workplace are given separate specific mention. The
role of religious institutions is recognized as playing a vital role in the national response.
The Law requires that all HIV prevention materials, such as condoms and sterile injecting
equipment, must be accompanied by printed information in Khmer to explain proper use.
The NAA will develop and enforce standards in relation to this requirement as well as
address compliance with advertisements for HIV/AIDS treatment or prevention materials.
Chapter 3 states that infection control in the community must respect the human rights of
PLHA but must also address unregulated activities such as tattooing and alternative
health practitioners. Infection control in health care facilities must be based on universal
precautions. People have the right to demand a HIV test of blood, organ or tissue
donations and penalties can be imposed for breaches of these Sections of the Law. The
intentional transmission of HIV is considered a criminal offence, but the Guidelines do not
recommended an over-reliance on criminal law and punitive approaches.
Chapter 4 covers counseling and testing which are recognized as central to an effective
response to HIV/AIDS. Pre and post-test counseling provide opportunities to deliver
education and information about HIV/AIDS. The Guidelines explain in simple language
the provisions of the Law that prohibits any HIV testing that is not voluntary and informed.
Premarital testing is given specific mention, as this is not required by law and testing
must always be anonymous, voluntary and informed for both persons, with disclosure of
results not permitted to anyone other than the person requesting the test. HIV testing for
minors requires the written consent of the person's legal guardian. The definition of
"minor" varies between different Cambodian Laws (marriage is permitted at age 18 for
women and age 20 for men, or younger with parental consent; anti-trafficking laws
defines a minor as under 15 years; and the employment law as under 16 years), but the
Guidelines state that an appropriate definition for the purposes of HIV testing is a person
under the age of 18 years. The written permission from the child's legal guardian must be
obtained before testing, but if this is impossible, a decision must be made as to whether
having a HIV test is in the best interests of the minor. If so, and the minor gives written
consent, the test may go ahead in the normal way. In the case of persons who are
mentally ill, the State can give consent for testing. This Chapter briefly mentions that
standards for HIV counseling and testing and the licensing of testing centres is the
responsibility of the Ministry of Health through NCHADS.
Chapter 5 notes that all sectors of society need to contribute to the provision of adequate
health care and support services for PLHA. Specific mention is made of the need to
increase the HIV/AIDS awareness and skills of Traditional Birth Attendants. Under the
Law, PLHA are entitled to receive free primary health care in all public health facilities.
The definition of primary health care is based on the Minimum Package of Activities
(MPA) provided at Health Centres, together with the Complementary Package of
Activities (CPA) at the Referral Hospital. The Guidelines note that many Health Centres
operate cost-recovery schemes and the NAA will lead a process of seeking external
62
funding to cover the health care costs of PLHA. People exposed to HIV/AIDS through
rape or health care staff through needle-stick injury are entitled to free post-exposure
prophylaxis. This Chapter also discusses the prevention of STI as a vital intervention to
reduce HIV transmission.
Chapter 6 notes that the Law requires a comprehensive program to monitor HIV
vulnerability and patterns of sexual behaviour. NCHADS will continue to conduct HSS
and BSS, but all data collection must respect confidentiality. The NAA has established a
Monitoring and Evaluation Working Group to assess needs and plan activities.
Chapter 7 provides a working definition of confidentiality: "not to disclose information
about a person's HIV status or any behaviour they may have engaged in that makes
them vulnerable to HIV infection and not to disclose the fact that they have been tested or
considered being tested, without that person's consent". Penalties can be imposed for
breaches of this Section of the Law. The only exceptions are where it is necessary to
give the information to health care workers involved in providing treatment to the person
who has HIV/AIDS, or where a court orders the information to be disclosed.
Chapter 8 covers discrimination and notes that imprisonment and large fines can be
imposed for persons found to be discriminating against anyone on the basis of HIV
status, which is defined by the Law as either known or suspected to have HIV/AIDS.
Discrimination in employment, in educational institutions, in health care services,
restrictions on freedom of movement and the right to seek public office, access to credit
and insurance are all given separate mention.
Chapter 9 lists the various Articles of the Law together with the Penalties that apply for
breaches of the Articles.
5.8 Gender Analysis in Cambodia

For a more complete gender analysis and to avoid unnecessary repetition, this Section should be
read in conjunction with Section 5.3 on the socio-economic impact of HIV/AIDS, Section 5.4 on
cultural and behavioural determinants of HIV/AIDS, Section 5.7 on human rights and legal
considerations, Section 5.9.2 on Sexual and Reproductive Health Services in Cambodia and
Section 5.11 which describes several high risk behaviour groups.
In April 2004, a detailed Cambodia Gender Assessment was published, co-authored by UNIFEM,
WB, ADB, UNDP and DFID (UK)137. The report noted that the effects of war and civil unrest have
contributed to a population with more women than men, leading to a surplus of women of
marriageable age and a consequent lowering of the status of women, as women without
husbands are marginalized in Cambodian society. The report notes that "cultural norms still firmly
place women at a lower status than men". Cambodia has strong traditions with gender
discrimination deeply embedded in and reinforced by social attitudes. The code of conduct for
women (chbap srey) is part of the primary school curriculum. The report states that it can be
difficult for a young woman to refuse rape, which is broadly seen as a crime against chastity
rather than a violation of personhood and dignity, with blame most often placed on the victim107.
Cambodian customs and the code of conduct suggest that women should be demure and
obedient, intelligent enough to hold a conversation but not too intelligent to argue with
their husbands, and they should be fulfilled completely by housework and caring for
husband and family88.
Key cultural issues relevant to gender inequity in this Gender Assessment report are:
It is believed to be socially unacceptable for Cambodian women to marry someone
with a lower educational status, which creates an added disincentive for young
women to pursue higher education
63
The division of labour is changing, with an increased tendency for women to engage
in a broader range of tasks
Women still have heavier work burdens than men
Men still make most of the household decisions. The CDHS 2000100 results indicated
that 52% of women believed important decisions should be made by men, 59% that it
was better to educate a son than a daughter, and 33% that married women should
not be allowed to work outside the home
Gender relations between men and women are shifting, with men's underemployment and loss of economic power leading to frustration and contributing to
domestic violence. However the increased economic autonomy of women allows
some of them to leave violent or abusive situations and avoid exploitation and high
risk employment such as commercial sex work
The Human Poverty index for women is greater than for men
Woman headed households are among the poorest in the community. Women head
26% of Cambodian households100.
The report has one chapter devoted to gender and health:

Household expenditure accounts for 73% of the total health expenditure one of the
highest proportions in the world
A health crisis can cripple a poor family. An Oxfam Cambodia study in 2000 found
that 46% of people who had recently lost land, had lost it as a consequence of
health-related debts (study cited in the report)
Women are disadvantaged in accessing basic health services
Poor access to health services is closely linked to poverty and women's education,
with inability to pay being the most common problem in accessing health services
The maternal mortality in Cambodia is among the highest in the region
Women's nutritional status is poor, with malnutrition and micro-nutrient deficiency
common as a result of underlying food insecurity, no access to clean water and
sanitation and poor food intake during pregnancy and lactation
There is a large unmet demand for family planning services
Women do not receive care during pregnancy and deliver in unsafe conditions
There is a shortage of skilled personnel to attend birth, especially in rural areas
(33.8% of rural women are delivered by a trained birth attendant compared to 62.5%
of urban women100)
disability is twice as common among men as among women due to landmine and
gunshot injuries and drug use is more common in men.
A separate chapter is devoted to HIV/AIDS and gender issues:
Women in Cambodia in long term stable relationships are at increased risk of HIV
infection, with condom use among married women less than 1% due to issues of trust
and suspicion of infidelity
New infections are reducing among men and leveling off among women
Increased condom used has led to reduced HIV prevalence among sex workers
The prevalence of infection among women attending antenatal clinics is decliningx
The main routes of transmission are changing with husband-to-wife (now 40% of new
infections) and mother-to-child cases increasing88
Strong gender stereotypes depict masculinity in terms of dominance, power and
promiscuity
Women face an increased burden of care
Women living with HIV/AIDS experience stigma and discrimination to a greater
degree than men. It is often believed that women transmit the disease.
Only 2.8% women have been tested for HIV (8.1% in urban areas and 1.6% rural)100.
x
Note that the incidence study described in Section 5.2 suggests that the rate of infection is not declining.
64
The Policy on Women, the Girl Child and STI/HIV/AIDS (Ministry of Women's and Veteran's
Affairs, 2003120) recognizes that girls and women are more vulnerable to HIV infection. Women
are noted to be disproportionately represented among the 36% of Cambodians who live below
the poverty line. Female unemployment, low wages and high illiteracy forces dependence on
male partners for financial support.
The National Poverty Reduction Strategy113 recognises that gender, poverty and HIV/AIDS are
"inextricably intertwined". The key gender issues identified in this Strategy are:
The significantly higher workload for women than men (women provide 65% of
agricultural labour and 75% of fisheries production)
Limited employment opportunities for women and limited sources of market
orientated skills training with women earning 30-40% less than men88
Limited educational opportunities for women
Higher risk of ill health
Increased numbers of women with HIV infection and increased burden of care
Trafficking and the sex trade targets vulnerable women and children
Issues of domestic violence: the 1998 Population Census found that 15% of married
women had experienced domestic violence in last 12 months
Exclusion of women from participation in many consultations during community and
government discussions.
However, while acknowledging that tradition plays a significant role in perpetuating gender
disparity in many societies, the NPRS document states the "this is not so much the case for
Cambodia" (p36). This statement is inconsistent with the view in most other reports on gender
issues "that Cambodia has strong traditions with gender discrimination deeply embedded in and
reinforced by social attitudes"137.
5.9 Health Service Review in Cambodia

5.9.1 Overview of health sector: Ministry of Health, Health Sector Strategic
Plan 2003-2007
The Ministry of Health manages a network of 940 Health Centres and 67 referral hospitals in 73
Operational Districts in 24 Provinces and Municipalities in the country138. The Health Coverage
Plan provides a Minimum Package of Activities (MPA) at the Health Centre level and a
Complementary Package of Activities (CPA) at the Referral Hospital level. Each Health Centre
serves a population of about 10,000 people, and each Operational District serves between
100,000 to 200,000 people. However, in 2000 only 18.5% of the population used public health
facilities, with 68% accessing the private or non-government sector100. The health utilization ratio
in late 2001 was 0.99 [0.27-1.75] contacts per person per year in a sample of four Ministry of
Health Provincial Hospitals, eight District Referral Hospitals and 18 Health Centres representing a
mix of Ministry of Health, contracting-in and contracting-out management139.
The working principles of the Ministry of Health Strategic Plan140 are:
social protection for vulnerable groups
listening to what people want
affordability and sustainability
focus on rural areas and the poor
capacity building, including human resource development
sector wide management
high quality evidence based interventions
good governance and accountability
65
The following elements provide the basis for the Strategic Plan:
sector wide management
provision of basic health services with full involvement of the community
provide affordable, essential specialised hospital services
decentralise and de-concentrate finance, planning and administrative functions
priority emphasis on prevention and control of communicable and selected chronic
and non-communicable diseases, on injury, the elderly, adolescents and vulnerable
groups such as the poor, and on managing public health crises
priority emphasis on provision of good quality care to mothers and children,
especially obstetric and paediatric care
active promotion of healthy lifestyles and health-seeking behaviour
emphasis on quality, effective and efficient provision of health services by health
providers
optimisation of human resources
increase promotion of effective public and private partnerships
effective use of health information for evidence-based planning, implementation,
monitoring and evaluation
implement health financing systems to promote equitable access to priority services
especially by the poor
further development of appropriate health legislation
The priority demographic and health concerns are:
rise in infant and child mortality, diarrhoeal diseases, acute respiratory infections,
vaccine-preventable diseases, dengue and malaria.
high rates of under-nutrition among women and malnutrition among children
high maternal mortality ratio and deaths from obstetric trauma and septic abortions
high case fatality rate from HIV/AIDS, TB and malaria
high total fertility rate
population growth
harmful practices among consumers and providers.
The Priority Areas of Work are:
Health service delivery
Behavioural change
Quality improvement
Human resource development
Health financing
Institutional development
This Strategic Plan contains the following HIV/AIDS specific actions:
reduce transmission in high risk groups through targeted STI treatment and
increased condom use
increase awareness of HIV and promote HIV counseling and testing to high risk
groups and the general population
strengthen the health system to respond to the increased demand for prevention and
care services.
In October 2004, the Ministry of Health released an Action Plan 2004-2007 to implement this
Strategic Plan141. The combined cost per capita of government funds, user fees and external aid
was calculated to be $US 6.92 in 2004, and projected to reach $US 7.45 by 2007. The Action
Plan has surprisingly few specific references to HIV, perhaps because these are detailed in the
NCHADS Strategic Plan.
66
The HIV/AIDS specific references in the Action Plan are:

the development of operational plans for cost-efficient interventions to control priority
communicable diseases: malaria, TB, diarrhea, ARI, vaccine preventable infections,
HIV/AIDS and helminthiasis [listed in this order in the document]
the development and strengthening of VCT services, with one output being the
provision of good quality VCT at the Referral Hospital level.
An Annex to the Action Plan contains a comprehensive list of all Laws, Policies, Regulations and
Standards approved by the Ministry of Health and effective at August 2004. This list includes all
the HIV/AIDS specific documents referenced in this literature review.
Behaviour Change Communication Policy
The National Centre for Health Promotion (NCHP), an agency of the Ministry of Health, is the
focal point and lead agency for behaviour change communication (BCC), although it appears that
NCHADS takes primary responsibility for behaviour change related to HIV/AIDS. Cambodia has
a National Behaviour Change Policy142 which states that in developing BCC materials, there
should be consultation with the relevant national program to ensure accuracy of technical content
and consultation with NCHP to ensure the quality of the communication aspects of the material.
Pharmaceutical Sector
A situation analysis of the Pharmaceutical sector was conducted in 2003, but the only publication
located for this review is stated to be a draft, and therefore the findings and recommendations
need to be interpreted with caution143. The analysis described three legal outlets for drug sales:
pharmacies run by a pharmacist; Depot A, run by an assistant pharmacist; and Depot B, run by
'retired' nurses. However over 71% of all drug shops (81% in provincial areas) were unlicensed.
The MoH Department of Food and Drugs has five Bureaus to deal with its responsibilities: drug
and cosmetic regulation; essential drugs; narcotic control; pharmaceutical trade; and drug
legislation, policies and guidelines. There have been significant changes in the procurement
system with an independent structure established in 2003. In the report, the Ministry of Economy
and Finance is noted as a key decision maker, but with a history of not seeking adequate
technical input from the MoH, which contributed to significant delays in procurement and drug
shortages in 2002. The key issues identified in the report are:
80% of the population purchase drugs from the private sector
only 50% of the drugs in the country are registered and illegal importation is a
problem
counterfeit drugs are a major concern
there are many unlicensed drug sellers
there are irrational prescribing practices including polypharmacy, abuse of
injectables, overuse of antibiotics, poor compliance and no prescriptions
drug providers have little/limited knowledge of rational drug use.
high levels of illiteracy in the population means that many labels cannot be
understood
procurement issues result in stock-outs at different levels
there is limited capacity for timely registration of drugs
there are a limited number of trained pharmacists.
5.9.2 Sexual and reproductive health services in Cambodia

Many of the challenges for sexual and reproductive health in Cambodia have been presented in
Section 5.8 (Gender Analysis). These include the generally poor health of women, imbalances in
the age-sex structure, high levels of poverty, low levels of human resource development and the
HIV epidemic. Specific sexual and reproductive health challenges are:
high maternal mortality
high fertility
large gap in unmet family planning needs
67
use of ineffective and harmful family planning practices82

limited access to reproductive health information and services144
limited human resources to deliver quality services
an unregulated private sector
a need to integrate RH services with other services, particularly HIV/AIDS services
a need to make reproductive health services more male friendly145.
In 2000, less than half (42.2%) of the total demand for family planning in Cambodia was satisfied
{the met need was 23.8%, the unmet need 32.6%, making a total demand of 56.4%), and with
43.6% being those who did not need contraception146. However this is a major improvement from
an unmet need of 84% in 1995. The Contraception Prevalence Rate in 2000 for modern methods
of contraception was 19% (32% in urban areas) with injectable contraception accounting for
31.2% of the modern methods, the oral contraceptive pill for 30.4%, female sterilization 6.4% and
Intrauterine Device (IUD) 5.0%, while condom use as a method of contraception was low at
4.3%100, 145. The use of modern methods of contraception has been rising from 7% in 1995, to
16% in 1998 and 19% in 2000, but accurate comparisons are difficult due to different survey
methods147.
There are several important enabling factors for effective family planning in Cambodia147:
high levels of awareness, approval and demand for services, with no religious or
cultural constraints
demonstrated political will
close cooperation between government and NGOs
Ministry of Health willingness to experiment with community based interventions for
service delivery
a functioning national logistics system for the flow of commodities.
The public sector currently provides 53% of all contraceptive supplies and services144 while the
Reproductive Health Association of Cambodia (RHAC), created in 1994, is the largest
reproductive health provider in Cambodia outside the government. In 2002, Population Services
International facilitated the formation of a Sun Quality Health Network of private sector clinics to
deliver family planning, STI and VCT services. By October 2004 there were 95 service delivery
points in four provinces, but only a minority were reporting to be providing VCT145.
Abortions have been legal in Cambodia since the Law on Abortions was ratified in 1997.
However, until 2003 no Operational Guidelines were available to put the Law into effect. While
there is no accurate data on the number of abortions in Cambodia, mortality from abortions is
believed to contribute to about 130 of the 437 maternal deaths/ 100,000 live births. The Law and
Guidelines recognise that there is a significant need and demand for safe abortion services in
Cambodia. However, there is little or no formal training for the WHO recommended abortion
techniques by qualified health providers. Many services are performed in the private sector by
unqualified persons, including traditional birth attendants and there are varied costs for the
service which further limits access for poorer women148.
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5.10 HIV/AIDS Services Review in Cambodia

The purpose of this section is to give a reasonably detailed review of current services and
interventions addressing HIV/AIDS in Cambodia. This will provide the context for the detailed
assessment of HIV counseling and testing services in Section 5.12.

Several of Cambodia's successful prevention interventions feature in a 2001 UNAIDS publication
highlighting best practice in Cambodia's response to HIV/AIDS. The interventions featured
include life-skills workshops for sex workers, social marketing of condoms and addressing
prevention among factory workers149.
HIV/AIDS/STI education and awareness
The UNAIDS December 2004 Overview88 provides a list of the major HIV/AIDS prevention
interventions that have been implemented in Cambodia, together with an outline of much of the
IEC material developed to support these interventions. In broad terms, these interventions have
either been directed towards the general population or to specific target groups. The
interventions have used a variety of methods including mass media, IEC materials distribution
through multiple channels, including community outreach sessions, and peer education. The
interventions have also been directed at all levels from individuals, families, peer networks,
workplaces, communities, districts, provinces and nationally.
NCHADS produced Guidelines for Implementation of Outreach and Peer Education in the
Community in 2003150. Peer education is designed for specific target groups while outreach
activities use existing community structures, occasions, events and cultural patterns to reach a
more general audience. The Guidelines discuss the rationale for peer education, the planning of
peer education activities, including the identification of the target groups, baseline data collection,
target group-specific messages, community approval and involvement, and the selection and
training of peer educators. Linkages with other programs are noted, especially with the 100%
Condom Use Program, targeted STI services, reproductive and other health services (with
counseling and testing services mentioned, but in no detail) and home and community care
services.
The Ministry of Education, Youth and Sport (MOEYS) is a very strategic partners in HIV/AIDS/STI
education with the potential to target 3.5 million students (1.5 million girls) and 76,000 teachers as
well as non-teaching staff, Parent's Associations and School Support Committees. However,
progress in implementing HIV/AIDS education in schools has been slow, and additional external
support is needed, especially since it is estimated that up to 3,000 teachers may themselves be
HIV positive88.
Condom Promotion and 100% Condom Use Program
Condom promotion has been an early and strong component of Cambodia's response to
HIV/AIDS. There has been successful social marketing of condoms, particularly the Number One
brand, but this is now perceived by the community to be closely linked to commercial sex and the
brothel-based 100% Condom Use Program. In addition, condom use is low in relationships
where trust and affection are implied, particularly sweetheart relationships. The PSI study cited in
Section 5.4108 found that 87% of the respondents agreed with the statement that "suggesting
condom use implies mistrust". Condom social marketing has therefore moved to promote
alternative brands for sweethearts and for family planning.
The PSI National Distribution Survey of August 2002151 assessed condom and birth spacing
commodities availability, brands, prices, sales and sources of stock in rural and urban retail
outers in all 24 Provinces. Brand awareness of the socially-marketed Number One condom was
95% overall in all Provinces, and much higher than the OK brand which is socially marketed by
PSI for couples. The average retail price of Number One condoms was 391 reil (US 10 cents)
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with a range from 200 to 2000 reil. Over 40% of vendors stated that condoms were never
purchased by female clients, or rarely purchased by female clients (19%).
The 100% Condom Use Program (100% CUP) began in Cambodia in 1998 and was modeled on
a similar successful program in Thailand. The 100% CUP was reviewed in 2003 with the
following findings152:
Sex work in Cambodia is characterized by mobility in terms of geographical location
and movement between direct sex work and indirect sex work
In urban locations, sex work is better organized, with higher incomes and better
health
Striking differences were observed between ethnic Khmer and Vietnamese sex
workers, with the latter more prosperous, well organized, more articulate and
entrepreneurial, and having closer contact with their families with the future
anticipation of settling down and marrying with the full knowledge of their families.
This is in marked contrast to the shame Khmer sex workers feel in relation to their
families.
Indirect sex workers were more likely to deny involvement in sex work, had fewer
clients, but received a higher income per client than direct sex workers
Violence and abuse were reported, but noted to have been present before the launch
of the 100% CUP. There was an impression that violence and abuse was less in
urban areas perhaps due to increased organization of sex workers in these locations
Mandatory STI screening and treatment of brothel based sex workers is part of the
100% CUP.
Blood safety
All official blood donations in Cambodia are screened for HIV. The prevalence of infection in
blood donors has declined significantly from 4.2% in 1998 to 1.8% in 2002. More recently there
has been an increased effort to recruit voluntary, non-remunerated donors who generally come
from lower risk groups, such as Buddhist monks. At present about 25% of current blood donors
are voluntary and 95% of these are first time donors88, 135.
Prevention of Mother-to-Child Transmission (PMTCT)
NCHADS and the National Maternal and Child Health Centre (NMCHC) produced a National
Policy on Preventing Mother-to-Child Transmission of HIV in 2001153. In relation to the link
between PMTCT and HIV testing, the policy states that:
"All women and men, irrespective of their HIV status, have the right to determine the
course of their reproductive life and health and to have access to information and
services that allow them to protect their own, and their families, health. Integrated RH
[reproductive health] and STI services and family counseling will be promoted. In
addition, VCT will be conducted as a long term strategy to protect HIV infected women
from stigma and discrimination".
The Policy also states that the PMTCT strategy will be integrated into existing mother and child
health, reproductive health, Integrated Management of Childhood Illness and STI programs within
the Ministry of Health, other related Ministries, International Organizations, bilateral agencies,
NGOs and the private sector. In relation to VCT, the Policy states that: HIV counseling must be
conducted and managed by properly skilled, trained and qualified staff; that VCT for HIV will be
incorporated into antenatal care services or provided in free standing sites, to allow women to
make choices based on their individual situation; that mandatory HIV testing of women or children
is prohibited; and that strict confidentiality of HIV test results must be maintained.
The PMTCT approach in Cambodia closely follows international recommendations for resourceconstrained settings. The main constraints are lack of access to, and utilization of, antenatal care
and trained providers at birth and the relatively low prevalence of HIV infection in pregnant
women, which means that many women will need to agree to be tested to identify the 2.5% who
are HIV infected154.
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The key components of the PMTCT program in Cambodia are135, 154, 155:
primary prevention of infection
prevention of unwanted pregnancies for all women, and especially for HIV infected
women
improved health services during antenatal, intra-partum and post-partum periods
destigmatisation of condom use and promotion of the dual protection role of condoms
improved safe birthing practices
improved diagnosis and treatment of malaria and other diseases
behaviour change to promote exclusive breast feeding
care and support for HIV infected mothers and infants
HIV counseling and testing
nevirapine prophylaxis for mother and infant where the mother is given a single dose
of nevirapine at the onset of labour (and at least two hours before delivery) while the
newborn infant is given a single oral dose of nevirapine syrup within 72 hours of birth.
In Cambodia, the "opt-out" approach is being implemented in a few PMTCT sites but the NMCHC
prefers the "opt-in" approach, because of the possible negative consequences if a housewife tells
her husband about STI or HIV infection.
Infant feeding counseling is considered a major challenge in Cambodia88. Current approaches in
Cambodia endorse international recommendations to give women, and their partners, sufficient
information in order to make an informed choice from a number of possible options. However, in
practice, the current recommendation in Cambodia for most HIV positive women is for exclusive
breast-feeding for the first six months, followed by abrupt weaning135. If the mother chooses
formula feeding, it must meet the five criteria of being acceptable, feasible, affordable,
sustainable and safe.
Current access to and uptake of VCT for PMTCT is low, as few women attend antenatal services
and even fewer deliver in public health facilities. Coverage in 2004 included Phnom Penh and 13
Health Centres in 11 Operational Districts, compared to only two sites in 2003. To date these
PMTCT centres have covered 26.6% or 132,767 of the estimated annual 500,000 pregnant
women. Of the women covered by these services, 11.7% attended pre-test counseling with
11.4% being tested. A cumulative total of 303 mothers and infants have taken nevirapine from
2002 to 2004. As a result of this low coverage and uptake of services, the cost-effectiveness of
the current PMTCT program is still under consideration88, 135.
Harm reduction
There is very limited data available on coverage of harm reduction services, which is still very
low. In 2003, the NGO Mith Samlanh/Friends saw 2,573 clients for drug-related problems. Only
recently has approval been given to pilot a needle and syringe program and drug substitution
therapy has only just started in Cambodia, but on a small pilot scale.
Unmet prevention needs
In preparation for the new 2006 - 2010 National Strategic Plan for HIV/AIDS, the Technical
Working Group on Prevention identified unmet prevention needs in their draft report135:
limited participation of commune level officials in prevention activities
limited prevention initiatives arising from communities
misconceptions about transmission persist, with low personal risk perception
lack of programs specifically targeting married women
limited participation of PLHA
low levels of consistent and correct condom use for casual sex partners and
sweethearts
lack of HIV prevalence data and behavioural data for young people
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Gaps in coverage of prevention interventions

The same Technical Working Group identified the following gaps in coverage of current services:
male sex workers and transgender sex workers are not given the priority they
deserve
under-age sex workers (boys and girls) are not being reached. Many are hidden by
brothel owners and not registered for 100%CUP
for PMTCT, a low proportion of women accept testing, a low proportion of HIV
infected mothers are identified and a low proportion of HIV exposed infants receive
ARV prophylaxis.

Continuum of Care
Cambodia has endorsed the Continuum of Care (CoC) approach with publication by NCHADS of
the Continuum of Care for People Living with HIV/AIDS: Operational Framework in 2003156. This
Framework follows the evolution of the needs of PLHA over time, with HIV testing services clearly
required for the initial diagnosis. The guiding principles for this Continuum of Care are: alignment
with the National Law on the prevention and control of HIV/AIDS; a focus on the needs of PLHA
and their families; early diagnosis; appropriate referral after diagnosis; reducing barriers to the
uptake of services; supporting adherence to treatment for PLHA; greater involvement of PLHA;
community mobilization; coordination; finding the balance between HIV specific services and
integrated services; and working with the private sector.
NCHADS and FHI have published a useful case study on the Continuum of Care documenting
experiences in Moung Russey District in Cambodia157, where the provision of ART has been
successfully introduced and expanded. Central to the CoC in Cambodia is the MMM (Mondul
Mith Chouy Mith) "friends helping friends" - a grouping of PLHAs and the different partners that
work with them to provide care and support. In this case study, the VCT centre is located in the
grounds of the hospital to facilitate coordination and referral. NCHADS provides a performance
based salary incentive of $US 60 per month for the counselors and lab technician. PMTCT and
ART services are included in the CoC. Among the successes reported are a perceived reduction
in discrimination among health staff towards PLHA who openly attend the hospital services.
Other successes of this approach have been a strengthening of the overall health system and
higher utilization of new services. Replication of this model is recommended by the report.
Home and Community Based Care
Cambodia has several official documents to guide home and community based care. National
Guidelines on Home and Community Care for People Living with HIV/AIDS were completed by
NCHADS with WHO support in January 2000158. National Protocols for case management of
adults and adolescents159 and pediatric patients have been completed as well as guidelines for
prophylaxis of opportunistic infections160.
The Ministry of Health Essential Drugs List161 contains basic medicines and commodities for the
Minimum Package of Activities (MPA) at Health Centres and additional medicines and
commodities for the Complementary Package of Activities at the Referral Hospital level and
above. Birth spacing supplies, including condoms, are listed along with medicines for specific
programs: STD case management, medicines for HIV/AIDS treatment and care, including
symptomatic treatment, palliative care, treatment and prophylaxis of opportunistic infections and
antiretroviral drugs.
Coverage of home and community based care is expanding. An unpublished report162 that was
the basis for the 2003 coverage assessment by WHO4 indicated that there were 7016 clients
receiving home and community based care in the 12 months to September 2003, with most of
this care managed by NGOs and their partners.
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Antiretroviral Therapy
Cambodia has made a strong commitment to support the WHO "3 by 5" initiative and the Global
Fund has provided resources from Round 2 and Round 4 to procure sufficient medications to
meet national need and capacity. NCHADS has produced National Guidelines for the use of ART
for adults, adolescents and children. These Guidelines advise that the first step is to confirm the
diagnosis of HIV infection through HIV antibody testing.
Counseling and testing services are therefore a very important entry point for treatment, care and
support where "the quality of the first encounter often influences future health and treatment
seeking behaviours"163. Experience in several other countries has demonstrated that the
availability of ART can have a great impact on the uptake of VCT services, which further supports
the urgent need for expansion of VCT services in Cambodia.
However, there are important issues that need to be addressed. In Phnom Penh, ART is officially
available at four national hospitals, but there are several procurement mechanisms operating
concurrently under different donors. In addition, ART can be bought in Phnom Penh and other
urban centres with or without a prescription from a number of pharmacies and wholesalers, many
of whom are neither trained nor registered. The cost can be as low as $30-50 per month88.
The challenges faced by the government are to increase commitment and ensure that low cost
drugs are available and administered appropriately. Cambodia's negotiations for the World Trade
Organisation could facilitate or constrain this. There is a need to inform the population and
encourage public debate to ensure that those who require treatment receive it, regardless of
poverty, gender and stigma88.
The number of people with advanced HIV infection receiving ART is increasing. In September
2003, it was estimated that 1,506 patients of an estimated need of between 22,000 to 32,000
were receiving ART from 11 sites. By October 2004, 4,300 patients were on ART88 and latest
figures from NCHADS state that at the end of 2005 about 10,000 PLHA were receiving ART
(personal communication).
HIV and Tuberculosis collaboration
The National Health Policies and Strategies for Tuberculosis (TB) control in the Kingdom of
Cambodia released in 2001 recognized the link between HIV/AIDS and TB, but gave little detail
or direction164. A review in 2001 exploring the links between HIV and TB noted major barriers to
collaboration and linking HIV and TB interventions165. At the time of this report there were only
six approved HIV counseling and testing centres in Cambodia, all in urban areas, and all using
non-rapid tests with delays in obtaining results. Other important barriers were limited coordination
between TB DOTS and HIV/AIDS Home Based Care teams, and the fact that private sector
providers and traditional healers were the first point of contact for 70% of the population
presenting a major barrier to case-detection. However, since 2001, there has been increased
attention and priority given to HIV/AIDS and TB collaboration.
Like HIV/AIDS, stigma and incorrect beliefs about TB contribute to delays in seeking treatment.
Tuberculosis prevalence of all forms in Cambodia in 2003 was estimated to be 540/ 100,000
while for new smear positive pulmonary TB the rate was estimated to be 241/ 100,000, with a
mortality of 90/ 100,000. The HIV seroprevalence among all TB patients increased from 2.5% in
1995 to 11.8% in 2003166. The 2002 HSS estimated that the HIV prevalence in newly diagnosed
TB patients was 8.4%167. The TB burden among VCT clients who test HIV+ and who are referred
for TB screening ranged from 13% to 32% in four pilot sites. Of TB patients sent for HIV testing,
between13% to 77% were found to be HIV+. Overall nearly 38% of TB patients were co-infected
with TB and HIV135.
In a cross sectional study of 441 HIV+ persons in a home care setting in Phnom Penh, 9% were
found to have active pulmonary TB on culture of which 71% were smear positive. Only one
person was on TB treatment and the total burden of pulmonary TB in this population was 12%168.
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Active case-finding identified three times as many cases as those already detected. HIV+
persons in this setting were 16 times more likely to have TB than the general population, with
high mortality as 49% of the TB cases identified subsequently died. The study evaluated the
utility of asking about a cough of three weeks duration for TB diagnosis and found this to be
poorly predictive. A single sputum screening test was recommended as having better diagnostic
utility for HIV+ persons with symptoms.
In August 2004, a workshop was held addressing the scale-up of TB/HIV collaborative activities in
Cambodia169. Several topics addressed the two-way referral between HIV counseling and testing
(and home based care) services and TB screening services.
The workshop findings for referral from VCT/Home Based Care to TB services noted that:
the quality of counseling skills was limited with a lack of understanding of the
impact of TB/HIV co-morbidity by counselors
there were no staff or others able to accompany the HIV+ client for TB screening
there was insufficient budget for transport support
waiting times for TB screening were long.
For referral from TB clinics to VCT centres, the findings were:
a lack of transport support
the VCT centre was usually far from the TB ward
information about VCT was limited
TB patients may not believe they are at risk of HIV infection
instances of staff discrimination against PLHA.
Recommendations were made for scale-up and to address these findings.
For referral from VCT/Home Based Care to TB services:
all HIV+ clients should be referred for TB screening with a referral slip
transport support should be provided
clients should be accompanied by a peer or volunteer
clear information on the location of the TB screening location should be provided
records should be kept of referral and follow-up
counseling should be provided on the importance of TB screening and treatment.
For referral from TB services to VCT:
all TB suspects should be referred for HIV counseling and testing
all TB patients registered and on treatment should be referred for HIV counseling
and testing
referrals should be recorded and tracked.
STI management
In the absence of laboratory services to diagnose STI in many health facilities, syndromic
management of STI is the core strategy of the national response. NCHADS produced Guidelines
for implementation of Sexual Transmitted Infection services in August 2001170. STI services are
seen as a priority for population groups with the highest prevalence of STI and the highest risk of
HIV infections. The Guidelines seek an appropriate balance of three complementary STI
prevention and care strategies:
integration of components of STI care as part of the Minimum Package of Activities
(MPA) at the primary health care level, combined with IEC distribution and partner
notification
specific approaches for the "early detection and treatment of persons at high risk of
acquiring or spreading STI through routine or periodic voluntary testing and screening
of high risk asymptomatic persons" (in reality this refers to female sex workers)
patient care with laboratory support at the referral hospital level through the
Complementary Package of Activities (CPA).
74
Barriers to effective STI management are the client's preference for private providers, including
traditional healers, or the use of self-medication. In addition there is very limited partner
notification and counseling available88.
5.11 Risk Behaviour Groups in Cambodia

5.11.1 Youth
In Cambodia, 33% of the population is aged 10-24 years. In 2003, UNICEF estimated that
between 26,000 to 39,000 people living with HIV/AIDS were young women aged 15-24 years
(2.0-3.0% of this population group) and between 10,000 to 15,000 were young men (0.77-1.2% of
this group). Awareness of HIV/AIDS is high, with over 94% of young people in Cambodia having
heard of HIV/AIDS. Knowledge of prevention is reasonably high with 64% knowing that having
one faithful partner can be protective; 64% knowing that correct condom use is protective and
55% knowing that abstinence is protective. However, misconceptions about incorrect routes of
transmission persist with only 60% knowing that HIV cannot be transmitted by supernatural
means and 52% knowing that HIV cannot be transmitted by mosquitoes. Sixty-two percent know
that a healthy looking person can have HIV infection. UNICEF used a composite indicator of two
prevention methods and three misconceptions to calculate that only 37% of young people aged
10-24 years in Cambodia have sufficient knowledge to protect themselves from HIV infection.
The median age at first sex for females was 21.5 years and 3% of females aged 20-24 reported
first sex before 15 years of age26.
Cultural traditions and values are changing, sometime rapidly. Sex among unmarried youth is
becoming more common in urban areas while there is increasing substance abuse among young
people88, 171. Reports of child rape and sexual abuse are increasing and some victims are badly
treated by poorly trained police and judges. Female rape survivors often have to live with lifelong
discrimination and stigmatization as "fallen women", experiencing further abuse and low selfesteem which may lead to prostitution.
Important lessons have been learned from several studies on HIV/AIDS and the sexual and
reproductive health of young people, which are summarized here. The EC/UNFPA funded Youth
Reproductive Health Programme Cambodia, which ran for four years from 1997 highlighted the
following lessons172:
urban young people have more recreational opportunities than rural youth
young women are criticized if family and neighbours perceive them to have a too
frequent social life
both urban and rural youth cited alcohol and drug use as potential sources of
recreation
almost all the youth felt that earning income to support the family was paramount
most were frightened by disease and illness, including STI, but were intensely
curious about sex and relationships, considering it natural for young people to have
sweethearts and experiment with sex
distance, ability to travel and quality of services are considerations limiting access to
sexual and reproductive health services, with rural youth more likely to face
discrimination when using such services
other barriers to services include a lack of confidence, mistrust of staff and poverty
SRH services are perceived to be for married couples and not for single youth
Tradition and culture suggest that young single women should not express interest in
SRH matters
the complex nature of values in relation to sexual and reproductive health are not
well understood, which limits the provision of relevant information for youth
young people are not well served by clinical services in Cambodia, and if aware of
NGO services, will preferentially seek these services rather than public sector
services
75
counseling for youth tends to be more based on giving advice, identifying problems
and suggesting solutions
there are broad interpretations of confidentiality among service providers that needs
to be discussed so that a more consistent approach is followed
use of mass media (radio) appears to be a powerful way to speak directly to youth
about SRH education
more information is needed about migration and the related vulnerability to SRH
problems.
In 2004, World Vision Cambodia arranged a consultancy for a highway-based HIV/AIDS

prevention, care and support project which included peer education for out-of-school or
community youth. The study examined the effectiveness of peer education for this target group
with the following relevant recommendations173:
need to clearly define the target groups
need to clarify the selection criteria for peer educators, provide a clear statement of
roles and responsibilities, improve training and follow-up and improve motivation to
minimize drop-out
need to improve linkages with other HIV/AIDS services, including HIV counseling and
testing services
need to encourage greater community participation in supporting peer education
need to increase the role of youth in monitoring and evaluation.
Cambodia is taking action to address the sexual and reproductive health needs of young people.
A review by Wilkinson of adolescent health in Cambodia in 2003174 found that adolescents were
barely mentioned in the Ministry of Health Strategic Plan 2003-2007, and that Cambodia had no
policy on adolescent sexual and reproductive health, or a multi-sectoral policy on youth. In
developing adolescent and youth-friendly services, the study noted that:
cost, convenience and confidentiality are the key factors that affect utilization of SRH
services by adolescents
for many young people there is little or no choice of where to go for services and their
reproductive health needs remain unmet
pharmacists, drug-sellers and private clinics are seen as more convenient and
confidential than government services, but cost and quality are variable
there was a demand from adolescents for a "one-stop-shop" that provides a wide
range of SRH services: a mix of contraceptive methods, STI management,
pregnancy testing, antenatal and postnatal care, post-abortion care and HIV
counseling. Comprehensive referral to other services such as abortion, information
on drug and alcohol abuse and VCT for HIV was highlighted
there is an increasing need for the provision of emergency contraception
provider attitudes are critical to service utilization by young people
Wilkinson identified the keys element for adolescent friendly SRH services in Cambodia as:
providing an enabling policy environment to develop a policy on Adolescent
Reproductive Health and a multi-sectoral policy on Youth.
improving quality of services, especially in relation to confidentiality and privacy
improving access to services by expanding STI management services, providing
emergency contraception, free (or subsidized) condoms and establishing closer
linkages between SRH services and schools
improving access to information on adolescent sexual and reproductive health by
reviewing and reprinting existing materials and developing new materials
addressing drug and alcohol abuse and gender based violence.
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The review concluded by presenting three models for adolescent-friendly reproductive health
services based on resource requirements: interventions using existing resources; interventions
requiring minimal additional resources; and interventions requiring significant additional
resources.
A complementary study by Fordham175 is one of 13 country studies on adolescent reproductive
health (ARH) in Asia and the Near East, including Cambodia and Viet Nam, funded by USAID.
This study again highlights that adolescent health is a clear priority, but with no national policy on
the subject. The study notes that:
twice as many girls as boys have no education
births to adolescent girls will double to 226,000 from 2000 to 2020
unmet contraceptive need is high for girls aged 15-19 years (37.1%) and 20-24 years
(36.1%)
there is low knowledge of reproductive health issues, including birth spacing
marriage and domestic labour are viewed as the primary goals for girls
there are double standards where adolescent girls are expected to uphold the virtues
and honour of the family by maintaining their virginity and a good reputation, but no
such strictures are placed on boys
there is substantial social pressure for young girls to marry, and the choice of partner
is still considered the right of the parents, especially for their daughters.
Adolescent and reproductive health issues that need to be addressed at the national level are:
early high-risk pregnancies (8.2% of females aged 15-19 years are mothers or
pregnant with their first child)
sex and violence, including rape, and the impact on the reputation and future of
"fallen" women
STI/HIV/AIDS with low condom use among sweethearts and links with alcohol and
violence
migrant adolescent workers from rural locations
increasing drug use
trafficking of women and children.
Fordham notes that there are no legal barriers to implement ARH activities, but there are
substantial infrastructural barriers and an apparent denial of the need for policies and programs to
target sexually active youth. He stresses the importance of school based ARH programs as well
as programs managed by communities with NGO and other support. The main recommendations
are the need to develop a national ARH policy and to conduct good qualitative research on the
sexual behaviours of specific population groups, including male sexuality and masculinity.
In response to the studies by Wilkinson, Fordham and others, draft National Guidelines for
Adolescent/ Youth Friendly Reproductive and Sexual Health Services, dated August 2005, were
being circulated for feedback at the time of writing, but not available for inclusion in this review.
5.11.2 Sex workers

There have been a number of attempts to estimate the number of sex workers in Cambodia. The
official figures from NCHADS estimate between 3,522 and 3,637 brothel based sex workers, 657
freelance sex workers and between 10,658 and 16,091 indirect female sex workers across
Cambodia in 2004, making a total of 14,837 to 20,385 sex workers of all categories88,135. HSS
and BSS data show reduced HIV prevalence among both direct and indirect sex workers, while
condom use has increased among direct sex workers, but less so among indirect sex workers.
There have been episodic government closures of karaoke bars and similar establishments which
have forced some sex workers to go underground where they are more vulnerable to abuse and
violence and more difficult to reach with prevention messages.
77
Section 5.10.1 presents details of the brothel-based 100% Condom Use Program. Lowe176, in
2002, documented the experience of sex workers involved in this Program in four sites, including
Koh Kong Province. The report found that:
The 100% CUP was not enough in itself, as sex workers continued to need to
negotiate condom use with some clients
Direct Sex Workers (DSW) are required to be registered and attend STI clinics but
this has not involved informed consent, is not confidential and there were reports that
sick and under-age sex workers were hidden from the registration process
STI clinic staff were perceived to be judgmental and vaginal examinations were rough
and painful
There was very limited sex worker involvement in the 100%CUP - compliance was
passive only
NGOs were mostly excluded from work with DSW.
In relation to HIV counseling and testing, the study found that sex workers receiving STI
management and who requested HIV tests were referred to other sites. Of those who were
tested, almost all received pre-and post-test counseling and the testing was stated to be
voluntary.
Another report relevant to this review was qualitative study conducted among 46 sex workers in
Koh Kong Province, where Marie Stopes Cambodia has a Clinic with plans to integrate HIV
counseling and testing177. This study found that most of the sex workers had only lived in the
area a short time, usually less than one year, and almost all were from Provinces elsewhere in
Cambodia or from Viet Nam. Most were working in Koh Kong voluntarily, but in the context of
family poverty and/or conflict. Many spoke of a future when they would cease sex work. The
women had sex with "boyfriends", sometimes for money, but also when there was an emotional
attachment. Sex with "guests", mostly Khmer men, was for money. Violence from clients was
reported, but the actual frequency difficult to determine. Some sex workers felt confident to
speak of 100% condom use with clients while others said it was ultimately the man's choice.
There were reported fears of STD, HIV/AIDS and unplanned pregnancies.
The presence of Vietnamese female sex workers in Cambodia is a controversial regional issue.
A three month study was conducted between July and November 2002178 with the findings that
Vietnamese sex workers in Cambodia were extremely vulnerable to HIV/AIDS. They experienced
ethnic discrimination from Cambodians, and violence, physical and sexual abuse from clients,
brothel owners and law enforcement officers. They had a high frequency of sexual contacts but
low rates of condom use. The political and economic situation encouraged them to migrate to
Cambodia for sex work. Some came voluntarily but others were trafficked into prostitution
against their will. Poverty, high mobility, discrimination, sexual abuse and human trafficking make
them a particularly important group to target with interventions, in both Cambodia and Viet Nam.
Many groups working with sex workers have developed useful prevention methods and tools. In
a project funded by the Asia Development Bank and UNDP, World Vision Cambodia in 2001 fieldtested a toolkit of prevention responses in Sihanoukville, a recognized HIV hot-spot179. The
components of the toolkit included: an outreach program to specific groups of sex workers and
their clients; IEC materials development and distribution; focus group discussions; public
campaigns; peer education; promoting available health services; social marketing of condoms
and social networking. This study was part of a regional project that included similar toolkits for
mobile fishermen and their families in Myanmar and Viet Nam. A brief summary of these toolkits
is presented in the country-specific sections that follow.
The studies noted above are focused mostly on direct or brothel-based sex workers (DSW). Two
studies on entertainment workers are presented here, as this group includes many women
classified as indirect sex workers (IDSW). One study interviewed 41 indirect sex workers in nightclubs, karaoke establishments and massage parlours in Phnom Penh in 2001180. This study was
78
limited by the Prime Minister's order to close all night-clubs, discotheques and karaoke bars on
November 20, 2001 because of reports of violence and drug trafficking. The data collection for
this survey was scheduled to commence a few days after this announcement and therefore it was
much more difficult to identify and obtain consent from these women. Key findings were:
Most women were aged between 16-25 years and had come from many different
provinces in Cambodia
Poverty, unemployment and low income attracted them to sex work
There were very different working conditions related to the expectation of providing
sexual services, depending on the type and location of employment
Some women lived on the premises and were in debt to the owner or procurer
(usually an older woman) and could not refuse sex or freely visit health practitioners
Discrimination encouraged these women to keep their illnesses secret. There was a
lack of regular health screening and a preference for drug-sellers and private sector
services which were seen as more confidential, with staff more courteous, treatment
more effective, faster and with sterilized equipment
Awareness and knowledge of HIV and STI was limited and all expressed a need for
HIV and STI education and services at a quiet location not far from their workplace,
with a preference for female service providers.
A more extensive KHANA study in 2001181 interviewed 1,594 people in five locations (including
Phnom Penh): 75% were female entertainment workers, 10% customers and 7% establishment
owners or managers. There were additional interviews with 112 NGO, UN and government staff.
The key findings were:
Young females constitute the majority of workers in the informal entertainment sector
Varied working conditions can increase vulnerability to HIV infection
There are many interconnected factors contributing to HIV vulnerability, especially
poverty, gender inequality and migration
Most workers live in shared private accommodation with co-workers
There is evidence of movement from direct sex work into entertainment work
Entertainment workers do not perceive themselves as sex workers and do not
perceive the sex they have with men during their work as high-risk behaviour. They
appear to be able to choose the men they have sex with and therefore reported
condom use is low.
Most customers view entertainment workers as sexually available and as "safe" and
"clean", again contributing to low condom use
Negotiating condom use is further complicated by the desire to avoid conflict,
violence and abuse
Alcohol consumption and/or drug use by workers or clients also reduces the ability to
negotiate condom use
Levels of harassment, violence and intimidation in the workplace are high
There are different types of relationships between workers and owners and
managers ranging from highly exploitative and controlling to more supportive
relationships
Relations between some groups of workers are competitive, especially for karaoke
workers and beer promoters, who compete for the attention of customers.
Personal health is perceived as a low priority and access is usually through
pharmacists and private clinics
There appears to be low levels of HIV discrimination in the workplaces studied.
The study recommended that:
Prevention messages should not imply that entertainment workers are involved in
commercial sex work as this is not how they perceive themselves
Promotion of condom use more widely in all relationships would allow increased
condom use for entertainment workers
79
Owner and management support could make the workplace a more supportive
environment to reduce HIV vulnerability.

Military personnel and police have been sentinel groups for both HIV Serosurveillance (HSS) and
Behavioural Surveillance (BSS) in Cambodia since 1997. Among both groups there has been a
consistent fall in HIV prevalence and, based on more recent studies, a fall in HIV incidence, along
with increased condom use with sex workers and reduced numbers of sexual partners.
Two studies among uniformed personnel are highlighted here. The first was a qualitative study in
2001 to assess risk behaviours among uniformed servicemen in Koh Kong Province182. The
study noted that police in Koh Kong had a HIV prevalence of 10.1%, more than three times the
national average for police in 2001. The key findings were:
sex with wives is not necessarily done for pleasure but rather to have children
most participants reported finding extra-marital partners if they wanted to enjoy sex
options for other partners included direct and indirect sex workers and sweethearts
sex outside marriage was common, with peer pressure a major contributing factor
frequent extra-marital sex was believed to make them stronger men among their
peers
money was an important factor in determining how frequently participants had sex
and with whom
there were generally high levels of knowledge of HIV transmission and prevention
and many had attended HIV/AIDS trainings
there was considerable discrimination towards PLHA
there was high knowledge of condom use as a means to prevent HIV infection but
several reasons were given justifying why condoms were not used: wanting to have
children, believing the partner was a virgin, fearing their partner would not think them
loyal, believing that some condoms contained HIV, and a loss of sensation. Being
drunk was the main reason why condoms were not used during extra-marital sex
Private clinics were the most popular health service used by respondents.
A second study in 2002, Strong Fighting, provides a useful outline of how cultural, gender and
behavioural factors interact among military personnel to increase their risk of HIV infection183.
Factors contributing to the decision to have sex with a partner other than one's wife were:
culture of masculinity
working away from family
excessive alcohol consumption
desire for sexual experimentation
peer pressure
availability of sex workers
high sexual drive and fear of injuring spouse
myths about masturbation
Factors contributing to the choice of sexual partner were:
excessive alcohol
risk assessment based on the woman's appearance
availability of partners
peers' choice of partners
income
misconceptions about safe partners
80
Factors influencing the decision to use condoms were:

excessive alcohol
ignorance of HIV transmission
belief in personal invulnerability
risk assessment based on partner's appearance
fear of already having HIV
ignorance about the window period for HIV infection
availability of condoms
culture of risk taking in the military
myths about condoms.
5.11.4 Mobile/ migrant Workers

Garment factory workers
Several sections of this report have mentioned the importance of providing HIV/AIDS prevention
for garment factory workers in Cambodia as this group represents a "substantial population that
could influence the course of the HIV epidemic in Cambodia"88. They are usually young women
from rural areas, living away from home in crowded and sometimes unsanitary conditions,
sometimes indebted, and cut off from family and usual social networks. Most are aware of
HIV/AIDS but have the perception that it is sex workers and their clients who are at risk, and that
the condoms are for sex with sex workers. There is now considerable experience in implementing
effective prevention interventions for this group. CARE Cambodia have published a report
describing the development and delivery of a participatory reproductive health education
curriculum to garment factory workers184. A review of the CARE program was published in
2003185. The review listed the three main components of this project as: to build the capacity of
factory health providers to deliver quality services and strengthen referral; to provide health
education in factories through peer education and peer networks; and advocacy for factory
management to improve reproductive health access and information. During this evaluation,
garment factory workers ranked nine possible services using a 0-10 scale. HIV testing scored
highest (9 out of 10) for both peer educators and their peer contacts.
Other mobile populations/ migrant workers
There is less published literature on effective interventions among other mobile populations but
with increasing recognition of the importance of reaching these groups. Two studies have
mapped HIV vulnerability among construction workers and local communities along National
Highways where major renovations have been planned. The most recent, published in March
2004186, noted that road and infrastructure development contributes to regional economic
development but can also contribute to increased HIV prevalence. This study identified hot spots
along National Highways in the north of the country. Hot spots are places where rest, petrol,
refreshments, food, overnight accommodation and sexual entertainment are provided. As the
road conditions improve there is the possibility that the numbers of sex workers will increase to
serve truck and taxi drivers. Young women in communities along the highways may be vulnerable
to economic pressures leading to sex work as the study found that the rural population were
mostly farmers, many were in debt, and young single adults and some married male adults had
moved from these communities in search of work. This study recommended that prevention
interventions need to be directed at both the construction workers and other mobile groups such
as truck drivers, and to the local communities. In addition to condom availability, voluntary HIV
counseling and testing services for both groups were needed. The second study was published
in 2000187 and mapped HIV vulnerability among National highways 1 and 5, both of which lead to
international borders. The study identified factors which could increase HIV vulnerability and
recommended that prevention efforts should involve collaboration between local communities,
construction contractors and the government.
81
Casino workers may also be an important mobile population. One study188 of casinos in Poipet
and Koh Kong, bordering Thailand, found that:
the vast majority of casino workers were young people, mostly single
almost all were functionally literate
most had moved to the casino location from other areas of Cambodia
casino work was considered desirable as it provided good income and benefits and
accompanying social status
workers usually lived and mixed with other casino employees, sometimes in casinoprovided accommodation
casino workers had some knowledge of HIV/AIDS/STI but required more
comprehensive information
all participants knew that condom use can prevent HIV infection.
Two qualitative studies of mobile populations in Koh Kong have been published by Greenwood.
One examined fishermen and noted that many had moved to Koh Kong in the early 1980s from a
variety of provinces. Income was highly seasonal and many had difficulties providing for their
families' basic needs. Social drinking, karaoke and visits to the brothels were popular
entertainment options. Condom use appeared to be low overall and condoms were not used with
sweethearts and within marriage189.
The second study, entitled "I'm not afraid of AIDS, I'm afraid of no sex", was among 60 motor taxi
drivers in Koh Kong190. All of the study participants had relocated to Koh Kong from other
provinces in the hope of finding improved fortunes, but with the collapse of the high-income
logging industry in early 1999, most now had reduced incomes, with little money for nonessentials, but did spend money on alcohol and women. Brothel based sex workers were
considered cheaper and more accessible than the more desirable karaoke workers. The study
found variable reports on condom use with direct sex workers but condom use with sweethearts
and within marriage was very low. The men had high levels of concern about STI/HIV/AIDS but
low levels of accurate knowledge.
5.11.5 Men who have sex with men (MSM)

It is estimated that there are 6,667 MSM in Cambodia with the majority aged 15-24 years, based
on projections from data obtained from studies in Phnom Penh135. There have been four recent
studies of MSM in Cambodia with reasonably consistent findings and recommendations.
The earliest study was conducted in 2000 by interviewing 206 men to assess the prevalence of
HIV, syphilis and other STIs and risk behaviours among MSM in Phnom Penh191. The majority of
MSM reported both homosexual and bisexual behaviours, with 83% having been paid for sex by
other males in the last 6 months. Over 75% used condoms consistently when buying sex from
women, but only 47% when buying sex from other men. The HIV prevalence was 14.4% and
syphilis prevalence 5.5%, with 26.5% of the sample having at least one STI, including HIV
infection. The study also identified a "considerable number" of MSM aged under 18 years who
could not be included in the study for legal and social reasons.
In September 2002, a rapid assessment of 370 MSM was conducted in Phnom Penh,
Battambang and Siem Reap192. Two thirds of the sample were aged 20-29 years, with almost all
being single and in the relatively higher socioeconomic groups. Condom and lubricant use during
sex with other men was low and inconsistent, with many myths and misconceptions about HIV
transmission. Another study conducted by FHI in late 2003 and early 2004193 confirmed earlier
findings that there are two distinct groups of MSM who do not normally mix. One group are
visible, transgender MSM, who self-identify as women and call themselves "long-hair". There is a
second hidden sub-group who self-identify as men and call themselves "short-hair". The findings
of this study concluded that there were at least 1,500 visible MSM in Phnom Penh. Most shorthair MSM are bisexual and have large numbers of sexual partners. Long hair MSM are easier to
identify and almost all members of this group sell sex.
82
The most recent study, published in January 2004194, added to this available information in
finding that MSM had low levels of knowledge of the risks of HIV infection through sex with other
men; that many, especially long-hair MSM, found it difficult to access HIV and sexual health
services and were subject to discriminatory treatment; and significantly, that MSM are a "bridge"
group for HIV transmission to the general population. Recommendations included conducting
further research; reviewing national polices and programs to address MSM; promoting the active
involvement of MSM in these activities; developing and delivering MSM sensitivity training for
police, service providers and staff of organizations targeting MSM; adopting new approaches for
Information, Education and Communication (IEC) materials for MSM; providing free condoms and
lubricant to MSM, especially long-hair MSM; and developing and delivering sexual health services
that are sensitive to the needs of MSM.
As in many other countries, HIV programs for MSM in Cambodia are hindered by the following
factors133:
denial that sex between men takes place
stigmatization of MSM
lack of epidemiological data
invisibility of MSM in the National response framework and programmatic response
harassment of MSM, particularly feminine or "long-hair" MSM, by police
rejection by families, communities, employers and others
shortage of HIV/AIDS and sexual health services that are sensitive to and nonjudgmental of the sexual health needs of MSM
inadequate information materials to address HIV/AIDS risks for MSM
5.11.6 Drug Use and Injecting Drug Users (IDUs

Public opinion seems to be that drug use in Cambodia is not an issue. However, evidence is
emerging that drug use is prevalent and associated with increased risk behaviour for HIV
infection88. Burrows, in 2003, conducted a Policy and Environment Assessment on illicit drug use
and HIV vulnerability195. He noted that responses to drug and HIV/AIDS related issues in
Cambodia had no joint policy making or planning processes. However, in the past five years,
illicit drug use has increased dramatically, with injecting drug use representing a small, but
increasing, proportion of drug users. This is in a context where there is high use of injectable
pharmaceutical drugs and vitamins by the general population. The review made
recommendations on the need to move towards a harm reduction approach through outreach to
IDUs, providing relevant and credible education, increasing access to safe injecting equipment
and condoms, drug treatment and supportive policies and legislation.
Most of the currently available data on drug use comes from the NGO Mith Samlanh/ Friends.
Among a sample of 47 Phnom Penh street youth who were injecting drugs, 15 agreed to HIV
testing and seven were HIV positive171. In addition, some IDUs are also sex workers or MSM
who are known to be highly vulnerable to HIV infection. One of the MSM studies cited above191
found that 24% of MSM were using drugs with 3% using intravenous drugs.
Mith Samlanh have also been conducting regular surveys to assess drug use among youth
involved in its programs, including street children. The data shows a clearly increasing trend with
injecting drug use in street children rising from 0.6% in 2000 to 4.3% in 2001 during a time when
the predominant practice was glue sniffing. The most recent one day survey among 2,271
children and youth up to 23 years, revealed that about half the sample had used drugs. Of these
61.5% used amphetamines and 20.7% had used heroin, both increases from previous years.
Glue use had decreased significantly196.
Mith Samlanh have published a report on the links between drug use and HIV transmission
among young people in Cambodia171. More than 1,000 people were involved in this study,
including 905 youth comprising street children, community and out-of-school youth. Nineteen
percent of the participating youth were female.
83
Key findings were that:

78% of 258 youth interviewed had used or were using some kind of illicit drug
glue and amphetamine use were most common across the country, with heroin
injection noted especially in Phnom Penh.
the most common routes of administration for amphetamines were ingestion and
inhalation, which have no HIV transmission risks, but users are at increased risk
through their sexual behaviour
glue use is mostly associated with poorer, younger males (14 and under). Older
youth tend to use glue as a second choice if amphetamines are not available
there are geographical variations in drug use which is low in Battambang and high in
Poipet. Injecting drug use is reported mostly in Phnom Penh
glue appears to be a "gateway drug" to future use of amphetamines, and entry into
the heroin drug scene is usually through peers, drug dealers and employers
there are some reports of forced use of drugs in order to be accepted into a group, or
pressure from a group leader from whom the user must then buy drugs
mobility is an important characteristic of these youth
amphetamines are seen to be "modern" and trendy and therefore attractive,
especially for males
young people believe that drugs are easy to give up, which encourages initial use
low HIV awareness and increased disposable income may increase risk for wealthier
youth
parents and families have little awareness of drug availability and the effects of drug
use and dependency.
The key recommendations relate to the need for more information on drug use patterns and
sexual behaviour of youth and the need to develop services to reduce vulnerability and manage
drug use. In response to these findings, the new National Strategic Plan for HIV/AIDS 2006-2010
acknowledges the increasing importance of injecting drug use as a high risk behaviour for HIV
infection. Primary prevention through awareness raising is stressed. The legal status of injecting
equipment and needle exchange needs to be clarified. At the time of preparing this review, Mith
Samlanh had obtained official permission from the National Authority for Combating Drugs to
launch a pilot needle and syringe program for 47 IDUs. Mith Samlanh has also opened a drug
treatment centre which averages 35 clients per month for a 14 day stay. However, there is no
data on relapse rates and the current situation regarding substitution therapy is not clear. Drug
use in prisons is not yet widespread but may become an emerging problem.
5.12 HIV Counseling and Testing Services Assessment in

Cambodia
5.12.1 Overview of HIV counseling and testing in Cambodia
A comprehensive review of Voluntary Confidential Counseling and Testing in Cambodia was
conducted by Fletcher in late 2002197. There have been significant changes in VCT services since
that date but the key findings are valuable to consider in the current situation at the end of 2005.
The review outlines the history of VCT in Cambodia and describes the situation in 2002 when
there were VCT centres managed by the government (NCHADS), NGOs and private Clinics such
as those managed by RHAC. HIV counseling was also being provided by other RHAC clinics,
partners of KHANA and the NGO Maryknoll, with referral of clients for actual testing. However,
mention was made of the many unofficial private locations where testing services were provided.
In 2002 test protocols were transitioning from ELISA tests to rapid tests. The Pasteur Institute
was playing a key role in quality control for testing but there was no standardized quality
assurance system for counseling. The issue of poor quality of counseling services, a problem still
persisting in 2005, was highlighted. The active participation of PLHA in HIV counseling and
testing services was discussed, but recommendations made in 2002 for their greater involvement
in such services have not been realized in most HIV counseling and testing services in 2005.
84
One major purpose of the review was to develop options for greater NGO/ government interaction
in VCT, and the report notes the great interest within the NGO sector for conducting trials of
different models of service delivery and concluded that "NCHADS is not averse to greater
involvement of NGOs in VCT provision".
In 2005, rapid tests are used in nearly all HIV testing centres. In general, NCHADS approves any
rapid test that meets WHO standards. The most popular tests used in public and NGO centres
are Abbot Determin, with Uni-Gold as the confirmatory test135. Serodia is another approved
and commonly used rapid-test.
Since 2004, in accordance with the Law on HIV/AIDS, all VCT centers, public, NGO or private,
are required to be registered with the Ministry of Health through NCHADS. While the registration
has yet to be strictly enforced, 58 of 86 operating VCT centers (67%) were registered by early
2005135. The main requirements for registration are:
Staff trained in counseling and testing through courses approved by or run by
NCHADS
Facilities meeting standards that are assessed by NCHADS staff conducting a sitevisit using a standardized checklist.
Key informants expressed different opinions as to whether HIV counseling and testing in
Cambodia was primarily a health-sector response or a multi-sectoral response, or both. While
VCT services are mostly within health facilities, community awareness raising and referral to
other HIV/AIDS services takes place in a multi-sectoral context. One Key Informant noted that
health staff working in other government Ministries understood the importance of HIV counseling
and testing but, as they were not under Ministry of Health (NCHADS) management, coordination
of a multi-sectoral was not as good as it could be.

The earlier testing protocol of an ELISA test followed by a rapid test (Multispot) if the ELISA test
was positive, was estimated to cost $US 1.38 per person. Two rapid tests, followed by an ELISA
test for confirmation for those who test positive on either of the first two tests was estimated to
cost $US 3.40 per person. However, the current recommended protocol involves only rapid tests.
NCHADS reports that public VCT services are provided free but cost the government around $US
6 per person which could be reduced to $US 4 as costs reduce. The Pasteur Institute charges a
subsidized cost of $US 7 and only expatriates are charged the actual cost of $US 3088.
Most Key Informants agreed that a fee could be charged based on ability to pay. However, one
Key Informant felt that VCT should be free for factory and construction workers. Others felt that
fees should be subsidized for youth and free of charge for those who are poor. A sliding scale for
fees was suggested. One Key Informant pointed out that Marie Stopes Cambodia needs to
ensure that those who cannot afford to pay know where to go for free VCT services.
5.12.3 Coverage of HIV counseling and testing services in Cambodia

The first HIV testing centre in Cambodia was opened in 1995. In 2001 it was estimated that
15,927 clients received VCT services at 14 public/ NGO sites. This represented about 20% of the
population in need of VCT services in 20013. A repeat survey in 2003 estimated that 31,233
clients had received VCT services in 2002 at 38 sites (24 managed by the government and 14 by
NGOs) in 16 Provinces and 37 Operational Health Districts198. It was estimated that 0.5% of the
adult population had received VCT in 20024. By mid 2004 there were 62 public/ NGO sites with
approved licenses providing VCT services, and in the 6 months to end of June 2004, 35,333
people were tested with between 17% and 25% positive for HIV88, 135. By August 2005 there were
95 HIV counseling and testing sites registered with the Ministry of Health155. At the time of
completing this report (January 2006) there were 109 licensed sites (Key Informant Interview,
NCHADS). NCHADS has a target of 112 VCT centres nationally by the end of 2007135.
85
The BSS 2003 data allows an assessment of utilization of VCT services by the different sentinel
groups (Section 5.2.3)94. VCT services were used by over 50% of karaoke workers and direct
sex workers for their last HIV test (32.5% for beer girls). There was lower use of VCT services by
male sentinel groups, with the last test at a VCT centre for 30.7% of the military, 10.7% of police
and 12.2% of motor-taxi drivers. The BSS Household Male Survey in 200096 found that only 12%
of men had ever been tested for HIV (7.7% rural and 25.2% urban). The CDHS 2000100 found
that only 3% of women aged 15-49 had been tested (8% in urban areas). The PSI population
survey (2003)98 noted only 5% of the men and women sampled had ever been tested (29% in
Phnom Penh) but there was a strong demand for testing. The BBC survey of 18-35 year old men
and women in 2003 found that 13% had been tested, with 43% wanting a test99.
The Key Informants made several comments related to coverage of VCT services. Available data
shows increasing numbers of women being tested, including "housewives" and factory workers.
There are also increasing numbers of children receiving testing. Several Key Informants noted
an increasing trend towards couple counseling prior to marriage, which has been promoted on
national TV, but stressed that such testing must remain voluntary. Concerns were expressed
about family conflict in the case of a woman requesting a test, which highlighted a role for couple
counseling among those already married.
The Key Informants generally agreed that a variety of HIV counseling and testing models was
both appropriate and needed in Cambodia. These included stand alone centres, VCT integrated
with public health facilities, VCT integrated with reproductive health and STI facilities, "one stop
shops" such as the Clinics managed by RHAC, the Mondul Mith Chuoy Mith centres, and mobile
clinics (although there were concerns about the cost-effectiveness of mobile clinics). A variety
models would contribute to the process of normalizing HIV testing as part of routine health care.

Section 5.7.2 on HIV/AIDS legislation gives specific information on human rights and legal issues
related to HIV counseling and testing. Other key documents are summarized here.
Policy, Strategy and Guidelines for HIV Counseling and Testing, NCHADS, 2001199
Section 2 of this document outlines the Policy for HIV testing. Key clauses state that mandatory
and compulsory testing are prohibited unless required by law; that all HIV testing must be by full
and informed agreement; and that all locations providing HIV testing must strictly follow the policy
and guidelines of the MoH and must be licensed and supervised by the MoH with staff trained
under courses approved by the MoH.
Section 3 describes the counseling and testing strategy which aims to expand counseling and
testing services throughout Cambodia, including "a variety of private sector settings"; to
standardize and disseminate a curriculum and training materials for HIV counseling; to establish
monitoring and supervision systems; and to strengthen PLHA support groups.
Section 4 provides specific guidelines for diagnostic testing and testing within voluntary
counseling and testing services. All VCT services, whether in the public or private sector, must
conform to the following standards:
they must be licensed by the Ministry of Health
they should provide testing services only to people who request these services
all testing must be accompanied by pre and post-test counseling
counseling and laboratory staff must be qualified according to MoH standards
testing procedures must conform with the testing protocol guidelines
they must maintain strict confidentiality of all test results.
86
Section 4 also gives procedures for ensuring confidentiality, guidance on pre-and post-test
counseling and supportive counseling and describes the approved testing protocol. The
document notes that NCHADS/ MoH has the responsibility to ensure quality control for all HIV
testing services in both private and public sectors, and that simple/rapid tests are recognized by
the Ministry of Health in Cambodia as acceptable, based on WHO recommendations.
Voluntary Confidential Counseling and Testing for HIV (VCCT): a guide for implementation,
(NCHADS, January 2004)200
This booklet provides updated and additional information for personnel working in VCT services
in Cambodia in the context of increased capacity for treatment and support for PLHA. The
document places VCT in the Continuum of Care with the process starting by raising community
awareness about the availability of VCT services. A separate paragraph addresses VCT for sex
workers, stressing the need for health providers to have a non-judgmental approach, avoid blame
and stigmatization, to screen for other STIs and support access to Family Planning Services.
Pre-marital counseling and testing is now an increasingly common practice, but both partners
should undergo testing voluntarily. This may be done as a couple or as separate individuals. HIV
testing in children is discussed, with the recommendation not to test for HIV antibodies until the
child is 18 months of age. VCT is acknowledged as an essential element of PMTCT. Referral for
TB screening is recommended as TB preventive therapy can reduce the incidence of active TB
among HIV+ people by 50%. Barriers to VCT are noted: stigma and discrimination; fear that the
test result will be disclosed or lack of confidentiality and privacy; and lack of perceived benefit
from testing. Quality assurance and supervision are mentioned, but not in detail, and lessons
learned from other countries are briefly presented, including the finding that "HIV counseling and
testing should be integrated into other services, including STI, antenatal and family planning
clinics and TB services".
Continuum of Care for People Living with HIV/AIDS: Operational Framework, NCHADS, 1st
Ed. April 2003156
This Framework provides further guidance for VCT services in the context of the Continuum of
Care. The framework notes several actions that need to be taken for HIV counseling and testing,
including: an assessment of current HIV testing usage patterns; recommendations of the
advantages and disadvantages of different VCT models; development of monitoring and
evaluation tools; revision of supervision tools; a national counseling network; and training and
employment of PLHA as counselors in VCT centres. The document encourages a diversity of
VCT services within the province or Operational District as "likely to increase the access to and
the utilization of VCT" with options including stand alone VCT sites located outside or inside the
referral hospital compound, VCT integrated services in Mondul Mith Chuoy Mith (Friend helping
Friends Centres), in clinical care settings, STI clinics, antenatal clinic and TB services.
5.12.5 Quality Assurance and Quality Control

Quality Assurance (QA) is defined as a set of planned and systematic activities providing
adequate confidence that requirements for quality will be met. NCHADS has the primary
responsibility for developing QA standards and for overseeing implementation, monitoring and
supervision of these standards. Supervision visits are organized at regular intervals when
supervisors check test kits, reagents, supplies, stores, equipment maintenance, record and log
books and observe the testing procedure. Quality Controls are the measures to verify that a test
is working in order to monitor the validity of the technical aspects of the test procedure. The
Pasteur Institute of Cambodia is the reference laboratory for Quality Control201.
5.12.6 Achievements
Cambodia has made significant progress in provision of HIV counseling and testing services, both
in terms of geographical coverage and in compliance with the Law on HIV/AIDS. The situation in
2001 described in Section 5.7, before the Law was passed and implemented, has improved
significantly. In 2001 there was "little awareness, much less compliance, with national policies for
HIV testing in public facilitiesMedical staff routinely test patients without informing them or
87
obtaining consent, results are sometimes withheld from the patient despite their request to be
told, test results are given to relatives and other medical staff without patient authorization, pre
and post-test counseling are often skipped and of poor quality"136. The Law and more recently
approved Implementing Guidelines have contributed to a much improved situation with respect to
human rights and the quality of the services, although important challenges remain (see Section
5.8 and below). Specific achievements include88:
improved training, supervision and procurement of equipment and reagents for public
VCT centres coordinated by NCHADS
improved capacity of the NCHADS VCT sub-unit
publication of a comprehensive set of National Policies and Guidelines
a Counseling Directory in English and Khmer developed by HACC.
5.12.7 Challenges
The Mid-Term Review of the NCHADS HIV/AIDS Strategy in 2003 included an appraisal of HIV
counseling and testing services198. At that time, the dominant model was a stand alone VCT
service. The review noted that there was widespread access to unregulated VCT services in
Phnom Penh and some major towns. There was low utilization of some public VCT services
related to poor quality of counseling, lack of confidentiality, staff attitude and financial barriers.
Although the test was meant to be free in public VCT centres, there were reports that some
clients were charged. The key challenges for HIV counseling and testing in Cambodia, collated
from a variety of recent sources88, 135, 198, and including comments from the Key Informants, are:
Access and Infrastructure
improving access and coverage: while coverage is improving, many of the potential
target population are not able to access VCT services
increasing awareness of the benefits of HIV testing and promoting the concept of
routine preventive health care, in the context of low self-perception of risk
stigma is decreasing but remains a barrier for some people.
Stigma and
discrimination in the workplace was highlighted by one Key Informant
low levels of antenatal care limits uptake of VCT for PMTCT
Stigma and Discrimination
improved ways to address potential for family conflict if a woman requests or has had
a HIV test
confidentiality is an important issue for all clients, but especially for women, youth
and high risk behaviour groups
Technical
there is no clear referral system to and from VCT centres, and counselors need more
training on the importance of referral to other services including home based care,
TB, PMTCT and ART services
inconsistent and poor quality of counseling services. One Key Informant stated that
"the success of VCT is more related to counseling than to testing"
existing supervision is limited to quantitative checklists and does not include quality of
counseling. There is no internal and external quality assessment for HIV tests for
most VCT centres
variations in HIV testing methods results in delays in providing results to clients
differences in incentives provided to VCT staff by various donors may create
problems
there are missed opportunities to link IEC/BCC to target populations
there are no mechanisms for follow-up or in-service training for counselors
there is a need for counseling support networks, especially to support counselors to
de-brief after seeing many clients
88
data collection needs strengthening. An Epi-Info based program has been used to
send data to NCHADS from VCT sites but the program has experienced some
problems. There is a need for a program with simple data entry, analysis and
reporting characteristics
private providers are doing HIV testing, with concerns about the lack of, or poor
quality, counseling, testing quality, no monitoring system and no license
issues of the credibility of results may need to be examined. One Key Informant
mentioned unconfirmed anecdotal stories that some persons were requesting a HIV
positive test, even though they had tested negative, as this would allow them to
collect a salary from their employer without having to do any work. Another story
related to persons testing HIV positive at pre-marriage testing and who requested
VCT staff to change to result to HIV negative.
5.12.8 Recommendations related to HIV counseling and testing

The following list of recommendations are collated from several sources covering the years 2001200494, 197, 198. Some significant progress has been made in addressing many of the earlier
recommendations. The Key Informants were asked to make recommendations specifically in
relation to the plans to provide integrated HIV counseling and testing in Maire Stopes Cambodia
clinics. These are presented in Section 5.14 below.
Counseling services within existing testing sites need to be improved, including
linkages between PLHA counselors and health professionals
Community-based counseling networks need to be developed, again with active
participation by PLHA
PLHA should play an active role in developing VCT services
Increasing commitment to and protection of client rights
Increasing access to and usage of VCT
Strengthening referral networks
Improved coordination through the formation of a VCT Technical Working Group
Improved linkages between policy, strategy and implementation
Improved supervision, monitoring and evaluation systems
Clear processes for quality control for testing, including external quality assessment
for all licensed VCT centres
Develop integrated VCT services in clinical settings, Mondul Mith Chuoy Mith
centres, STI clinics, antenatal clinic and TB services
Improve the social marketing of VCT to promote the services.
5.12.9 Key resource documents for HIV counseling and testing in

Cambodia
VCCT Counseling Training Manual (NCHADS), 2004202
This training manual, available in English and Khmer, has been developed based on existing
NCHADS VCT training materials, WHO and UNAIDS guidelines, the client-centered and risk
reduction model of the US Centers for Disease Control and Prevention, the technical framework
and experience of Family Health International, the training approach of the EC/AIHD AIDS Project
and ACCESS Foundation in Thailand, and the lessons and experiences of agencies providing
VCT in Cambodia, namely World Vision Cambodia, RHAC and NCHADS. The content and case
examples have been written to fit the Cambodian context and situation.
The primary objective of the training manual is to provide VCT counselors with a training that will
equip them with basic appropriate HIV counseling skills. Many of the sessions can also be used
for basic training of HIV counselors working in other health care settings or in the communities.
Because it is crucial that HIV counselors have good knowledge about HIV/AIDS, the curriculum
integrates HIV-related issues into all curriculum activities. The manual emphasizes the need for
counselors to respect clients, to give importance to confidentiality, be non-judgmental, and client-
89
centered, and understand the feelings involved when being tested for HIV and in facing up to the
effects of living with HIV/AIDS. The training comes with 12 short video sessions demonstrating
six deficient counseling sessions and six good counseling scenarios. The training emphasizes
active listening, paying attention to feelings, and the provision of preventive and supportive
counseling.
At the end of the recommended five-day training, each participant should work under the
supervision of an experienced VCT counselor for at least 3-5 days to gain some real experience
before returning to their VCT service and working on their own. The Manual notes that counselors
should be given further opportunities to continue their learning through a variety of methods such
as refresher trainings, case conferences, and sharing of experience within a counseling network.
The active participation of PLHA in training as counselors is encouraged.
The Manual is divided into 18 Activities, with Lesson Plans and supporting transparencies and
graphs. The Activities present an overview of HIV/AIDS in Cambodia (using 2002 data which
now needs to be updated); the place of VCT in HIV prevention and care; knowledge about
HIV/AIDS; risk assessment; attitudes and values; principles and skills of counseling, leading to
specific pre-test and post-test counseling; referral; and concluding with an outline of the approved
VCT policy, guidelines and protocols for Cambodia.
Health Messenger Issue 24, September 2005 on HIV/AIDS Voluntary, Confidential,
Counselling and Testing and Prevention of Mother-to-Child Transmission155
Health Messenger is a quarterly publication in Khmer and English that is widely distributed among
health professionals in Cambodia and has covered many health and HIV/AIDS subjects. The
September 2005 issue was devoted to HIV counseling and testing and PMTCT, was sponsored
by UNICEF, and published with the close cooperation of NCHADS and the NMCHC. The
contents include an overview of VCT, legal considerations, pre and post-test counseling, the
psychological perspective, overcoming barriers to HIV testing, HIV testing and quality control, the
current PMTCT situation in Cambodia, mechanisms of MTCT, PMTCT during pregnancy, PMTCT
during labour and delivery, Universal Precautions, HIV and infant feeding options and Care of the
HIV exposed infant. The issue ends with a useful dual language list of all currently licensed HIV
counseling and testing sites in Cambodia, by Province and indicating whether PMTCT services
are also provided at each site.
5.12.10 HIV testing protocol for Cambodia

The same testing protocol is used in Cambodia for counseling and testing services as for
diagnostic purposes in health institutions. This protocol will be updated from time to time by the
Ministry of Health. All serum/plasma is first tested with a simple/rapid assay for HIV antibodies.
Serum that is non-reactive on the first test is considered HIV antibody negative with posttest counseling provided for a negative result
Serum found reactive on the first assay is re-tested with another rapid assay or ELISA
Serum that is reactive on both tests is considered HIV antibody positive and post-test
counseling for a positive result is provided
Serum that is reactive on the first test, but non-reactive on the second test, must be
retested with the two assays, on the same serum sample
Concordant results after repeat testing will indicate a positive or negative test result
If the results of the tests remain discordant, the serum/blood is considered indeterminate,
and a new sample should be taken and the testing procedure repeated.
90
5.13 Marie Stopes Clinics in Cambodia

Marie Stopes Cambodia (MSC), formerly known as the Cambodian Women's Clinic, was
established as a local NGO in 1998 with financial, technical and managerial support from Marie
Stopes International (MSI). MSC is registered with the Ministry of Interior and provides
comprehensive health and HIV/AIDS services under a Memorandum of Understanding with the
Ministry of Health.
MSC currently operates three clinics in Phnom Penh, Kandal and Koh Kong provinces with a total
of 40 staff. The Chbar Ampov (Phnom Penh) clinic was established in November 2000 and has
become the service provider of choice for many women in the surrounding areas. The centre
offers a full range of sexual and reproductive health services: family planning, contraceptives and
counseling; antenatal care; STI prevention, screening and treatment; and plans to provide full HIV
testing and counseling. With funding from the EC, a Clinic offering the same services was
established in 2003 in Takhmau (Kandal Province), an area with a high proportion of young
women factory workers. In 2004 a third Clinic was established in Koh Kong, a province on the
border with Thailand. MSC also co-managed a clinic in Svay Pak, Phnom Penh with Medecins
Sans Frontiers (MSF) from June 2001, and assumed full management responsibilities in January
2002. The clinic was then handed over to Pharmaciens Sans Frontiers (PSF) in July 2003. The
number of clients receiving services at MSC Clinics has increased significantly from 2001 to
2005.
Program Results
Number of Client visits
2001
4,019
2002
6,890
2003
7,763
2004
12,895
2005
16,753
In 2005, 27.0% of all visits were for STI management, 18.1% for antenatal care, 10.4% for family
planning services, 6.4% for management of complications of abortion/safe abortion, 4% for
HIV/AIDS services and 3.5% for the tubal ligation service (with other services provided to 34.6%
of clients). The majority of clients are women (95%) with 50% employed as factory workers. In
addition, the community outreach program in 2005 trained 739 female sex workers, 1,460 factory
workers (1,106 women), 2,688 youth (1,651 young women) and 699 persons from groups such
as uniformed personnel, making a total of 5,586 who received training through community
outreach.
A detailed Site Assessment for each of the three MSC Clinics is planned as part of the
preparation phase to integrate HIV counseling and testing into the existing sexual and
reproductive health services being provided. Separate reports for these Site Assessments will be
prepared over the six months January to June 2006.
In addition to these Clinics, MSC has experience in implementing a number of Sexual and
Reproductive Health Projects with a variety of donors.
Current Projects:
The Mekong VCT project to integrate and scale-up VCT in Marie Stopes Clinics in
Cambodia, Myanmar and Vietnam with funding from the European Commission for three
years from July 2005.
A project to address the unmet need for comprehensive reproductive health information
and services among vulnerable groups and the general population in Phnom Penh,
Kandal and Koh Kong, funded by the European Commission for three years from June
2003.
Voluntary Surgical Contraception (VSC) to provide tubal ligation and vasectomy services
in MSC Clinics, with funding from Marie Stopes International, UK on an annual basis.
91
Recent Projects
A project to improve access and utilization of quality, client-focused reproductive health
services for target groups in Chbar Ampov, Phnom Penh was implemented for 12 months
from May 2002 and funded by the British Embassy in Phnom Penh.
A project to improve the sexual and reproductive health (SRH) of urban poor populations
in Phnom Penh was implemented for 12 months from March 2003 with funding from the
States of Jersey.
A project to increase awareness among the urban poor population of Phnom Penh of the
sexual and reproductive health (SRH) information and services available at the MSC
Clinic in Chbar Ampov was implemented for 12 months from January 2003 with funding
from the Hewlett Foundation.
A project called "Implementation of the Positive Lives", a campaign in conjunction with
street theatre in Phnom Penh was implemented for 12 months from June 2003 with
funding from Levi Strauss Positive Lives.
A project to promote health seeking behaviour to reduce the rate of STI/HIV transmission
among high-risk target groups in Svay Pak, Phnom Penh was implemented for 12
months in 2002 with funding from the Canadian Initiative Fund, Canadian Cooperation
Office, Phnom Penh.
A project to promote health seeking behaviour by improving access for high risk
adolescent groups in the Svay Pak area to youth friendly RH information and education
was implemented over 18 months from April 2002 with funding from UNFPA.
A project to improve access to reproductive health information and services and to
prevent the transmission of Sexually Transmitted Infections (STIs), including HIV/AIDS,
amongst garment factory workers in Phnom Penh was implemented in 2002 with funding
from Oxfam GB.
National Reproductive Health Project (1997-2001). MSI Australia worked in partnership
with the Government to implement the National Reproductive Health Project. This
included training to public and private providers of SRH services and the delivery of these
services through the creation of a reproductive health infrastructure and appropriate
protocols. Funding was from UNFPA, WHO and DFID/UK.
5.14 Recommendations for Integration of VCT into Maire Stopes

Clinics in Cambodia
The following short section brings together specific recommendations related to the integration of
VCT into Marie Stopes Clinics in Cambodia. These recommendations are derived from the
literature review and Key Informants, with some adaptation based on the author's experience. All
recommendations should be carefully reviewed by the MSC Management to determine if they are
appropriate and feasible.
The active promotion of couple's counseling should be a key strategy in providing a VCT
service. This should be integrated with an overall approach to encourage greater
involvement of men in sexual and reproductive health, in particular, the male partners of
female clients who receive STI, antenatal care and family planning services at MSC
Clinics. This should be done both through the Clinic-based services and community
outreach activities. Couple's counseling will include pre-marriage counseling and testing
as well as services for those already married.
MSC, as a provider of quality sexual and reproductive health services for women, should
develop culturally appropriate ways to encourage disclosure of results to the male
partners of woman clients and to support women who fear or experience gender-based
violence in the context of wanting or having a HIV test.
92
MSC should consider the involvement of PLHA as community outreach workers to

promote VCT services and as providers of group or individual pre-test counseling, and
possibly post-test counseling. MSC could develop and test selection criteria, training
requirements, job descriptions (roles and responsibilities) and monitor and evaluate the
role of PLHA in promotion and counseling.
Youth are a key target group for the Mekong VCT project. MSC should draw on the
experience of youth-friendly sexual and reproductive health services currently operating
in Cambodia (for example, RHAC Clinics) and the experience of MSIVN, to develop this
youth-friendly approach in its Clinics. The initial focus should be on female youth aged
15- 19 years who are currently underrepresented as clients receiving services at MSC
Clinics.
The MSC Clinics in Chbar Ampov (Phnom Penh) and Takhmau (Kandal Province) have a
significant number of female factory workers as clients. The Mekong VCT project will
allow expansion of current HIV/AIDS awareness raising through outreach, and the
promotion of VCT services among this group. While most of these women are single, the
male partners of those who are married should also be targeted for promotion of VCT
services. Similarly, while most factory workers are aged over 19 years, the small minority
aged under 19 years should be a special focus of attention for outreach activities.
MSC currently reaches sex workers through both outreach and Clinic services. The
Mekong VCT project will support the promotion of VCT services to sex workers.
MSC could also explore opportunities to reach drug users through community outreach,
with a focus on prevention of injecting drug use, harm reduction and promotion of VCT
services. Female drug users and the female partners of male drug users may be
appropriate groups for these activities.
The Mekong VCT project provides Marie Stopes Cambodia with an opportunity to actively
participate in supporting the national PMTCT program. Clients receiving antenatal
services can receive pre-test counseling, testing and post-test counseling, with those
testing positive being referred for PMTCT services. MSC may also have the opportunity
to support follow-up and referral to other HIV/AIDS services for mothers who are HIV
positive.
MSC can make a significant contribution to the strengthening of all other referral linkages
for clients who test positive to HIV/AIDS. Particular attention should be given to
increased collaboration with TB screening programs. This can be done at the facility/
district level, but also at the Provincial and national level. Increased participation in the
HACC network would provide opportunities to learn from the experiences of others and to
share MSC experiences in these areas.
MSC can effectively use the Mekong VCT project resources to develop a high quality
VCT service. This will include Monitoring and Evaluation, Quality Assurance and Quality
Control mechanisms which can support national initiatives in these areas. In addition,
MSC should participate in, and actively support, counselor networks comprising both
public and private sector VCT counselors. Stress-management skills for counselors
should be shared within these networks.
MSC needs to develop clear guidelines for any fee for the HIV counseling and testing
service . The opinion of Key Informants and Baseline Survey results (a separate report)
suggest that there are population groups able and willing to pay and others for which a
full fee would be a significant barrier to having a HIV test. MSC will need to develop a
practical and equitable working definition to identify clients for whom HIV counseling and
testing would be free or subsidised. MSC should promote "fee for service" as a strategy
to contribute to financial sustainability of the VCT service once donor funding has ended.
The active promotion of free government VCT services should be part of MSC's
community outreach to provide choice to people in deciding on where to have a HIV test.
Further partnership with NCHADS could include exploring the possibility of innovative
steps such as the secondment of government staff to MSC for short "on-the-job"
experience and the secondment of MSC staff to government VCT centres for the same
purpose.
93
6. MYANMAR SITUATION ANALYSIS

6.1 Key Indicators and Introduction for Myanmar
Key Indicators for Myanmar
Indicator
Maternal mortality ratio/ 100000 live births, 2000 adjusted (1)
HDI rank (2)
Economic
52,170,000
31%
2.02%
2.3
30%
360
76
106
61
129
50
90%
86%
80%
not available
$US 220
$US 30
1.2% [0.6-2.2]
330,000
27.5%
34.4%
1.8%
955
6.8%
34%
57%
76%
32%
(1) UNICEF, unless indicated, data is for 2004. (2) Human Development Indicators, 2005. (3) HIV/AIDS
data from most recent national sources. (4) Statistical Year Book 2003, Central Statistical Organisation,
Yangon, Myanmar.
In contrast to Cambodia and Viet Nam, there was less available published literature on HIV/AIDS
in Myanmar for this review. The most important references were the UN Expanded Theme Group
on HIV/AIDS, Joint Programme for HIV/AIDS: Myanmar 2003-2005203, the Joint Programme for
HIV/AIDS in Myanmar Progress Report 2003-2004 and Fund for HIV/AIDS in Myanmar (FHAM)
Annual Progress Report April 2004-March 2005 (one combined document)204 and a Synthesis of
Social, Behavioural and Economic Research Studies on HIV Infection and AIDS Conducted in
94
Myanmar, dated 1998205. This Section follows the same sequence as for Cambodia, but where
information is limited, some sub-sections have been combined under a single heading.
In addition to a review of publications and reports, a total of six Key Informant Interviews were
conducted with eight representatives from the government, International Organisations and
NGOs in Myanmar (Annex 3). The Key Informants interviewed in Myanmar stated that the most
important issues related to the spread of HIV were (not in any particular order):
increased vulnerability of the general population, with the epidemic continuing to
spread among high-risk behaviour groups and also moving into a more generalized
form
the need to promote wider discussion on sexual, cultural and behavourial practices to
increase awareness of HIV/AIDS
the need to develop enabling policies and the availability of reliable data to inform
programs
measures to address high levels of stigma and discrimination, both towards people
living with HIV/AIDS and Injecting Drug Users
addressing broader socioeconomic issues, such as the widening gap between the
rich and the poor
limited ability to form effective partnerships to allow scale-up of critical interventions
an urgent need to build the capacity of government, IO, NGO and private providers
involved in responding to HIV/AIDS.
6.2 HIV/AIDS Epidemiology in Myanmar

At the end of 2003, it was estimated that there were 330,000 [170,000-620,000] adults and
children living with HIV/AIDS in Myanmar, of whom 97,000 [51,000-180,000] were women aged
15-49. In the same year there were an estimated 20,000 [11,000-35,000] deaths from AIDS206.
New estimates from the Ministry of Health for 2004 show 338,911 people infected with HIV. The
HIV prevalence among adults aged 15-45 was calculated to be 1.2% in 2003 and 1.3% in 2004.
The prevalence among 15-24 year olds was estimated to be 1.65% in Yangon and 1.8% in other
locations in 2002204. By the end of 2003, a cumulative total of 7,174 AIDS cases and 3,324 AIDS
deaths had been reported206.
The adult HIV prevalence in Myanmar has been the subject of some debate. Beyer and
colleagues207 used data from the 1999 national HIV sentinel surveillance survey and other
available population data to estimate the HIV burden in 1999. The findings showed regional
variations in HIV prevalence, with the highest rates in the North, East and South, the lowest in the
West and intermediate levels in the central regions. The highest rate was in the East in the Shan
State, where the female prevalence was estimated to be 3% [1.9-4.5]. The HIV prevalence
among adults 15-44 years was "at least 3.46% [2.72-4.19]" with 218,000 [159,000-277,100]
women and 468,000 [343,300-594,000] men living with HIV/AIDS, higher than the UNAIDS
estimates for the same year.
The main routes of transmission are heterosexual (57-65%), injecting drug use (22-26%),
contaminated blood (4.4-5%), perinatal (1.8%), homosexual/bisexual (1.2%) and unknown
(13.5%)206. The UNAIDS 2004 Update for Myanmar contains many gaps where data is not
available. There is no data recorded on reported cases of STI, syphilis in women, and STI
among female sex workers. There is no data specific for young people (aged 15-24) on
knowledge of HIV prevention, reported condom use at last higher risk sex, ever used condoms,
age at first sex and adolescent pregnancies. There is limited data on access to health care.
95

HIV Sentinel Serosurveillance (HSS) started in Myanmar in 1992 and included 29 sites in 2002
and 30 sites in the most recent HSS. Surveys were conducted twice a year to 2000, and annually
since that time. Sentinel groups are male and female STD patients at STI Clinics, IDUs at
treatment centres, commercial sex workers, pregnant women at mother and child health clinics,
blood donors and new military recruits. Key trends are presented here 77, 204, 206, 208.
The HIV prevalence in IDUs was 75% in 1992, 60% in 2000, 40% in 2001, 48% in
2003 (with a range from 23% to 77% in the six sentinel sites) and 34.4% in 2004. The
apparent reduction in prevalence from 2000 to 2001 may be explained by differences
in sampling and definition of IDUs rather than a real reduction
The HIV prevalence in Commercial Sex Workers (CSW) was less than 1% in 1992,
rising to a high of 48% in 1999, reducing to 34% in 2002, 31% in 2003 (33% in
Yangon and 53.6% in Mandalay) and 27.5% in 2004
The prevalence in military recruits has risen from 0.5% in 1992 to 1.4% in 2000,
2.09% in 2003 and reduced to 1.6% in 2004
Among blood donors the prevalence has risen from 0.3% in 1992, 1% in 2000, 1.23%
in 2003 and fallen to 0.84% in 2004
The prevalence among antenatal clinic women was 2% in Yangon and 0.5% in
Mandalay in 2003, a level which has remained relatively constant in these two urban
centres for the past five years. An overall rate of 1.75% has been estimated for 2004.
However, there are lower rates in most rural areas, but ranging from 0% to 7.5%.
This means that HIV is entrenched in the lower-risk population in several parts of
Myanmar
Among male and female STI clients, the prevalence of HIV in 2003 was 6% and
12.6% respectively, and 3.2% among male STI clients in 2004.
6.2.2 National Behavioural Sentinel Surveillance

Behavioural surveys started in 1997 in two sites, one in Yangon and one in Mandalay, with
expansion in 2000 to other sites, and with further modifications to the methodology in 2002 to
include the general population and youth, as well as the sentinel groups of CSW, IDUs and men
with multiple sexual partners. Results of the BSS 2000 recorded that 7.4% of urban men had sex
with a CSW in the last six months, of whom 62.6% used condoms, and 6.3% had sex with a
casual partner, of whom 50.7% stated they used condoms208. Sixty-eight percent of men
expressed a desire to have access to HIV testing, 55% knew where to go for testing but only 5%
reported ever having undergone a HIV test204 (citing data from the National AIDS Programme
[NAP]). A national BSS survey was conducted in late 2003 by the NAP with support from WHO
and the findings were due to be published in late 2005, but were not available for inclusion in this
review. The next BSS was planned for the end of 2005 by the government, with the assistance of
a private company and the United Nations.
The UN Theme Group report204 noted an unpublished KAP study conducted in January 2005
among trishaw drivers, taxi drivers, truckers, highway drivers, fishermen and miners, as male
sentinel groups, and among female sex workers. Significant findings were:
an increased proportion of males who knew that a healthy looking person could have
HIV/AIDS (from 45.7% in January 2003 to 53.4% in January 2005
an increased proportion of males who agreed that they were confident in using a
condom (from 74.2% in January 2003 to 84.5% in January 2005)
female sex workers who considered themselves at moderate or high risk of HIV
infection had increased from 8.8% in January 2003 to 30.1% in January 2005.

STI surveillance started in 1997 and included 29 sites in 2002 with the target group being male
and female STD patients at STI clinics (identical to the HSS). Results from the 2000 study were
that 6.8% males and 7.2% females were VDRL reactive (for syphilis) in Yangon, with lower rates
in other urban centres (2.7% for males and 3.6% for females)208.
96

Myanmar
Many recent reports mention the current and potential impact of HIV/AIDS in Myanmar, but no
specific reports were located which focused in detail on this subject. The short summary
presented here is drawn from other sections of this review for Myanmar. A snapshot of the socioeconomic situation in Myanmar is presented in the Table of Key Indicators in Section 6.1 showing
high levels of literacy in the context of a relatively high maternal mortality, low per captia total
health expenditure, low contraceptive prevalence rate and relatively high rate of child malnutrition.
The official HIV prevalence rate of 1.3% translates into 338,911 people infected with HIV/AIDS
with limited treatment, care and support services currently available. Levels of stigma and
discrimination are high, limiting the effectiveness of prevention and treatment, care and support
interventions. Resources to address HIV/AIDS are limited, both financially and in terms of human
resources. The withdrawal of the Global Fund (see below) has compounded this situation.
There are very few International and Local NGOs working to address HIV/AIDS in Myanmar
compared to Viet Nam, and especially to Cambodia. Active involvement of PLHA is constrained
by the high levels of stigma and discrimination. Mass media approaches to prevention have only
recently been expanded.
Based on international experience, and the fact that HIV infection has moved from a concentrated
to a more generalized epidemic, the socio-economic impact of HIV/AIDS in Myanmar can be
predicted to be severe. There is a need for increased coordination and commitment by
government, UN agencies, International and Local NGOs, and particularly by an informed and
aware community.

Myanmar
This section is based primarily on one key reference dated 1998205. The findings reported here
allow some assessment of gender related issues, but not to the extent of a formal gender
analysis, and provide some descriptive data on risk behaviour groups. For ease of reading, the
key findings of this study are all presented here, but summarized and cross-referenced in the
sections on Gender (6.8) and Risk Behaviour Groups in Myanmar (6.11).
There are few readily available studies addressing the cultural and behavioural determinants of
HIV/AIDS in Myanmar. The 1998 report summarized here was an attempt to synthesize the
findings of many small studies that had been done in Myanmar between 1991 and 1998. The
study noted that "in Myanmar, serious information gaps in HIV infection and AIDS remain",
limiting the effectiveness of HIV/AIDS prevention interventions, a situation that remains much the
same in 2005. Epidemiological and surveillance system reports were intentionally excluded from
this study. In the absence of more recent studies, and the likelihood that many of the findings in
1998 remain valid, a summary of the key findings of this report is presented here:
Basic awareness of HIV/AIDS was quite high (90% in urban areas and 60-70% in
rural areas) and this level remained stable through the 1990s
Misconceptions regarding the transmission of HIV were widespread, especially
transmission through insect bites and sharing utensils
Condom use was low among high risk groups and the general population. Only 9%
of men and 3% of women in relatively low risk areas had ever used condoms (1997).
Reasons for non-use included reduced sexual sensation, condoms not on hand, too
ashamed to buy condoms, fear of rejection by partners, lack of trust in quality and
drunkenness. Condom use was seen to be associated with commercial sex and
infidelity and therefore heavily stigmatized. Condoms were almost never used within
marriage and were not a popular method of birth control as they were seen as more
97
expensive and less convenient than injectables and pills. There were also low levels
of belief that condoms could prevent HIV infection.
The perceived risk of contracting HIV was low among most of the population,
regardless of behaviour, with the exception of IDUs and some CSW. Perceived risk
was especially low among married women who did not engage in high risk behaviour
and tended to have "unquestionable faith" in the fidelity of their partners.
Information about the characteristics of female sex workers was unclear and there
was no information about male sex workers. Female sex workers were usually
young, poor and with little education. Many were divorced or widowed and from large
families with broken homes. They were mobile and in high demand in mining towns
and transport hubs. Rates of condom use were low: regular condom use varied
between studies from 34-62%. Brothel based sex workers had relatively good
access to health care through mandatory check-ups, but the quality of care was
questionable as the services were delivered almost exclusively through private clinics
giving antibiotic injections. Stigma and discrimination towards sex workers appeared
to vary by ethnicity, with little reported among the Shan ethnic group.
MSM were a particularly vulnerable and isolated group with little known about their
social networks and behaviours. Two groups are apparent: effeminate transgender
men among whom a few studies have been done; and covert gay men who are often
married to women and have children, of whom very little is known. Condom use was
very low (2% in one study) and they tended to have multiple sexual partners with a
low perception of risk of contracting HIV infection. There is no large scale
commercial sex trade for MSM and homosexuality is fairly well accepted in Myanmar
because of the role transvestites play in religious rituals.
Attitudes towards PLHA were "overwhelmingly hostile", based in part on
misconceptions regarding transmission and AIDS being seen as punishment for
immorality. In 1992 only 53% of medical students stated they would be willing to care
for a HIV positive patient. However, attitudes are more accepting for HIV infected
children, and there is no evidence that PLHA are abandoned by families and
communities.
A significant number of men had their first sexual contact with commercial sex
workers, and extra-marital and pre-marital sex is not "as rare as would be expected".
Among different groups reporting extra-marital sex were 76% of truck drivers, 29% of
transport workers, 16% of migrant workers, 14% of high-risk men, 13% of military
trainees, 18% of low-risk rural men and 2% of low-risk rural women. Visiting brothels
after drinking alcohol was a social group activity for some young men.
Different target groups receive health information from different sources, with TV and
video having the most potential for general dissemination of HIV knowledge. Peer
education and workplace based education is appropriate for some groups and large
posters and billboards are an important source of information for transport workers
and truck drivers.
Transport workers and migrant workers have mostly been studied only for knowledge
and sexual behaviour. Migration is usually for economic reasons and fairly common.
There is very little Knowledge, Attitudes, Practice and Behaviour data on IDUs with
most information coming from studies in institutional settings where HIV/AIDS
education leads to apparent high levels of knowledge. Syringes are illegal in
Myanmar and home-made devices are impossible to sterilize.
This synthesis report notes that much of the early research was small scale, descriptive and
quantitative. There were methodological concerns about the representativeness of the samples
and the variety of indicators, leading to a reduced ability to generalize findings, compare studies
and assess trends. The report ends with an Annotated Bibliography by year, providing reference
details and an abstract of most of the studies included in the synthesis.
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6.5 National Response, Policies and Strategic Plans in Myanmar

6.5.1 Response by the Government of Myanmar
National AIDS Program (NAP)
The National AIDS Programme (NAP) is located under the Disease Control Division of the
Department of Health, Ministry of Health. The NAP has a Central Office, a Central AIDS/STD
Clinic and AIDS counseling team in Yangon, six state/divisional AIDS/STD offices and 43
AIDS/STD control teams at the township level, covering 35 of the 63 districts in the country. The
general objective of the National AIDS Programme is to increase the awareness and perception
of HIV/AIDS in the community by promoting access to information and education leading to
behavioural change and adoption of healthy lifestyles. There are 10 specific objectives for the
NAP which address the whole community, blood safety, health worker occupational safety,
injecting drug users, data collection, care and counseling and capacity building. The Programme
is implementing several activities to achieve these objectives including HIV education and
advocacy, STD management, HIV surveillance, PMTCT, 100% targeted condom use programme,
training for service providers, school-based HIV/AIDS/STD preventive education, inter and intrasectoral coordination and collaboration with International Organisations and NGOs209.
During the Key Informant Interview with the National AIDS Control Program Manager, he advised
that the launch of the process to develop a new National Strategic Plan for 2006-2101, had just
taken place (December 2005), and the Strategic Plan should be finalised within four to six
months.
Other Government Responses
No publications were found related to progress in Myanmar towards the Millennium Development
Goals and no official Poverty Reduction Strategy appears to exist. However, one Key Informant
advised that the Rural Health Development Plan, 2001-2006 makes reference to poverty
reduction.

United Nations
The United Nations Expanded Theme Group on HIV/AIDS was established in 2003 and
comprises four representatives from the Ministry of Health, nine from UN organizations (UNDP,
UNFPA, UNICEF, UNODC, WHO and WFP), three from international NGOs, three from national
NGOs and six from the donor community. There is a Technical Working Group and five
Technical Sub-Groups: one for each component of the Programme (described below). Among
the implementing partners for the Programme are several Government Ministries: Health (NAP),
Education, Home Affairs (Central Committee for Drug Abuse Control [CCDAC]), Labour, Social
Welfare, Railways, Religious Affairs and Road Transport and Internal Waterways.
The UN Expanded Theme Group is implementing the Joint Programme for HIV/AIDS: Myanmar
2003-2005. This Programme supports the government of Myanmar's National Strategic Plan for
expanding and upgrading of HIV/AIDS activities in Myanmar, 2001-2005 and the National Health
Strategic Plan. The Programme document lists International NGO partners, including Marie
Stopes International Myanmar and several local NGOs203.
The Program document identifies several important risk factors for HIV/AIDS in Myanmar:
poverty, gender inequality, internal and external mobility, risk behaviours and generalized lack of
response capacity. This, together with an acknowledged high prevalence means that "there is a
genuine potential for this very serious epidemic to grow out of control unless an efficient
coordinated response is urgently implemented".
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The Programme, revised in April 2004, has 5 components:

1. reducing the individual risk of sexual transmission
2. reducing the risk of HIV transmission among IDUs and their partners
3. improving the knowledge and attitude related to HIV/AIDS among the general
population, particularly young people
4. increasing access and quality of care, treatment and support for PLHA
5. providing the essential elements of the enabling environment for an efficient,
expanded national strategic response.
The Programme was estimated to cost around $US88 million for the years 2003-2005. Estimates
of the total financial resources required for HIV/AIDS management in Myanmar indicate a
significant unmet need of between $US 15 to 21 million for 2006 and between $17 to 31 million
for 2007, with the higher figures applicable if Global Fund Round 5 funding is not approved204.
Using the Fund for HIV/AIDS in Myanmar (FHAM), the UNFPA has a focus on three of the Joint
Programme components: sexual transmission of HIV infection; awareness raising; and care,
treatment and support for PLHA210. The UNDP HIV/AIDS Prevention and Care Project is working
with local NGOs, Community Based Organisations (CBOs) and local volunteers to build
community capacity to develop effective responses to the socio-economic causes and
consequences of the epidemic211.
The World Bank websitexi states that, while Myanmar remains a member of the World Bank, the
Bank has approved no new lending for Myanmar since 1987 and has no plans to resume its
program as the country is currently in arrears to the World Bank and has failed to enact economic
and other reforms.
The USAID Burma country profile212 notes that the country has made some modest gains in
building capacity and designing and implementing HIV/AIDS prevention, social marketing, and
care and support activities, but highlights that the limited number of NGOs makes community
capacity building difficult to achieve. USAID opened a regional office in Bangkok in 2003 and is
developing a regional HIV/AIDS strategy that will include a Myanmar-specific response as well as
regional activities (see Section 4.3).
The World Bank Myanmar County Profile213 notes the following additional multilateral and
bilateral donor agencies providing funds for HIV/AIDS interventions in Myanmar:
AusAID (and UNICEF): Mekong Sub-Regional HIV/AIDS Program (1999-2002):
$USD 0.77 million
AusAID (and World Vision Australia): Eastern Shan State HIV/AIDS Project
(1998-2002): $USD 0.19 million
AusAID (and World Vision Australia): Southern Myanmar HIV/AIDS Project
(1998-2002): $USD 0.19 million
DFID (UK): Community action for HIV/AIDS care and support in the Mekong
Subregion (2001-2004): $USD 0.34 million
JICA (Japan): Equipment supply program for AIDS control and Blood tests
(2000-2002): $USD 0.55 million
The Global Fund Round 3 Grant Agreement for HIV/AIDS, TB and Malaria was signed on 14 Jan
2005 with a Start Date of 1 April 2005. The total funding request was $US 54 million for five
years, with approved funding of $US 19 million for the first two years and a total amount
disbursed of $US 6 million by August 2005214. However, on 18 August 2005, the Global Fund
issued a Press Release215 detailing the reasons why all Global Fund Grants to Myanmar were
being terminated. The main reasons related to new restrictions imposed by the government
xi
www.worldbank.org
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which contravened earlier assurances. The Global Fund, in consultation with the UNDP, the
Principal Recipient, concluded that the grants could not be implemented in a way that ensures
effective program implementation. The decision was made with full awareness of the proportions
of the three epidemics (HIV/AIDS, TB and malaria) in Myanmar, and the fact that, "without
resolute intervention, these diseases could soon reach catastrophic proportions, affecting the
entire region".
In Myanmar, several international organizations, including Marie Stopes International Myanmar
(MSIM), were granted sub-recipient status for The Global Fund. Four national NGOs were also
approved to participate in the project: Myanmar Council of Churches, Myanmar Anti-Narcotics
Association, Myanmar Medical Association and Myanmar Nurses Association. The Press
Release states that The Global Fund will work with the UNDP to gradually terminate activities,
including all sub-recipient contracts, by 1 December 2005.
Even though the Global Fund have decided not to proceed with disbursement for Round 3, the
details of the Global Fund proposal are summarized here as particularly relevant to the provision
of HIV counseling and testing services in Myanmar. The Goal of the proposal was "to reduce HIV
transmission and enhance care services by improving access to education, care and support for
the general population and targeted groups".
There were three Objectives
1. to reduce the risk of HIV infection through sexual transmission by expanding the 100%
targeted condom use program (CUP)
2. to reduce the risk of HIV infection among IDUs through a range of harm reduction
interventions
3. to build capacity for VCT and care and support services
Activities for Objective 1 (selected for this summary) were:
nationwide coverage of the 100% targeted CUP
strengthening STI services in public health settings
development of peer education networks for sex workers
Activities for Objective 2 (selected for this summary) were:
rapid assessment of IDUs
range of treatment modalities
drop-in centres for IDUs and peer education networks
HIV/AIDS education for prisoners
needle and syringe exchange programs
Activities for Objective 3 (in detail) were:
establish public sector VCT centres in 40 towns per year over 5 years
provision of VCT through 100 specially trained GPs
development of VCT services in 25 existing NGO/CBO services
establish 25 new public sector STI services to provide VCT, STI and
HIV/AIDS education, prevention, care and treatment services
opening 7 adolescent reproductive health centres to provide a
comprehensive range of RH services including VCT, HIV/STI prevention,
diagnosis and treatment
promoting VCT services through advocacy, mass media, IEC materials and
peer education
peer based HIV/AIDS education
establishing a range of support services in 40 towns per year over 5 years
providing ART and Opportunistic Infection (OI) treatment in 40 towns per
year over 5 years
extending PMTCT services to 40 towns per year over 5 years
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The proposal noted that access to VCT services is an entry point to related services and is a
major element of the Global Fund proposal. The proposal links directly to the UNAIDS Expanded
Theme Group Joint Program for HIV/AIDS Myanmar, 2003-2005. Innovative aspects of the
proposal are stated to be:
"VCT can now be provided by appropriate NGOs and private practitioners. The
provision of VCT services was previously confined to pubic sector services"
condoms can now be more openly promoted
harm minimization approaches have been adopted my Myanmar in the last 12
months.

As noted previously, Myanmar has relatively few International and National NGOs. However,
these are represented on the UN Expanded Theme Group, active in the Technical Sub-Groups,
and are partners in implementing interventions through the Fund for HIV/AIDS in Myanmar
(FHAM). Five NGOs have formed a Consortium to coordinate responses to HIV/AIDS: CARE
International, Myanmar Nurses Association, Marie Stopes International Myanmar, Save the
Children-UK and World Vision International Myanmar.

There was insufficient information in the available literature and reports to make any assessment
of the extent to which PLHA are involved in responding to HIV/AIDS. However, a number of Key
Informants confirmed that there were some small organized groups of PLHA and that the National
AIDS Program was involving these groups in its responses to HIV/AIDS. The International
HIV/AIDS Alliance was mentioned as being involved in the formation of some of these groups.
6.5.5 Response by business and employers: HIV/AIDS in the workplace

The FHAM Report notes that the Myanmar Business Coalition has been able to scale up
workplace based HIV interventions using FHAM support and matched contributions from the
private sector204. Little other additional information on response to HIV/AIDS from business and
employers was found. One Key Informant also mentioned the Myanmar Business Coalition, but
stated that it was mainly Yangon-based and was uncertain about any HIV counseling and testing
interventions that were being implemented by this group.

UNAIDS has monitored the frequency of articles related to HIV in a selection of 10 major periodic
publications since July 2004 and noted a trend of increasing numbers of HIV messages. In
addition, mass media using advertisements in journals, billboards, IEC and TV series have been
used to raise knowledge and awareness of HIV/AIDS, but there was no published information
assessing the impact of these interventions204.
6.5.7 Key achievements

The most recent report on achievements in responding to HIV/AIDS in Myanmar is the latest
published UN Expanded Theme Group Report204 which is summarized here. The Foreword to
the Report acknowledges that the well-prepared Myanmar County Coordinating Mechanism
proposal for the 5th Round of the Global Fund was used for much of the information in the report.
An external review of the Joint Programme in May 2005 also contributed to the report. The
achievements are presented by the Programme priorities:
1. Reducing sexual transmission.
Condom distribution has increased by 24% since 2002 (but is less than 0.7 condoms per capita
per year) and the number of patients diagnosed and treated for STI has increased by almost 50%
for the same period. Condom use by men for all five last commercial acts rose from 49% in 2003
to 76% in 2005 (citing a UN Theme Group presentation). The 100% Targeted Condom
Promotion programme was expanded to 110 townships in 2005.
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2. Reducing IDU transmission.

In the two years of operation, 14 drop-in centres have been opened in 10 strategic townships.
Half a million needles and syringes were distributed in 2004, double the number for 2003.
However, there is still low coverage of services for injecting drug users, with one estimate of less
than 5% coverage. National leadership in the field of drug reduction is provided by the Central
Committee for Drug Abuse Control (CCDAC) within the Ministry of Home Affairs along with the
Department of Health's Drug Detoxification/Treatment and Rehabilitation Unit (DDTRU). In 2006
it is anticipated that substitution therapy will be rolled-out linked to VCT.
3. Improving knowledge and attitudes of the general population.
In the last two years mass media and workplace-based messages have increased along with
expanded peer education. However, there is no national level data on recent changes in
knowledge and attitudes. A draft Communication for Behavioural Impact plan for HIV prevention
has been developed for Myanmar.
4. Increasing access to and quality of care, treatment and support of PLHA.
The report gives details on the number of persons receiving ART, number of VCT clients, number
of mother-baby pairs receiving nevirapine and numbers of PLHA receiving home based care.
These details are presented in Section 6.10 below. The report also provides updated information
on VCT which are presented in Section 6.12.
5. Enabling environment.
This component of the plan deals with advocacy, capacity building and HIV prevention in health
care settings. The report notes progress in the increased attention given to HIV/AIDS by the
government with assistance and advocacy by partners, and increased resources.
An additional achievement, which covers all the priority components of the Plan, has been the
finalization of a detailed Monitoring and Evaluation Framework.

In addition to the government structures, the main national level network for addressing HIV/AIDS
in Myanmar is the UN Expanded Theme Group on HIV/AIDS, its Technical Working Group and
five Technical Sub-Groups, where International NGOs and local NGOs are represented. Key
Informants also advised that there is a harm reduction network comprising UNODC, Medicine du
Monde, CARE and the Myanmar Narcotics Association. Other external partners of this network
include the Asia Harm Reduction Network and the MacFarlane Burnett Centre in Australia, which
provides technical assistance. The five-member NGO Consortium has been mentioned in the
Section 6.5 above. While there are some self-support groups of PLHA, there is no national level
network that brings these groups together in a coordinated way.
6.7 Legal Considerations in Myanmar related to HIV/AIDS

No recent documents detailing specific legal considerations in relation to HIV/AIDS in Myanmar
were identified for this literature review. Myanmar has passed The Child Law, dated 14 July
1993, which includes implementation of the UN Convention on the Rights of the Child and the
establishment of a National Committee on the Rights of the Child216. Some additional information
on legal issues related to HIV counseling and testing was obtained from the Key Informant
interviews, and is presented in Section 6.12.
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6.8 Gender Analysis in Myanmar

No recent published gender analysis reports for Myanmar were identified for this literature review.
A brief summary of the key findings related to gender obtained from indirect sources and detailed
in other sections of this review (especially Section 6.4) are presented here:
Almost 30% of PLHA at the end of 2003 were women or girls
The HIV prevalence in commercial female sex workers was 27.5% in 2004
Female sex workers are usually young, poor and have had little education. They are
a mobile population and regular condom use with clients is low
The HIV prevalence among women attending antenatal clinics was 2% in Yangon,
0.5% in Mandalay, and, while generally lower in rural was, was reported to be up to
7.5% in one rural location
The HIV prevalence among female STI clinic clients was 12.6% in 2003
7.2% of female STI clinic clients were VDRL positive (syphilis) in 2000
Condom use is very low within marriage and is strongly linked to commercial sex and
infidelity. Condoms are not popular for birth spacing.
Married women have a low perceived risk of HIV infection directly related to their own
low-risk behaviour and "unquestionable faith" in the fidelity of their partners
Extra-marital sex is common among some male occupational groups (truck drivers,
transport workers, migrant workers and military trainees) as well as relatively high
among lower-risk rural men
There appears to be very little information available on the female sexual partners of
male IDUs
Service coverage for VCT is low with no specific data on access to services for
women
Service coverage for PMTCT is also very low and well short of the estimated need
Little specific information is available on the burden of care but it is reasonable to
assume that women and girls in Myanmar bear a greater burden of care for family
members with HIV/AIDS
Overall literacy levels are good for women (adult female literacy rate is 81%)
There is a high unmet demand for contraception (CPR 37%) and lack of reliable
information on adolescent reproductive health, gender and male involvement in
reproductive health
Maternal mortality is high (360/ 100,000 live births) with 56% of births attended by a
trained provider and 76% of women receiving antenatal care
Very limited information is available on gender related violence including domestic
violence.
6.9 Health Services Review in Myanmar

6.9.1 Overview of Health Sector
Health Services in Myanmar are delivered through 824 government hospitals, 442 dispensaries,
86 primary and secondary health centres, 348 maternal and child health centres, 1,452 rural
health centres and 80 school health teams. There are 17,564 doctors (in both public and private
sector), 17,864 nurses and 1,767 health assistants (citing Health in Myanmar, 2005, MoH)204.
6.9.2 Sexual and Reproductive Health Services in Myanmar

The maternal mortality ratio in Myanmar is high at 360 deaths/ 100,000 live births with the main
causes being haemorrhage, infection, unsafe abortion, eclampsia and obstructed labour. The
CPR has risen markedly from 16.8% in 1991 to 32.7% in 1997 and 37% in 2001, with modern
methods accounting for 32.8%. The Fertility and Reproductive Health Survey (2001) indicated
that the most popular methods were injectables (14.8%), pills (8.6%), female sterilization (4.6%),
IUD (1.8%), male sterilization (1.5%) and condoms (0.3%). The unmet need for contraception is
104
estimated to be 16% among married women of reproductive age and would be higher if
unmarried women were included. A reproductive health assessment in 1999 found that almost all
antenatal care services, many deliveries and most treatment of obstetrical and abortion related
complications were provided by the public sector217.
Myanmar does not have a national population policy but the UNFPA contributed to the
development of a population policy in 1992 which "remains in draft." There is a scarcity of
reliable population data on which to base interventions217.
The UNFPA Myanmar website210 lists several past and current HIV/AIDS and reproductive health
related projects. A Reproductive Health Services project (2002-2005) is implemented by UNFPA,
WHO, the Department of Health and the Myanmar Medical Association to: improve and expand
reproductive health services; strengthen program management; promote access to secure,
reliable supply of contraceptives; and improve reproductive health information and research. An
Information and Education for Behaviour Change Project (2002-2005) is implemented by UNFPA
and a Japanese NGO (JOICFP) with the Department of Health Planning and the Myanmar
Maternal and Child Welfare Association (MMCWA) to deliver targeted behaviour change
communication and life skills education. A Data Analysis of Fertility and Reproductive Health
Survey project aims to utilize data collected over the past 10 years and study trends. The second
Fertility and Reproductive Health Survey was conducted in 2001. A HIV/AIDS Prevention for
Targeted Populations Group project (2003-2005) implemented by UNFPA, National AIDS
Program and Population Services International aims to expand the 100% targeted condom use
program. An Improving Adolescent Reproductive Health project (2003-2005) will increase
utilization of reproductive health services by adolescents (UNFPA, IPPF, MMCWA and Marie
Stopes International Myanmar).
The major sexual and reproductive health challenges faced by Myanmar are: a high unmet
demand for contraception; a lack of reliable information on adolescent and reproductive health;
gender inequality; and male involvement in reproductive health82.
6.10 HIV/AIDS Services Review in Myanmar

6.10.1 Prevention Interventions
This is addressed by the Joint Programme under the components to prevent sexual transmission
of HIV/AIDS (1), prevent transmission through injecting drug use (2) and improved knowledge
and attitudes (3). There is currently no data available to estimate coverage of these interventions
for the general population and for specific target groups but the results of the 2003 BSS are
expected to be available in early 2006.
Condom Promotion
This is also covered by the Joint Programme, with information available on the number of
condoms distributed and expansion of the 100% Targeted Condom Promotion program in
Myanmar. No recent impact level data is available to assess changes in reported practice in
relation to condom use, but the 2003 BSS results, when available, should provide some useful
results.
Blood safety
100% of all blood for transfusion through official channels is screened for HIV infection with the
HIV prevalence in 2004 reported to be 0.84%. No information is available on unofficial use of
blood for transfusion and the use of paid donors, who may be at higher risk, for blood transfusion.
105
Prevention of Mother-to-Child Transmission

There are an estimated 8,300 pregnancies each year to HIV infected mothers in Myanmar
leading to about 3,000 potential infections in infants. In 2001 there was very limited PMTCT
coverage in Myanmar4. However, in 2002 there were 12 PMTCT pilot sites206 and by March
2005, PMTCT services were available in 50 townships, including 36 community-based and 17
hospital-based services. In 2004, 405 mother-baby pairs of an estimated need of 18,000 pairs
nationwide received nevirapine, compared to 118 in 2002. Coverage remains low at less than
5%204.
It is significant to note that over two-thirds of all VCT in Myanmar is currently in the context of
PMTCT, which appears to be more socially acceptable than some other HIV interventions. One
Key Informant said that the acceptance rate, using an "opt-in" approach, was about 60%.
However, the limited involvement of male partners remains a major constraint to the expansion of
both PMTCT and VCT services204.
Harm reduction
The achievements described in Section 6.5.7 included significant increases in needle and syringe
distribution, but still with coverage at less than 5% of the need. Condom distribution, with
education on safer sex, forms another important component of the harm reduction approach.
While progress has been made in preparing for procurement of methadone for substitution
therapy, and Guidelines for management finalized, actual implementation is scheduled for only
four townships in late 2005 or early 2006204.
During discussions with Key Informants, particularly from the UNODC, it was confirmed that the
government have given approval to commence a methadone substitution program, but
implementation has been delayed due to problems with procurement of supplies of adequate
quality and quantity. A pilot project, involving a UN-NGO partnership will start in the N.E. Shan
State once these issues have been resolved. The Key Informants also confirmed that legal
barriers to harm reduction were being addressed and that needle and syringe exchange
programs were being actively implemented. The Harm Reduction Network of UN, IO and local
NGOs has been mentioned in Section 6.6. Further details on harm reduction approaches are
given in the discussion of Injecting Drug Users in Section 6.11.6.
6.10.2 Care, Treatment and Support Interventions

Continuum of Care
The concept of the Continuum of Care is recognized, but this has not been operationalised in
official Policies and Guidelines.
Myanmar does not yet have official government approved Policies and Guidelines for Home and
Community Based Care but there are many such activities being implemented by local
communities, local and international organizations. The Myanmar Nurses Association, with other
partners, has produced a Home Based Care Resources and Training Guide (2002). Module 5
covers counseling, stigmatization and confidentiality218.
In 2004, in addition to government health services, 11 NGOs and three UN agencies were
working to provide home-based care to more than 3,800 PLHA in about 40 townships. The
numbers of PLHA receiving home-based care has been steadily increasing since 2000 when only
144 PLHA were recorded as receiving such care. One MSF-Holland project has demonstrated a
strong commitment to the greater involvement of people with HIV/AIDS, with 80% of counselors
being PLHA. Self-help groups have been formed with support of government, international and
NGOs, but stigma and discrimination remain key factors limiting PLHA involvement204.
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Key documents to support the provision of ART have been prepared or drafted: National Care
and Treatment Guidelines for Opportunistic Infection and Anti-Retroviral Therapy in adults and
adolescents and Clinical Management Guidelines for HIV/AIDS in children. The estimated
number of PLHA who needed ART was 46,500 in February 2004. Antiretroviral therapy for
people with advanced HIV infection was initiated in Yangon in 2003. In October 2004, there were
361 patients on treatment, and by mid-2005 about 1,000 PLHA were receiving ART at
government approved centres. There were an estimated additional 1,000 to 2,000 PLHA
receiving ART in the private-for-profit sector, but with concerns about drug quality, compliance
and the development of drug resistance204.
Myanmar has one of the highest TB rates worldwide, with 97,000 new cases detected each year.
Multi-drug resistant TB has increased from 1.5% in 1995 to 4% among new patients, and 15.5%
among previously treated patients. WHO, using 2002 data, estimated that between 6.8% - 10.9%
of TB patients are co-infected with HIV and that 60-80% of AIDS patients have TB infection204, 215.
STI management
This is addressed by the Joint Programme with specific objectives and targets to increase access
to quality services following recently updated National Treatment Guidelines. The Joint Program
Annual Report notes the increase in number of patients diagnosed and treated for STI and the
increase in the number of service delivery points providing integrated STI services204.
6.11 Risk Behaviour Groups in Myanmar

This section summarises important information given in Sections 6.2 and 6.4 and provides
additional detail where this is available.
6.11.1 Youth
While 30% of the population is aged 10-24 years, there is limited youth-specific HIV/AIDS data.
The UNICEF publication, Opportunity in Crisis26 has no youth-specific data for Myanmar on: the
numbers and percentages of young men and women living with HIV/AIDS; knowledge on
misconceptions related to transmission; knowledge of prevention; the median age at first sex; and
the percentage of females aged 20-24 years who first had sex before age 15 years.
However, the UN Theme Group Progress Report released in late 2005 provides prevalence data
for 2002 for youth aged 15-24 years in Yangon (1.65%) and in other locations (1.8%), but does
not provide separate results for males and females204. This report also provides the following
youth-specific data for Myanmar (unpublished study, 2004 unless otherwise indicated):
9.9% of sexually active youth used condoms during last sex with non-regular partner
(UNGASS 2002)
85.4% of sexually active youth used condoms with paid partners and 44.5% used
condoms with casual partners
26.5% of youth had accepting attitudes towards PLHA
21% of youth correctly identified the 3 most common routes of transmissions
(UNGASS 2002)
41.6% of youth correctly identified the 3 most common routes of transmission
25.1% of youth rejected major misconceptions about transmission
2.7% of youth accessed VCT in the last 12 months
The primary focus of youth HIV interventions in Myanmar is prevention messages on life skills,
behaviour change communication, adolescent reproductive health information and HIV IEC.
Youth-friendly corners have been established by the Department of Health in 30 townships, some
in collaboration with Marie Stopes International Myanmar. Youth participation in project activities
is a key strategy for effective behaviour change. UNICEF introduced the School-Based Healthy
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Living and HIV/AIDS Prevention Education (SHAPE) program in 1998 and this is now part of the
national education curriculum in Myanmar, with 2.1 million pupils reached in the first semester of
2005. Over 54,000 teachers have received training on health and social issues, including HIV
and drugs204.
6.11.2 Sex workers

The prevalence of HIV infection among sex workers in 2003 was 31%, but with marked regional
variations (33% in Yangon and 53.6% in Mandalay). The earlier review on social and behavioural
studies (Section 6.4) presents a profile of the female sex worker: young, poor, with little
education, highly mobile and low condom use rates. Access to quality health and HIV/AIDS
services is very limited.

The prevalence of HIV infection among new military recruits has been increasing since 1992 to
2.09% in 2003 but was calculated to be 1.6% in 2004. No studies specific to this important target
group were available for review.
6.11.4 Mobile/migrant workers

Migration appears to be fairly common and usually for economic reasons. Most of the few
studies done to date have focused on knowledge and sexual behaviour. World Vision
International, with support from the Asian Development Bank, prepared and tested a Toolkit in
2001 for mobile fishermen and their families in one location in Myanmar219. The process used
Participatory Learning and Action (PLA) methods to form a village task group who then led a local
situation analysis. Capacity building was provided for the village team with the purpose of
building a HIV-resilient community through use of IEC material, PLA exercises, Focus Group
Discussions, referral for STD management and HIV testing and condom social marketing.
6.11.5 Men Who Have Sex with Men

Homosexual/ bisexual transmission is estimated to account for about 1.2% all HIV infections in
Myanmar. Section 6.4 presents available information on this vulnerable and isolated risk
behaviour group. There are two main sub-groups: effeminate transgender men and covert gay
men. Condom use is very low, multiple sexual partners common and perceived risk of HIV
infection low. There appears to be less stigma and discrimination towards transvestites who play
important roles in some religious rituals.

Injecting drug users accounts for between 22 to 26% all HIV infections in Myanmar, and among
IDUs the prevalence of HIV infection was 48% in 2003 (with a range from 23% to 77% in the six
sentinel sites). This is one of the highest rates in the world. Different sources give various
estimates of the number of injecting drug users in Myanmar. An estimate in 1999 was between
70,000 300,00085, while in 2000, one estimate was between 150,000 to 200,000 IDUs87. Key
Informants from the UNODC said that about 5 to 15% of IDUs are female.
In Myanmar, IDUs become infected with HIV early in their drug using career resulting in many
young adults who are HIV positive. Penalties for drug use are severe. The Burma Excise Act
prohibits the carrying of needles and the use of drugs is an offence in itself. Police often arrest
people for possession and users must "voluntarily" register and enter treatment or be liable to 3 to
5 years in prison. In effect, drug treatment is compulsory, orientated to total abstinence with no
substitution therapy options, and with an estimated 60-70% relapse within one month of
discharge84.
108
The situation is slowly changing. The Joint Programme and the aborted Global Fund proposal
clearly acknowledge the importance of prevention, treatment, care and support for IDUs with
several specific objectives and interventions. Preparations for substitution therapy are well
advanced, and more innovative approaches to drug-use, including drop-in centres and peer
education, are being tested and expanded.

Myanmar
6.12.1 Overview of HIV counseling and testing in Myanmar
Almost all Key Informants agreed that VCT in Myanmar was mostly a health intervention at
present, with recognition of the need to move towards a more multi-sectoral approach. Over twothirds of VCT currently occurs in the context of PMTCT. Concerns were expressed by some Key
Informants about unregulated testing in the private-for-profit sector, often without counseling and
any quality control. Current demand for VCT services was much greater than the available
services can meet.
The Joint Programme and Round 3 Global Fund Proposal both emphasise the importance of HIV
counseling and testing and recognize that VCT is an entry point for access to other HIV/AIDS
services. Currently full VCT services are only provided in the public sector through a network of
laboratories managed by 43 AIDS/STD teams at the township level, the National Health
Laboratory and township hospitals. A number of NGOs provide pre and post-test counseling but
refer patients to public services for testing, or take blood and send to the public centres for
testing. The National Health Laboratory is developing operational guidelines for accreditation to
allow NGOs and private providers to deliver testing services204.

No information of the costs of HIV counseling and testing services were found in the literature and
reports available. However, Key Informants advised that testing was officially free of charge,
including the testing of pregnant women in the PMTCT program. When asked about the
appropriateness of charging a fee for testing, there were different opinions among the Key
Informants. Some recommended a social marketing approach, but acknowledged that the fee
should probably be subsidized, unless there was a known ability and willingness to pay, or a
means test to exempt the poor from fees was used. Other Key Informants felt strongly that
testing should be free, especially to groups such as youth, and, if any fee was to be charged, it
should be very small. An amount of about $US 0.50 was mentioned as appropriate by one Key
Informant.
6.12.3 Coverage of HIV counseling and testing services in Myanmar

In 2001, there were only two public/NGO sites providing VCT services to about 13% of the
population who needed VCT services3. The follow-up coverage assessment in 20034 gave no
data on the number of VCT clients, number of sites or the percentage of adults tested in the last
year. However, by the end of 2004, 69 townships were providing VCT at 114 service delivery
points with services to 64,000 clients, compared to 800 clients in 2002204.
The opinions of the Key informants were consistent with these findings. Coverage levels were
low or non-existent in some rural areas. Generally, coverage levels were felt to be low for
women, but increasing, especially through VCT as part of PMTCT. However, coverage of VCT
for youth outside the high-risk behaviour groups was stated to be very low by most Key
Informants. One Key Informants made the useful distinction between counseling services and
testing services, stating that coverage was greater for testing than for counseling.
109
The Key Informants listed several barriers to VCT (in no particular order):
limited promotion of VCT services
a perception that there was little benefit to be gained from knowing one's HIV status
with limited post-test services available and high levels of stigma and discrimination
concerns about the consequences for women who test positive for HIV or STI
limited geographical access with the cost of transport as a barrier
limited resources for expansion of services
concerns about confidentiality and the "registration" of persons who are HIV+
current HIV counseling services are not seen as "youth friendly", especially for
sexually active youth who are not married
long waiting times
perceived poor quality of services
attitude of health providers
delay in provision of results as rapid tests are still not regularly used.
A variety of HIV counseling and testing models were suggested by the Key Informants as
appropriate and needed for Myanmar:
community-based models integrated into antenatal clinics, STI clinics and
reproductive health services
stand alone centres in major urban areas with high client loads
specialized services for specific groups such as MSM and Sex Workers, including
mobile clinics
private franchised General Practitioner-based model with GPs trained in STI and HIV
management., including VCT (Sun Network promoted by PSI).

This sub-section includes reference to key resource documents for HIV counseling and testing in
Myanmar as well as information on the approved HIV testing protocol.
Manual for HIV/AIDS Counseling
In preparation for the expansion of HIV counseling and testing services, especially linked to
PMTCT, the National AIDS Program recently published a Manual for HIV/AIDS Counseling in
2003 (available in English)220. The Manual has 5 Parts. Part 1 provides basic information on
HIV/AIDS. Part 2 addresses psycho-social-cultural issues and values, attitudes, culture and
traditions in a general sense rather than specific for Myanmar. Part 3 is the largest section,
covering all important aspects of the counseling process and skills, including pre and post-test
counseling and HIV antibody testing. Part 4 deals with special issues for women of reproductive
age, sexuality, the prevention of mother-to-child transmission and feeding options for children
born to HIV infected mothers. Part 5 presents counseling scenarios and role plays. The Annex
to this Manual provides more details on HIV testing, the medical management of opportunistic
infections and a summary of the care of HIV infected persons.
The Manual presents the three WHO recommended HIV testing strategies and states that all
three are currently used in Myanmar. Strategy 1 uses one test only for transfusion safety and
surveillance of high risk groups. Strategy 2 uses two different tests for surveillance of low risk
groups, diagnosis of cases of suspected HIV infection and diagnosis of asymptomatic high risk
persons. Strategy 3 uses three different tests for diagnosis of asymptomatic low risk persons.
However, these guidelines are under review with attention being given to increased use of
approved rapid tests204.
110
Voluntary Counselling and Confidential Testing, Operational Guidelines, Draft 2005221

As this document is still in draft form and not officially approved, only a short summary of the draft
contents is presented here. The document provides an overview of VCT with details on the
counseling process, operational procedures for HIV testing and issues of quality. Details are
provided on the infrastructure and operation of a VCT service, including linkages and referral and
the promotion and monitoring of services. The roles and responsibilities of key staff are listed,
along with recommendations for training, refresher training and supervision. Details are given of
the suggested contents of a service referral directory. Separate sections cover special issues
such as injecting drug users, sex workers, youth and children, men who have sex with men,
PMTCT and mobile populations.
Monitoring and Evaluation Framework
In order to monitor and evaluate HIV counseling and testing services, the recently released M&E
Framework for the Joint Programme 2003-2005, lists the following indicators relevant for
integrated VCT services:
% young people 15-24 years, sex workers, IDUs and men with multiple sexual
partners who report accessing VCT in the last 12 months
the number of clients by age and gender receiving HIV testing and post-test
counseling
the VCT acceptance rate among pregnant women by age
% male and female STI clients at health facilities appropriately diagnosed,
treated and counseled using standardized protocols
% health workers with accepting attitudes towards PLHA.
The National AIDS Program Manager advised that the legal age for testing was 18 years and that
parental consent would be required to test anyone under that age. During the Key Informant
interviews, questions were asked about any mandatory HIV testing practices, either as policy or
in practice. Some Key Informants advised that taxi and truck drivers were required to have a HIV
test in order to obtain a license. Key Informants were unclear as to whether HIV testing was
mandatory in the military. Key Informants were also unclear as to whether there was any practice
of mandatory testing of prisoners and drug users in treatment centres.
6.12 5 Achievements, challenges and recommendations

Clearly, much has been achieved in the provision of HIV counseling and testing services for
Myanmar, but much more remains to be done. The demand for VCT has been consistently
higher than anticipated and needs to be significantly and rapidly scaled up to strengthen both
prevention and care and support204. Some NGOs already play an important role in this process
through the provision of pre and post-test counseling. PSI have been given official approval to
provide full VCT services, including testing, in early 2006. The 2004 FHAM report222 noted:
"Strict regulations surrounding the implementation of VCCT have not allowed potentially
interested partners to provide VCCT services that include testing. Therefore it has been
impossible to scale up VCCT nationwide, despite demonstrated high demand. There
remains a high demand for counseling, while current policy is causing delays in providing
results and counseling post-testing. A policy that facilitates testing, with the availability of
HIV rapid tests, should allow rapid one-day testing".
A challenge mentioned by one Key Informant was the involvement of male partners in HIV testing
for the PMTCT program. Currently, counseling is provided to women by trained midwives, but
male counselors will be needed if men are going to participate in this program. Another
challenge, mentioned by a few Key Informants, related to the ethical questions raised by
promoting a service to know one's HIV status in the context of limited post-test services. The
expansion of ART and home care services would be an important motivating factor for VCT. In
addressing the challenge of partner notification, one Key Informants advised that this could be
done by the client themselves, or by the service provider with explicit client approval.
111
6.13 Marie Stopes Clinics in Myanmar

Marie Stopes International Myanmar (MSIM) first started providing sexual and reproductive health
services in 1997. MSIM provides comprehensive sexual and reproductive health and HIV/AIDS
services under a Memorandum of Understanding with the Ministry of Health in Myanmar.
MSIM currently manages 12 Clinics in Myanmar:
Thaketa -Yangon
Thingungyun - Yangon
Pyigyitagon -Mandalay
Mahar Aung Myay -Mandalay
Pathein - Ayeyarwaddy
Myingyan - Mandalay
Mawlamyine - Mon State
Bago Bago Division
Thanton Mon State
Chan Aye Thazan - Mandalay
Chan Mya Tharzi -Mandalay
Pyay Bago Division
The main services provided are family planning, antenatal care, STI management and HIV/AIDS
services, including pre and post-test counseling. These Clinic-based services are complemented
by community based services including family planning and contraceptive services; contraceptive
social marketing; and community outreach, peer education and counseling services for HIV/AIDS.
In 2005, the 12 MSIM Clinics provided services to a total of 122,415 clients, with 66.4% being
family planning services, 10.2% STI case management and 1.35 % for antenatal care.
MSIM currently has 360 staff in total in the 12 Clinics and Head Office. The Clinic services are
largely funded by a transparent cost-recovery process with fees charged for services. MSIM also
implements specific projects. Current projects are (from MSIA website):
Adolescent Reproductive Health Service Provision funded by UNFPA

Affordable, quality family planning and reproductive health services in Upper and
Lower Myanmar
STI services and BCC funded by Funds for HIV/AIDS Myanmar ( FHAM)
Mekong Regional VCT Project funded by the European Commission
A detailed Site Assessment for 10 of the 12 MSIM Clinics is planned as part of the preparation
phase to integrate HIV counseling and testing into the existing sexual and reproductive health
services being provided. Separate reports for these Site Assessments will be prepared over the
twelve months from January to December 2005.

Clinics in Myanmar
VCT into Marie Stopes Clinics in Myanmar. These recommendations are derived from the
recommendations should be carefully reviewed by the MSIM Management to determine if they
are appropriate and feasible.
112
The promotion of VCT services through MSIM Clinics and outreach should focus on
raising awareness of the benefits of knowing one's HIV status, together with advocacy
efforts to increase available post-test services, including treatment.
Couple's counseling for HIV testing, both pre-marriage and for those already married, can
be done. MSIM should carefully monitor this situation to promote couple's counseling.
However, current efforts to promote greater involvement of men in sexual and
reproductive health, in particular, the male partners of female clients who receive STI,
antenatal care and family planning services at MSIM Clinics, should be strongly
supported.
MSIM, as a provider of quality sexual and reproductive health services for women, should
develop culturally appropriate ways to encourage disclosure of HIV test results (and STI
results) to the male partners of woman clients, and to support women who fear or
experience gender-based violence in the context of wanting or having a HIV test.
Given the high levels of stigma and discrimination related to HIV/AIDS in Myanmar,
MSIM will need to give careful consideration to the involvement of PLHA as community
outreach workers to promote VCT services and as providers of group or individual pretest counseling, and possibly post-test counseling.
Youth are a key target group for the Mekong VCT project. MSIM should continue to
expand youth-friendly sexual and reproductive health services, especially for unmarried
female youth, with an additional focus on the promotion of VCT services. Counselors
may need additional specific training in counseling skills for youth. Resources should
continue to be allocated to outreach to in-school and out-of-school youth, including
promotion of VCT services.
Some MSIM Clinics may be well placed to expand services, including VCT services, to
reach migrant workers, particularly women.
The Mekong VCT project provides MSIM with an opportunity to actively participate in
supporting the national PMTCT program. Clients receiving antenatal services can
currently receive pre-test and post-test counseling, with testing hopefully approved in the
near future. Pregnant women who test positive can be referred to existing PMTCT
services. Depending on available resources, MSIM may also have the opportunity to
support follow-up and referral to other HIV/AIDS services for mothers who are HIV
positive.
MSIM can make a significant contribution to the strengthening of all other referral
linkages for clients who test positive to HIV/AIDS. This can be done at the facility/ district
level, but also at the Provincial and national level. Continued participation in national
level networks such as the UN Theme Group and the NGO Consortium will provide
opportunities to learn from the experiences of others and to share MSIM experiences in
these areas.
MSIM can effectively use the Mekong VCT project resources to develop a high quality
MSIM should participate in, and actively support, counselor networks comprising both
MSIM needs to develop clear guidelines for any fee for HIV counseling and testing. Key
Informants were divided on the issue of whether VCT should be free or clients should pay
a fee. If a fee is charged for some clients, based on ability to pay, MSIM will need to
develop a practical and equitable working definition to identify clients for whom HIV
counseling and testing would be free or subsidised.
113
7. VIET NAM SITUATION ANALYSIS

7.1 Key Indicators and Introduction for Viet Nam
Key Indicators for Viet Nam
Indicator
Maternal mortality ratio/ 100000 live births, 2000 adjusted (1)
HDI rank (2)
Economic
83,123,000
31%
1.6%
2.3
26%
130
17
23
71
108
83
47
90%
87%
73%
27.3%
$US 550
$US 148
<2%
0.4% [0.2-0.8]
220,000
4.4%
29.3%
0.35%
1,000+
1.8-3.0%
79%
85%
86%
28%
(1) UNICEF, unless indicated, data is for 2004. (2) Human Development Indicators, 2005
(3) HIV/AIDS data from most recent national sources
The UNAIDS Viet Nam website (www.unaids.org.vn/) provided links to many of the documents
used for this review. These included many poster presentations from the XV International AIDS
Conference in Bangkok in 2004. With a few exceptions, only those directly related to VCT were
selected for inclusion in this review.
114
In addition to a review of publications and reports, a total of seven Key Informant Interviews were
conducted with 13 representatives from the government, International Organisations and NGOs
in Viet Nam (Annex 4). These Key Informants identified the following issues as most important in
relation to HIV/AIDS in Viet Nam (in no particular order):
need to continue to focus on higher risk groups, but to include their partners and
lower risk groups as the epidemic is showing signs of becoming more generalized
the need to expand access to treatment, care and support is becoming increasingly
important
increased need to move away from a "social evil" approach to a harm reduction
approach
levels of stigma and discrimination towards PLHA, and towards IDUs and sex
workers, are high and need to be addressed
social and cultural norms need to be clearly understood in planning behaviour
change communication
broader underlying issues, particularly poverty, need to be addressed.
7.2 HIV/AIDS Epidemiology in Viet Nam

At the end of 2003 there were estimated to be 220,000 [110,000-360,000] people living with
HIV/AIDS in Viet Nam, of whom 65,000 [31,000-110,000], or 14.5%, were women. The national
HIV prevalence for 2003 was estimated to be 0.4% [0.2-0.8%] with an estimated 9,000 [4,50016,000] deaths from AIDS in the same year223. In contrast, the actual cumulative numbers of
reported cases at May 2005 were 95,512 persons with HIV, 15,539 AIDS cases and 8,965 deaths
from AIDS224.
While the majority of cases were among IDUs (63% of cumulative cases) most infections (81%)
are sexually transmitted223. The epidemic mainly affects young people and at the end of 2002,
63% of PLHA were aged 20-29 years225. The epidemic is concentrated in large cities such as Ho
Chi Minh, Hanoi and Haiphong, as well as in the provinces of Binh Dinh, Can Tho, Quang Ninh
and An Giang (along the Cambodian border)226.
Viet Nam is experiencing three somewhat separate epidemics77, 224, 227.
The most advanced is among older male IDUs in cities in the South and Central Viet
Nam, with a prevalence between 5 to 50%, and with a new group of younger men,
and some women blending with this older group.
A more recent epidemic is occurring among young male IDUs who live along the
main heroin trafficking routes and in cities in the far North.
The third pattern is among female sex workers (FSW) in the southern provinces,
many of whom are believed to have acquired the infection in Cambodia or in Viet
Nam close to the Cambodian border. Injecting drug use contributes to transmission
in this group.

Viet Nam began HIV Sentinel Surveillance (HSS) in 1994, and by 2002 was covering 40
provinces with IDUs, Female Sex Workers, male STD clients, Tuberculosis cases, antenatal
women and military recruits comprising the sentinel groups. There is wide variation in HIV
prevalence among sentinel groups from different provinces which makes summary assessments
difficult. In addition, multiple risk behaviours are apparent, especially injecting drug use among
female sex workers. However the following overall trends, complied from multiple sources, have
been observed77, 223, 224, 225, 227.
The average HIV prevalence among IDUs has increased from 9.4% in 1996 to 29.3%
in 2004 with levels of 60-70% in some provinces.
115
The overall prevalence among FSW increased from 0.6% in 1995, to 5.9% in 2002
and reduced to 4.4% in 2004. However rates remain high in Hanoi (3.7% in 1998
and 14.5% in 2002) and Ho Chi Minh City (3.1% in 1998 and 23.4% in 2002) with
"extreme variations" between provinces
The prevalence among antenatal women has increased from 0.0% in 1994, to 0.34%
in 2002, 0.24% in 2003 and 0.35% in 2004
The prevalence among military recruits has increased from 0.0% in 1994 to 0.8% in
2001 in Hanoi
The HIV prevalence among STD patients was 0.5% in 1994 and 1.6% in 1999. In
2001 the median prevalence in major urban centres was 7.25% and 1.9% outside
major urban centres.
7.2.2 National Behavioural Sentinel Surveillance and other national

Knowledge, Attitudes and Practices surveys
National Behavioural Sentinel Surveillance
Behavioral Sentinel Surveillance in 2000 (Round 1)228, 229 was conducted in five Provinces with
street based sex workers (SSW), karaoke based sex workers, IDUs and Long Distance Truck
Drivers (LDTD) in all 5 provinces, and migrant workers in specific provinces: seafarers and
fishermen in Hai Phong and Da Nang, construction workers in Hanoi and HCMC, porters and
stevedores in Can Tho. The most relevant findings were:
Street based sex workers (SSW) were older, more likely to be divorced, widowed or
separated, less mobile, more likely to have used drugs, more likely to have had STD
in last 12 months and with more sex partners than karaoke based sex workers
(KSW). Knowledge of condoms to prevent HIV/AIDS was high but actual condom
use was low and variable. High use of condoms (90%) was reported with one-time
clients for last sex for both SSW and KSW, but lower with regular clients.
Heroin and opium were the most common drugs injected by Sex Workers. The rate of
sharing needles in the last 6 months ranged between Provinces from 8% to 44%.
There was also variation in the number of sex partners in the last 12 months, with
generally very low condom use with all types of sex partners.
Of the Long Distance Truck Drivers (LDTD), two thirds were currently married, less
than 10% stated they ever used drugs, most had more than one sex partner in last
12 months and condom use with commercial sex partners was reported to be over
90%.
Behavioural characteristics varied among the different occupations of the migrant
workers. Overall, drug use was reported to be low, less than 10% had a casual sex
partner in last 12 months, but higher percentages had sex with commercial sex
partners. Condom use was low with casual partners but higher with commercial
partners.
Behavioural findings from other sources relevant to this review were:
needle sharing among IDUs in the last month was reported by between 15 to 49% of
IDUs in 200277
PLHA who used a condom during their last sex was found to be between 23 to 50%
in 200277
a study of HIV positive persons in Viet Nam recorded "extraordinarily high levels of
risk behaviour". Up to 62% of IDUs who knew they were HIV positive shared
needles, while commercial sex was higher among HIV+ men than other high risk
behaviour groups. Up to three quarters of men living with HIV reported unprotected
sex with sex workers74 (citing an unreferenced study).
116
Other Relevant KAP Surveys

Behavioural characteristics vary among different ethnic groups in Viet Nam. While national level
BSS and HSS data is not disaggregated by ethnic group, some smaller surveys have been
conducted, but their findings may not be generalized to other ethnic groups in Viet Nam. In a
cross sectional study in 2001230 in Quang Ninh province, interviews were collected from 630
people from three distinct areas: one rural district; one mountainous district inhabited by ethnic
minority groups; and one urban district. Findings were:
Premarital intercourse ranged from 9% to 16% among married men and 4% to 7%
among married women for the whole sample
Among all single men, 6% to 16% had ever had sex and fewer than 3% reported sex
with a sex worker
Knowledge of HIV/AIDS was high in both rural and urban areas but lower in the more
mountainous setting among ethnic minorities. The report concluded that the low
educational levels of ethnic groups in mountainous regions may limit the
effectiveness of written HIV/AIDS messages.
In 2000 a study on knowledge, attitudes and behaviours related to HIV, sexually transmitted
diseases (STDs), hepatitis and sexual health was conducted among a sample of 620 high school
students in grades 10, 11 and 12 at four high schools in Ha Noi231. Key findings were:
HIV was understood to be a disease largely associated with injecting drug use
The students knowledge of HIV was limited. While more than 90% of students
correctly identified transmission by sharing needles, only around 55% to 65% had
correct information about the sexual transmission of HIV. Between a quarter and a
third of students were unaware of HIV transmission through male homosexual activity
and only half knew that HIV could be passed on by someone who looked healthy
Many could not identify STDs by name or symptoms, with equally poor knowledge of
the sexual transmission of STDs
Students generally displayed non-discriminatory attitudes towards people with HIV.
The study report noted that the low prevalence of HIV in Ha Noi meant that many
students may not have met anyone with HIV/AIDS
Only a small proportion of boys (about 2%) and no girls reported sexual intercourse
which is consistent with other small studies of Vietnamese young people.

Viet Nam
In 2003, The POLICY Project published a study assessing the impact of HIV/AIDS on individuals,
families, communities, business, government and the macroeconomic setting in Viet Nam232. At
that time about 10% of the total HIV/AIDS budget in Viet Nam was spent on care and treatment
(in comparison to 65% in Thailand) with very limited access to antiretroviral therapy. The report
noted that, with the need to increase provision of care and treatment services, there will need to
be a shift in resource allocation. The review cited a 1999 study of household wealth assessment
in Viet Nam which identified limited resources and insecure livelihoods for the poorest households
who are therefore very vulnerable to increased health expenditure or reduced household income
from HIV infection.
The UNAIDS Viet Nam website contains an undated report with observations on the
socioeconomic impact of HIV/AIDS in Viet Nam233. This report presented some preliminary
findings from data collected in the Household Impact Case Study of Households of PLHA
conducted in October 2003 (for which no separate reference could be found on the website).
Relevant findings were:
increased health care costs for households with PLHA
increased funeral costs for households from deaths due to AIDS
117
loss of jobs and income by PLHA: about one third of PLHA were employed, but lost
their job due to ill health or stigma and discrimination in the workplace
loss of jobs and income by caregivers: 75% of caregivers were women and 50%
were mothers. About three-quarters of the PLHA required assistance from a caregiver for an average of 5 hours per day; one-quarter of care-givers had to give up
their job; and one third experienced a reduction in income as a result of care-giving
households with PLHA function in a highly stigmatized environment
households cope most commonly by borrowing money, often at high interest,
followed by reducing food intake and reduced health care

Viet Nam
The following paragraphs are summarised from the introduction to a study by Starink and de
Briun234. Four main philosophies/ religions underlie the spiritual life for most Vietnamese people:
Confucianism, Taoism, Buddhism and Christianity, with fusion of the first three of these with
popular Chinese beliefs and ancient animist beliefs to form Tam Giao (Triple Religion). These
cultural backgrounds influence many attitudes and practices such as:
pressure to conformity, where people are expected to follow the social order, obey
those in positions of authority and fulfil his/her duty towards family
lack of critical sense, where people are not encouraged to be freethinkers
low status and role of women in society, where there are gender divisions in relation
to labour, power and sex. Women have to be faithful and remain virgins until
marriage. In contrast, men are expected to be sexually experienced and teach their
wives. Men are considered as not being able to control themselves, and are easily
forgiven
honour and fear of losing face, which will often prevent people from doing something
illegal or immoral
sex taboo, where women are expected to be naive about sex, and never to talk about
sex and other private issues
magic thoughts/invincibility, where people can convince themselves through irrational
thoughts, and deny involvement in high risk, illegal or immoral activities
Karma in Buddhism and Hinduism is the belief that a persons actions in one life
determine fate in the next. This can lead to fatalism, passivity and despair, where
people may think that they do not have the power to change their lives or to improve
their living conditions.
7.5 National Response, Policies and Strategic Plans in Viet Nam

7.5.1 Response by the Vietnamese Government and its agencies
National Strategic Plan on HIV/AIDS Prevention and Control in Viet Nam until 2010 with a
Vision to 2020.
This is the key document outlining the response of the Vietnamese Government to HIV/AIDS.
The Strategic Plan was officially approved on March 17, 2004235. The introduction to the official
approval noted that HIV/AIDS prevention and control "must be considered a pivotal, urgent and
long-term task that requires multisectoral coordination and intensification of mobilization of the
participation of the whole society".
The National Strategic Plan presents an overview of the global and regional HIV/AIDS situation
with details on the epidemiology in Viet Nam, together with estimations of the numbers of PLHA
for 2004 through to 2010.
118
The Priority actions of the Plan are to:

intensify behaviour change information, education and communication
step up harm reduction measures
promote counseling, care and treatment for HIV/AIDS infected people
strengthen program management, monitoring, supervision and
capabilities.
evaluation
The overall objective of the Plan is to control the HIV prevalence to less than 0.3% among the
general population by 2010. The specific objectives are to:
increase HIV/AIDS prevention and control in all socioeconomic development
programs
increase people's knowledge about prevention
control HIV/AIDS transmission from high risk groups to the community through
implementation of comprehensive harm reduction interventions
ensure appropriate care and treatment for HIV/AIDS infected people
perfect the management, monitoring, supervision and evaluation systems
prevent HIV/AIDS transmission through medical services.
The National Plan recognizes the need to improve the legal documentation on HIV/AIDS "step by
step", including the review, revision and cancellation of measures no longer considered
appropriate. The National Plan allows for the provision for harm reduction activities among drug
users and female sex workers for the first time, and also refers to comprehensive antiretroviral
therapy and care services225.
One of a list of technical solutions in the Plan is to "strengthen and improve the quality of
HIV/AIDS voluntary counseling and testing activities". Among the difficulties and challenges
noted is that voluntary counseling and testing is not systematically organized due to the absence
of specific regulations and guidelines. A separate paragraph in the Plan gives more details in
relation to voluntary counseling and testing:
implement voluntary counseling and testing programs in 40 Provinces by 2005 and
100% of Provinces by 2010
integrate counseling services into health care programs, family planning, maternal
and child care and protection and primary health care
to guarantee all tests are conducted on an anonymity principle to preserve the
confidentiality of tested people
to expand voluntary counseling and testing services to the district level
to build up the voluntary test notification and referral system and mobilize the
participation of the private system in providing counseling and support
to train staff in voluntary counseling and testing and to mobilize multisectoral
participation in this work.
A Directive of the Prime Minister in Strengthening HIV/AIDS Prevention and Control236 lists the
reasons for the rapid increase in the number of HIV infected persons as due to:
an increase in social evils, especially prostitution and drug abuse
lack of coordination among Ministries and localities
inadequate community knowledge about HIV/AIDS and about people living with
HIV/AIDS
lack of comprehensive management, care, support and treatment for PLHA.
The Directive describes the lead roles to be taken by various government Ministries and how they
should cooperate in fulfilling their roles.
The Ministry of Culture and Information leads the strengthening of IEC activities
The Ministry of Public Security leads the management of people living with HIV/AIDS
in prisons and re-education centres
119
The Ministry of Labour, Invalids and Social Affairs leads the management of PLHA in
the community
The Ministry of Planning and Investment and Ministry of Finance leads budgeting
considerations
The Ministry of Education and Training has the lead role in including HIV/AIDS in the
teaching curricula in all schools
The Ministry of Health is the lead Ministry to consolidate and strengthen systems to
prevent and control HIV/AIDS, to strengthen harm reduction, epidemiological
surveillance, safe blood transfusion, PMTCT, STI management, care and support of
PLHA and to develop a proposal related to production of generic drugs.
A review conducted by The POLICY project estimated the HIV/AIDS budget needed for 2007 at
$US 214 million, with $101 million for preventive interventions and $112 million for treatment and
care. There was a large gap of $178 million between the funds available in 2003 and those
needed for 2007. Funds required for VCT were estimated to be $2.5 million in 2005, increasing
to 3.6 million in 2007232.

United Nations
The UN response in Viet Nam is coordinated by UNAIDS and the UNAIDS Viet Nam website
provided many of the references for this literature review.
On March 29, 2005 the World Bank approved a $US 35 million grant to help Viet Nam curb
HIV/AIDS by supporting locally developed and implemented plans in 18 provinces and the cities
of Ho Chi Minh and Hai Phong following the National Strategic Plan. Other recent multilateral and
bilateral donors include237:
AusAID, HIV/AIDS Capacity Building Project (2002-2004): $US 0.82 million
AusAID/ UNDP, HIV/AIDS Youth Awareness Project (2002-2005): $US 0.71
million
AusAID/CARE, Confronting HIV/AIDS (2000-2003) $US 0.35 million
AusAID, Participatory HIV/AIDS Prevention (1998-2001): $US 0.57 million
AusAID/UNDP, HIV/AIDS Awareness raising for youth, co-financing (2000-2003):
$US 1.14 million
UNDP, HIV/AIDS capacity building (1999-2001): $US 0.75 million
UNDP, HIV/AIDS, environment and youth (1999-2001): $US 0.63 million
UNDP, Strengthening the capacity for coordination, management and planning of
HIV/AIDS in Viet Nam (1994-2000): $US 1.04 million
DFID, HIV/AIDS control (2001-2002): $US 24.59 million
USAID provides support for Viet Nam through a regional HIV/AIDS office in Bangkok. USAID
supports the FHI/ IMPACT project in three high-prevalence provinces. There is cooperation
between FHI and the US Centre for Disease Control and Prevention in a joint program in
providing voluntary counseling and testing. USAID also support POLICY Project activities226.
More recently, Viet Nam has received support from the US President's Emergency Plan for AIDS
Relief (PEPFAR)) as the 15th focus country of the Plan, to receive $US 17.3 million in FY2004
and an additional $US 27.5 million in FY2005238.
Viet Nam obtained funding from Round 1 of the Global Fund for Strengthening Care, Counseling,
Support to People living with HIV/AIDS and Related Community-based Activities to Prevent
HIV/AIDS in Viet Nam239. The Grant agreement was signed on 5 September 2003 with a start
date of 1 February 2004. The total funding request was for $12 million, of which $7.5 million had
been approved, and $6.8 million disbursed (at September 2005).
120
The funding is to be used to establish community based networks of "care and support" and
capacity building for local health workers. This includes the provision of VCT, community-based
care, hospital care and PMTCT in 20 provinces/cities with the highest prevalence. The main
objectives of this Global Fund activity are to:
strengthen HIV/AIDS care, counseling and support networks
provide access to care and support services for 90% of PLHA in 20 provinces/
cities and increase the number of PLHA on ART to 750 by the second year
provide 100,000 pregnant women at antenatal care with information on HIV and
access to PMTCT and provide appropriate care and support to HIV positive
children by the end of the second year.
The planned activities related to VCT are: to develop and finalise HIV/AIDS care-related policies
and regulations, guidelines and training modules (including VCT and PMTCT) and to pilot models
of HIV/AIDS care and support, VCT and PMCT. The intended results are to establish VCT
services in the 20 provinces/cities and to provide information on HIV and access to VCT to
100,000 pregnant women receiving antenatal care in these areas.

There are a number of NGOs working with the government to respond to HIV/AIDS in Viet Nam
(see Section 7.6). These include CARE Viet Nam, Family Health International and World Vision
Viet Nam. Representatives from all three NGOs were interviewed as Key Informants. FHI have
three principle strategies in Viet Nam240:
to promote public health approaches through VCT services, risk reduction, BCC,
outreach and application of BSS data to interventions
capacity building of individuals and organizations
to develop and implement effective behaviour change and risk reduction
interventions among vulnerable populations.

In 2003, CARE and The POLICY Project released a study assessing the involvement of People
Living with HIV/AIDS in responding to HIV/AIDS in Viet Nam241. The study was based on a desk
review and in-depth interviews with key policy makers and programmers, with verification by
PLHA. The official government position is to give strong political commitment to support the
GIPA principle, and there is an expectation that a more enabling environment to allow this is
emerging. The Key Informants described the rationale for the greater involvement of PLHA as: to
reduce stigma and discrimination; to increase the effectiveness of policies and programs; and
to improve the lives of PLHA. However, the study concluded that, in practice, PLHA were
primarily seen as a "target audience" and occasionally as "contributors" and "speakers", all
degrees of tokenism. The barriers to more active participation were found to be:
lack of capacity among PLHA and service providers
high levels of stigma and discrimination, especially related to IDU
insufficient funds
lack of a legal framework for civil society groups
high levels of poverty among most PLHA
7.5.5 Response by business and employers: HIV/AIDS in the workplace and

Media response to HIV/AIDS
There was insufficient information in the literature and reports available for this review to make
informed comments on the response by business and employees to HIV/AIDS and the approach
taken by the media to support HIV/AIDS interventions.
121

The UNAIDS Viet Nam website contains a 58 page document with the names, contact persons
and details, background, locations, activities, target groups, funding agencies and outlook for five
Vietnamese NGOs, 29 International Organisations and five United Nations bodies, as well as The
Global Fund in Viet Nam, the Asia Development Bank and Regional Program partners242. The list
was complied in 2002 and an updated version is needed. The same website also contains an
Excel spreadsheet dated 2004, with a list of organizations, programs, areas of operation, target
groups and timelines, and with columns to indicate which interventions are being implemented:
BCC, harm reduction, care and support, monitoring and evaluation, treatment, PMTCT, STI
management, safe blood and capacity building243. Surprisingly, there is no mention of HIV
counseling and testing as an intervention, although counseling is listed as an activity under BCC,
but probably does not refer to pre or post test counseling.
7.7 Human Rights and Legal Considerations in Viet Nam related

to HIV/AIDS
The Government of Viet Nam has passed many Laws, Decrees and Ordinances directly or
indirectly related to HIV/AIDS since 1992. This Section summarises the current situation, but
refers earlier legislation to demonstrate significant changes in the legal response to HIV/AIDS in
Viet Nam. The UNAIDS Viet Nam website, <Action at National and Local Levels>, gives a list of
Legal Documents with links to English and Vietnamese language copies. A study by Nguyen Duy
Tung et al on data related to HIV/AIDS/STD and commercial sex workers in Viet Nam gives a list
of various government Laws, Decrees and Ordinances related to prostitution244. The legal
situation in relation to drug use and Injecting Drug Users is covered in detail in Section 7.10.
In October 2005, the Health Ministry submitted a draft Law on Prevention of HIV/AIDS to the
National Assembly Standing Committee. The Law is designed to protect the human rights of
people living with HIV/AIDS, fight discrimination and stigma, ensure personal secrecy and legal
rights, strengthen responsibilities of the family and society, and to abide by the basic principles of
international laws on HIV/AIDS prevention. This draft Law addresses many of the concerns
raised about the existing ordinances245.
One of the earlier legal documents related to HIV/AIDS was Government Decree No. 34-CP of 1
June, 1996 guiding the implementation of the Ordinance on the prevention and control of
HIV/AIDS infection246. This Ordinance had the following features:
Section 1 stated that information, education, and communication on HIV/AIDS is to
include measures for the prevention and control of drug abuse and prostitution; the
adoption of a healthy lifestyle; and measures to reduce the risk of the spread of
HIV/AIDS. Under Section 3, it was prohibited for persons with HIV infection/AIDS to act
in any manner likely to spread the disease and, in particular, to donate blood, sperm,
tissues, organs, or body parts. Section 4 required any person with a positive result
following a HIV/AIDS screening test to immediately inform his or her spouse and take
measures to prevent the spread of the disease, failing which this is to be done by the
medical establishment.
Sections 5 to 10 dealt with the responsibilities of the various parties concerned: directors
of hospitals and medical establishments, the mass communications media, families and
communities, employers, etc. Section 8 states that directors of hospitals or medical
establishments have the authority to request a "risk HIV/AIDS person" to have a HIV test.
Section 11 states that when a HIV/AIDS infected (foreign) person enters Viet Nam,
he/she has to declare their health situation at the border's medical checkpoint.
122
Sections 12 and 13 relate to the roles and responsibilities of the National AIDS
Committee. Section 13.3 states that the Ministry of Health shall have responsibility to
organize tests and create favorable conditions for Vietnamese and foreigners in Viet Nam
to voluntarily have tests to detect HIV/AIDS infection and to provide counseling on the
prevention and control of HIV AIDS infection for the persons who come for tests.
Sections 14 to 17 deal, respectively, with the duties of the Ministry of Culture and
Information, the Ministry of Education and Training, the Ministry of Labour, War Invalids
and Social Affairs, and the Ministry of Finance. Section 18 refers to the roles of the
People's Committees at all levels. These include a duty to ensure that HIV/AIDS
prevention and control is closely associated with the prevention and combat of
prostitution and drug abuse; to mobilize and guide the people to take part in the medical
and mental care for HIV/AIDS patients; and to "ensure that they are not treated in a
discriminatory manner and facilitate their integration into the community."
Under a Decree dated 15 May 2003247, the Ministry of Health is responsible for regulating the
professional and technical standards for HIV/AIDS and to act as the standing office on HIV/AIDS
for the National Committee for HIV/AIDS, Drugs and Prostitution Prevention and Control. A
separate document dated 15 August 2003248, states that the General Department of Preventive
Medicine and HIV/AIDS Control is "mainly responsible for the development of strategy, masterplans and plans for HIV/AIDS control". Viet Nam also enacted legislation in 2003 in relation to
International Cooperation in the Field of Drug Prevention and Combat249. This document refers to
drug addicts, drug-related crimes and other drug-related illegal acts as "drug evils for short".
In November 2003, CARE International in Viet Nam published a review examining international
law, national policy and legislation for the prevention of HIV/AIDS and protection of human rights
of PLHA in Viet Nam250. The key findings were:
Despite positive steps, "there remain shortcomings, both in law and in reality, in
protecting the human rights of patients in general and of people living with HIV/AIDS
in particular"
The information currently disseminated is based more on the need to prevent HIV
transmission than on human rights based principles and practices
The law does not contain provisions specifically for associations of PLHA
Sections of the Ordinance on the Prevention and Control of HIV/AIDS (see above)
need to be reviewed and revised to include the rights and obligations of PLHA
Other Laws that should be reviewed include the Law on the Protection and Health of
People, 1989 which provides for mandatory treatment of persons with HIV/AIDS and
the Law on Marriage and the Family which requires foreigners to produce evidence
that they are HIV negative before marriage to a Vietnamese citizen
In relation to HIV counseling and testing, the review notes that this should be on a
voluntary basis with respect for dignity and fundamental human rights. Specific
recommendations are that more establishments should be opened with various forms
of counseling, and to ensure a high standard of specialised counseling.
In relation to other international Conventions, Viet Nam has ratified the Convention of the
Elimination of all forms of Discrimination Against Women (CEDAW), the International Convention
of Civil and Political Rights in 1982, the International Convention on Economic, Social and
Cultural Rights, the Convention on the Elimination of all Forms Racial Discrimination and the
Convention on the Rights of the Child in 1990 (with two Optional Protocols signed in 2000).
However, Viet Nam is not yet a signatory to the Convention Against Torture and Other Cruel and
Inhuman or Degrading Treatment or Punishment251.
123
Stigma and discrimination is a critical issue in responding to HIV/AIDS in Viet Nam. Among the
reasons given for stigma and discrimination towards people living with HIV/AIDS are16, 250, 252, 253:
fear for one's own personal safety because of an over-estimation of the
infectiousness of HIV. People generally understand ways in which HIV is transmitted
but ambiguity persists, leading to fears of acquiring HIV casually with the adoption of
actions that stigmatize PLHA in an attempt to avoid infection
a view of PLHA as individuals involved in social evils. In the minds of the community,
leaders and health workers, HIV/AIDS is "inextricably linked" to drug use and sex
work, which are both regarded as social evils
a perception that PLHA can no longer work and cannot contribute to society and the
family
a perception that PLHA carry a "moral" disease, and that priority should not be given
to such a group when there are many other groups in society who need to receive
attention
women with HIV/AIDS tend to be more highly stigmatized than men on the
assumption that HIV is acquired through immoral means and the expectation of
society that women should uphold the morality and integrity of family and society.
However, there are also encouraging signs in relation to stigma and discrimination. One study in
Can Tho and Hai Phong, published in 2004, found that "despite the stigma and discrimination,
most PLHA receive love, care and support from their families and compassion from some
members of their communities"253. At the national level the National Strategy 2004-2010 openly
acknowledges the increasing HIV epidemic and the increased sexual transmission of HIV, fully
recognizes the problem of stigma and discrimination and identifies the roles of the Party,
government, mass organizations and the community to combat stigma and discrimination252.
7.8 Gender Analysis in Viet Nam

For a more complete gender analysis and to avoid unnecessary repetition, this Section should be
read in conjunction with Section 7.4 on the cultural and behavioural determinants of HIV/AIDS,
Section 7.7 on human rights and legal considerations, Section 7.9.2 on sexual and reproductive
health services and Section 7.11 which describes several high risk behaviour groups.
The study by Starink and de Bruin in 2001234 included a literature review on the position of
women in Viet Nam. The review found that women were at a definite disadvantage economically,
politically, socially and culturally. This position of relative weakness made women more
vulnerable to HIV/AIDS. The review examined the impact of the economic shift to a free market
economy which has promoted competition and increasing consumer choice. In the context of
high urban unemployment and the rural to urban population shift, one negative impact has been
pressure on poor women to enter the sex industry in order to obtain an income (see also
Sheehan254). There was a perception of women as vessels and vectors of HIV transmission
which leads to women being blamed for transmitting the infection.
Most women in Viet Nam lack knowledge, skills and power to negotiate safe sex because the
Vietnamese culture does not encourage women to address this, especially not with their partners
(see also Sheehan254). According to traditional Vietnamese values, women are responsible for
the household, childcare and the happiness of their family and "a good wife should have
kindness, tidiness, domestic skills but most of all obedience as her virtues".
A qualitative study published in 2002255 used in-depth interviews and focus groups with 18 men
and 18 women in the general population in northern Viet Nam to assess how traditional gender
roles may affect Vietnamese women's interpretation of STD symptoms and health seeking
behaviour. The findings were that a married woman in northern Viet Nam was expected to
behave in a faithful and obedient manner towards her husband. However, traditional norms were
124
more permissive in their tolerance of premarital and extramarital sex for men. In relation to STDs,
both men and women expressed anxiety about telling their partners about an STD. Women's
expressions were characterized more by fear of social and physical consequences, whereas men
expressed embarrassment.
A separate study has examined violence towards women in Viet Nam in some detail251. While
the Vietnamese Constitution grants de jure equality between men and women in political,
economic, cultural, social and family spheres, violence and other discrimination against women
still persist in Viet Nam. Traditionally, women in Viet Nam were considered to enjoy special
position and privilege in the family and in society compared to women in other countries in the
region. However, the arrival of Confucianism 1000 years ago is understood to have weakened
this traditional gender equity, which was only formally restored by the Socialist government in
modern times.
This study noted many positive features in relation to the position of women in Viet Nam.
More than 50% of women are members of the Vietnamese Women's Union, an
organization which should be consulted and involved in any discussions on women
and children at all levels of government.
There is a National Committee for the Advancement of Women, the peak government
body addressing women's issues
Vietnamese women enjoy relatively high levels of health, education and gender
equity compared with other countries in the region and States with comparable gross
domestic product. However, there are important differences for rural areas and
among minority ethnic groups where 60% of women give birth without a qualified
birth attendant and where many rural health centres have inadequately trained staff,
poor quality equipment and supplies and limited budgets256
Women are entitled to equal access to educational opportunities, which has been
largely realized for primary and secondary education, but less so for tertiary
education. However, 20% of women from the poorest quintile are illiterate256.
The main areas where gender inequality remains an important issue are256:
Labour: women constitute 52% of the total labour force but are concentrated in lower
status occupations with substantially less income (72% of the male salary for
equivalent work). With the shift to a market economy, women have been pushed into
more precarious household and informal sector work.
Land ownership: in theory there is legal equality in relation to land ownership but
women frequently depend on male relatives for access to land. 80-90% of land titles
are in the husband's name, creating difficulties for divorced or widowed women
Age for Marriage: men and women are legally considered equal, but the minimum
age for marriage is 20 for men and 18 for women
Indigenous and Minority Women face multiple layers of discrimination based on
gender and ethnicity: they are geographically isolated, have higher levels of poverty,
ill health and reduced access to services
Access to credit: women have less access to formal credit (more women are
customers of mass organizations credit funds).
Violence against women in the family has been given limited attention by the government and
there is no accurate data, as many victims do not report domestic violence. In 1999, a
comprehensive study commissioned by the World Bank (cited by Bourke-Martignoni251) described
domestic violence as "a very real and widespread issue in Viet Nam, affecting women from all
social and geographical groups". Wife battering was not perceived as a criminal act, despite
provisions in the criminal law against such actions. The term "marital rape" is unknown in Viet
Nam but there is evidence of "forced" sex in marriage. Reported acid attacks on women as
punishment for alleged adultery are increasing in number. The re-emergence of a bride price in
some areas of Viet Nam has also been noted with concern.
125
Violence in the community includes rape and other forms of sexual violence. This is covered by
criminal law and, while there are an increased numbers of reports, many cases are not reported.
Sex work is viewed as a social evil, and, while sex work itself is not criminalized, third party
involvement in prostitution is a criminal offence. Sex work is linked to domestic violence and
trafficking of women.
In response to the issues noted above, the government has taking action. A Gender
Mainstreaming document has been published by the National Committee for the Advancement of
Women to support all government officials to understand their roles and responsibilities and
develop skills to achieve gender equality257. This 156 page document (English version) describes
gender mainstreaming as an approach or strategy towards gender equality. Part 1 discusses the
Vietnamese approach to advancing women and achieving gender equality. The government has
a National Strategy for the Advancement of Women in Viet Nam by 2010 which was published in
2002 and refers to the rights of women in labour and employment, education, health care and
leadership. The Comprehensive Poverty Reduction Strategy, May 2002, recognizes the
relationship between gender inequality and poverty and sustainable economic growth. The
Millennium Development Goals have been contextualized with specific Viet Nam Development
Goals addressing Education, Gender Equality and Women's Empowerment.
Most of this lengthy document discusses gender issues in general terms, but Part 4 addresses
sector-specific gender issues. A separate section is given to Health and HIV/AIDS in Viet Nam
with the key issues identified as:
the impact of health reform on the poor and on poor women
women's health status, nutrition, maternal health and maternal mortality
access for women and men to reproductive health and family planning services
HIV/AIDS infection rates in men and women
violence against women
long working hours resulting in less rest, relaxation and opportunities for learning and
participation for women. Women spend 2.5 times longer than men every day with
housework256.
7.9 Health Services Review in Viet Nam

7.9.1 Overview of health sector
A review of the health sector in the context of HIV/AIDS conducted by The POLICY Project and
published in 2003232 identified a number of challenges:
the need to expand health services to remote areas inhabited by minority groups
the need to modernize and rehabilitate the health infrastructure in the rest of the
country
the need to regulate the fast developing private sector
the need to balance the bias towards curative medicine
the need to organize community-based health education and HIV/AIDS prevention
programs
the need to improve supervision, management capacity and referral at each level
the need to ensure rapid drug procurement
the need to address multi-drug resistant TB
the need to provide sustainable and effective HIV/AIDS services in both urban and
rural settings.
126
7.9.2 Sexual and reproductive health services in Viet Nam

Viet Nam has made considerable progress in improving sexual and reproductive health,
particularly in the areas of maternal mortality and provision of family planning services. Viet Nam
has a National Reproductive Health Strategy for 2001-2010 with actions to improve behaviour
change communication, to improve the quality of services, to develop appropriate strategies, to
build intersectoral and international cooperation, to strengthen research and training, to improve
finances and logistics and to strengthen leadership and management.
The UNFPA has identified the following challenges to further improvements82:
Reproductive health information needs to be more available in rural areas and for
adolescents and young unmarried adults
The incidence of induced abortion is high and rising among adolescent groups. Viet
Nam has one of the highest termination of pregnancy rates in the world and this has
been attributed to services not reaching all segments of the population, especially
urban sexually active youth, and also to failure rates among traditional and modern
methods of contraception258
There is a high risk of reproductive tract infection/ STI among women of reproductive
age
HIV is an emerging public health issue for all women.
7.10 HIV/AIDS Services Review in Viet Nam

HIV/AIDS/STI education and awareness is a priority action in the National Strategic Plan for Viet
Nam, with specific objectives to achieve this goal. Section 7.5 lists many of the past and present
major HIV/AIDS interventions addressing education and awareness. Many NGOs are working in
collaboration with the government in this area.
The importance of actively involving men in the response to HIV/AIDS in Viet Nam has been a
feature of a number of programs, in particular the Family Health International/ IMPACT project259.
FHI have demonstrated success in reaching strategic segments of the male population with
education and prevention messages through peer education for barbers, shoeshine boys and
motorcycle taxi drivers as well as through workplace based interventions.
Condom Promotion and 100% Condom Use Project
Viet Nam does not have a formal 100% Condom Use Program similar to that operating in
Cambodia and Thailand. This reflects the fact that prostitution is still viewed as a "social evil" and
a 100% condom use project would give the impression that prostitution was tolerated.
However, condom promotion for the general population is an important response, but faces many
challenges. Doyle258 has reviewed the social marketing of condoms in Viet Nam in a study with
the National Committee for Population and Family Planning. The study assessed the needs of
married couples registered for family planning services, particularly with regard to the use of
condoms in the family planning mix. The study concluded that it was not appropriate to have a
"family planning condom" as opposed to a "STI prevention condom'". This report, and others,
showed that the majority of current condom users would be willing to pay for condoms. The
report was critical of the indiscriminate subsidy of condoms across a wide range of the
population, which has led to distortions in the free market delivery system as well as lowering the
perception of the value of condoms generally. The report stated that "all agencies involved in the
supply of condoms should operate on the principle that subsidy is only to be given where there is
a demonstrable need or there is a specific strategic objective that requires subsidy".
127
The study also noted the growing number of young people who have sex before marriage and
recommended that the Government and NGOs make this vulnerable group a key priority. A
segmented approach to social marketing was recommended for the following specific groups:
married couples, young unmarried women and men, clients of sex workers, sex workers, IDUs
and their partners and men who have sex with men.
Blood safety
In 1992, Viet Nam passed regulations to establish standards and guidelines for blood safety. By
2000, 100% of blood units were stated to be screened for HIV.
Prevention of Mother-to-Child Transmission
The Prevention of Mother-to-Child Transmission is a relatively new intervention in Viet Nam.
Coverage in 2001 was estimated to be 2% of the women who needed PMTCT services3 and in
2003 seven sites were recorded as providing these services4. In the 12 months to September
2004238, 1,220 pregnant women were recorded as receiving PMTCT servicesxii.
The Ministry of Health has a National Plan on the Prevention of Mother to Child Transmission and
the third draft, dated June 2005, is summarized here260. The goal of the Plan is to control the
MTCT rate to less than 15% by 2010, with the objectives being to:
reduce the risk of HIV infection for women of reproductive age
increase the percentage of pregnant women with access to HIV counseling and
testing services
increase the percentage of HIV infected pregnant women and their children who
receive prophylactic treatment
increase post-partum care and support for these women and children.
Several technical solutions are listed in the Plan, including the following relevant to this review:
to prevent MTCT by promoting HIV counseling and testing prior to marriage,
pregnancy and delivery
to establish a network of HIV counseling and testing services for pregnant women at
the province, district and commune levels
to conduct HIV screening with rapid tests and the confirmatory test at standardized
laboratories
to integrate VCT activities into other activities such as antenatal care and family
planning services.
The National Plan proposes two options for infant feeding. Option 1 is formula feeding only if
eligible (the family agree, have sufficient funds, clean water and good sanitation, able to prepare
the formula and ensure supply), while Option 2 is exclusive breast feeding for 4 to 6 months with
immediate weaning. Specific regimens for prophylaxis are provided in the Plan. The monitoring
and evaluation indicators related to VCT are the number of women receiving HIV counseling, the
number accepting testing, and districts with available PMTCT services.
Pilot PMTCT projects have been conducted in several locations but the National Plan lists some
of the difficulties faced:
there are no policies for HIV infected women in disadvantaged family conditions, for
HIV infected children and for children affected by HIV/AIDS
there are no specific guidelines with details of roles and responsibilities for
implementation at different levels
there is limited IEC material specific for PMTCT
stigma and discrimination about HIV/AIDS is strongly linked to the social evils
concept
xii
The data is from the US government PEPFAR report for 2005 and it is not clear whether this refers to all PMTCT
programs in Viet Nam or only to PEPFAR-funded programs.
128
there is limited capacity for implementation of PMTCT in smaller health

establishments, where there is less knowledge and skills on PMTCT
there are limited HIV testing supplies outside the larger hospitals
costs of testing are relatively high as the current protocol requires three tests with
three different methods to confirm diagnosis at authorized laboratories, and a
consequent delay in obtaining results
many women attend for antenatal care only in the third trimester of pregnancy
infant formula is too expensive for many women
there is a poor care and follow-up system for HIV infected mothers
there is limited multisectoral cooperation
there is inadequate funding for the PMTCT program
there is a weak monitoring and evaluation system.
Harm reduction and drug detoxification

Viet Nam is currently transitioning from the "social evil" approach to a harm reduction approach.
Current interventions for drug users include a variety of treatment methods such as cool bathing,
massage, acupuncture, traditional and tonic medicine and psychological therapy. In 2000, a law was
approved for the prevention and control of drug use which stated that all drug users aged 18 or more
who continued to use drugs after family or community based withdrawal courses should be confined
to a compulsory rehabilitation centre for one to two years261. These centres use detoxification to
achieve a drug free state, but with high relapse rates84.
Harm reduction programs for IDUs have been piloted in Viet Nam since 1993, but with
inconsistent support and in conflict with drug control laws. Many of these programs have been of
short duration (one to three years) and dependent on external funding262. However, there is
evidence of increased political commitment for a harm reduction approach, which is endorse by
the National Strategy for HIV/AIDS Prevention and Control, but until the new Law on HIV/AIDS is
passed, the use of drugs remains an offence, while the possession of needles and syringes is not
clear. Limited capacity and resources are also important challenges to a harm reduction
approach along with concerns that the unsafe disposal of needles in some pilot projects has
raised safety concerns and may be seen as a health threat to the community262.
Priority populations for prevention interventions
While there is no formal list of priority population groups, the following list has been derived from
available publications and reports:
injecting drug users and partners of IDUs
female sex workers
clients of female sex workers
migrant/ mobile workers
People Living with HIV/AIDS, especially male PLHA
pregnant women
Men who have sex with men
young people.

Continuum of Care
The National Strategic Plan acknowledges the need to increase investment in care, treatment
and support services. While there is no officially approved Continuum of Care document, some
NGOs and government partners are applying a continuum of care approach in their work.
Home and community based care form an important part of the continuum of care and the
comments in the paragraph above are applicable here.
129
The provision of antiretroviral therapy (ART) is acknowledged as an emerging need for Viet Nam
with the National Plan having a goal to treat 70% of AIDS patients by 2010. In June 2004 there
were about 1000 adults aged 15-49 years with advanced AIDS on ART of an estimated need (in
2003) of 22,000223.
National Guidelines for Diagnosis and Treatment of HIV/AIDS were released by the Ministry of
Health in March 2005. This document comprehensively covers diagnosis and clinical staging,
clinical management, prevention of opportunistic infections, management of common clinical
syndromes, diagnosis and management of Opportunistic Infections (OI) and ARV therapy. The
section on PMTCT presents three regimens based on the time at which a pregnant woman is
diagnosed HIV positive. Of relevance to this literature review on HIV testing are the diagnostic
requirements. For diagnosis, the serum sample is "confirmed HIV positive when it is reactive to 3
HIV serology tests with different test principles and different antigen preparations (Strategy III)"
and..."Only laboratories meeting Ministry of Health standards are authorized to inform the positive
HIV results".
The incidence of tuberculosis in 2003 was estimated to be 178 for all cases (including those
HIV+) per 100,000 people (WHO website). Between 1996 and 2001, 298,418 new infectious
cases were treated with a 89% cure rate. By 1999, 100% of districts in Viet Nam were covered
by the DOTS strategy. There are an increasing proportion of TB infections in females which is
thought to be due to gender barriers in accessing TB services with consequent delays in
diagnosis and treatment263.
HIV surveillance among TB patients shows an increase in the national rate from 0.57% in 1995 to
3.0% in 2002, but 10 Provinces had rates over 3%, including a rate of 9.4% in Ho Chi Minh City.
However, there is some inconsistency in the data, with a national rate of HIV infection in TB
patients of 1.8% in 2002 cited in a WHO publication225. Between 1997 and 2002 there were
1,842 cases of co-infection in Ho Chi Minh City with cure rates of about 50% and death rates over
30%263. Steep increases in HIV prevalence among tuberculosis patients were reported in 12
urban districts of Ho Chi Minh City from 0.5% in 1995 to 4% in 2000264 . The immediate concern
for the tuberculosis programme in this city was to provide appropriate care to tuberculosis
patients with HIV co-infection and to strengthen HIV counseling services.
7.11 Risk Behaviour Groups in Viet Nam

7.11.1 Youth
This Section should be read in conjunction with Section 7.4 on cultural and behavioural
determinants of HIV infection, Section 7.8 on gender and Section 7.9.2 on sexual and
reproductive health services in Viet Nam.
Almost one-third of the population of Viet Nam is aged 10-24 years. There were an estimated
11,000 to 16,000 (0.13% to 0.20%) females aged 15-24 and 20,000 to 31,000 males (0.25%
to0.38%) living with HIV/AIDS in 200326. The primary reference for this Section is the Survey of
Vietnamese Youth (SAVY), released in 2005, the "largest and most comprehensive survey of
youth ever undertaken in Viet Nam"265. This was a household survey of 7,584 youth aged 14-25
years from 42 Provinces using both face-to-face interviews and a self-administered anonymous
survey. Key findings relevant for this literature review are presented here. Relevant findings from
other sources have been integrated, where possible, with separate references:
Families
young people in Viet Nam have a very strong sense of connection with their
families and families are a protective factor for youth.
130
Education
school attendance and literacy levels are high and attitudes to schooling and
teachers are very positive.
Work and Employment
work and increased opportunities to work are the highest priorities for future
aspirations it is considered difficult to find a job.
Friendship, Sexuality and Reproductive Health
traditional attitudes and practices towards relationships are the norm in Viet Nam
where premarital sex is still considered improper and relationships with young
people of the same sex is usual, with very little acceptance of homosexuality
sexual intercourse is not common, and when it does occur, it is usually wellconsidered, in an already committed relationship and in safe environments
young people believe in the practical effectiveness of condoms but attitudes
towards condom use were generally negative as they were associated with
indecent relationships including sex work
contraception is used by many married couples, but irregularly by single people
two thirds of young women still have limited knowledge of the fertile time in the
menstrual cycle
sex work is generally viewed negatively
33% of single urban men aged 22-25 years reported premarital sex compared to
3.7% of single urban women and 26% of single rural men had premarital sex
compared to 3.3% of single rural women in the same age range
of those sexually active, 85% had only one partner in the last 12 months
the first sexual experience was with a girlfriend/ boyfriend for 72% of those who
had ever had sex
the average age at first sex was 20 for men and 19.4 for women
very few sexually active men had ever had sex with sex workers (5.3%)
condom use with sex workers was high at 93%, with higher rates in urban youth
compared to rural youth, but attitudes towards condoms were negative. These
included reduced pleasure and association of condoms with prostitutes and
unfaithful people
Pregnancy and Abortion Experiences
there is still stigma associated with pregnancy for unmarried women
a high percentage of women reported having antenatal care for their first
pregnancy
abortion services are used by both married and unmarried women, but reported
rates are lower than other surveys
Reproductive Health Knowledge
generally young people are well informed about reproductive health (less so
about STI), but accuracy of knowledge is not high
HIV/AIDS
there were high levels of knowledge about HIV/AIDS, but accuracy of knowledge
was lower, with a clear relationship between education and more accurate
knowledge. Using a composite score for knowledge of transmission and
prevention, 52% scored high, 39% medium and 9% low. UNICEF data from
other sources indicates that 63% of youth aged 15-24 years know that HIV
infection can be prevented by having one faithful partner, 60% know that
condoms can prevent transmission, 34% that abstinence can prevent
transmission, 44% that mosquitoes cannot transmit HIV infection and 63% know
that a healthy looking person can have HIV/AIDS26
there were generally positive attitudes towards PLHA with limited fear, but three
times as many ethnic youth said they would not help someone with HIV/AIDS
awareness of HIV/AIDS was less in ethnic minorities and among those who had
never attended school
131
the four most frequent sources of HIV/AIDS information were mass media,
family, professionals and mass organizations
64% of the sample could identify at least 3 different HIV testing sites, but the
report noted that fear, lack of confidentiality, stigma, cost, lack of treatment for
HIV and poor process in sharing results were all barriers to VCT
while attitudes towards condoms were negative, 97% agreed that condoms can
prevent HIV/AIDS.
Substance Use
there was easy access to legal drugs, including alcohol. Young men are
encouraged to drink through peer pressure, but social constraints on young
women limit alcohol consumption
69% of males and 28% of females had finished a drink of alcohol at least once
Of these, 58% of males and 30% of females had been drunk at least once
illicit drug use was low (0.5%), almost certainly reflecting under-reporting
95% knew that not sharing needles can prevent HIV/AIDS
one quarter of the sample said they knew someone who used illicit drugs.
Health Services
70% of the youth sampled had bought medication for self-treatment
27.4% had received medical care at a private clinic
26.7% had received medical care at a commune health centre, but this utilization
rate was much lower for urban youth.
The Study identified the following areas for effective intervention:
promote the positive behaviour of youth, including monogamy and fidelity in
marriage
address poverty and under-employment by providing work opportunities for
young men and women
focus on ethnic minority youth who are more disadvantaged
HIV/AIDS efforts should focus on the most vulnerable youth, including IDUs and
sex workers
gender equality is improving in education and employment but further efforts are
needed to improve SRH knowledge and skills and access to services.
These national level findings are reasonably consistent with smaller, more specific samples. A
study among 569 Grade 12 students from 20 randomly selected schools in Ho Chi Minh City in
2001 used an interviewer administered questionnaire266. Key findings were that 1.9% of the total
survey (2.6% males) had used heroin or other addicting substances and that 6.7% had ever had
sex, but only 4.9% in the last 12 months (mostly males). Among those who had sex in the last 12
months, 35.7% used condoms during last sex. Only 0.2% reported having an STD. Between
86% to 94% had correct knowledge of HIV/AIDS and 75% accepted HIV infected students
attending school.
An earlier study, also published in 2001231 looked at the issue of sexually transmitted infections.
In reviewing available studies, the report confirmed the finding that few high school students are
likely to be sexually active. However, the report noted evidence that more adolescents were
becoming sexually active during and soon after attending high school. Student's knowledge of
STD, HIV and contraception was considered to be low and the study concluded that Viet Nam's
young people were "ill-equipped to deal with a rapidly emerging HIV epidemic". In this study,
very few students reported having a HIV antibody test (2.1% males and 1.2% females). This was
felt to be related to the perception by the majority of the students about their low risk of getting
HIV.
132
A recent review of adolescent reproductive health in Viet Nam was conducted as part of a 13
country study, which included Cambodia. The key findings for Viet Nam, which have not already
been highlighted in the studies cited above, are summarized here267:
In 2000 an estimated 37% of pregnancies in youth resulted in abortion and 48% in
births. The increase in abortion is probably due to young unmarried women choosing
to terminate a pregnancy. Repeat abortions are also common.
The unmet need for family planning is low at 9.7% for those aged 15-19 years and
13.3% for those aged 20-24 years (based on 1997 data)
Gender socialization is changing in response to the socioeconomic situation in Viet
Nam
The gender gap in education is minimal, but there is a greater gap between urban
and rural areas. Three times as many urban men than rural men attend university
and five times as many urban women
The legal age for employment is 15 years, and women comprise 49.5% of all
employed 15-29 year olds. Unemployment is highest in the 15-19 year age group
(11%) and next highest in the 20-24 year age group (6.6%), compared to the national
average of 4%
With the change to a market economy, more young men are moving to urban areas
for employment, resulting in a greater proportion of young rural women who are
under increased pressure to marry due to the shortage of male partners
There are relatively few early high risk pregnancies (5.7% of 15-19 year olds were
pregnant or had given birth to their first child). The majority of the pregnant young
women who had no antenatal care and delivered at home were ethnic minority
women from remote areas.
This review noted that, while there are no legal barriers to promoting adolescent and reproductive
health (ARH) in Viet Nam, there are no specific government policies for ARH. Adolescents have
been largely ignored in population and family planning policies, but there is gradually increasing
attention. A National Plan of Action on ARH was drafted in 1999, but has not been officially
adopted (at January 2003) and therefore not widely disseminated. The National Strategy for
Reproductive Health (NSRH) 2001-2010 has been approved by the Prime Minister and does
draw attention to adolescent health. This Strategy recommends the following approaches to
ARH:
IEC materials development and dissemination for adolescents on sexual
development and sexuality
increased access to RH and Family Planning services
the inclusion of sex and sexuality education into the school curriculum.
The review concluded by identifying the following important barriers to ARH in Viet Nam:
young people's lack of knowledge and skills
adults hesitant to discuss ARH issues
teachers and parents lacking knowledge and skills related to sexual health
lack of capacity and resources for ARH
limited reproductive health services for unmarried adolescents.
Several published reports have suggested specific responses to ARH issues in Viet Nam. The
study among high school students Ha Noi231 recommended that new ways be found to provide
sexuality and gender education in Viet Nam, based on the importance of Confucian morality and
Citizen Education, but also dealing with changing cultural values and circumstances. Mensch
and colleagues268 noted that most research among adolescents in Viet Nam has examined
unprotected sexual activity and its health consequences, namely abortion and STI, and especially
HIV. Their review advises caution against an approach that focuses only on risky sexual
behaviours. They suggest that the lack of adequate employment opportunities may be more of a
threat to adolescent reproductive health.
133
A case study of new approaches for reproductive health education for youth in Quang Ninh was
published in 2001269. These approaches seek to integrate social activities with improving life
skills through youth community development so that youth are empowered in decision-making
and implementing their own activities. The study notes that when such approaches are
implemented by "outsiders", activities are less likely to continue long term.
7.11.2 Female Sex Workers

This section presents the relevant findings from several studies of female sex workers in Viet
Nam, with a separate sub-section on mobility among female sex workers. An important
characteristic of the HIV epidemic in Viet Nam is the presence of female sex workers who are
also injecting drug users. Findings from studies for this specific group are presented immediately
after this Section, which in turn is followed by a Section on other Injecting Drug Users.
Characteristics of Female Sex Workers (complied from multiple sources)
There have been many studies on commercial sex workers (CSW) in Viet Nam, with a diverse
spread of research objectives, methods and sample sizes, which limits the ability to draw
generalized conclusions270. The findings presented here should be considered in this context.
Most CSWs are in their mid-twenties, are single or divorced with some dependents to support
(80% have one or two children), and come from poor families in rural areas whose principal
livelihood is farming. The educational level of CSWs is low and many have not finished secondary
school and may even be illiterate. Economic hardship and family debt are the major reasons
driving these women into sex work. In many cases friends or relatives have guided CSWs into
this profession, although some have been deceived or forced into the decision244, 270.
There are several different classifications for sex workers used in various studies, usually based
on work location, level of income and type and number of clients. One classification divides sex
workers into "indirect CSW, who are generally young and attractive and work in entertainment
venues. At the low end are direct CSW, who work from brothels or on the streets. A
gatekeeper (a pimp, owner, driver or boyfriend) controls working arrangements and provides
CSW with protection and transportation, in addition to contact with clients. CSW often become
indebted to their gatekeepers, who provide them with high-interest loans to buy clothing and
accessories to attract clients or to pay off police to avoid arrest270.
A study of the nature of sexual networks among sex workers in Ho Chi Minh City271 noted the
context of social evil and the periodic crackdowns by police and local authorities on sex workers.
Sex workers with residency permits were usually fined, but may have to borrow money from the
owner of the establishment where they work to pay the fine. Others are sent to re-education
centres for six months where mandatory examinations, STD and HIV testing are conducted.
There have been fewer studies of "indirect" sex workers. One study in 1996272 surveyed 500
women in entertainment services in Vung Tau in southern Viet Nam. The women were not asked
directly about commercial sex work because of the "social evil" view of prostitution, but proxy
measures were used to assess possible commercial sex involvement. Most of these women
were unmarried (77%), half were migrants from other areas, and half had only been working in
their current employment for less than six months. Over half (53%) reported sex during the last
12 months and 70% of these women did so with a non-regular partner. The mean number of
sexual partners among married women was 22.5 and 18.8 among unmarried women during the
last year. The HIV prevalence among sexually active women was 0.5%. Higher income was
associated with increased risk behaviour and greater number of partners. There were no reports
of injecting drug use.
134
Female Sex Workers and Mobility

Starink and de Bruin explored mobility and vulnerability among female sex workers in Ho Chi
Minh City in 2000234. They described the steps involved in moving from a rural location to the city
in the context of the social networks of these women. Many women were encouraged to move by
someone from their traditional social network, often at a time when they were experiencing
difficulties at home. On arrival in the city, usually without the right papers, they faced problems
with finding employment, a place to live and access to health care. If they were forced to borrow
money, their difficulties increased. On starting sex work they usually experienced shame and
fear which further limited access to services. Just after starting sex work, their attitude towards
their work was characterised by shame and fear. Several levels of mobility were distinguished:
"mobility from home to working place; from meeting place to place where sex worker and
client have sex; between working places on a short term; between working places on a
long term; national mobility; international mobility; and off work mobility. The most
important factors stimulating mobility are clients and police. There is a close link
between mobility and vulnerability. Mobility can make sex workers vulnerable, and
vulnerabilities - or avoiding vulnerabilities - can make sex workers mobile".
Some studies have classified sex workers into two groups based on location of work: those who
work within Viet Nam only, and cross-border sex workers. In reality there is often a shift between
the two groups273. The Cambodia Country Review (Section 5.11.2: Sex Workers) referred to the
presence of Vietnamese female sex workers in Cambodia as a controversial regional issue178.
Poverty, high mobility, discrimination, sexual abuse and human trafficking are the characteristics
of these women that make them very vulnerable to HIV infection.
7.11.3 Female Sex Workers who also Inject Drugs
In Viet Nam there is an "unusually large overlap between injecting drug users and sex workers2".
There is wide variation between provinces in the prevalence of injecting drug use among female
sex workers. In Ho Chi Minh City about 38% of 1000 sex workers were injecting drugs and 49%
of injecting female sex workers were HIV positive, compared to a rate of 8% in sex workers who
did not use drugs. In Hai Phong about 40% of all sex workers said they injected drugs compared
to 17% in Hanoi. Sex workers using drugs were half as likely to use condoms with clients as
those who did not use drugs223. There is a pattern of relatively high drug use and inconsistent
and low condom use among sex workers who inject drugs, but concerns have been raised about
the representativeness of samples that only include sex workers from rehabilitation and reeducation centres274.
One study, which may not be representative for the reasons noted above, was an assessment of
risk factors for drug abuse among 500 female prostitutes in different areas of Viet Nam, including
Hanoi and Ho Chi Minh City, conducted by the Department of Social Evils Prevention of the
Ministry of Labour, Invalids and Social Affairs and the UN Drug Control Program in 2001275. The
relevant findings werexiii:
70.8% were drug addicts
63.5% of the sample were aged 18-25 years and 52.1% were not married
41.9% were migrants from other provinces, usually rural
7% stated they were forced or deceived into prostitution
31% supported their parents with income earned, 27% supported children, 6%
supported siblings and 4% supported their husbands
of those who use drugs, 65% were injecting drug users, with a pattern of initially
smoking then moving to injecting drugs
over half the sample stated they had seen a death caused by drug overdose
85% of those who did not use drugs stated they always used condoms with clients,
compared to 48.5% of those in the drug use group.
xiii
The report is written in the "social evil" language of sex work and drug use and is presented here using this same
language.
135
7.11.4 Injecting Drug Users (IDUs)

Estimates of the number of drug users and injecting drug users in Viet Nam vary depending on
the source. The National Standing Bureau for Drug Control stated that there were 142,001
registered drug users in Viet Nam in 2003, of whom 25,453 were in detoxification centres,
prisons, or other re-education centres (cited by Khuat Thu Hong et al253). In 2000, UNAIDS
estimated there were between 90,000 and 185,000 drug users, with the majority injecting opiates.
Among these there were an estimated 75,000 to 80,000 HIV infections but only 12,410 confirmed
infections84. Other sources state that there are between 185,000 to 300,000 drug users, but it is
unclear whether this refers to all users of illicit drugs or only to injecting drug users87.
The epidemiology of HIV among IDUs in Viet Nam shows wide variation in the pattern, extent and
mode of illicit drug use between urban and rural settings and between Provinces. Patterns of
drug use are changing, with the average age of IDUs now younger than before, with many
injecting two or more times a day and most being sexually active228, 229. A situation assessment
in 2001262 found that most drug users were aged between 18-35 years, with heroin as the most
commonly injected drug. There were three main sub-groups of IDUs:
1. a pre-1975 IDUs group in South and Central Viet Nam who were older and used
opium
2. a younger IDUs group geographically widespread, who inject heroin and have low
rates of condom use
3. female IDUs who first used drugs then moved into prostitution to support their drug
habit.
Stigma and discrimination remain strong towards IDUs. In a poster presentation at the XV
International AIDS Conference in Bangkok in 2004, the results of in-depth interviews with 42 IDUs
in Bac Ninh were presented276. All participants perceived significant IDU-related stigma in their
communities. HIV awareness was high and the majority perceived themselves to be at risk of
infection, however many were reluctant to be tested. The most common reasons and barriers to
testing were:
fear of increased social stigma
that knowing would only lead to more worry
why know if treatment is not available?
the cost of testing
distance to the testing centre
perceived lack of confidentiality and being stigmatized as an IDUs.
A separate study in 2002229 found that, in various Provinces, only between 7.8% and 22.8% of
IDUs knew their HIV status.

No recent studies, publications or reports were identified examining HIV/AIDS among the military
and police in Viet Nam. The HSS results presented in Section 7.2.1 show an increasing
prevalence from 0.0% in 1994 to 0.8% in 2001 among military recruits in Hanoi.
7.11.6 Mobile/migrant workers

Several studies were reviewed to examine the relationship between HIV/AIDS and mobile
populations. One study was a comprehensive report on the social characteristics of HIV
transmission among mobile populations on national highway routes in Viet Nam, with particular
reference to cross-border trafficking of women and children273. With the move to a market
economy there has been increased trade along national highways and the creation of other
services to meet the demands of travelers. Females outnumber males in moving for work, with
over half working in manufacturing, particularly in textile, clothing and food processing industries,
while another quarter work in trade, sales and service; and about 10% as domestic servants.
136
The report discusses characteristics of each of the main mobile population groups. Additional
data from other studies is included here.
Truck drivers: Mobility and use of commercial sex services are characteristics of long
distance truck drivers. Studies suggest that condom use among truck drivers is high
with commercial sex workers (citing a 1998 World Vision Viet Nam study). In a
separate study of 1,098 Long Distance Truck Drivers277 in 2000 in four locations (two
bordering Cambodia and two bordering Laos) the key findings were:
o over 96% had completed primary school and 43% finished secondary school
o 67% knew at least two modes of transmission, but knowledge of MTCT was
low at 49%
o there were low levels of misconceptions about transmission (5%)
o 54.7% knew at least two means of prevention
o 36.2% stated they always used condoms with non-regular sex partners
o 39% had extramarital sex in the last month
o only 1% reported ever using drugs
Seafarers and sailors: this group may also use commercial sex services while away
from home, but little information is available on their sexual behaviours.
Construction workers and workers at factories: Many in this group live in the locality
where they are working. There is often there is a shortage of entertainment in these
areas but commercial sex is usually available.
Migrant workers in general are vulnerable to HIV infection because of poor living
conditions, difficulty in accessing information and health care and an inadequate
legal structure to support their human rights.
Traders are a high risk population because of their mobility and stress in work. Their
income is quite high and they often spend money on drinking and entertainment with
friends, which may include using commercial sex services.
State officials are often required to travel outside their duty stations and may visit
commercial sex workers during these times.
Foreign tourists may also use commercial sex, sometimes as part of sex tours
operating under the guide of tourism.
This review, and two other published studies on assessing vulnerability to HIV on national
highways in Viet Nam (which are based on the same research)278, 279, describe the characteristics
of hot spots for prostitution on national highways. The studies note that prostitution on highways
is quite open and with reasonable prices so that clients are easily attracted. Sex workers may be
based in service establishments or function as freelance workers. Hot spots are easy to identify
and many are located at truck stops, gas stations and entertainment establishments on the
national highway routes. Other locations are tourist sites, industrial zones and border areas
where there can be considerable cross-border movement of sex workers. Sex workers in these
establishments regularly change locations to avoid anti-social evil campaigns, or are dismissed
by the establishment's owner, or move to a higher paying establishment. This mobility makes it
difficult to implement effective prevention interventions. Hot spots fluctuate in the degree of
activity, with new hot spots developing as others are suppressed. There is also evidence of a
network to direct the operation of sex workers to areas where there is greater demand for
services. Alcohol use at hot spots contributes to low condom use in commercial sex.
A smaller and more focused rapid assessment study along National Highway 7 reached the
following conclusions280:
drivers basic knowledge of HIV is high and most drivers claim to use condoms for
commercial sex
some sex workers report using drugs, including injecting heroin
sex workers appear to have a high knowledge of HIV but some do not use condoms
people from ethnic minorities are among the those injecting drugs.
137
Viet Nam was included in the field testing of a toolkit to prevent HIV infection among fishermen
and the communities in which they live in Hai Phong281. This is an industrial zone and the centre
of the epidemic in northern Viet Nam, which attracts migrants from rural areas, traders and
transport workers. Similar studies, all conducted by World Vision, among sex workers in
Cambodia and fishermen in Myanmar have already been described. The steps involved in the
field testing were to form a Task Group, conduct a situation analysis and lead PLA exercises with
the community. These exercises included casual diagrams of HIV infection, 10 seed analysis to
rank community attitudes towards PLHA and identify high risk behaviour, and pie diagrams to
identify who could positively influence behaviour. About 70% of the fishermen were migrant
workers with limited HIV/AIDS knowledge. HIV testing was available free of charge at nearby
government facilities. Interventions included condom social marketing, distribution of IEC
materials and mobile Peer Educators to reach fishermen who were working. The results were:
increased awareness of HIV, the related social and economic relationships and the importance of
condoms; starting the process for community groups to work together; good central and local
political support; and appreciation of the PLA exercises by the community.
The two main sources for this Section are a Master of Public Health Treatise by Colby in 2001282
and a review of MSM in Viet Nam in 2003 by Colby et al283. Men who have sex with men in Viet
Nam are increasing in numbers and visibility in urban areas, but the homosexual lifestyle is not
considered normal or acceptable, even though it is not viewed as a social evil. Because of the
influential writings of a well known Vietnamese Doctor, which are not based on scientific
evidence, "true" homosexuality is believed by many to be very rare, while "fake" homosexuality is
more common, and refers to men lured into trying the homosexual lifestyle who will eventually
return to a heterosexual life.
The limited data available highlights an increased risk for HIV infection for MSM through poor
knowledge of HIV transmission, high numbers of sexual partners, high rates of unsafe sex and
inconsistent condom use. Many MSM also have sex with women, and many are married. In Viet
Nam, media and public health prevention programs have tended to ignore MSM as a risk
population and many MSM therefore believe they are at low risk of infection and less likely to
protect themselves. The HIV prevalence in MSM is not known but one study of 208 MSM in Ho
Chi Minh City attending VCT showed a 5.8% HIV infection rate (study cited by Colby et al283).
Colby's MPH study in 2001 among 219 MSM aged 17-51 years in Ho Chi Minh City found the
following:
66% of the men were homosexual and 31% bisexual
the median number of sexual partners was two in the last month and seven in the last
year
81% had sex, usually anal sex, with non-regular partners
40% used a condom for the last anal sex
condom use with female partners was consistently higher for all types of female
partners
HIV transmission and prevention knowledge was "fairly good"
only 6% rated their HIV risk as high
less than 2% admitted to injecting drug use
30% had ever had a HIV test, with the last test taken an average of 6 months before
the interview and with 70% reporting the test as negative, 5% as positive and 24%
who chose not to respond to the question
those previously tested were significantly more likely to have ever used a condom,
used a condom with last sex and to have used a condom with last anal sex with a
non-regular partner compared with those who were not tested.
138
There is even less published data on male sex workers in Viet Nam. One study in Hanoi found
most were aged 18-25 years, self-identified as heterosexual and engaged in commercial sex
because it was an easy way to make money. The majority of clients were Vietnamese men and
drug use was perceived to be uncommon (study cited by Colby et al283).
The conclusions of these studies are that MSM in Viet Nam are mostly underground, tend to be
ignored and have no routine surveillance through HSS or BSS. However, they are easy to locate
and willing to interact with outreach workers so that Peer Education, combined with condom and
lubricant distribution, should be possible282.

Viet Nam
7.12.1 Overview of HIV counseling and testing in Viet Nam
Voluntary confidential counseling and testing (VCCT) for HIV is a relatively new concept for Viet
Nam, although HIV testing has been available since the early 1990s. The Government has been
working in partnership with a number of International Organizations to establish a national VCT
program since 2002. Viet Nam's longest-standing anonymous HIV counseling and testing site
was opened in Ho Chi Minh City in November 2001 and a recent client satisfaction survey found
the most valued features were the anonymous testing (86%), the free services (30%) and being
counseled in a private room (76%)284, 285.
Prior to initiating the national VCT program, key stakeholders discussed what they could offer and
how they would commit to supporting VCT clients. The stakeholders included staff from the VCT
program, the TB program, STD clinics, hospital infectious diseases departments, family planning
centres, drug treatment programs and peer support groups. These stakeholders developed a list
of service providers which helped to quickly establish a functioning referral network using
available resources286. However, VCT in Viet Nam is mostly a health-sector intervention, an
opinion shared by most Key Informants, although examples of a more multi-sectoral approach are
evident (see the short paragraph on Ho Chi Minh City below).
The CDC Global AIDS Program (LIFE-GAP) in Viet Nam has opened 53 anonymous VCT sites
for vulnerable populations using a number of different models in 40 Provinces287. Family Health
International currently manage five community based VCT sites and one hospital based VCT site
in Viet Nam240. Community based outreach and peer education, especially for IDUs and CSW
are important additional components to promote VCT among vulnerable groups. In one study,
the percentage of clients referred to VCT by outreach workers increased from 2.2% in 2002 to
19.2% by June 2005288. A number of Key Informants also made reference to VCT services
funded by the Global Fund, but it was unclear whether these were part of, or separate to, VCT
services managed by the government. With a number of different organizations implementing
VCT services, UNAIDS is playing an important role in coordinating HIV counseling and testing in
Viet Nam (Key Informant Interview).
A comparison of sites where VCT was integrated into existing facilities with free-standing clinics
was presented during the XV International AIDS Conference in Bangkok in 2004289. Data was
reviewed from nine facility based sites and three free-standing sites. Facility based sites
averaged 94.3 clients per month, compared with 67.5 clients for free-standing sites. HIV positive
rates were 20% in facility based sites and 27% in free standing sites. Client return rates were
higher (85%) in facility based sites compared with free standing sites (77%). The proportions of
reported recent IDU and CSW were similar for both types of service but the proportion of MSM
and high risk sex partners was higher in free-standing sites. The study concluded that both types
of services have strengths and are complementary.
139
There is some experience in operating a mobile VCT service for sex workers, IDUs and their
immediate family members which started in December 2003 in Ho Chi Minh City290. The services
provided are peer education, medical examinations, IEC material distribution, screening tests for
HIV, Hepatitis B and C, STI and TB as well as Hepatitis B vaccination and referral to other
services. While these services are provided free of charge, the construction cost of the mobile
clinic was $US 50,000 with ongoing costs of $US 4,500 per month.
Most Key Informants agreed that it was both needed and appropriate for Viet Nam to have
different models of HIV counseling and testing services to increase coverage. Stand-alone,
hospital-based, antenatal clinic-based, reproductive health clinic-based, STI-clinic based,
community-based and mobile clinics were all mentioned as appropriate models for the various
target groups. Models to support stronger linkages with TB services were mentioned by one Key
Informant.
Referral to other HIV/AIDS services is a critical issue for Viet Nam where home based care and
ART services are only just being developed. The Ho Chi Minh City VCT centre mentioned above
noted the frustration experienced by clients in accessing care and support services, mostly due to
high costs and lack of confidentiality. In response the counseling staff developed a
comprehensive list of 60 agencies to which clients could be referred291.
The Key Informant Interview with the representative of the Ho Chi Minh City Provincial AIDS
Committee (PAC) was of interest in understanding what appears to be a successful multi-sectoral
approach to HIV counseling and testing. The PAC is itself multi-sectoral with 21 members and
has strong links to mass organizations and to mass media. The Standing Office manages and
coordinates the HIV/AIDS response. There is strong political support from the city leaders and
funds are provided by both local government and international donors. There are currently 28
VCT sites in HCMC, all of which are moving towards a confidential, rather than anonymous,
approach to testing. The key unit is the Community Based Counseling and Support Centre
(CCSC) at the District level. There are currently 14 of these in the City which provide VCT
services as well as Peer Education, support for PLHA self-help groups and clinical services such
as ART, TB, treatment for Opportunistic Infections and referral to other services. Most of these
services were stated to be free. One CCSC is also designated as a training centre for
counselors, using trainers from city hospitals. Results show increasing numbers of VCT clients
among sex workers, IDUs and pregnant women.
Monitoring and evaluation of VCT services is gradually being strengthened. CDC/LIFE-GAP are
using an EPI-Info based computerized data management system in the VCT sites they
support287.

In practice, most HIV testing at VCT centres in Viet Nam is provided free of charge. However,
government health facilities in Viet Nam have been charging official fees for some services for
some time. As part of this scheme, pregnant women attending antenatal care at government
health facilities are expected to pay a fee, and the cost of any voluntary HIV test is included in this
fee.
Several of the Key Informants stated that in Viet Nam people are used to paying a fee for some
services. Pregnant women in hospital pay about $US 3 for a HIV test. The VCT services
managed by CDC-LIFE GAP and FHI are free of charge. However, while most Key Informants
felt that a fee was appropriate in certain circumstances, one felt it was not appropriate, primarily
because it may be a barrier to testing. A fee was felt to be appropriate in the situation where
willingness and ability to pay had been assessed. Urban people were felt to be more able to pay,
and some Key Informants felt that VCT should be free or subsidized for rural populations, in "hot
spots" and for youth. There are national government level discussions about whether or not to
regulate for free HIV testing services, but no decision has yet been made.
140
7.12.3 Coverage of HIV counseling and testing services in Viet Nam

Coverage of VCT services for the general population remains low, but is increasing for the key
vulnerable groups such as IDUs and CSW. The POLICY Coverage survey in 20034 noted that
18,250 clients received VCT services at 75 sites. The PEPFAR Country Profile reported that
23,200 clients received VCT in the 12 months to September 2004238.
Coverage for pregnant women has increased at the Provincial Hospital level, but test acceptance
rates are low (less than 30% in 2002). However, data from a 2002 cross-sectional study of 550
pregnant women aged 18 years attending a hospital in Hai Phong for the first antenatal visit, and
who had never been tested, showed a HIV test acceptance rate of 53.2%292. The reasons for
refusing a test were because of concerns about the minimal medical and family support in case of
illness and worry about the husband's disapproval if he learned that a test had been taken. The
study concluded that the provision of information about available social supports and the
involvement of husbands in making decisions about testing could increase the acceptance rate.
The Key Informants agreed that HIV counseling and testing services were not readily accessible
for the majority of the rural population, but that coverage for PMTCT was expanding. Migrant
workers and populations living in border areas were also felt to have inadequate access to VCT.
Women and youth may not access existing services as they are perceived to be mainly for IDUs
and sex workers. One Key Informant added that youth would be hesitant to visit VCT services in
hospitals for fear of being recognized by others. Two Key Informants stated that testing services
currently had a wider coverage than counseling services.
7.12.4 Profile of clients attending VCT Centres in Viet Nam

Several short studies based on VCT records provide a profile of clients attending VCT centres at
different locations in Viet Nam. At the national level, between November 2002 and October 2003,
6,340 clients (35% female) were tested and counseled in 18 Provinces293. Of those tested, 85%
returned for test results. In Quang Ninh in 2003, 974 clients were tested and 42% were positive
(23% were women). Injecting drug use was the main transmission risk for men, but not for
women294. In a study of 44,142 clients who were counseled, 93.9% were tested and 91.6%
returned for results, with 17.2% being positive287. The main risk behaviours were: IDUs, 24.4%
(with 61.7% HIV+); CSW, 6.9% (4.9% HIV+); multiple sexual partners, 13.6% (9.0% HIV+); sex
partners of IDUs, 13% (10.1% HIV+); and sex partners of CSW, 15.8% (11.3% HIV+). Another
study of risk factors among 6,913 anonymous VCT clients in 16 provinces295 found the following
risk factors: IDUs 23%, CSW 5%, CSW/IDUs 2%, MSM 0.3%, sexual partners of HIV infected
persons 10% and sexual partners of high-risk persons 28%. Overall 22% tested positive, of
whom 57% were IDUs, 4% CSW, 4% CSW/IDUs, 0.5% MSM, 11.7% sexual partners of HIV
infected persons and 15.8% high risk partners. Overall 36% of these clients were infected
through sexual transmission. The HIV prevalence was highest in IDUs (55%), CSW/IDUs (47%),
MSM (42%) and sexual partners of HIV infected persons (26%).
7.12.5 National Policies and Guidelines and key resource documents for
HIV counseling and testing in Viet Nam
It was unclear whether there are official government Policies and Guidelines specific for VCT,
other than references made in the National Strategic Plans (see Section 7.5.1). However, CDC
LIFE-GAP and FHI have many relevant Vietnamese-language resources which are approved for
use by government partners. These include the following detailed curricula:
VCT Participants Manual
VCT Training Manual
VCT Training of Trainers (TOT) Manual.
CDC LIFE-GAP also have Procedures, Training Curricula, TOT curricula, Quality Assurance
tools, data collection tools and integrated data management for community outreach, outpatient
HIV care, PMTCT and Peer Education for high risk groups.
141
Key Informants confirmed that the current VCT program in Viet Nam uses a variety of serological
tests, including rapid tests for screening. However, confirmation requires three further tests using
different methods and can only be done at approved government laboratories, resulting in delays
of up to 7 days for test results to be available.
Key Informants were asked about the age of consent for HIV testing. There appears to be no
official age of consent, but FHI stated that they will test clients aged 16 years who are able to give
written informed consent. The proposed new law may help to clarify this matter as well as legal
issues related to partner disclosure.
7.12.6 Laboratory services for VCT in Viet Nam

In preparing for the national VCT program, a study assessing laboratory services in Viet Nam was
conducted by the National AIDS Standing Bureau in 2001227. The general objective of this study
was to assess the infrastructure, human resources and activities of HIV testing laboratories from
the national to the local level and develop recommendations on feasible activities to improve the
capacity and quality of those laboratories. The specific objectives related to assessing capacity
and needs nationwide: equipment for HIV testing and blood screening, equipment maintenance
and repair, procurement of supplies, procedure for blood collection and reporting results, and
human resources and training needs.
The study reviewed the history of HIV testing and surveillance since 1988 and noted that all 61
provinces were able to use SERODIA for testing while 55 provinces could do ELISA testing. The
study also detailed the reporting process where data are submitted to the Regional Pasteur
Institute and the National Institute of Hygiene and Epidemiology (NIPH) using reporting forms
issued by National AIDS Standing Bureau and AIDS Division. This data is processed and then
reported to the AIDS Division, Ministry of Heath and NAC (now called the National Committee for
AIDS Prevention and Drug and Prostitution Control).
The study covered 494 laboratories nationwide with the following findings relevant for this
situation analysis report
At the national laboratory level, equipment was adequate, but less so at the
provincial and lower levels where there was a shortage of cold-storage and
sterilization equipment
Infrastructure at all levels was generally good but 9.9% of laboratories did not have a
stable electricity supply and only 56% had a clean water supply
There were limited reference materials on HIV counseling and testing, particularly at
the district level
There was a notable redundancy of SERODIA test kits, as some laboratories only
used ELISA test kits. The SERODIA test required 50 samples to be tested at one
time resulting in delays in obtaining test results
National laboratories did many more tests than Provincial or District laboratories, with
the latter averaging 150 tests per year
Many laboratories participating in the national HIV/AIDS Sentinel Surveillance could
not reach the sample size required for the sentinel populations
Screening of blood for transfusion followed national procedures with testing for HIV,
hepatitis B and C. However, some laboratories did not screen for syphilis and
malaria
91 laboratory staff were occupationally exposed to HIV in 1999 and during the first six
months of 2000. However, it was estimated that only 8% of exposures at the district
level were reported, resulting in a low number of staff who were offered preventive
treatment
Test result reporting was described as inconsistent in some provinces. Only 20% of
laboratories had a computer for data management, with 77% using manual
calculations and calculators
142
There was an overall lack of laboratory staff, who had other tasks in addition to HIV
testing. The education level of lab staff was not high, with only half having graduated
from technical or high schools
At the national level, laboratory staff were well trained and experienced in more
complicated testing such as ELISA and Western Blot methods
Organisational restructuring resulted in staff trained in HIV testing being moved to
other roles.
7.12.7 Achievements and challenges

There is evidence from Viet Nam that people who have voluntarily presented for HIV counseling
and testing and returned for their test results have safer behaviour than those who do not know
their status. Among MSM in Ho Chi Minh City, 68% of those tested and counseled used a
condom during last anal sex with a casual partner, compared to 48% of MSM who had not
requested a test (cited by Colby et al283). However, drug injectors in the same city, who knew
their HIV status were no less likely to share needles than those who did not know their status74
(citing a report by Hien et al, 2001).
The following list of barriers and challenges to VCT in Viet Nam has been compiled from multiple
sources 296, 297, 298, 299, including feedback from Key Informants.
Access and Infrastructure
VCT is still a new concept that is not well understood and not well promoted most
people are not aware of the benefits of VCT
access to and uptake of VCT services is currently low
there is a lack of expertise in marketing and advertising VCT services
creating consumer demand for VCT through social marketing and behaviour change
communication is needed
costs associated with testing are barriers for many people
distance to travel to reach testing services and the costs of travel are barriers.
Stigma and discrimination
gender-related issues, including sexual negotiation, limit awareness and access
there is a need to make VCT services "friendly" to MSM, CSW and IDUs
fear of being badly treated by health workers is an important barrier
reducing stigma related to testing and disclosure, including stigma related to injecting
drug use and commercial sex is an important issue to address
need to promote the benefits of testing to reduce fear among sex workers that testing
may result in loss of income.
Technical
quality of counseling, including perceived lack of confidentiality, needs to be
improved
selection and training of staff providing VCT services, especially a shortage of trained
counselors, limits expansion of services
integration of VCT services with other on-site services, including reproductive health
services is needed
the current testing strategy is difficult and costly
official endorsement of rapid tests to reduce waiting time is needed
increasing access to treatment and care will increase uptake of VCT
limited infrastructure for referral, especially in relation to ART and STI services, is a
barrier
improved linkages between VCT and some vertical programs, in particular with TB
services, are needed
constantly changing monitoring and evaluation requirements create confusion
143
there is a need to develop a more effective system for a person testing HIV positive
to obtain treatment. The current system requires the client to be registered and retested by the treatment provider to confirm HIV status before starting treatment
concerns about the safety of health workers need to be addressed
7.13 Marie Stopes Clinics in Viet Nam

Marie Stopes International Viet Nam (MSIVN) started its sexual and reproductive health (SRH)
program in 1989. From 1994, MSIVN has provided comprehensive SRH services under a number
of Working Agreements with local government agencies, mostly with local health authorities at the
provincial level through a network of 10 Marie Stopes Clinics. The main services provided are
family planning, safe abortion, antenatal care, STI management and HIV/AIDS services, including
HIV counseling and testing. These Clinic-based services are complemented by community
based services, including contraceptive services; contraceptive social marketing; and community
outreach, peer education and counseling for HIV/AIDS. MSIVN has also established and
managed two dedicated youth-friendly SRH centres combining IEC with clinical services.
From 2003, five MSIVN Clinics were handed back to local partner management at the request of
local government officials. MSIVN currently manages five SRH Clinics in Viet Nam. Because of
the handover, the number of client visits provided by MSIVN has fallen from 100,352 in 2002
(with 42% of visits being for family planning) to 26,444 in 2004 (55% for family planning). The
actual number of services provided also fell from 166,870 in 2002 to 54,779 in 2004. MSIVN
currently has a total of 48 staff in the five Clinics. The Clinic services are largely funded by a
transparent cost-recovery process with fees charged for services. The Table below shows the
Network of Marie Stopes Clinics established in Viet Nam since 1994.
Established
Centre
Location
Aug 1994
MSI Nghe An
24 Phan Dinh Phung, Vinh City, Nghe An province
Nov 1997
MSI Ha Tinh
20 Nguyen Bieu Street, Ha Tinh Township, Ha Tinh province
Jun 1999
MSI Nam Dinh
37 Dong Thap Muoi street, Nam Dinh city (handed back to local
project partner in 2002)
Jun 1999
MSI HCM 01
101A Hoang Van Thu, Ward 8, Phu Nhuan District, Ho Chi Minh City
(handed back to local project partner in February 2004)
Oct 1999
MSI Thai Binh
26A Quang Trung, Thai Binh township, Thai Binh province (handed
back to provincial project partner in 2004).
Jan 2000
MSI Hue
29 Hai Ba Trung, Hue city (handed back to local project partner end of
2002)
Oct 2000
MSI Hanoi 01
5 Nguyen Quy Duc, Thanh Xuan District, Hanoi (handed back to local
project partner end of 2002)
Jul 2001
MSI HCM 02
161 Tran Tuan Khai, District 5, Ho Chi Minh City
Apr 2005
MSI Ha Noi
Apartment number 2, Ground Floor, A4 Building, Thang Long

International Village- Dich Vong Ward, Cau Giay district, Hanoi
Oct 2005
MSI Binh Duong
30/12 Moi street, Nhi Dong quarter, Di An town, Binh Duong province
144
MSIVN also implements specific projects. The following Table shows the experience and
technical expertise of MSIVN in working with a diverse range of donors.
Year
Projects
Donors
Duration
1989 Provide technical assistance to the district health centers of Hai Phong and
Quang Ninh provinces to improve reproductive health care quality

Development of UK
4 years
1993 Preventive maternal and child health and family planning project for lowincome women and their families, including community health volunteer
training in Nghe An Province
European Commission
4 years
1996 Address the unmet needs of women and men in family planning and
reproductive health through establishment of three static clinics and mobile
teams in the provinces of Ha Tinh, Nam Dinh and Thai Binh
European Commission
4 years
1998 Adolescent reproductive health in Thua Thien Hue (Project No. RAS/98/P21)
and Ha Noi (Project No. RAS/98/P22) under the Reproductive Health
Initiative in Asia of EU/UNFPA
European Commission and

UNFPA
4 years
1998 Community based family planning and reproductive health clinic in Ho Chi
Minh City (Project No. JFS 1492)

Development of UK
4 years
2000 Family Planning and Reproductive Health Serving Women and their Families
with Quality, Affordable Services through Innovative Mini-Clinics and
Outreach Teams in the Urban and Peri-urban Areas of Ho Chi Minh City
The Community Fund

(formerly National Lottery
Charity Board of UK
4 years
2002 Project to provide mobile family planning & reproductive health services to
poor women in remote areas of Nghe An, Ha Tinh & Thai Binh provinces
The British Embassy in

Vietnam
2 years
2003 Project to pilot the integration of HIV Voluntary and Confidential Counselling
and Screening Test into existing Marie Stopes clinics in Vietnam
States of Jersey
10 months
2003 Project to conduct needs assessment and design interventions to meet the
unmet needs on information and services of FP/ RH of migrant workers in
the supplier factories of Adidas Salomon in Ho Chi Minh city
Adidas Salomon Asia

Regional Office
6 months
2003 Project to continue the provision of VCCT at Marie Stopes clinics in Vietnam
with HIV/AIDS community prevention education with a focus on vulnerable
groups: young students, commercial sex workers and migrant workers
AusAID
11 months
2004 Provide technical assistance to local NGOs to promote health seeking

behaviour and provide youth friendly services to adolescents and youths.
Part of the second phase of the Reproductive Health Initiative in Asia
European Union through

UNFPA
33 months
2004 Project to provide mobile family planning and reproductive health services to
poor women of two isolated island communes of Thanh An and Tam Thon
Hiep, Can Gio district, Ho Chi Minh city
British Embassy in Vietnam
1 year
2004 Build technical capacity for the public service providers of the Maternal and
Child Health Care/Family Planning network in Ho Chi Minh City in providing
quality FP/RH services
Dutch Core Grant
9 months
2004 Improve maternal and child health through the development of capacity of
Traditional Birth Attendants in Vietnams northern province of Lao Cai
NZAID
3 years
2005 Improve sexual and reproductive health amongst the workers of supplier
factories of Adidas in Ho Chi Minh City and Binh Duong Province
Adidas-Salomon Asia
Regional Office
4 years
145
2005 Photovoice. A participatory development project to improve sexual

reproductive health status of migrant workers in Hanoi, Viet Nam
World Bank
1 year
2005 Building the capacity of commune health services to provide quality

reproductive healthcare in Khanh Hoa and Danang provinces.
Atlantic Philanthropies
3 years
The Marie Stopes Clinics in Viet Nam began providing VCT services in 2003. Between
December 2003 and April 2005, MSIVN provided VCT services to 2,632 clients (62% of whom
were women), all of whom received pre-test counseling. A high proportion (86% or 2,257 clients)
agreed to have a HIV test and 85.6% of these clients returned for the test results. Technical and
general workers comprised 18.3% of the VCT clients, government officials 20%, housewives
and/or farmers 13%, small business people 11%, sex workers 10% and students 6%xiv. The ECfunded Mekong VCT Project provides MSIVN with the opportunity to strengthen and expand
these current VCT services. A detailed Site Assessment for four of the five MSIVN Clinics is
planned as part of this expansion phase. Separate reports for these Site Assessments will be
prepared over the 12 months January to December 2005.

Clinics in Viet Nam
VCT into Marie Stopes Clinics in Viet Nam. These recommendations are derived from the
recommendations should be carefully reviewed by the MSIVN Management to determine if they
are appropriate and feasible.
xiv
The promotion of VCT services through MSIVN Clinics and outreach should focus on
raising awareness of the benefits of knowing one's HIV status, together with advocacy
efforts to increase available post-test services, including treatment. MSIVN should
strengthen linkages with mass organizations for these promotion activities.
MSIVN should review all current check-lists or similar tools used by clinical staff in
providing current SRH services and add in appropriate prompts or questions to ask all
clients if they are interested in accessing the MSIVN VCT services. Similarly, all tools
used in providing current VCT services should be reviewed with the addition of
appropriate prompts to ask clients about any needs they may have for family planning/
contraceptive services, antenatal services and STI management. This will support
effective and integrated "cross-promotion" of MSIVN SRH services.
Couple's counseling appears to be acceptable in the current context in Viet Nam. MSIVN
should explore this possibility. This could be integrated with the current MSIVN approach
to encourage greater involvement of men in sexual and reproductive health, in particular,
the male partners of female clients who receive STI, antenatal care and family planning
services at MSIVN Clinics. This should be done both through the Clinic-based services
and community outreach activities. Couple's counseling will include pre-marriage
counseling and testing as well as services for those already married.
MSIVN, as a provider of quality sexual and reproductive health services for women,
should develop culturally appropriate ways to encourage disclosure of results to the male
partners of woman clients and to support women who fear or experience gender-based
violence in the context of wanting or having a HIV test.
Given the relatively high levels of stigma and discrimination related to HIV/AIDS in Viet
Nam, MSIVN will need to give careful consideration to the involvement of PLHA as
community outreach workers to promote VCT services and as providers of group or
individual pre-test counseling, and possibly post-test counseling.
MSIVN Powerpoint Presentation, November 2005
146
Youth are a key target group for the Mekong VCT project. MSIVN already has
considerable experience in providing youth-friendly sexual and reproductive health
services, and the Mekong VCT project resources will allow expansion of these services,
with increased promotion of VCT services.
MSIVN already have one Clinic reaching large numbers of migrant workers. Again, the
Mekong VCT project resources will allow increased promotion of VCT to this important
population group.
The Mekong VCT project provides MSIVN with an opportunity to actively participate in
supporting the national PMTCT program. Clients receiving antenatal services can
receive pre-test counseling and a screening test, with those testing positive being
referred for confirmatory testing and, if positive, referred to government PMTCT services.
Depending on available resources, MSIVN may also have the opportunity to support
follow-up and referral to other HIV/AIDS services for mothers who are HIV positive.
MSIVN can make a significant contribution to the strengthening of all other referral
linkages for clients who test positive to HIV/AIDS. Particular attention should be given to
increased collaboration with TB screening programs. This can be done at the facility/
district level, but also at the Provincial and national level. Increased participation in
national level HIV/AIDS networks, such as the VCT Working Group coordinated by
UNAIDS, will provide opportunities to learn from the experiences of others and to share
MSIVN experiences in these areas.
MSIVN can effectively use the Mekong VCT project resources to develop a high quality
MSIVN should participate in, and actively support, counselor networks comprising both
MSIVN needs to develop clear guidelines for any fee for HIV counseling and testing. Key
Informants were divided on the issue of whether VCT should be free or clients should pay
a fee. The government may also regulate for testing to be provided free. If a fee is
charged for some clients, based on ability to pay, MSIVN will need to develop a practical
and equitable working definition to identify clients for whom HIV counseling and testing
would be free or subsidised. If, for any reason, a fee is not charged for HIV counseling
and testing, MSIVN should develop a sustainability strategy from the start of this project,
with the goal of being able to continue to provide VCT services after current donor
funding ends. This will include the identification of any other available resources.
MSIVN should explore any role in reaching female IDUs and the female partners of male
IDUs. Female sex workers who also inject drugs are a very important population group
that may also be reached by MSIVN services. Counselors may require additional
counseling skill training if such groups are offered VCT services.
147
8. COMMON THEMES AND TRENDS

There are significant and important differences between Cambodia, Myanmar and Viet Nam in
terms of HIV epidemiology, socioeconomic circumstances, cultural and behavioural determinants,
the national response, human rights and legal issues, gender inequity, HIV/AIDS services and
risk behaviour groups. Similarly, there are important differences in how each of the three
countries is addressing the need for HIV counseling and testing. However, there are also some
common themes and trends. Because this situation analysis is prepared for a project that will be
implemented in the three countries, it is useful to highlight the more important of these common
themes and trends for program planning. The factors that fuel these epidemics are similar in all
three countries, although to varying extents: poverty, STI, the sex industry, human trafficking,
sexual exploitation, mobility within and across borders, stigma and discrimination, the increased
vulnerability of women in the context of gender inequity and risk behaviours among injecting drug
users and men who have sex with men.
Gender Inequality
In all three countries, cultural beliefs and practices place women in less equal and more
vulnerable situations. In particular, young women in all three countries are expected to remain
virgins and not to express interest in or knowledge of sexual matters, while the sexual behaviour
of men is more openly tolerated. This highlights the need to both empower women and to
increase involvement of men and boys in reducing gender inequities. In relation to HIV
counseling and testing, important issues to address relate to accessibility of services for women
and awareness of the possibility of gender based violence associated with disclosure that a
woman has had, or is planning to have, a HIV test.
Stigma and Discrimination
Stigma and discrimination remain substantial barriers to addressing HIV/AIDS in all three
countries, but with evidence from Cambodia that this is reducing. HIV counseling and testing
services can contribute to reduced stigma and discrimination through ensuring confidentiality and
having a non-judgmental attitude towards clients.
The Greater Involvement of PLHA
This principle remains a challenge in all three countries, mostly because of stigma and
discrimination, with Cambodia having made most progress to date. There are some examples
from Viet Nam and Cambodia where PLHA have been used as counselors for VCT and more
examples where PHLA have actively participated in raising awareness of HIV/AIDS, including
VCT, through community outreach approaches.
Antiretroviral Therapy and Prevention of Mother to Child Transmission
Antiretroviral therapy is increasingly available in Cambodia and Viet Nam, and starting to become
available in Myanmar. This will have a significant impact on HIV epidemiology and increase the
demand for treatment, care and support services, including HIV counseling and testing services.
At the same time this will create tensions in prioritizing resources for continued prevention efforts.
All three countries have implemented PMTCT programs but with relatively low uptake to date.
These programs also require high quality HIV counseling and testing services.
Tuberculosis and HIV co-infection
All three countries have a high burden of tuberculosis with increasing rates of co-infection and TB
mortality. There is a need to increase coordination between TB and HIV/AIDS services, with
strong links between HIV counseling and testing services, HIV/AIDS home care and TB screening
and treatment services.
148
Risk Behaviour Groups

Surveys of youth in all three countries indicate low levels of sexual activity, generally high levels
of awareness of HIV, but persistence of misconceptions related to transmission that contribute to
stigma and discrimination. In all three countries, there are limited "youth-friendly" SRH services,
and the experience of MSIVN in this area should be widely shared. Youth also tend to have low
self-perceptions of HIV risk which contributes to low uptake of VCT services.
Harm reduction approaches to injecting drug use are only just starting in all three countries, with
many still regarded as pilot projects. The need to scale-up this approach is urgent in Myanmar
and Viet Nam. The provision of quality VCT services will support this harm reduction approach.
There is evidence to indicate increasing use of condoms in commercial sex work in all three
countries, most marked in Cambodia. The combination of injecting drug use and sex work in Viet
Nam requires a more intense harm reduction approach. The provision of quality VCT, with
assurances of confidentiality and a non-judgmental attitude from health providers can support this
behaviour change approach.
HIV counseling and testing services
In all three countries there is a strong demand for HIV counseling and testing services, in the
presence of low service coverage.
All three countries have access to international and
nationally-adapted resources for training in HIV counseling and testing. There are also nationally
endorsed monitoring and evaluation frameworks available in each country. The issue of a fee for
HIV counseling and testing is common to the three countries but will require country-specific
responses.
149
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GLOBAL AND REGIONAL
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UNAIDS. 2004 Report on the global AIDS epidemic, 4th global report; June 2004.
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World Health Organization. Coverage of selected health services for HIV/AIDS prevention and care in
less developed countries in 2001; 2002.
4
The POLICY Project. Coverage of selected services for HIV/AIDS prevention and care in low and
middle income countries in 2003; June 2004.
5
United Nations General Assembly. Progress towards implementation of the declaration of Commitment
on HIV/AIDS. Report of the Secretary General, 58th session, 25 July 2003
6
World Health Organization. Monitoring and Evaluation Toolkit: HIV/AIDS, Tuberculosis and Malaria;
June 2004.
7
World Health Organization, Department of HIV/AID. National AIDS Programmes: a guide to
indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people:
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8
World Health Organization, Department of Gender and Women's Health. Integrating gender into
HIV/AIDS programmes: a review paper; 2003.
9
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162
10. ANNEXES
ANNEX 1: LIST OF KEY WEB SITES AND RESOURCE CENTRES
Website address
Name of Site and Notes
hivinsite.ucsf.edu/global?page=cr08-cb-00
Centre for HIV Information at the University of

California San Francisco - Cambodia
California San Francisco Myanmar
California San Francisco Viet Nam
UNFPA, Myanmar
International AIDS Alliance: search for Cambodia:
Khmer HIV/AIDS NGO Alliance (KHANA)
US Centre for Disease Control
US CDC: rapid HIV tests approved by FDA
USAID: search for documents by country
US Federal Drug Administration: approved HIV tests
Family Health International
UNDP Human Development Report
UNDP SE Asia HIV and Development Programme
Country Reports on HIV indicators (disaggregated)
Medicam, Cambodia: look at Library Reference List with
documents available online or from Medicam library
UNDP Myanmar
National Centre for HIV/AIDS, Dermatology and STIs
(NCHADS), Cambodia
The POLICY Project: website under construction but
many POLICY documents sourced from other websites.
Reproductive and Child Health Alliance, Cambodia:
resource library with online links
Links to testing manufacturer's Web pages
UNDP Cambodia
UNFPA Cambodia
UNFPA, Viet Nam
UNAIDS: search by Topic (Testing and Counseling) or
by Country
UNAIDS Viet Nam: resources listed by topic and links to
download
UNFPA
WHO HIV site
UNAIDS/WHO Global HIV/AIDS Online database: data
query (reports, charts, maps), mapping and resources
WHO. Health legislation and including Pharmaceuticals,
testing and counseling
WHO: Laboratory supplies
World Bank
World Bank Cambodia
World Bank Myanmar
World Bank Viet Nam
World Bank AIDS in Asia/ Pacific Region
hivinsite.ucsf.edu/global?page=cr08-bm-00
hivinsite.ucsf.edu/global?page=cr08-vm-00
http://myanmar.unfpa.org
www.adb.org/
www.aidsalliance.org
www.cdc.gov/hiv/
www.cdc.gov/hiv/rapid_testing/
www.dec.org/
www.fda.gov/cber/products/testkits.htm
www.fhi.org
www.hdr.undp.org/
www.hiv-development.org
www.measuredhs.com/hivdata
www.medicam-cambodia.org
www.mm.undp.org/
www.nchads.org
www.policyproject.com
www.racha.org.kh/
www.rapid-diagnostics.org/rti-hiv-com.htm
www.un.org.kh/undp
www.un.org.kh/unfpa
www.un.org.vn/unfpa
www.unaids.org
www.unaids.org.vn
www.unfpa.org/
www.who.int/hiv/en/
www.who.int/globalatlas/default.asp
http://www3.who.int/idhl-rils/frame.cfm?language=english
www.who.int/diagnostics_laboratory/procurement/en/
www.worldbank.org
www.worldbank.org/kh
www.worldbank.org/mm
www.worldbank.org/vn
www.worldbank.org/eapaids
163
ANNEX 2: KEY INFORMANTS FOR CAMBODIA SITUATION ANALYSIS

Acronym
DFID
HACC
NAA
NCHADS
UNAIDS
Organization
Department for
International Development
HIV/AIDS Coordinating
Committee
National Aids Authority
National Center for
HIV/AIDS, Dermatology
and STD
UNAIDS
Contact/ Position
Ms Nicolet Hutter
Program Support Officer
Mr. Seng Sopheap
Executive Officer
Dr Teng Kunthy
Vice-Secretary General
Dr Prum Phanit
Chief of VCCT Sub-Unit
email
dfidpso@online.com.kh
HACC@online.com.kh
kunthy@naa.org.kh
phaprom@yahoo.com
Mr Matthew Warner-Smith
warnersmithm@unaids.org
M&E Advisor
UNICEF
United Nations
Mr. Chin Sedtha, HIV/AIDS
schin@unicef.org
Children Fund, Cambodia
Assistant Project Officer
USCDC
Center for Disease Control/ Dr. Hour Bun Leng
lhor@state.gov
Global AIDS Program
Deputy Director
WVC
World Vision Cambodia
Dr Srey Mony
mony_srey@wvi.org
HIV Program Manager
Notes: An in-depth interview with Dr Ping Chutema of the Reproductive Health Association of Cambodia
(RHAC) was conducted in August 2005, before the development of the Generic Questionnaire. Similarly,
a meeting was held with Om Chhen, a representative of Population Services International (PSI) at around
the same time. The MSC Program Manager and MSIA Project Support Manager met with Betina Maas,
Country Director of UNFPA, early in the process of developing this review and a separate Key Informant
Interview was considered unnecessary. Multiple requests to attempt to arrange an interview with a
representative of the Ministry of Women's and Veteran's Affairs were unsuccessful.
ANNEX 3: KEY INFORMANTS FOR MYANMAR SITUATION ANALYSIS

Acronym
CARE
NAP
PSI
UNAIDS
Organization
CARE
International
Myanmar
National Control
AIDS Program
Population
Services
International
UNAIDS
Contact/ Position
Ms Dympha Kenny,
Assistant Country Director
(Programs)
Dr Min Thwe,
Deputy Director &
Programme Manager
Mr Guy Stallworthy,
Myanmar Country Director
email
dymphna@care.org.mm
thwe@mptmail.net.mm
guy@psimyanmar.org.mm
Mr Brian Williams,
williamsb@unaids.org
Country Coordinator
sid.naing.unaids@undp.org
Dr Sid Naing,
Program Advisor
UNODC
United Nations
jean-luc.LEMAHIEU@unodc.org
Mr Jean-Luc Lemahieu,
Office on Drugs
Country Representative
lermetotcu@idu.org.mm
and Crime
Mr Olivier Lermet,
International Coordinator
UNICEF
United Nations
Ms Anne Vincent,
avincent@unicef.org
Children's Fund
Chief, Health and Nutrition
Section
Note: This Table lists the details of persons contacted for Key Informant Interviews who gave permission
for their names and contact details to be referenced for this report.
164
ANNEX 4: KEY INFORMANTS FOR VIET NAM SITUATION ANALYSIS

Acronym
CARE
CDC
FHI
PAC
UNAIDS
VAAC
WVV
Organization
CARE International
in Viet Nam
US Centre for
Diseases Control,
Global AIDS
Program
Family Health
International
Provincial AIDS
Committee, Ho Chi
Minh City Standing
Office
UNAIDS
Viet Nam
Administration of
HIV/AIDS Control,
Ministry of Health
World Vision
Vietnam
Contact/ Position
Nguyen Ngoc Thang,
Component Manager
Dr Mitchell Wolfe,
Country Director
Mr Tran Tien Dat and
Dr Dao Quang Vinh,
Medical Research Technologists
(Coordinator), Voluntary HIV
Counseling and Testing Program
Dr Vu Ngoc Bao,
Program Manager
Dao Duc Giang,
Program Officer, HIV Counseling
and Testing
Dr Tran Thinh,
Project Coordinator, PAC
email
nnthang@care.org.vn
Louise Dann,
UNV Associate Volunteer,
Planning and Management Officer
Dr Nguyen Huy Nga,
Director-General
louise@unaids.org.vn
Sera Bonds,
HIV/AIDS Technical Advisor
Monique Zammit,
Project Assistant, HIV/AIDS and
Information Management
sera_bonds@wvi.org
MSW6@CDC.GOV
TranDT2@state.gov
DaoVQ@vn.cdc.gov
bao@fhi.org.vn
giang@fhi.org.vn
tranthinhpac@yahoo.com
huynga@netnam.vn
Monique_zammit@wvi.org
165
ANNEX 5: GENERIC QUESTIONNAIRE FOR KEY INFORMANTS

Mekong VCT Project
Key Informant Interviews: Generic Questionnaire
Date of Interview: _ _ _ _ _ _ _ _ _
Location of Interview: _ _ _ _ _ _ _ _ _ _ _ _ _
Name of Key Informant: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Current Position/ Organization: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact details: Phone: _ _ _ _ _ _ _ _ _ _ _
Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
INTRODUCTION
Introduce self and Maire Stopes organisation

Outline EC funded Mekong VCT Project goals, impact etc
Explain reason for seeking Key Informant Interview
Obtain informed consent to take notes during the interview and to quote responses in
Situation Analysis using the name of the Key Informant, if appropriate.
Inform the Key Informant that if he/she does not want any specific responses quoted,
then this will be respected and confidentiality kept.
Advise the Key Informant that the final report will contain a list of persons who were
interviewed obtain permission to include Key Informant's name in this list.
Advise Key Informants that they will receive a copy of the completed Situation Analysis.
QUESTIONS
CORE: must ask this question
REC: recommended try to make sure this question is asked
OPTIONAL: ask only if there is enough time or an opportunity
1. CORE (for Gov, IO and ?NGO):
What are the key issues related to the spread of HIV/AIDS in [name of country]: cultural/
behavioural issues? social/ economic issues? gender/ human rights issues?
2. CORE (for Gov and IO):
What is the current place (or role) of HIV testing and counseling in [name of country]
responding to HIV/AIDS in [name of country]? Is HIV testing and counseling seen mainly
as a health intervention or a multi-sectoral responsibility, or both?
3. CORE (for Gov, IO and NGO):
What is your assessment of the current coverage of HIV testing and counseling services
in [name of country]? geographical coverage, coverage of specific population groups?
What are the most important barriers to HIV testing and counseling services in [name of
country]for the general population and for specific population groups (women, youth, high
risk behaviour groups)? [Assessment of stigma and discrimination as a barrier].
5. CORE (for Gov, IO and ?NGO):
What models of HIV testing and counseling are needed and appropriate to [name of
country] to scale-up HIV testing and counseling to reach more of the general population?
What appropriate models to reach specific population groups youth, women, risk
behaviour groups?
166

What do you see as the main roles and responsibilities of NGOs in HIV testing and
counseling services in [name of country]? - pre-test counseling only, pre and post-test
counseling only, pre and post-test counseling with testing, community mobilization,
supporting referral for post-test servicesother?
Depending on the response to Q6: What do you think are the most appropriate/ strategic
target groups for NGOs to reach with HIV counseling (and testing) services in [name of
country]?
8. CORE (for Gov, IO, NGO):
What are the most important considerations to sustain VCT services? Do you think
charging a fee for HIV testing is appropriate? actual cost or subsidized? who should be
exempted from fees? [Assess the appropriateness of cost sharing or user fees].
9. CORE (for Gov, IO):
Are there important legal or ethical issues that Marie Stopes needs to be aware of in
[name of country] in implementing an integrated HIV testing and counseling services?
age of consent, licensing for VCT services, partner notification, disclosure of results,
mandatory practices for screening certain groups?
10. REC (for Gov, IO): LAST QUESTION
What recommendations would you give to NGOs to support effective HIV testing and
counseling services integrated with existing sexual and reproductive health services in
[name of country]?
ASK THE FOLLOWING QUESTIONS ONLY IF TIME PERMITS:
11. OPTIONAL (for Gov, IO and NGO):
What strategies do you think are most likely to be successful in [name of country] to
promote community awareness of HIV testing and counseling services?
12.OPTIONAL (for Gov and IO)
What ideas/ suggestions do you have to improve quality of HIV testing and counseling
services in [name of country]? To improve the monitoring and evaluation of HIV testing
and counseling services?
Additional questions for individual Key Informants based on their professional expertise/
organization's expertise: (in order to keep the number of questions to a reasonable limit, it
may be necessary to replace some of the CORE questions above with specific questions
in the following areas: PMTCT, HIV and TB, HIV and STI, IDU, Sex Workers, Migrant workers
(internal and international), Youth.
END: Thank you
Check that all responses can be quoted, if appropriate (or confirm what can/ cannot be
quoted).
Check contact details and inform Key Informant that they will get a copy of the Situation
Analysis when it is completed.
167

HIV Counseling and Testing: Situation Analysis in Cambodia, Myanmar and Vietnam

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HIV Counseling and Testing: Situation Analysis in Cambodia, Myanmar and Vietnam

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HIV Counseling and Testing: a

Situation Analysis in Cambodia,

Marie Stopes International Australia

1. PURPOSE OF THE SITUATION ANALYSIS

2. METHODOLOGY FOR THE SITUATION ANALYSIS

3. GLOBAL OVERVIEW OF HIV/AIDS AND HIV COUNSELING AND

4. MEKONG REGION OVERVIEW OF HIV/AIDS: FOCUS ON

5. CAMBODIA SITUATION ANALYSIS

6. MYANMAR SITUATION ANALYSIS

7. VIET NAM SITUATION ANALYSIS

7.5 National Response, Policies and Strategic Plans in Viet Nam

8. COMMON THEMES AND TRENDS

List of key web-sites and resource centres

Millennium Development Goals

Men who have Sex with Men

Community Based Organisation

Sexually Transmitted Disease

Sexually Transmitted Infection

Global Fund for AIDS, TB and

Indirect Sex Worker

Information, Education and

Joint United Nations Programme on

Key Informant Interview

United Nations Office on Drugs and

Ministry of Women's and Veteran's

Marie Stopes Cambodia

National AIDS Authority

HIV/AIDS Coordinating Committee

Khmer HIV/AIDS NGO Alliance

National AIDS (Control)

Marie Stopes International

Provincial AIDS Committee

Survey of Vietnamese Youth

1. PURPOSE OF THE SITUATION ANALYSIS

2. METHODOLOGY FOR THE SITUATION ANALYSIS

3. GLOBAL OVERVIEW OF HIV/AIDS AND HIV COUNSELING

3.1.2 Global impact of HIV/AIDS

3.1.3 Gender issues in the global response to HIV/AIDS

In summary, the key gender issues in responding to HIV/AIDS are8:

3.1.4 Human Rights and HIV/AIDS: the international situation

3.1.5 Global overview of HIV prevention

3.1.6 Global overview of HIV/AIDS treatment, care and support

3.1.7 Young people and HIV/AIDS

3.1.8 Sexually Transmitted Infections and HIV/AIDS

3.1.9 Tuberculosis and HIV/AIDS

3.2 Global Overview of HIV Counseling and Testing

3.2.3 Guiding principles of HIV counseling and testing

To be successful, HIV counseling and testing services must40:

3.2.4 Components of HIV counseling and testing

3.2.5 Impact of HIV counseling and testing

3.2.6 Lessons learned from international experience in HIV counseling and

3.2.7 Training resources for HIV counseling and testing

3.3 HIV Counseling and Testing Service Models

Types of HIV testing based on methods to ensure confidentiality

3.3.2 Ethical and legal considerations

3.4 Integration of HIV Counseling and Testing into Sexual and

3.4.2 Practical steps for integration

perception of the consequences of living with HIV

3.5 HIV tests: Selection and Availability

3.5.2 Types of rapid tests

3.5.3 Selection of rapid test kits

3.5.4 Quantification and availability of rapid test kits

3.6 Monitoring and Evaluation of HIV Counseling and Testing