HIV
&
CAMBODIA ROAD IMPROVEMENT PROJECT
Infrastructure
Mitigating HIV Risks in Cambodia
T
he Asian Development Bank’s (ADB’s) Cambodia
Road Improvement Project (CRIP) has incorporated
a number of human immunodeficiency virus
(HIV)-prevention measures to avoid exacerbating the
risk of HIV transmission in association with the road
construction and rehabilitation activities of the project.
CRIP aims to complete the Greater Mekong Subregion
(GMS) regional highway road 1 (R1), rehabilitating
150 kilometers (km) of national roads 5 and 6 (NR5,
NR6) and 45 bridges along national roads 56 and 68
(NR56, NR68). The road construction works are taking
place in three of the country’s poorest and most war-
devastated provinces. About 60% of households in this
area suffer from food deficiency because of perennial
ADB Experience
floods and inaccessibility during the rainy season while
physical infrastructure, social, health, and other services
are inadequate.
The objective of the road project is to promote general
economic growth at the subregional and national levels
and to promote economic and social development in
the area. The total cost of the project is estimated to be
$77.5 million, of which $193,280 (0.25%) is assigned to
the HIV/acquired immunodeficiency syndrome (AIDS)2
program and $175,000 (0.23%) for the contractors’
HIV- and sexually transmitted infection (STI)-prevention
activities. The original estimated project duration was
from 2003 to 2007, but completion of the civil works
component is delayed until 2009.
Methodology for Case Study Review
of HIV Activities
ADB’s case study review was undertaken to assess
the design and implementation issues, as well as
impact (where data were available), of the HIV-related
measures incorporated into the project implementation.
The study involved document reviews, field visits, and
meetings and interviews with key stakeholders. Among
the key stakeholders consulted were construction
company employees, government officials, ethnic
minority groups, nongovernment organizations
(NGOs), women’s groups, other donors, and mobile
and migrant workers.
 5km from NR5, NR6, NR56, and NR68 with an HIV- prevention
program as well as antidrug and human trafficking activities.
It is to be implemented for 3 years in parallel with the road
construction.7 A private Cambodian firm has been contracted
to implement the activities that comprise HIV, STI, drug, and
human trafficking awareness campaigns. These campaigns are
organized at the village level and involve 10–20 villagers per
session (target ages range from 14–59 years) using flipcharts
and two leaflets. As of June 2007, this program is ongoing and
will continue for 3 years.

Contractors’ HIV-Mitigation Program. The Thai and Chinese

contractors are required to include an HIV and STI information and
education program that targets both the contractor’s workforce
and the local population within the construction corridor. A local
NGO with experience in implementing HIV-prevention projects
in the infrastructure sector has been contracted for 3 years, with
Rationale for HIV-Focused Interventions
contingency for a 1-year extension in case of construction delays.
As of June 2007, this contract is also ongoing.
Cambodia has one of the highest HIV prevalence figures in
Southeast Asia. The epidemic peaked in 1997–1998 when about
To date, the NGO’s activities have focused on the construction
3.3% of the adult population was estimated to be infected with
workers. The NGO is conducting participative sessions on
the virus. This figure was estimated to be 1.6% in 2007.2 The
HIV-prevention and life skills training with a group of 10–20
Government’s policy on 100% condom use is attributed with
construction workers per civil works package (there are four)
reducing the number of new infections among sex workers
per week. Monthly schedules are prepared in consultation with
by half from 1999 to 2002. According to the Joint United
the supervisors so that programs are delivered cognizant of the
Nations Programme on HIV/AIDS (UNAIDS), the incidence and
work schedules. In the first year, it reported conducting HIV-
prevalence of infections among brothel-based sex workers and
awareness campaigns for 2,500 workers.8
their clients have significantly declined since 1998. However,
more men are turning to non-brothel-based sex workers, non-
regular partners, and girlfriends for sex, with whom less condom Key Issues
use has been reported. In recent years, HIV is largely acquired
through husband-to-wife and mother-to-child transmission3 While implementation of the activities is still ongoing, the
and through injecting drug use (predominantly heroin).4 case study analysis identified a number of key structural
and operational issues that will be useful in designing and
The CRIP construction sites are in the region of the country with implementing programs similar to this one.
the highest prevalence of HIV. Poipet, the border town with
Thailand on NR5, is considered one regional epicenter of the HIV
epidemic.5 Subsistence poverty is widespread in the project’s three
provinces because of the legacy of genocide, civil war, and famine.
Consequently, migration and mobility have become modes of
survival for many families seeking seasonal work, and there are
anecdotal reports of human trafficking, especially in Poipet.6

HIV-Prevention Measures

Considering the HIV risk factors associated with any road project
and, in particular, with this location, ADB and the Cambodian
Ministry of Public Works and Transport (MPWT) agreed to
include two mechanisms for delivering HIV-related programs: (i)
an HIV-prevention component in the main project design; and
(ii) a requirement on construction contractors, as outlined in
the bidding and contract documents, to deliver an HIV and STI
information and education campaign to construction workers.

The HIV/AIDS Project Component. This component was

designed to target affected communities within a radius of
Structural
• Strong government support is needed. The Government
of Cambodia agreed to use funds from the project loan for
the HIV/AIDS program indicating strong support for the
component objectives. The project management unit and
MPWT also provided strong support for the project’s HIV-
prevention activities.
• Separate implementing agencies may be inefficient.
PMU engaged two HIV implementing organizations to handle
separate target groups. This appears to have been associated
with inefficiencies and confusion in implementation
strategies because of the limited coordination between the
organizations.
• Need for detailed technical design. The feasibility study
and loan documents did not include detailed designs, and
there was a limited amount of additional technical work
at inception. PMU and the Social and Environmental Unit
(SEU) within MPWT did not have the technical capacity, so
some limitations in the design and implementation could
have been addressed from the outset.
• Build the monitoring capacity. Establishment of the
SEU, with responsibility for activities on preventing HIV and
human trafficking, was a major achievement for the project.
However, to date, SEU staff have not received training
related to the prevention of HIV and human trafficking, and
monitoring activities have subsequently been weak.
• Contracting mechanisms can be complex and
expensive. Under the project implementation arrangements,
the construction contractors were responsible for
contracting implementing agencies (local NGOs in this case)
for the HIV- and STI-prevention program. This arrangement
meant the PMU and supervising consultant had no direct
role or responsibility in the HIV-prevention activities and was
somewhat cost-inefficient because of the overhead charged
by the lead contractor.
• Coordination with local authorities is necessary. The
contracts for HIV-prevention implementing organizations
stipulated that they should design and implement HIV-
prevention activities in close collaboration with local health
authorities and NGOs. Local authorities report that they
have had limited involvement. This may ultimately limit the
likelihood of sustainability and local capacity building.
• Housing Arrangements must be considered.
Construction employees do not live in camps but stay in
nearby villages or towns where daily interaction between
employees and villagers creates an environment that
increases HIV risk to workers and communities. In such
situations, separate programs for construction workers
and villagers may not make sense or be cost-effective
compared to settings where construction workers live in
camp settings. The specifics of the living arrangements and
other interactions will vary between projects and need to be
considered in design and implementation.
Operational
• Drug and human trafficking programs require
expertise. In the GMS region, few agencies that specialize
in HIV-prevention programs also have specialist capacity in
prevention activities in drug and human trafficking. While
there is an overlap in the target audience and probably some
overlap in the methodologies to be used (e.g., life-skills
training), some specialist expertise in these areas need to be
incorporated. In the case of CRIP, the implementing agency
for the HIV-awareness and prevention program has involved
government and other relevant agencies in an attempt to
bridge this lack of expertise.
• Need for effective education and communication
materials. To date, the education and communication methods
used have been limited—mainly flipcharts and leaflets in the
Khmer language. This has limited effectiveness with foreign
construction workers who do not understand the language.
• Target management staff and consultants. Studies
have shown that the management staff and consultants to a
construction contract are often at greater risk of contracting
HIV because they have the financial and logistical resources
to travel from the site and engage in risk behaviors. The NGO
contracted for the CRIP project has recognized this and targeted
these groups specifically for HIV-awareness campaigns.
Recommendations
Based on this review of implementation experience and the
emerging issues, a number of recommendations can be made
for future programs:
1. Government support. Strong government support is
needed for successful HIV-prevention interventions in
association with infrastructure projects. This must include
a multisectoral approach to fighting AIDS, as demonstrated
by the commitment of the Cambodian government to
mainstream HIV prevention in its line ministries and
support—with financing—HIV-prevention programs such as
the one incorporated in the CRIP.
2. Capacity Development. The relevant staff of the ministries
of transport (or their equivalent) need to be adequately
trained in conducting HIV impact assessments, and
designing and monitoring HIV-prevention projects. Similarly,
training in human trafficking issues could be considered. The
relevant staff or unit may also benefit from establishing a
relationship with the national AIDS authority to help design
and monitor HIV-related activities.
3. Implementing Arrangements. Implementation arrange-
ments should avoid having more than one organization and/
or agency implementing HIV-related activities in association
with a single road construction (or similar) project. The HIV-
prevention program should be part of a specific project
component to ensure that adequate funding is earmarked
and that the PMU can directly contract and monitor the
implementing organization and/or agency.
4. Local authorities. Local health authorities—particularly
provincial and district AIDS committees/authorities—must
be involved at every stage, particularly in implementation.
This supports existing government systems, facilitates
coordination and collaboration, and promotes
sustainability.
5. Drug and human trafficking. Projects should consider
engaging additional, specialized expertise in relation to drug
and human trafficking since finding a single organization
and/or agency with capacity to address these issues, along
with HIV, is often difficult.
6. Education and Communication. Innovative information,
education, and communication approaches should include
multilingual materials and multimedia (especially videos),
sustained advertising, peer education, and community
mobilization.9 HIV-prevention activities should be carried
out with the same intensity from the beginning to the end
of the project, and should be repeated to reinforce behavior
change messages.

1
Current terminology protocols separate human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS); it does not use HIV/AIDS.
However, at the time the project was designed, the accepted terminology was HIV/AIDS.
2
Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006. 2006 Report on the Global AIDS Epidemic. Geneva.
3
UNAIDS website for Cambodia. Available: www.un.org.kh/?url=/newscenter/statements/&speech_id=11&mode=DETAIL
4
UNAIDS. 2006. Situational Analysis of Illicit Drug Use Issues and Responses in the Asia-Pacific Region. Geneva.
5
National Center for HIV/AIDS, Dermatology, and sexually transmitted diseases (STDs). 2000. HIV Sentinel Surveillance in Cambodia 2000. Phnom Penh.
6
The Asia Foundation. 2006. Combating Human Trafficking in Cambodia. Phnom Penh.
7
The HIV/AIDS Program is still scheduled to run from 2003–2007, even if the completion date for the civil works component has been revised to 2009.
8
This could be an overestimate since some construction workers attend multiple workshops.
9
The nongovernment organization did not recommend peer education since rural communities and construction laborers have generally low educational
levels, and HIV information becomes less accurate when passed from trainer to peer educator to peers.

This paper was prepared by Charmaine Cu-Unjieng (Consultant) and Lisa Studdert, Southeast Asia Department (SERD), under Regional Technical
Assistance 6321: Fighting HIV/AIDS in Asia and the Pacific (subproject 3: HIV Prevention and the Infrastructure Sector in the Greater Mekong
Subregion).

The helpful contributions of Van Than, Pheng Sovicheano, Veasna Nuon, and Rikard Elfving, among others, are appreciated.

The views and assessments contained herein do not necessarily reflect the views of Asian Development Bank (ADB), or its Board of Directors, or the
governments they represent. ADB does not guarantee the accuracy of the data and accepts no responsibility for any consequence of their use.

All photos were taken by Charmaine Cu-Unjieng.

For any queries, contact:

lstuddert@adb.org