Time to tackle the high-risk groups

People most at-risk from HIV (key populations) in Cambodia are the subject of the latest research findings from KHANA, an Alliance Linking Organisation.

New HIV infections in Cambodia dropped by half from 2002 to 2012. However, HIV prevalence remains high in people among key populations.

Men who have sex with men (MSM) and female entertainment workers have prevalence levels of 2.2% and 9.8% respectively. In addition, the incidence of new HIV infections in couples where one partner is HIV positive and the other HIV negative (serodiscordant couples) is high.

The KHANA Center for Population Health Research is a leading think tank, which has produced substantial scientific evidence for policy development and advocacy for the refinement of population health in Cambodia. The Center was fully established in 2015, resulting in the publication of approximately 20 peer-reviewed research articles all of which have important implications for improving HIV prevention, treatment and care for key populations in the country. Four papers address the following core issues:

Tailoring HIV education for serodiscordant couples

One study explored the factors determining inconsistent condom use among serodiscordant couples. Among its 262 participating couples it found that:

  • Female HIV-positive partners were significantly less likely to report consistent condom use compared to male HIV positive partners.
  • The length of living in a serodiscordant relationship was important in determining consistent condom use (with consistency increasing with the length of a relationship).
  • Frequent alcohol users were more likely to report inconsistent condom use.
  • A perception that antiretroviral therapy (ART) could prevent HIV transmission increased the likelihood of inconsistent condom use.

The authors conclude that gender-sensitive interventions to promote consistent condom use among serodiscordant couples should be integrated into HIV programmes. Also, that female HIV-positive partners may need additional support, education and counselling, and intervention is needed to mitigate alcohol use and abuse.

In addition, the findings have implications for messages about preventing HIV transmission through ART, and point to a need for further research exploring the role of pre-exposure prophylaxis for HIV-negative partners.

Condom use among serodiscordant couples has been a key intervention message given by KHANA, particularly among HIV positive females. Condoms are available at all pre-ART and ART sites, and KHANA uses a tracking system to monitor the uptake of HIV testing among serodiscordant couples.

Reaching female entertainment workers through texts

Another study showed that mobile phone text messages could be an effective way of reaching young female entertainment workers with HIV information. Since a 2008 law criminalised brothel-based sex workers, sex work has gone underground in Cambodia. Much of it now takes place in restaurants, karaoke bars, beer gardens, cafes, pubs and massage parlours.

The findings show half of the 96 entertainment workers in Phnom Penh who took part in the study sent text messages on a daily basis, with younger workers more likely to text daily. Most of the participating workers reported feeling comfortable receiving private health messages, even though around half said they shared a phone with colleagues.

Despite concerns about the multiple uses of SIM cards, the privacy implications of sharing phones and issues surrounding low literacy levels, the authors suggest that mobile health (mHealth) interventions may be a feasible way of reaching female entertainment workers in Phnom Penh. The findings have supported the development of a proposal for a three-year mHealth intervention.


Improving mental health in female entertainment workers

Female entertainment workers in Cambodia experience high levels of mental distress and another study aimed to identify the factors associated with this. Poor mental health is known to contribute to poor HIV prevention, treatment and care outcomes.

Data was collected as part of an impact evaluation of the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project implemented by KHANA. It shows that almost half of female entertainment workers had a high level of psychological distress. Nearly one in five (19.5%) reported having had suicidal thoughts; 7.3% saying they had attempted suicide in the past three months.

The authors say intervention programmes aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk.

Improving mental health in men who have sex with men (MSM)

Data from SAHACOM was also used to explore mental health in MSM in Cambodia. The findings show a strong association between psychological distress and older age, low condom use, alcohol and illicit drug use, verbal abuse and family violence.

The authors conclude that mental health interventions need to be better integrated into HIV prevention treatment and care for MSM. In particular, they recommend that health professionals working in HIV programmes and clinics are equipped to screen and identify non-severe mental disorders early, and can refer more complex cases to specialised health providers.

They also suggest the reconfiguring of HIV services to allow for peer-based outreach social support for MSM suffering mental distress.

USAID funding

KHANA research manager Tuot Sovannary, said: “The KHANA Center for Population Health Research aims to promote the quality of life and health of the population through providing evidence-based information for the development of effective health programmes and policies. One of the key agendas of our research centre is the dissemination of our findings, including through peer-review publications.

“Most of the data used for these publications were collected as part of a USAID-funded project and a research grant from Touro University California’s Public Health Program.”