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Condom Campaign
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KOH KONG, CAMBODIA. It is Saturday night at the White Night Club and the rain does not deter male customers from enjoying a night of drinking, karaoke, and the company of women.
In a back room, a hospitality worker, who also an official peer educator, dispenses advice to her younger coworkers.
Doung, who has been at the club in this isolated border town for 3 years, is addressing half a dozen attentive young women.
“Do you know that not only your customers should use a condom, but also your boyfriend if you go out with him?” she asks.
The girls nod in unison.
“Even if boyfriends are good-looking and healthy in appearance—because they might also be ill.”
Her younger listeners, like Bopha— pale, slim 20-year-old—say they appreciate the motherly warnings, especially as they are away from home. Like Bopha, who is from Kandal Province, sex workers typically leave their hometowns to avoid bringing shame to their families.
Such counsel—repeated in other karaoke bars, brothels, and massage parlors—is part of a campaign to promote “100% condom use.” This is a key element of an integrated Asian Development Bank (ADB)-financed community action project being applied by local government authorities in cooperation with nongovernment organizations (NGOs) under the Ministry of Health’s Strategic Plan for HIV/AIDS and STI Prevention and Care 2004–2007.
“We are promoting condom use in brothels, karaoke bars, and massage parlors,” said one government doctor. “And who better to advise the [women] than one of their own?”
The project also includes treatment for sexually transmitted infections (STIs) and counseling, with voluntary confidential counseling and testing services; developing information, education and communication materials; and introducing the “continuum of care” for people living with HIV/AIDS, including antiretroviral (ARV) therapy.
According to Program Manager Dr. Leng Veng Se, it has already succeeded in reducing HIV/AIDS infection rates among sex workers from an “epidemic” rate of more than 50% to a still serious, but more manageable, 30%.
Why this sleepy southwestern town should be a focus of national and international attention is puzzling at first.
Koh Kong is difficult to access from other parts of Cambodia: a trip by road from Phnom Penh, for example, involves crossing four rivers by makeshift ferries and takes most of a day in the dry season—and longer when monsoon rains churn the red earth track into a quagmire.
"We are promoting condom use in brothels, karaoke bars, and massage parlors, and who better to advise the [women] than one of their own?"
- Cambodian Government Doctor
Yet Koh Kong’s location on Cambodia’s southwest border with Thailand, and its significant migrant population have given the town the dubious distinction of being a “hot spot” for HIV/AIDS.
In the 1990s, says Dr. Se, the area— which includes many islands—was a magnet for migrants involved in activities such as logging, fishing, and smuggling.
In the last few years, soldiers and construction workers brought in to build bridges and roads have also boosted the town’s temporary population.
And, recently, Koh Kong has drawn a new kind of migrant—workers to staff a new casino, a safari park, and other recreational facilities that are part of a burgeoning tourism industry.
With these waves of migrants came young women from poor families seeking to work in the sex industry.
The mix of lonely migrant men and underprivileged women proved a deadly cocktail.
Infection rates in this border town soon reached alarming proportions. By 2002, a survey showed that a little more than half of the direct sex workers in Koh Kong were infected with HIV/AIDS, higher than the national average of 33%.
For those infected, the horror was often made worse by the fact that they were without family or other support networks.
The situation had already prompted local health authorities to take action, setting up a clinic in 2000 to provide STI services to sex workers. The clinic has since been strengthened by the addition of doctors and nurses and a renovated laboratory, and now also provides voluntary confidential testing and counseling services.
In March 2003, CARE Cambodia, an NGO, joined in and began work with government agencies to contribute additional support for a series of outreach programs that today include home-based care for chronically ill patients; support for orphans and vulnerable children; and MMM (meaning Mondul Mith Chuy Mith, or “friend help friend”) center meetings where HIV/AIDS patients share their experiences, plan group activities, meditate, and receive treatment from health workers.
Many of the program’s activities are based in a cluster of buildings in the Operational District Referral Hospital compound. At the medical clinic for sex workers, young women watch a children’s television program as they wait for a checkup with the doctor.
Inside one doctor’s office, a sex worker is shown how to place condoms on clients. “The rate of infections among sex workers started dropping in 2002 and fell significantly in 2003,” says Dr. Suy Sinoeun, one of the clinic staff. “Part of the reason is the work of our clinic and the outreach programs, and partly because of improved medication.”
The disease has spread beyond the sex industry to affect some wives and girlfriends. Notes Vincent de Wit, an ADB senior health specialist: “Rural women are vulnerable as they are often illiterate and poor, with little access to information or health care, and are ill equipped to protect themselves.”
In a nearby building, nearly 70 HIV/AIDS patients—who are not sex workers— are attending a meeting addressed by counselors, including a saffron-robed Buddhist monk. Many patients have formed selfhelp groups to share experiences or to achieve a goal, such as increasing savings or generating income. Doctors and nurses are on hand to provide diagnosis and treatment.
On a blue mat outside the building, more than two dozen children are playing and being fed by CARE volunteers. The offspring of HIV/AIDS patients, they are a somber reminder that the disease also affects those left behind.
Eleven-year-old Er, with large, knowing eyes, has responsibilities well beyond her age. She is spooning food into the mouths of her younger sisters, Channa, 6, and Ka, only 18 months. Their 28-year-old mother is one of the patients attending the counseling session.
Smiles light up the children’s faces as they play, but this adds to the poignancy felt by volunteers who know that many of those in their charge may soon become orphans.
“Since many of the parents are migrants and have no relatives here, these children are referred to the Department for Social Affairs,” says Sum Sitha, a team leader for CARE’s Children in Distress program. “We have about 300 orphans this month, but the local orphanage has room for only 25 children.”
The good news is that the community action project will soon be bolstered by the arrival of ARV drugs, which can stave off the worst effects of the disease.
Under a national program, ARV drugs are gradually being introduced to the country, and the pace is expected to accelerate as such drugs become cheaper.
More than 4,200 people are currently on ARV drugs in the Cambodian public sector and NGO programs, up from 650 in 2002, says Peter Godwin, Phnom Penhbased coordinator of the ADB regional project for Community Action for Preventing HIV/AIDS, of which the Koh Kong program is a part.
The aim is to increase this to 6,000 by end-2004, 12,000 by 2005, and more than 26,000 people—about 75% of all those who need the ARV drugs—by 2009. Koh Kong could receive ARV drugs by the end of 2004, with associated equipment, such as a CD4 count machine—which measures the quantity of a type of white blood cell in the body—and a program to train clinicians and caregivers, says Mr. Godwin.
He says ARV drugs are also being introduced in the Lao PDR and Viet Nam, though on a much smaller scale.
In this border town, a coordinated campaign by the Government, NGOs, and funding agencies may be turning the tide against the epidemic.
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