1. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention
Kuala Lumpur, 1 July 2013
Achieving Universal Access and Moving towards the Elimination of New HIV Infections in Cambodia
First of all, I would like to express my sincere thanks to the organizer to invite me to speak in this plenary session. It is the great honor for me to share the experience of Cambodia in the last two decades and our perspective for achieving elimination of new HIV infections by 2020.
Dr Mean Chhi Vun
National Centre for HIV/AIDS, Dermatology and STD (NCHADS) Ministry of Health, Cambodia

2. Country Profile Population: 13.4 million Urban: 20%; Rural: 80%
GDP: US$ 830 per capita
Life expectancy:
Male: 57 years
Female: 65 years
Total Fertility Rate: 3.0
Infant MR: 45/1,000
Under 5 MR: 54/1,000
Maternal MR: 206/100,000
Cambodia is a low-income country and is still trying to catch up from the long era of internal conflicts.
Health indicators are rapidly improving but still a long way to go. 2
Source: Cambodia Demographic and Health Survey, 2010 2

3. Health Infrastructure
90 Referral Hospitals
8 National hospitals
24 Provinces
77 Operational Districts
The health service delivery system consists of two types of facilities – one is the health center providing basic care including ANC, Delivery, TB diagnosis and treatment; the other one is referral hospitals which provide a wider range of clinical care including ART and laboratory services.
1,049 Health Centers
Each cover 10–20,000 population

4. Trends in the HIV Epidemic in Cambodia
Cambodia, facing in the mid-1990s one of the fastest growing HIV epidemics in Asia, became within five years one of the few countries to have reversed its trend.
We saw a 10 fold reduction in annual new infections in the last 20 years and an 3 fold reduction of annual AIDS related deaths in the last 10 years.
The country received a millennium development goal (MDG) award in 2010 from the United Nations as a global recognition of the country’s response to HIV.
Source: Conceptual Framework for Elimination of New HIV Infections in Cambodia by 2020 (NCHADS, 2012) 4

5. Mode of HIV Transmission in Cambodia: 1991 to 2015
Total 1,210
Sex work used to be a dominant mode of transmission in 1990’s. The mode has changed over time and the transmissions between spouses and casual partnerships now account for around a half of the total new transmission. 5

6. Evolution of health sector response to HIV from 1991 to 2020
Phase 1:
Phase 2:
Phase 3:
Cambodia 1.0
% HIV peaked at 1.7 in
1998
HIV prevention among
general population and
MARP
100% condom use in sex
work settings
VCT in main cities
Few home-based care
Cambodia 2.0
% HIV declined to 0.7 in 2011
Universal access to ART (CoC)
PMTCT (Linked Response) and
TB/HIV (5Is)
MARPs prevention and link to
health services
Continuous Quality
Improvement (CQI) for HIV
prevention and care services
Cambodia 3.0
Elimination of new HIV infections
ART as prevention
(early HIV case detection
immediate/early ART)
(Boosted CoC)
eMTCT (Boosted LR)
MARPs (Boosted CoPCT)
Health/Community System
Strengthening
Monitoring and evaluation of
impact
The evolution of Health sector response to HIV in Cambodia could be classified into three phases.
During the first decade, in responding to the most serious HIV epidemic in Asia, we prioritized the 100% condom use program targeting brothel based sex work.
In Phase 2, ART, PMTCT, TB/HIV and HIV prevention among MARPs and other services were rapidly expanded.
Now, we are entering the Phase 3, called Cambodia By 2020, we aim to eliminate new HIV infections through combination of ART as prevention, eMTCT and MARP prevention and links to health services.

7. Cambodia 1.0 – HIV Prevention
Local Authority
Police
Health Workers
100%
CUP
Advocacy
RH/NGO
Monitoring
brothel owners
Sex workers
Media (TV, radio, News paper)
STD Clinic
IEC/BCC
STI case management
During the 1st phase of the national response, 100% CUP was successfully implemented through close collaboration of many key stakeholders. They include sex workers, brothel owners, local authority, and health workers particularly those involved in STI services. HC
Special campaigns (Posters, leaflets, bill boards…)

8. HIV, behavioral and STI trends among brothel-based sex workers, Phnom Penh
We achieved a rapid increase of condom use among sex workers within a few years and we observed reduction of STI and HIV in this population.

9. Strategic Expansion of HTC
Cambodia 2.0: Rapid Expansion
Strategic Expansion of HTC
VCT in all ODs and at ¼ of HC
During the 2nd phase of the country’s response, we rapidly expanded VCT to cover all operational districts and even health center level.
We also introduced PITC in most health centers as well as referral hospitals. In addition, we introduced outreach testing for MARPs recently.
PITC for TB and PW in most Health Centers
Community/Peer Initiated Testing and Counseling for MARPs

10. Strategic Expansion of ART Sites
For ART, we strategically targeted high burden operational districts for expansion. Out of the total of 77 ODs, ART are available in 55 ODs where 92% of PLHIV in the country were diagnosed.
- ART sites in 55/77 ODs covering 92% of PLHIV found
- Indicating the need of Satellite ART sites

11. Not only expanding services, but systematically linking with the community and creating demand
I just would like to highlight that we focused not only service expansion, but systematic linkages with the community and creation of demand among PLHIV.

12. Continuum of Care Framework Facilitated Expansion of ART
In 2003, we developed this CoC framework together with all the stakeholders including PLHIV network and development partners.
This framework facilitated the systematic coordination and service linkages between the community, PLHIV, home-based care NGOs and district health based health services for accelerating access to HTC and maximizing retention in HIV treatment and care.
The core of this continuum of care is “MMM” which is indicated in red at the center. What is MMM?
(District Level) 12

13. MMM Activities
MMM is a PLHIV friendly mechanism which foster the local partnership among PLHIV, families, NGOs, health workers, religious leaders and local authority.
When we were thinking of ART expansion strategy in 2002, we were considering different approaches for service delivery model. Among several options, through extensive consultations, we have concluded the model of partnership between PLHIV network, NGOs and health services should be the way to go. 13

14. every two month at OD level
CoC-CC Meeting
every two month at OD level
The MMM is backed up by the regular local CoC coordination meetings at operational district level.

15. Number of people with HIV, in need of ART and on ART aged 15+ (2000-2015)
ART Retention
89% at 12M
84% at 24M
75% at 60M
As a result, we have also been able to reach over 85% ART coverage and achieved high level of retention in treatment through a range of quality assurance activities.
ART Coverage 87%
Source: Conceptual Framework for Elimination of New HIV Infections in Cambodia by 2020 (NCHADS, 2012) 15

16. “Linking Model” 2000 2005 2010 PMTCT TWG (’99) PMTCT pilot (’01)
PMTCT GL: SD-NVP (’02)
PMTCT GL rev: Dual prophyl (’05)
PMTCT Review (’07)
Linked Response (’08)
PMTCT GL rev: Option B (’10)
TB-HIV Sub-committee (‘99)
TB/HIV Framework (’02)
TB/HIV pilot (’03)
Joint Statement: Role & Responsibility (’03)
SOPs PITC in TB cases (’06)
CAMELIA and ID-TB/HIV results (’09)
SOP, Joint Statement: 3I’s (’10)
3I’s Role Out (’11)
2000
2005
2010
From late 1990’s, we were working on PMTCT and TB/HIV separately, but did not work well. In around 2006, we realized that the development of a common “linkage model” would be essential to operationalize both PMTCT and TB/HIV.

17. Linking Model (2008- ): Facilitated expansion of PMTCT and TB/HIV+ +
Referral and Follow-up HC HC
Satellite HC
HCBC Team/NGO
VCCT
Referral and Follow-up
Referral and Follow-up
Referral and Follow-up
Health worker/NGO
HCBC Team/NGO
HCBC Team/NGO +
Both MCH and TB services were available at health center level while HIV services were only at referral hospitals.
To improve both PMTCT and TB/HIV services, we created the linking model.    
RH (Hub)
Referral and Follow-up
HCBC Team/NGO
VCCT
Community

18. Linkages: Kirivong Operational District
20 HCs have only 2 VCCT sites,
1 OI/ART services
VCCT
For example, we introduced PITC at health center level building upon existing MCH and TB services and established common blood sample referral system linked to referral hospitals.
In this district, only 2 sites offered ANC testing – because ANC testing was only offered at those sites co-located with a VCCT site. 18

19. Linkages: Kirivong Operational District
New PMTCT
14 HC refer blood samples to 5 sub-satellites &
1 satellite
New
New PMTCT
New VCCT
New PMTCT
After introducing the ‘linking model’, 4 new VCCT sites were established. Then, health centres were geographically ‘linked’ to their nearest VCCT, allowing for universal ANC testing.
New PMTCT 19

20. Linking Model Demonstration Results (2007-9)
Linking Model started
As a result, a rapid and sustained uptake of HIV testing at ANC was observed. As the green line shows, other MCH services such as syphilis testing can be added on - to achieve rapid ‘universal’ coverage also.
* Introduction of syphilis testing in the first quarter of 2009
** Percentage of pregnant women tested for HIV/ syphilis at antenatal care out of total expected pregnant women 20

21. PMTCT Coverage
We used this success in demonstration sites for resource mobilization to rapidly scale-up this approach nation-wide.
Together with other elements of linkages, we are improving coverage of PMTCT cascades progressively over the last several years. For example, the coverage of HIV testing and triple ARV prophylaxis or ART in pregnant women doubled from 2009 to 2011.

22. TB/HIV Coverage
Similarly, we achieved rapid expansion of TB/HIV collaborative activities. In particular, % of HIV positive TB cases who stated or continued on ART increased by 6 folds within 3 years.

23. Moving Towards Integration
between HIV-MCH-TB
Moving towards integration, we are intensifying the synergies between the three programs. The photo at the top shows “shaking hands” by the dragon, tiger and lion of the three national programs.

24. Responding to changing epidemics:
Overcoming political, legal and social barriers
Reaching the most-at-risk populations
Linking them to health services
Let us now come back to HIV prevention among MARPs. We have tackled multiple challenges, such as (i) Overcoming political, legal and social barriers; (ii) Reaching the most-at-risk populations; (iii) Linking them to health services, in the rapidly changing situation over the last decade.

25. Changing conditions
One big change is the shift from brothel based direct sex work to entertainment establishment based indirect sex work, as well as the increase of sex workers overall.

26. Changing conditions (2)
2008 Law on Suppression of Human Trafficking
Massive brothel closure, poorly organized
Sex workers driven underground increasing vulnerability and risk
Virtual collapse of 100% CUP as key partners and structures disappear
Increasing attentions to human rights marginalized populations
Another change we faced was issuance of a new law of human trafficking. Most brothels were cracked down so that we had to explore new strategies to reach sex workers.

27. HIV concentrated among MARPs:
Population Size HIV prevalence
EW (38,000) 10% (Clients >7/w)
(NGO report 2012) (SSS 2011)
MSM (16,000) 2.1%
TG (NGO report 2012) (Bros Khmer 2010)
PWID 1, %
(IBBS 2012) (IBBS 2012)
PWUD 13, %
(IBBS 2012) (IBBS 2012)
While we were addressing the changes related to sex work, we started to see the increasing trend of HIV epidemics among other MARPs such as MSM, TG, PWID and PWUD.

28. Health service delivery at district level
Continuum of Prevention to Care and Treatment: COPCT (2009-) MARPs prevention and access to health services
Health service delivery at district level
Sex Workers
Peer Network
Peer Educator
NGO
HBC Team
PHC network
CBO
NGO
Health Workers
In order to respond to the epidemics among MARPs in a comprehensive and systematic manner, we have developed a new framework.
As you see in this slide, we mobilized civil society and peer network to reach MARPs and help them access HIV testing, STI services, HIV treatment and other health services.
Community/Peer Initiated Counseling & Testing (CPITC), VCT, Pre-ART/ART
STI, ANC, SRH, Safe Abortion,
Safe Delivery, EPI, Nutrition (children)
TB, Malaria
Laboratory

29. Key Lessons Learned from Cambodia 2
Key Lessons Learned from Cambodia 2.0: How Cambodia Achieved Universal Access?
Know your epidemic and response remains key
Started with vertical response
Common service delivery frameworks coordinated by NCHADS involving all stakeholders for strategic expansion
“Real” involvement of community (PLHIV and MARPs)
Systematic linkages and integration to maximize resources
I would like to summarize how Cambodia achieved universal access;
We invested in strategic information to know our epidemic and chose high impact and low cost interventions
To control HIV epidemic, focused vertical response was necessary in early phases of the epidemic.
I would like to tell you we had NO PILOT PROJECT for HIV in Cambodia because we did not want to see numerous “pilot projects” by different partners, which cannot be expanded. Instead, we WORKED WITH all the partners to develop A SINGLE COMMON service delivery framework for initial learning and then expanded the agreed model to cover the whole country quickly.
In Cambodia, we do not have GIPA, but we have RIPA - “Real” involvement of community such as PLHIV and MARPs. They were involved not only service delivery, but also policy formulation, program design and monitoring and evaluation.
As the epidemic and the response matured, we shifted from vertical response to linking model and then moving towards integrated approach to maximize resources.

30. Cambodia 3.0: Virtual elimination of new HIV infections by 2020
e-MTCT
(Boosted LR)
Pregnant Women and
Sex Partners
MARP Prevention and Links to Health Service
(Boosted COPCT)
MARP and Sex Partners
STI case management
Boosted CoC
VCCT,
PITC (TB, ANC)
Community Peer Initiated TC
Building on the accomplishments made during the last two decades, we are now moving towards the ambitious goal of elimination of new HIV infections. However, we are still waiting for the global guidance for countries to set elimination criteria.
Our national targets by 2020 include;
Reduction of HIV incidence in population 15+ from 18/100,000 to 3/100,000 or less
Reduction of HIV transmission from mothers to children from 13% in 2010 to 2% or less
Increase of coverage of screening/treatment for syphilis among pregnant women to 95%
Our Cambodia 3.0 framework consists of three domains of work; i.e. MARP prevention and links to health services, eMTCT, and ART as Prevention.
PLHIV Partners
PLHIV on Pre-ART
Immediate
ART (CD4≤500)
ART as Prevention

31. MARP Prevention & Links to Health Services
(1) Sharper epidemiological targeting:
Boosted
COPCT Response
PWID
PWID selling sex
Male/TG sex workers
MSM ‘pleasure circuit’
PWUD selling sex
‘EW (Massage, KTV, Beer promoters, etc
All
Some
Few
Casino workers, Migrants, etc.
In terms of MARP Prevention & Links to Health Services, we will sharpen epidemiological targeting based on available evidence. We will try to reach ALL PWID selling sex, PWID, Male and TG sex workers, MSM pleasure circuit and PWUD selling sex.

32. MARP Prevention & Links to Health Services
(2) Reach unreached populations (MSM, TG, PWID, PWUD
and their partners) and explore hidden populations
(3) Expand outreach finger prick HTC and link to STI and ART
(4) Expand NSP and MMT for PWID
(5) Strengthen strategic information and response;
e.g. ‘rapid response mechanism’, Unique Identifier System
We also;
Try to each unreached populations (MSM, TG, PWID, PWUD and their partners) and explore hidden populations
Expand outreach finger prick HTC and link to STI and ART, as well as NSP and MMT for PWID
And Strengthen strategic information and response, e.g. By introducing ‘rapid response mechanism’ and developing Unique Identifier system

33. eMTCT and TasP Streamlining HTC procedures and referral
Partner tracing and testing
Active case management to maximize retention across HTC–PreART/ART–PMTCT–TB/HIV
TasP (Discordant Couples  MARPs)
PMTCT Option B+
For the eMTCT and TasP, we focus on;
Streamlining HTC procedures and referral
Partner tracing and testing
Active case management to maximize retention across HTC–PreART/ART–PMTCT–TB/HIV
TasP (Discordant Couples  MARPs)
PMTCT Option B+

34. Streamlining HTC procedures and referral
Cambodia 2.0
Cambodia 3.0
Referral Hosp with VCT/ART
Pre-ART&ART
Referral Hosp with VCT/ART
Confirmatory Test, PreART&ART
Patient
Referral if (+)
Health Center with VCT
1st Test, Confirmatory Test
Patient
referral if (+)
Among these new initiatives, I would like to share the plan of streamlining of HTC procedures and referral.
Under Cambodia 2.0 at the left side, those who access HTC at health center level have to go through 4 referral steps across three levels of facilities.
In the Cambodia 3.0, we will drastically streamline these cumbersome procedures by introducing finger prick testing and simplifying the referral process.
Sample
referral
1st Test
Result
Patient
Referral if (+)
Health Center without VCT
Blood Taking
Every Health Center
First Test with Finger Prick

35. Current trends in HIV financing
With regard to financing of the national HIV program;
Given Cambodia’s Low-Income-Country status, our response is 90% dependent on international funding – mainly the Global Fund and PEPFAR.
Since the external funding started to decline, it is urgent for our country to increase domestic contribution to achieve our elimination goal and sustain it.
Source: NASA IV Report, 2013 35

36. Challenges Reaching and serving highest risk populations
Partner notification/involvement
Overload of health workers receiving very low salary
Fragmented health and community systems (PHC, TB, Malaria etc)
Limited leadership and management capacity at sub-national level
Real time data generation & use (surveillance, program, financial), Limited data for modeling, Impact monitoring, Verifying elimination
Program efficiency, Cost effectiveness, Financial sustainability
In summary, our remaining and emerging challenges are as follows;
- Reaching and serving highest risk populations
- Partner notification/involvement
- Overload of health workers receiving very low salary
- Fragmented health and community systems (PHC, TB, Malaria etc)
- Limited leadership and management capacity at sub-national level
- Real time data generation & use (surveillance, program, financial), Limited data for modeling, Impact monitoring, Verifying elimination
- Program efficiency, Cost effectiveness, Financial sustainability

37. Immediate Next Steps and Way Forward
In the short term (next 12 months)
Launch Cambodia 3.0 strategy in 16 High Burden Districts
Follow-up National Health Sector HIV Program Review
Cost Cambodia 3.0 services and activities
Health Sector HIV Strategic Plan ( ) and resource mobilization
In the longer term (2-5 years)
Expansion of Cambodia 3.0 to all High Burden Districts
Review of progress and adjust scale-up of Cambodia 3.0 strategy
Diversify funding sources and increase national resources for HIV
While we have quite some key milestones to achieve before we can actually roll-out the Cambodia 3.0 strategy, I am confident that through continued close collaboration between all national stakeholders and our international partners, and with continued adequate funding support, we will eventually be one of the first countries to achieve the Vision of Three Zeros.
We thank you for your attention and welcome your questions and comments.