1. Mean Chhi Vun, MD, MPH NCHADS Director mchhivun@nchads.org Update on HIV and STI Epidemic and its Response, July 2010

2. 1- HIV Prevalence Among Adult pop. 15-49 between 1995 and 2006 2- AEM-Projected Prevalence of HIV among the general population aged 15-49 year from 2006 to 2012 (With ART available) 3- HIV Incidence * among ANC by Survey year Current HIV Status in Cambodia

3. 3 Adjusted HIV prevalence* among DFSW, by age group and year, 1998-2006 *Adjusted for results of quality assurance testing

4. STI prevalence among MSM by survey site Source: NCHADS, Cambodia STI Survey 2005

5. STI Prevalence 1996-2005 – Brothel-based Sex Workers Source: NCHADS 2002, Ryan et al 1998

6. Source: NCHADS, Cambodia STI Survey 2005 STI prevalence among FSW by survey year

7. STI cases diagnosed & treated among EWs, 2007 to 2009 Based on quarterly report of the Data Management Unit/NCHADS STI cases : cervicitis, cervicitis + vaginitis, PID, GU, GW, syphilis by RPR (+),

8. 8 HIV prevalence by drug use, July to October 2007 Note: there were 6 HIV+ among 27 women drug users recruited from community (5.4%-41.9%) (0.2%-3.7%) (17.9%-32%) (0.7%-2.3%) (16.4%-33.2%) (0.4%-3.2%)

10. HIV Screening among Pregnant Women at ANC, Q1 2010 0.39%0.17% 0.18% 0.07%0.25%0.10% 70.4% 86.5%

11. Number of Samples Tested Each Month – 2010 Data Source: DNA PCR Register June Total Samples TestedSamples NegativeSamples Positive January32311 February78744 March52511 April58526 May988414 June50464 July (so far)60555

12.   Prevention Package: Behaviour Change Programme: the 100% Condom Use package (condom promotion, targeted STI care, outreach to sex workers), interventions for non-brothel-based sex workers, outreach for other high risk group, and IEC Two complementary STI Services for high and low risk groups   Continuum of Care Package The Continuum of Care for PLHA: establishing the Continuum of Care itself, Health Facility Based Care including ART, Home-based Care, Voluntary Confidential Counselling and Testing, and Universal Precautions Linking HIV/STI/RH/MNCH/TB services at OD level   Research and Surveillance Package HIV/AIDS and STI Surveillance and Research   Management package Planning, Resource Management and Coordination of the Programme; decentralization to Province and OD; integration within the health sector Monitoring, Reporting and Evaluation HIV Response in the Health sector, 1998 to 2009

13. Update the Result of HIV and STI Response

14. (Sexual Behavioral among EW)

18. CD4<= 250 cc/mm3 Adult: 35,100 Children:4,500 T: 39,600 39,600 CD4<= 350cc/mm3 A: 42,000 C: 4,500 T: 46,500

19. Number of ART sites and Number of Active Patients on ART from 2001 to Q2, 2010 % of PLHIV on ART are still alive at 12 month after ART initiation (A:86.7% and C: 93.9%) % of PLHIV do not lost to follow up at 12 month is > 90% % of PLHIV are still on first line regimen at 12 month after ART initiation is > 90%

20. Actual number of Patients Receiving ART in Q2/2010 (86.2%) (86,3%) (86%) 2010: CD4 < 350cells/mm3 A: 42,000 C: 4,500 T: 46,500

21. PMTCT: Result from 2005 to 2007, Prior Linked Response (source: NCMCHC/ NCHADS/WHO) Indicators200520062007 Estimated # PW 461,000461,000442,000 Estimated # and % of HIV PW 9,700(2.1%)9,700 (2.1%) (2.1%)4,509 (1%) (1%) # and % of PW tested for HIV 17,382 (3.8%) (3.8%)33,251(7.2%)55,994(12.6%) # and % of PW identified HIV + 279(1.6%)383(1.1%)435(0.77%) # and % HIV PW who received ARV Prophylaxis or HAART 228(2.4%)312(3.2%) 505 (11.2%) (405 were on OI/ART before pregnancy) # Exposed Children tested for HIV NA6 (3 HIV +) 73 ( HIV +) % of Exp. Children who received ARV Prophylaxis 2.4%3.3%11.5%

22. PMTCT: Result from 2006 to 2009 (source: NCMCHC/ NCHADS/WHO) Indicators2006200720082009 Estimated # PW 461,000442,000342,756348,536 Estimated # and % of HIV PW 9,700(2.1%)4,509 (1%) (1%)2,879 (0.8%) (0.8%)2475(0.7%) # and % of PW tested for HIV 33,251 (7.2%) (7.2%)55,994(12.6%)67,977(19.8%)146,453(42%) # and % of PW identified HIV + 383(1.1%)435(0.77%)435(0.77%)306(0.48%) # and % HIV PW who received ARV Prophylaxis or HAART 312(3.2%) 505 (11.2%) (405 were on OI or ART, prior pregnancy) 614 (27%) (363 were on OI or ART, before pregnancy) 798 (32.3%) (482 were on OI or ART, before preg.) # Exposed Children tested for HIV 6 (3 HIV +) 73 ( 17 HIV +) 283 (27 HIV +) 288 % of Exp. Children who received ARV Prophylaxis 3.3%11.5%22%29% LR

23. Service utilization rate for target populations, April 2008 to December 2009 Service Utilization Rate for Target Population, April 2008 to 2009

24. HIV Response in the Health Sector 2010 to 2015:  To avoid the 2 nd Wave of HIV Epidemic To Eliminate Pediatric HIV (<2% by 2020)

25. Main Route of HIV Transmission High risk Population Partner Spouse HIV, STI HIV MSM HIV SW DU/IDU HIV

26. CoPCT: Combination of HIV Prevention and Care including treatment among General population and MARP (EW) Health service delivery at OD Public and NGO-Private VCCT, STI, OI-ART(A and P) ANC, BS/FP, Safe Delivery, EPI, Nutrition (children) Safe abortion TB, Malaria Laboratory EW and Partners           Community Create Demand EW Network: PE and PF NGO HBC Team PHC Volunt CBO NGO Health Workers RRT

27. Referral and Follow up Mechanism for the LR HC + + Satellite HC Hub - RH + Community VCCT OI/ART, PAC, VCCT, ANC, BS, Safe Delivery, STI, EPI, TB, Nutrition, Lab, LSM, DM, TB + (HIV testing) HIV information, Blood Draw for HIV testing TB + (HIV testing) Linked HIV Testing, VCCT, Safe Delivery, TB + (HIV testing) Referral and Follow-up VCCT          

28. The 3 “S” Strategy Referral & Follow-up OD Management Team: Facilitate coordination between health service providers, between facilities and community based support Manage data to monitor and improve service delivery Monitor progress of mother- infant pairs Referral & Follow-up “S” No. 1 Strengthening linkages between facilities and communities Home-based Care CBS Community-based Support (CBS) “S” No. 2 Strengthening linkages between and within facility based services “S” No. 3 Strengthening linkages within communities Referral and Follow-up ANC, Labor & Delivery, Family Planning, TB VCCT, PMTCT, Pediatric AIDS Care, OI/ART, STI Health Facilities Community   

29. Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (1)   VCCT: Entry point for HIV prevention and care including treatment 2010- 2011: Increase VCCT from 233 sites in 2009 to 245 sites in 2010 and 260 sites in 2011 Increase the uptake of VCCT service from 600,000 in 2010 to 800,000 in 2011 Increase the uptake of VCCT service among EW by 50% in 2011 (if enabling environment being existed)   STI Services: 2010 – 2011: FHC (available at Provincial Hospital and some RH at OD): 32 sites in 22 provinces Increase FHC from 32 sites in 2010 to 35 sites in 2011 NGO STI clinic: 26 clinics in 11 provinces and PP Establish CQI for STI service: ongoing Increase the uptake of STI service among EW (if enabling environment being existed)

30. Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (2)   OI and ART service: 2010- 2011 Increase OI/ART sites for Adult PLHIV from 50 sites in 2010 to 53 sites in 2011 Increase the ART coverage from 90% in 2010 to 95 % in 2011 Increase PAC from 33 sites in 2010 to 43 sites in 2011 ( being integrated in some Adult services) Increase PAC coverage from 90 % in 2010 to 95 % in 2011   Laboratory to support HIV Service: 2010 -2011 Increase CD4 testing (free of charge for PLHIV): 7 sites in 2010 to 9 sites, if needed Increase the uptake of CD4 testing from 70,000 in 2010 to 90,000 in 2011 Start the Viral load testing (free of charge for PLHIV) at NCHADS Lab in early 2011 Contribute to strengthen integrated laboratory at Province and OD   Positive prevention among PLHIV: 2010 – 2011: Start the integration of BS/FP at OI and ART services for HIV women (condom distribution for free, oral pill, Progesterone Injection) by BS staff 2 to 3 days per week) in late 2010: URC is committed to cover the user fee for contraceptive under health equity fund PSI and AHF are committed to donate condom for free ( 2 to 3 millions pieces per year) NCMCHC is committed to supply the contraceptive

31. Integrated HIV and STI into Health Service Delivery (Public and NGO including Private) (3)   Elimination of Pediatric HIV: 2010- 2011 Scale up LR country wide in 2011 Strengthen the Referral and Follow up mechanism to support HIV positive mothers and their babies focusing on the HIV newly identified (active search approach) Improve General Pediatric Care including Pediatric AIDS Care Strengthen Positive Prevention through Integration of Birth Spacing service at OI and ART service Improve collaboration between HIV/STI/RH including MNCH through joint work plan, joint training activity, joint logistic supply management, joint monitoring including reporting Strengthen harmonization and alignment amongst partners through common vision, common strategic plan, common monitoring   Reduce drastically TB infection among PLHIV: Expansion the implementation of 3 I (ICF,IPT and IC) from 21 OI and ART sites to 35 sites in 2011 and country wide in 2012   CoPCT at prison: Expansion CoPCT from 5 prisons to 10 selected prisons

32.  Started in 2008-2009 Started in 2010 Scaling up Phase of Linked Response YearProvinceODHC 20082567 2009817251 2010744434 Total17/2466/76752 6 7 1 1 1 1 1 1 4 2011

33. Integrated Monitoring of HIV services and Linked with RH/MNCH/TB/Lab   Integrated HIV and STI Surveillance System: being started in 2014   HIV and STI Surveillance in 2010-2011: NCHADS and Partners BSS (Round 8): ongoing (Data Analysis being finalized in Dec 2010) HSS (Round 11): ongoing (Data Analysis be finalized in early 2011) SSS (Round 4): will be started in 2011 Bros Khmer Study (FHI/NCHADS): ongoing HIV related Operational Research: BCC, clinical trial,...   QA for HIV services: Early Warning Indicators Assessment: Annually then every two years (2010: ongoing) CQI for OI and ART service: Expansion and will include the LR services in 2011 ARV Drug Resistance Study: ongoing ART regular monitoring system: ongoing   HIV and STI Case Notification (Routine reporting): Longitudinal data base system for HIV and STI patient: on the process Linking HIV data base system with TB and RH/MNCH/Lab: be started in 2011 Be integrated in the HIS at OD level: being started in 2012

34. Conclusion: Is it possible to avoid the 2 nd wave of Epidemic and to eliminate Pediatric HIV in Cambodia ?   Yes: Strong Political Commitment at all levels, especially Samdeach Prime Minister Strong ownership for the program implementation at all levels: clear and common vision, strong leadership with clear strategic and innovative thinking (team work) good management with transparency and accountability Common strategic plan with Integrated or joint WP, Monitoring, LSM and capacity building, common intervention model or approach with rapid expansion. Good partnership: all partners (government and development partners) Share vision, strategic intervention (model or approach), monitoring Good coordination at all levels through the existing mechanism (not competition) Integration or Linking services: CoPCT Linked Response between HIV/STI/RH including MNCH/TB/Lab/other chronic diseases Integrated monitoring Decentralization to OD level: resource (human and $) and capacity Participation of the PLHIV network, CBO

35. Thank you