1. Cambodia Perspectives Towards Elimination of New HIV Infections and ART as Prevention Mean Chhi Vun, MD, MPH National Center for HIV, Dermatology and STI Control (NCHADS), MoH of Cambodia Email: mchhivun@nchads.org www.nchads.org

2. Outline Evolution of the health sector response to HIV Emergency response Comprehensive response Towards the elimination of new HIV infections Challenges and Conclusions

3. Evolution of Health sector response to HIV: From 1991 to 2020 Phase 1: 1991-2000 Phase 2: 2001-2011 Phase 3: 2012-2020 Cambodia 1.0 % HIV peaked at 1.7 in 1998 100% condom use in sex work settings VCT Home-based care Cambodia 2.0 % HIV declined to 0.8 in 2010 Universal access to ART PMTCT and TB/HIV (5Is) MARPs prevention and link to health services Continuous Quality Improvement Cambodia 3.0 Elimination of new HIV infections ─ART as prevention ─eMTCT ─MARPs Health/Community System Strengthening Monitoring and evaluation of impact

4. Cambodia 1.0 – HIV Prevention100%CUP STI case management IEC/BCC Health Workers Local Authority Police brothel owners Sex workers Special campaigns (Posters, leaflets, bill boards…) Media (TV, radio, News paper) STD Clinic HC Advocacy Monitoring RH/NGO

5. Cambodia 2.0: Continuum of Care Framework Facilitated Expansion of ART (District Level)

6. Linked Response Approach (2008- ): Guided expansion of PMTCT and TB/HIV HC + + Satellite HC RH (Hub) + Community VCCT Referral and Follow-up VCCT           HCBC Team/NGO Health worker/NGO

7. Continuum of Prevention to Care and Treatment (2009-) MARPs prevention and access to health services Health service delivery at district level Community/Peer Initiated Counseling & Testing (CPITC), VCT, Pre-ART/ART STI, ANC, SRH, Safe Abortion, Safe Delivery, EPI, Nutrition (children) TB, Malaria Laboratory Sex Workers and MSM Peer Network Peer Educator NGO HBC Team PHC network CBO NGO Health Workers

8. Expansion of ART ART coverage: Over 85% (CD4≤ 350 cc/mm³) Survival rate: 86% @ 12M, 84%@24M and 78% @ 60M Median of CD4 at ART initiation is more than 200

9. Projected HIV Incidence and Prevalence First brothel based prevention projects

11. Cambodia 3.0: Virtual elimination of new HIV infections by 2020 VCCT, PITC (TB, ANC) Community Peer Initiated TC Immediate ART (CD4≤500) PLHIV and Sex partners on Pre-ART MARP Prevention and Links to Health Service (Boosted COPCT) MARP and Sex Partners e-MTCT (Boosted LR) Pregnant Women and Sex Partners STI case management ART as Prevention

12. Challenges Partner notification/involvement Monitoring of impact / Verification of elimination Overload of health workers receiving very low salary Limited leadership and management capacity at sub- national level Fragmented health and community systems (PHC, TB, Malaria, HIV, etc) Financial sustainability

13. Conclusion Know your epidemic and response remains key Focused vertical response has controlled HIV during the early phases of the epidemic Common service delivery framework for linkage and integration has maximized resources Now we enter the last phase of active case finding and early ART whilst enhancing prevention efforts