December 1, 2004
In the Southeast Asian country hardest hit by HIV/AIDS, Doctors Without Borders/Médecins Sans Frontières (MSF) is battling the disease with life-prolonging antiretroviral medication. But in Cambodia, there are still obstacles that must be overcome before AIDS treatment is available for all.
Driving through a small village in Cambodia's Sotnikum district looking for a khruu khmer – a traditional Cambodian healer – the last thing we expect is to actually find one. When the villagers see us in our clearly marked MSF car, wearing our MSF t-shirts, they are reluctant to even admit that they know what a khruu khmer is, let alone point us in his direction.
So it's with a good measure of anticipation that we finally walk onto a small yard surrounded by thatched huts and shelters and meet the village's khruu khmer. The bespectacled, middle-aged healer courteously greets us and we start chatting about his practice.
But our conversation takes a more serious turn when the healer admits to having a “suspected HIV positive patient” in his care.
This is more than a suspected case,” says Eric Legendre, MSF's project coordinator in Sotnikum, immediately after seeing the girl's condition. She seems to be in the late stages of AIDS, and the fluids in the IV bags suspended around her, are not doing much to improve her condition.
Through its ARV projects, MSF has already shown that these drugs can be successfully introduced in resource-poor settings, such as the Khayelitsha township in Cape Town, South Africa. And Cambodia is in dire need of effective treatment for AIDS – 2.6 percent of the country's adult population is HIV positive, making it the country with the highest prevalence of the human immunodeficiency virus in Southeast Asia.
Drugs and counseling
That's why MSF is providing ARV treatment in chronic diseases clinics (CDCs) in two of the province's hospitals: Siem Reap provincial referral hospital and Sotnikum district hospital. The primary goal of the CDCs is to improve the health and well being of people living with chronic diseases such as HIV/AIDS. In the CDCs, AIDS patients receive ARV drugs and counseling to ensure that they adhere to their treatment.
Since the Siem Reap CDC started providing ARV treatment in October 2002, some 478 patients have begun receiving the medication. By the end of 2004, this number is expected to each 700.
“Even though we're treating more and more people, our resources are limited. We can't provide ARV for all Cambodians in need of it. Our CDCs are models, albeit large-scale models, of a system that we hope the Ministry of Health will implement in the future,” says Dr. Deres H. Brook, MSF's project coordinator in Siem Reap.
Before HIV positive persons can start the treatment, they have to go through preparatory counseling. In these sessions, the MSF counselor determines whether or not the patients understand that they need to strictly adhere to their treatment and are willing and able to do so for the rest of their lives.
And it certainly seems that the preparatory counseling is working.
“95 percent of our patients are now adhering to their treatment regimens. They know that if they really want to survive, they can,” says MSF counselor Loy Diep.
The CDCs also provide high quality home based care to people living with HIV/AIDS, often dubbed PHAs. Siep Plsita is one of three PHAs who also volunteer at the CDC, where they do counseling, work in the reception, and make home visits to patients receiving ARV treatment.
“I've received ARV drugs for one year and three months now, and my health is definitely improving,” Siep Plsita says.
“It's good to be able to work for MSF. It gives me time to talk to friends who are in the same situation as me.”
Infected and stigmatized
Not only is she also infected with tuberculosis, an opportunistic infection that frequently takes root when AIDS has weakened the immune system. She also faces stigmatization by her fellow villagers.
“They don't understand what HIV is,” she says.
“They think it can be transmitted by mosquitoes, so they are afraid.”
Fake drugs, healers and poverty
Health care is one of the main causes of impoverishment in Cambodia today. It is not uncommon to seek out expensive private practitioners or khruu khmer, who easily let their patients spend all their savings in desperate bids to save their lives. And, as in the case of the girl Sokhun, the healers' business concerns can also have fatal results.
A huge poster outside the Siem Reap hospital proclaims the availability of ARV treatment within. This is not only to encourage PHAs to seek free and effective treatment, but also to help lift the shroud of ignorance that envelops AIDS in Cambodia. Similarly, the TV screen in the reception of the Siem Reap CDC is not there to entertain the patients. It shows only educational films about HIV and AIDS. Thus, MSF contributes to preventing the kind of stigmatization that Sengtouch and countless others face every day.
In Siem Reap, MSF focuses primarily on the clinical aspects of HIV/AIDS care, but the whole concept of the CDCs is also designed to strike a blow at stigmatization.
“Here at the clinic we don't only treat AIDS patients. People with diabetes, hypertension and other chronic diseases also come here,” says Brook.
“The idea is to treat HIV/AIDS as any other chronic disease. We don't differentiate between this illness and other chronic diseases. In this way, we are also communicating to the society that people living with AIDS should not be stigmatized and shunned. They should be given a chance to continue contributing to their community.”
And with increasing availability of ARV drugs, more and more people living with AIDS can be given that chance.
“I want to work!”
The 38-year-old was tested for HIV by the non-governmental organization Caritas, a partner of MSF in Cambodia, which referred him to MSF's chronic diseases clinic. Now, thanks to faithfully adhering to his ARV treatment, Koeut Chrel is no longer begging for alms from passers-by.
When we meet him by the Tonle Sap river, near Siem Reap's marketplace, Koeut Chrel and his wife are selling books and postcards from the two carts that make up their store. A sign taped to one of the carts says: “I do not beg. I want to work!”
And the one-legged HIV-positive ex-soldier, ex-beggar is working.
“On an average day, I sell about five books. On a good day, maybe ten,” Koeut Chrel says.
Even though his wife is HIV positive and not yet receiving treatment, the proud father of three has reason to smile. Two of his children have tested negative for HIV, the youngest one has yet to be tested.
And his condition has improved enormously in the six months he has been on ARV treatment. MSF driver Sok Leap remembers the first time Koeut Chrel came to the CDC: “He was very weak and had a bad skin rash. He's much better now.”
“In the future I'll still be selling books,” Koeut Chrel says.
And seeing him strap on his prosthetic leg and start pushing his cart home, it's difficult to doubt him.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)