World AIDS Day 2004 — Field Spotlight: December 1, 2004
AIDS in Cambodia: A Second Chance at Life

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.

Sokhun We find her in a thatch house built on tall wooden pillars. Twenty-year-old Sokhun is lying on the floor next to the khruu khmer's shrine. She's very thin, looks weak, and hardly seems aware of our presence. Both of her parents are by her side, watching their daughter's health deteriorate.

Photo © Espen Rasmussen

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.

Photo © Espen Rasmussen

Sokhun's mother tells us that the girl has been in the khruu khmer's care for a month and a half. The healer is treating her with what he calls “modern and traditional drugs together” – a multivitamin solution and extracts from plants used in traditional Cambodian medicine.

“If we don't get her to the hospital, she will die for sure. If she goes, she has a chance,” Eric says. Sokhun and her parents all want her to get to the hospital, and local MSF doctor Char Bun Paul convinces the khruu khmer to let her go. We radio for an ambulance, and within the hour, Sokhun is admitted to Sotnikum district hospital. But valuable time has been lost for Sokhun in the care of the khruu khmer. She's now severely malnourished and has anemia and tuberculosis. “It's a problem we see too often, that patients come very late to the clinic. If this girl had come to us immediately, her chances would have been much better,” says MSF doctor Esayas Abay at Sotnikum district hospital.

Photo © Espen Rasmussen Photo © Espen Rasmussen

Photo © Espen Rasmussen

Sokhun dies four days later, some ten days before she is scheduled to start receiving the only effective treatment there is for combating AIDS. One pill twice a day Antiretroviral drugs – ARV, for short – prolong the lives of people living with AIDS, as well as giving them the chance to get back on their feet; to work, provide for their families, and take care of their children. It's a simple treatment, one pill to be taken twice a day, but the patients have to stick to the treatment for the rest of their lives. If they don't, they die.

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
The northwestern province of Siem Reap is perhaps best known for Angkor Wat, Cambodia's number one tourist attraction. But there is also a darker side to Siem Reap – the prevalence of HIV/AIDS in the province is 6.6 percent, the highest in Cambodia.

Photo © Espen Rasmussen

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.

Photo © Espen Rasmussen

“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.”

Photo © Espen Rasmussen

Infected and stigmatized
Sitting in the shade of a tree in the Siem Reap hospital compound, is 26-year-old Sengtouch. She is HIV positive and receiving ARV treatment. She tells us that she has already lost her husband to AIDS. Sengtouch lives in a village some 25 kilometers outside of Siem Reap town, and she's here now to collect her medicines. But it's difficult for her to return home.

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
At the heart of the problem of stigmatization is the problem of ignorance. In rural Cambodia, not many people understand what AIDS is or know how it can be treated. In marketplaces in the countryside, hawkers sell drugs – often fake drugs – like candy in a candy store. It is, of course, impossible to know for sure what one is buying in these places.

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.

Photo © Espen Rasmussen

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!”
Koeut Chrel's army career came to a sudden halt when he stepped on a landmine and lost his left leg. Shortly thereafter, his wife died. Koeut Chrel was broke. He had no choice but to become a beggar. He didn't yet know that he was HIV positive when he met Nou Sreymeth and married her, but it became increasingly obvious as his health began to deteriorate.

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!”

Photo © Espen Rasmussen

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.