Episode: "House Arrest"

Country Background: Cambodia

In the late 1970s, Cambodia, a former French colony, was decimated by waves of violence. The US bombings from 1969-1973 killed anywhere from 150,000 to 500,000 people. Between 1975 and 1978, a brutal governing regime, the Khmer Rouge, wiped out an estimated 1.7 million people, using torture and summary executions in its murderous campaign against accused “enemies of the state.”

Fifteen years later, the people of Cambodia confront another deadly force – HIV/AIDS. Since 1991, when the country’s first case of AIDS was identified, the explosion of the Cambodian epidemic has been fuelled by a booming commercial sex trade, crushing poverty, social stigma attached to the disease, and official reluctance to confront the need to aggressively treat people living with HIV/AIDS.

In 2002, the HIV prevalence rate in Cambodia was approximately 2.7%, the highest in southeast Asia, and approximately 170,000 people were estimated to be living with HIV/AIDS. In the last two years, public awareness of the disease and use of condoms and other safer sex practices have increased. Nevertheless, as one of the poorest countries in Asia, with severely limited resources for public health, the nation is hard-put to fight the epidemic.

The Cambodian AIDS Epidemic: Treatment is the Best Form of Prevention

In Cambodia’s capital city, Phnom Penh, MSF works in the Preah Bath Norodom Sihanouk Hospital providing voluntary counseling and testing, treatment of opportunistic infections, psycho-social support, and antiretroviral therapy for people living with HIV/AIDS. In this episode, Dr. Eric Cua is assigned to the Infectious Diseases Department at Sihanouk Hospital. Eric’s work is crucial; for a patient whose immune system has been destroyed by AIDS, an opportunistic disease such as cryptococcal meningitis often deals the deathblow.

But as important as opportunistic disease treatment is, for a large, poverty-stricken urban population surrounded by a spiraling epidemic, the only true lifeline is access to affordable antiretroviral (ARV) treatment – medicines targeted at containing the virus itself. These medicines revolutionized HIV/AIDS treatment in wealthy countries in the mid-1990s, reducing AIDS-related deaths by approximately 70%,. While ARV therapy is not a cure for AIDS, it greatly improves the health of many people with AIDS and reduces the amount of virus circulating in the blood to nearly undetectable levels, allowing people with HIV/AIDS to live a relatively natural and healthy life.

In Phnom Penh, as in so many HIV/AIDS hotspots, the price of ARVs places them out of reach, making the cost of treatment one of the most serious obstacles to effectively combating the disease in the developing world. However, in recent years, the introduction of generic competition has caused ARV drug prices to tumble from $10,000-15,000 per person per year in 2000 (from “brand-name” multi-national pharmaceutical companies) to just over $200 per person per year in 2003 (from generic manufacturers).

Although this is still far too much for the vast majority of people with HIV/AIDS to pay, it has forced many developing countries to begin thinking about developing treatment programs, and has forced donor countries to begin devoting resources to treatment, in addition to prevention. There are nowhere near enough resources available to most countries to undertake this enormous task yet, but the decrease in AIDS drugs prices, due to generic competition, has fundamentally changed the playing field.

One other major obstacle to addressing the AIDS epidemic has been the social stigma that lends itself to denial and discrimination. In this respect, Cambodia has presented HIV/AIDS with the perfect environment to prosper – a society in which prostitution is a ubiquitous and profitable trade.

Behind a thin veil of secrecy, the practice is condoned: a thriving “sex tourism” industry patronized largely by men from developed countries spreads the virus; Cambodian husbands visit brothels and bring the virus home to their wives; soldiers carry it to their girlfriends; truck drivers and migrant workers carry it from town to town.

In such an environment, confronting the need to promote openness about HIV is one of the most important steps in fighting the disease, because it leads to successful prevention and encourages those already infected to come forward and get tested. By giving people with HIV/AIDS a new lease on life, effective treatment erases much of the fear and the stigma associated with AIDS, transforming it from a shadowy and misunderstood killer to more of a communal threat – a problem to be confronted publicly rather than suffered through in silence.

The relationship between the availability of treatment and people’s willingness to get tested and disclose their own HIV status has been thoroughly documented by MSF in South Africa and elsewhere. Unfortunately, Cambodia's poverty renders the country almost entirely dependent on foreign aid from developed countries, which often comes with stipulations emphasizing prevention over treatment.

Project Update: HIV/AIDS Care at Sihanouk Hospital

Although Sihanouk hospital’s in-patient ward only has 60 beds, MSF operates a rapidly escalating HIV/AIDS treatment project from the out-patient clinic, which was recently expanded and rebuilt by MSF logisticians. Since this episode was filmed in mid-2002, MSF has scaled up ARV treatment at Sihanouk sharply, from an estimated 200-300 people on ARVs at the time of filming to more than 650 as of June 2003. (MSF’s goal for the end of the year is 1,000.) MSF patients are responding very well to treatment, with clinical outcomes similar to those seen in wealthy countries.

MSF has also drastically increased its voluntary counseling and testing (VCT) program and its monitoring of people already infected with HIV/AIDS who haven’t yet reached the point of clinically requiring ARVs. In 2002, MSF followed 3,007 such patients, tracking their health and offering treatment for opportunistic diseases and palliative care as needed. Overall, in the rebuilt out-patient clinic at Sihanouk, MSF doctors and nurses, along with Cambodian government health workers, conducted 13,820 consultations in 2002, almost doubling the total from 2001.

In 2003, MSF plans to expand its successful ARV program to a Kompong Cham city, and to increase access to HIV/AIDS care at the district level.

MSF is the only non-governmental organization in the country providing free ARV treatment within a state-run hospital. MSF has been active at Sihanouk hospital since 1997, and has provided ARV treatment since 2001.