The new Community Based Prevention, Care and Support (CBPCS) model upholds the principles of cost-effectiveness, sustainability, greater involvement of key populations and people living with HIV, gender sensitivity and a greater emphasis on a health sector approach.

Focusing Community-Based Support for PLHIV with the Greatest Need:

The streamlined CBPCS model is targeted at those PLHIV who remain at greatest need: newly identified HIV-reactive and/or diagnosed cases, PLHIV who have poor treatment adherence, sero-discordant couples, PLHIV as KP, HIV-positive pregnant women, HIV-positive children and adolescents, HIV-exposed infants, and PLHIV who have been identified as “poor” (as outlined in the ID Poor System). This new model will be integrated into the active case management mechanism, to focus limited resources in providing segmented support to the different sub-groups. Programmatic evidence obtained from the USAID SAHACOM project suggest that PLHIV with the greatest need represent approximately 30% of the entire PLHIV population in Cambodia.

Reduction in Community-Based Support for "Stabilized" PLHIV:

The needs of PLHIV have decreased significantly, benefiting from broad ART coverage and the resulting improved health status and better economic status. PLHIV who have been stable on ART for many years, and are employed and living in urban settings will require significantly less support from CBPCS services compared with PLHIV who are newly diagnosed, who are members of key populations, and live in rural settings. PLHIV who are identified as stable will be provided with a lower intensity of routine care and support, perhaps with annual viral load tests and 3-6-monthly prescriptions of ARVs (rather than monthly). It is important to note that monitoring is vital, as stabilized PLHIV can slide into the greatest need category (and vice versa).

Target and Geography Focus:

The streamlined CBPCS model will be geographically focused at Pre-ART/ART sites, and as such will leverage the existing MMM AND AUA structure and active case management mechanism, including the involvement of the following key stakeholders: Case Management Providers (CMP), Case Management Coordinators (CMC), and Case Management Assistants (CMA).

Structure and Approaches:


The following set of interventions will be implemented as part of the New CBPCS Model:


  • Map PLHIV with greatest need, stabilized PLHIV, and ID Poor.
  • Strengthen community structure: recruit CSVs, establish VSLGs; establish structural network and follow-up mechanism between the facility and community level.
  • Strengthen facility structure: establish/strengthen the MMM mechanism at certain sites where it is found to be lacking/weak and establish mechanism to link with HEF.
  • Provide tailored package of support to PLHIV who are in greatest need: referral support to Pre-ART/ART clinic including transportation, home visit as required and counseling at Pre-ART/ART clinic.

  • Training, capacity building and technical support provided to CSV, MMM facilitators, CMPs and CMC/CMA on the roll out of the new CBPCS model