The USAID-funded HIV/AIDS Flagship Project aimed to provide more appropriate information and testing for individuals and, at the same time, collect better demographic information about their target populations. An electronic risk screening tool for Android plate form was developed in early 2014 to replace a hardcopy version. The objectives of the risk screening tool are to identify the level of risk of individuals who are members of key populations (KP), and to support NCHADS’ new strategy for improving the effectiveness and reducing the cost of outreach and HIV prevention programming more generally. Following consultation with local Implementing Partners (IP), a draft version of the tool was produced, piloted, further refined (based on findings from the pilot) and approved by NCHADS. Subsequently, initial training sessions were held with staff and outreach workers (OWs) to help them understand and maximize the benefits of the tablet. The first-round implementation of risk screening activity will have been conducted in 5 provinces and Phnom Penh, with more than 30 tablets distributed to IPs.
Target Population:
- Female entertainment workers
- Men who have sex with men
- Transgender women
Despite substantial reduction in HIV prevalence in Cambodia over the past two decades, rates remain relatively high among most-at-risk populations. Estimated prevalence is up to 14% for some EW; around 2.3% for MSM, and 5.9% for TG. Condom use among these at-risk groups with regular partners remains stubbornly low. Social marketing of condoms began in Cambodia in late 1993. Since then condom availability has improved dramatically, and a number of wholly commercial brands have entered the market alongside socially marketed brands. However, most are sold through retail outlets, such as pharmacies, many of which are not open into the evening and are not situated near known hot spots (night clubs, karaoke bars, massage parlors, and beer gardens). This is an initiative under Flagship. It set out to develop peer-to-peer sales, enabling KPs to purchase condoms at times better suited to their work; to improve anonymity and reduce embarrassment of buying condoms in large quantities; and to ensure socially marketed condoms reach most-at-risk populations. Peer sellers are recruited through local IPs and trained by Population Services Khmer (a PSI local affiliate). Where owners of venues are reluctant to allow condom sales on site, the IPs seek to recruit street sellers. Condoms come in a choice of plain or flavored versions, or with extra lubricant. Additional coaching is also provided by a sales supervisor employed by the IP. Coaching is short and takes under half an hour per peer seller. Condoms are sold at a wholesale price to the peer sellers, who then sell them at a profit. Suggested sales prices allow for profit margin of around 1/3 of the retail price. This supplements their income and provides a service to those around them. Typical sales will generate around $10-$20/ month income for a peer seller.
Target populations:
- Female entertainment workers
- Men who have sex with men
- Transgender women
Social Behavior Change (SBC) builds upon behavior change communication methodology. By strategically segmenting the audience into sub-categories and connecting this with national agendas and five-year program strategies, this adds a clear strategic focus to the approach. Since 2009, HIV prevention in Cambodia has taken this a step further, by using branded programs delivered largely by peer outreach, to bring about targeted SBC in KPs. Although started under USAID funding, the branded programs have also attracted funding from a variety of donors including the Global Fund, UNFPA and ADB, and been delivered through more than a dozen local IPs. Branded programs such as SMARTgirl (for EWs) and MStyle (for MSM) have enabled new initiatives to be developed and delivered through existing channels. Target populations know and trust these brands and increasingly look to them for information, support and advocacy. During Flagship, branded SBC programs have added such components as family planning, finger prick testing, risk screening, condom and lube social marketing, and HPV awareness and screening (for EW). For every new element, a pre-existing team, network, and known program reach are available to assist in planning and rapid roll-out. New components build the credibility of the program by demonstrating a more holistic interest in the populations being reached. In 2013, following recognition by the national program that MSM and TG are distinct populations, Flagship launched Srey Sros (“Pretty Girl” in English), separating out programming for the transgender community. Under Flagship, the SBC innovation has altered its focus to place greater emphasis on capacity building of local partners. Each local branded program has an SBC coordinator who is paired with the SBC advisor from FHI 360. Sometimes there is more than one local IP working with a brand (for example, SMARTgirl is delivered through CWPD in Phnom Penh and Siem Reap and PSOD in Kampong Cham). Where this is the case, the larger NGO (normally based in the capital) will take the lead as SBC coordinator for the brand. The SBC coordinators receive training to develop an annual communication log frame, and subsequently, quarterly plans. This entails development of the theme and concepts for the tools and testing of each one prior to implementation. Once the messages are ready, the coordinators support the implementation by outreach workers at field level.
Target populations:
- Female entertainment workers
- Men who have sex with men
- Transgender women
- Within these populations, sub-populations who use drugs are also a specific target population.
- Capacity building is targeted at local IPs.
SMARTgirl has been providing peer outreach to EWs for HIV prevention since 2009. Research, such as Morineau (2011) , had indicated up to 28% of EWs had previously had an abortion, suggesting a substantial unmet need for improved information about, and access to, contraception. Although condom use with clients is often reported to be around 85-90%, it is normally reported as being below 50% with “boyfriends” or “sweethearts”. SMARTgirl provides information through direct outreach into entertainment establishments, such as beer gardens, karaoke clubs, massage parlors and nightclubs. In addition, staff and peer educators run drop-in centers within red-light districts or in close proximity to KP hotspots. Since mid-2013, CWPD and PSOD, through Flagship, have been aiming to promote condom use for HIV prevention, along with awareness of other contraceptive methods. Staffing was increased to include a midwife to offer counselling, and additional outreach staff. Peer leaders are also recruited as models for the HIV/family planning integration program, talking about the condom plus strategy (condom use plus a contraceptive method). Initially CWPD and PSOD had hoped to supply contraception; however, based on donor’s compliance and regulations, services have been restricted to being advisory. However, staff do provide referral support to EWs to health centers where necessary. Clinic options include an NGO clinic with free provision, PSK’s franchised clinics, NGO clinics offering paid services, and government clinics.
Target populations:
- Female entertainment workers and their partners
The increasing emphasis on mHealth improves Flagship’s ability to confidentially reach, engage and serve KPs at risk of HIV anywhere and at any time. It is also a reflection on the rapidly changing access to social media, which has altered dramatically during the life of Flagship. Flagship, tasked with innovating in the community, adopted the mHealth initiative to improve access to information and resources for KPs through all the three branded programs (SMARTgirl, MStyle, and Srey Sros). By building on existing programs, the new initiative is able to capitalize on existing resources and, crucially, on the trust that each brand has developed with their target populations. Technical assistance for mHealth is provided by Flagship Consortium Partner FHI360, with overall implementation under KHANA’s supervision. The initial consultation involved discussions with both local IPs and target populations. After the initial development of websites – with accompanying official Facebook pages, IPs take responsibility for content and updating. All websites are in Khmer, with some limited functionality in English. Training was provided to IPs to enable them to write content for their program’s Facebook and web pages. These provide standalone information as well as individual stories, and act as a referral point to the mHealth toll-free hotline. Within the mHealth portfolio exists a hotline approach called “Voice4U” (with a short code dial of 1295). Using the keypad, callers select options and submenus depending on if they are EWs, MSM or TG. Callers listen to pre-recorded information about drop-in centers, local HIV and STI testing facilities, and other relevant prevention messaging. As an added incentive to call, there are quizzes. For those wanting more specific advice, Voice4U also has an option for callers to talk to an online counselor from Monday to Friday 8am to 5pm. Multiple partnerships were required including the National AIDS Authority (NAA); the Ministry of Telecommunications and Post who provided a short-code telephone number; the Open Institute who helped to define and shape the innovation; social enterprise InSTEDD who assisted in content development; and a Content Advisory Group. INTHANOU and Marie Stopes International Cambodia were contracted to provide online counseling as part of
Voice4U.
Target populations:
- Female entertainment workers
- Men who have sex with men
- Transgender women
confidential counselling and testing (VCCT) for KPs under the auspices of NCHADS. At the time, around 30-40 cases of HIV were being identified every quarter among EWs, PWID/PWUD, MSM, and TG. Traditional approaches to risk tracing involving the service provider yielded very few partners being brought or referred to the clinic. Focusing on this population was considered important in identifying HIV-positive individuals connected with someone already identified as being at higher risk, which would enable more efficient use of resources and earlier access to treatment. The Risk Tracing Snowball (RTS) involved eight staffers plus one midwife at the clinic. Clients who attended for either an initial HIV test or a confirmatory test from an outreach program were encouraged to refer their neighbors, friends and sexual partners. Informed consent was required, and then they were enrolled as “seeds” for the program. Each seed received a book of five coupons and were screened for their risks, each with a unique serial number to enable tracking. When the referred individual arrived at the clinic, they would be asked to participate in an electronic risk assessment on a tablet and tested for HIV (upon their consent). If they completed these two processes, they would be entitled to $2.50
towards the cost of transportation. A fingerprint scanner was used to reduce duplication. The referrer (seed) would then be entitled to collect $2.50 as an incentive for each successful referral assessed as being “at risk”. Then the referred individuals were asked to be next referrers and follow the same process as described above.
Target populations:
- Female entertainment workers
- Men who have sex with men
- Transgender women
- People who use/inject drugs
- Those who prefer to identify as being from the “general population” but have elevated risk factors.
Cervical cancer is ranked as the most frequent form of cancer among women in Cambodia. Current estimates indicate that every year, 1,512 women are diagnosed with cervical cancer, and 795 die from the disease. Women living with HIV are between 2-12 times more likely to develop precancerous lesions that can develop into invasive cervical cancer. Providers in Cambodia are concerned that women are unaware of the dangers of cervical cancer and access healthcare too late. Therefore, providing testing and treatment for both HPV and HIV through service integration is highly desirable. Earlier research in Phnom Penh that was conducted with EWs found the prevalence of cervical HPV to be 41.1% among 220 EWs (Couture 2012). The intervention in Cambodia has been tested at the Chhouk Sar NGO clinic in Phnom Penh, with
the intention of:
- Detecting and treating precancerous lesions on time among high-risk populations;
- Enabling women to know their status;
- Assisting with follow-up and promoting prevention messages to high-risk populations. Consultation with partners began in 2014, and testing began in July 2015. Training was provided by the Sihanouk Hospital Centre of Hope (SHCH) NGO hospital. IPs under the USAID-funded HIV/ AIDS Flagship Project refer most EWs to one of the two Chhouk Sar clinics in Phnom Penh. There, one doctor and two midwives offer counselling and screening. Chhouk Sar uses Visual Inspection with Acetic acid (VIA) screening, based on a protocol developed with technical assistance from FHI360 as part of Flagship. Screening is available for women aged 20-49 years old. If a woman is identified as VIA positive, they are offered cryotherapy and followed up for any infection after two weeks. They are then recalled for a further VIA after a year. Those who are VIA negative are recommended for a rescreening after three years. If the VIA reveals a suspected cancer, the woman is referred to either SHCH or the government run Khmer-Soviet Friendship hospital. Treatment is free at either site.
Target populations:
- Female entertainment workers
- Those who prefer to identify as being from the “general population” but have elevated risk factors
“Positive Prevention” works with people living with HIV (PLHIV) to educate them on how to minimize transmission, support them in accessing healthcare, and assist them to stay on treatment. The initiative is multi-faceted and is delivered through local IPs, most of whom are peer-led organizations. One such organization, the ARV Users Association (AUA), employs two counsellors in Phnom Penh’s Khmer Soviet Friendship Hospital (KSFH) who identify individuals in need of support. This includes those who have a reactive result from a rapid test as well as those who are confirmed as HIV-positive. AUA collaborates with different departments within the hospital, including the TB ward, maternity and the STI clinic. Supported individuals are then referred to one of six support group organizers (social workers) at one of Flagship’s Centers of Excellence. Through one-to-one counseling and support groups, individuals are able to learn about how to minimize the risk of transmission to a partner. Cambodia has adopted Option B+ for pregnant women (i.e. provision of triple ARV drugs to all HIV-positive pregnant women beginning in the antenatal clinic setting, and then continuing the therapy for all of these women for life). The “Positive Prevention” program works to actively raise awareness of the ability to prevent mother-to-child transmission among women living with HIV. Although Positive Prevention is operated by NGOs under Flagship, it does so under the jurisdiction of the government’s National Center for HIV, Dermatology, and STIs (NCHADS). The partnership aims to ensure that when protocols change, information reaches local IPs and PLHIV. In turn, this assists with compliance and monitoring of follow-up, helping Cambodia achieve better outcomes in care and treatment. In 2014 the government adopted a new Standard Operating Procedure to allow for the supply of ARV drugs to serodiscordant couples, children under the age of five, and key populations with a CD4 count <500 cells/mm3. Further recent changes, effective 2017 onwards, will enable all those identified as being HIV-positive to commence treatment irrespective of CD4 count. Treatment aside, Positive Prevention also supports individuals and families. Social behavior change messages, for example, explain the importance of good nutrition based on locally sourced foods and dietary preferences. Onward referral is also available for family planning. During home visits, AUA asks whether PLHIV are in a relationship and checks to see if they have received condoms from the ART site. In addition, they work closely with midwives so that the number of exposed infants referred for PCR tests is now more closely followed up.
Target populations:
- Already diagnosed and newly diagnosed PLHIV
Regional studies suggest that Cambodia’s reported number of MSM is likely to be underreported by a considerable margin. Cambodia’s conservative society is evolving specially in urban areas into one that is much more liberal, accepting and cosmopolitan. With HIV prevalence of around 2.3% among the MSM community, it is important to identify more reliable estimates where possible. Flagship’s research team designed the study, drafted protocols, provided training, and lead field data collection and report writing. OWs assisted in mapping locations and acted as a guide in the 12 (out of 25) provinces. In total, the project took 12 months from the commencement of planning to final writing of the report, with field work and report-writing taking the final 6 months. The study had three objectives:
- To estimate the population size of MSM in Cambodia
- To measure HIV-related risk behaviors among MSM in Cambodia
- To measure HIV prevalence among MSM in Cambodia
Previous GIS mapping had enabled the identification of 575 hot spots/venues, from which 133 were chosen at random. Approximately 200 participants were identified in 7 provinces plus a further 400 in the capital, Phnom Penh. From these, 1,646 MSM were interviewed about their sexual behaviors, and a blood sample taken. This facilitated a richer analysis of the data to help guide programming at a national level. Allowances were made for a “hidden” population, account for 35% of the total, plus an additional 11% who were not considered sexually active. These figures were derived from key informant interviews with 96 individuals during the study design phase. (For the full methodology and report, see http://www.nchads.org/DataMGT/passive/MSMReport-20 14.pdf )
Previous studies had found around 21,500 MSM (out of a population of 15.5 million), although these had always conflated MSM and transgender individuals. Following a change in national policy in 2012, NGOs and the national program agreed to separate out the two groups. A study in the same year identified 2,686 transgendered individuals in seven cities in Cambodia.
Target populations:
Prior to the introduction of the HIV/AIDS Flagship Project, USAID had three separate contracts running on HIV in Cambodia (prevention and home-based care; prevention, care and treatment; social marketing). In addition, the Global Fund supported the national program and a number of the same local IPs. Untangling the numbers of key populations reached proved impossible. During that time, several alternative approaches were explored, including both biometric and familial-code-based systems. Due to Cambodia’s recent past experience with genocide during which specific sub-populations were hunted down, many believed that a unique identifier that could be forcibly read/understood (such as a fingerprint) would be unacceptable and inappropriate. Whilst the introduction of the USAID-funded HIV/AIDS Flagship Project removed the organizational discrepancies for USAID contracts, it was still unable to create the linkages necessary to follow individuals through the clinical cascade. In 2014, the Flagship team started the development on an agreed Unique Identifier System (UIS). The team consisted of technical staff from KHANA, PSI/PSK and FHI360. PSI (PSK’s affiliate parent) had already implemented a Unique Identifier Code (UIC) approach in Nepal and brought their learning to Cambodia. The national program through NCHADS ws actively involved. They provided leadership, bringing various stakeholders together to review studies on the development and use of UICs. This has enabled Flagship to work closely with NCHADS and develop a UIS to support client tracking and case management and revamp linkages between services. Each individual is given a card comprising of a nine-digit alphanumeric unique code. Khmer script is translated into a Latin script using a standardized table (because not all electronic devices have Khmer fonts available). The code consists of:
- The first two letters of a father’s name
- The first two letters of a mother’s name
- Two digits representing the province of birth (from a standardized list)
- One digit representing gender
- Year of birth in a two-digit format
After developing the concept, Flagship provided training on implementation to IPs. OWs, field staff and M&E staff were all trained during a two-day training course on how to generate the codes, and subsequently, on how the program would roll out. Interaction with individual clients’ rests with existing IP, who run dedicated, branded programs for KPs. After the unique code is requested and generated, a card is printed and supplied to the local respective IP who passes it on to the individual. Crucially, as an added incentive for individuals to use the UIC card, they can access a number of health services such as STI testing for free.
Target populations:
- Female entertainment workers
- Men who have sex with men
- Transgender women
- People who inject drugs
English 
Khmer