PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: RHAC, under a new cooperative
agreement, replaces part of the activities listed as TBD in the COP 2008.
The Reproductive Health Association of Cambodia (RHAC) provides HIV counseling and testing for
pregnant women through RHAC's clinics and supports MoH (Ministry of Health) PMTCT (Prevention of
Mother to Child Transmission) sites that provide PMTCT services.
RHAC has 17 clinics established in 14 Operational Districts (ODs) in eight provinces. In FY 2009, RHAC will
establish three additional clinics. RHAC's clinics provide integrated reproductive health and HIV/AIDS
services including family planning, ante-natal care, post-natal care, STI treatment and HIV voluntary
counseling and testing (VCT) for general clients and targeted high risk groups, including pregnant women.
RHAC's clinics will continue to provide comprehensive health education messages, especially about VCT
and PMTCT, and promote HIV counseling and testing particularly among pregnant women. RHAC provides
appropriate counseling about safe infant feeding options for HIV infected pregnant women and family
planning counseling is provided to help HIV infected women make informed choices with regard to having
children. Family planning services are available for all HIV positive women to reduce unwanted
pregnancies and HIV-exposed infants. RHAC refers HIV positive pregnant women to OI/ART (Opportunistic
Infection/Antiretroviral Therapy) clinics or PMTCT centers for further services, including ARV (Antiretroviral)
prophylaxis, ARV/OI treatment, home-based care, and TB services. Most clinics are located near official
ARV and PMTCT centers. Nationally, there has been a significant lack of systematic follow-up of pregnant
women after they have been found to be HIV positive. RHAC will address this challenge by continuing to
refer HIV positive pregnant women to appropriate services and accompany referred women to OI/ARV or
PMTCT facilities if necessary. Where relevant, RHAC also provides funding for transportation to enable
women to travel to PMTCT or OI/ART centers. RHAC will continue to strengthen collaboration with these
service facilities by updating the list of PMTCT and OI/ART sites for staff and clients and closely monitoring
pregnant women to assure they receive prophylactic services.
RHAC has supported a PMTCT Ministry of Health (MoH) site in Sangke OD (Operational District) of
Battambang province since 2007 and plans to expand to support to as many as 18 PMTCT sites in 17
Operational Districts (ODs) of Kampong Speu, Battambang, Sihanoukville, Kampong Cham and Pailin
provinces from October 2009 to September 2010 depending on the evolution and expansion of the national
PMTCT program. RHAC will provide health personnel training on provider initiated testing and counseling
(PITC) and link equipment/supplies and transportation support for pregnant women referred for HIV
counseling and testing and OI/ART services. RHAC's PMTCT sites are in the same ODs where RHAC will
also be implementing mother and newborn care programs. Training will focus on HIV counseling antenatal
care (ANC) referrals. In addition, RHAC will train community-based volunteers on ANC, PNC (post-natal
care), birth preparedness and HIV/AIDS and related referral services. RHAC will also establish contact with
existing home-based care teams to support follow up of pregnant women identified as HIV positive. RHAC
will strengthen the implementation of the linked response strategy of the MoH, especially in health centers
where there is no comprehensive family planning, ANC, STI treatment, child delivery, post abortion care
(PAC), VCT, or PMTCT services provided to ensure comprehensive PMTCT services as needed.
The target group for PMTCT service is not only pregnant women but also their husbands as well as other
married couples/partners. RHAC will continue to promote couple counseling and testing and has introduced
male involvement education so that they can be of greater support to their women. RHAC's clinics provide
male-friendly services by providing male providers/counselors and separate male facilities to make men feel
comfortable when receiving services.
RHAC will continue to improve quality of care services at its clinics to attract more clients. PMTCT services
are integrated with other reproductive health services, incorporating counseling and testing services such as
ANC, PNC and family planning. In 2007, 91% of the women who received ANC services at RHAC's clinics
agreed to testing and counseling and about 95% returned to get their results. RHAC's clinics will continue
to implement other activities such as mother classes, ANC and PNC as a means to promote uptake of
PMTCT services. The client flow is designed to provide opportunity for all pregnant women to receive
testing and counseling if they wish. RHAC's community-based program will continue to support community
health education volunteers who refer pregnant women for HIV counseling and testing at RHAC's clinics. In
the Operational Districts where RHAC supports MoH PMTCT sites, RHAC will work through the Village
Health Support Group (VHSG) to help pregnant women prepare birth plans and provide ANC referrals and
PMTCT services if necessary.
Resources for PMTCT services are provided by USAID, Global Fund and client fees. USAID supports part
of the operational costs of RHAC clinics including staff, staff training, rental and utilities. In all clinics, non-
PEPFAR USAID support for RH/FP and MNCH wraps around PEPFAR PMTCT funding for the provision of
comprehensive integrated sexual reproductive health and HIV/AIDS related clinical services including family
planning, ANC, PNC, STI management, and VCT services. HIV test kits will be procured under Global
Fund.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Construction/Renovation
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $45,784
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Program Budget Code: 02 - HVAB Sexual Prevention: AB
Total Planned Funding for Program Budget Code: $667,419
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Cambodia has a concentrated epidemic with a 2008 estimated adult prevalence of 0.8%. Data is from a Consensus Workshop
held in June 2007 using the 2005 Cambodian Demographic and Health Survey (DHS), HIV Sentinel Surveillance (HSS), data from
the National Institute of Statistics, Behavioral Surveillance Survey (BSS), Integrated Biological and Behavioral Survey (IBBS) and
medical literature.
The HIV/AIDS epidemic is driven by men buying sex. Though prevalence continues to decline, groups that engage in high-risk
behaviors threaten Cambodia's progress in fighting HIV/AIDS. The 2005 DHS reported that among never married 15-19 year old
females over 99% have never had sex nor have 96% of males in this same age group. Among never married males aged 20-24
years, 73% have never had sex, and over 99% of females in this age group have never had sex. Women aged 25-29 have the
highest HIV prevalence rate among women, at 1.3 %. Men over age 30 have the highest HIV prevalence rates at 1.2% for 30-34
year olds and 1.3% for men ages 35-39 and 45-49. Among men who had sex in the past 12 months, 36% of 15 and 24 year olds
had sex with a nonmarital, noncohabiting partner, almost 20% had more than 2 partners and 6% paid for sex.
Among sentinel groups in the 2003 BSS, first sexual intercourse was between ages 21 and 23 years; comparable to the DHS
data. Fifty-nine to eighty percent of this group reported ever having sex with a FSW; 99% in brothels, but also with karaoke girls
and beer promoters. About half had concurrent sexual partnerships with sweethearts and 49-65% were currently married. Recent
data from a targeted survey among sexually active men with sweethearts reported that 18% were married, 16% had more than
one sweetheart, 85% paid for sex in the past 12 months, and 16% reported having ever tried drugs, with less than 1% reporting
ever injecting drugs.
HIV prevalence among brothel-based female sex workers (FSW) has declined from a peak of 44.7% in 1996 to 14.7% in 2006.
HIV prevalence among non-brothel-based FSW was 19.3% in 1999 and 11.7% in 2003. Though brothel based FSW report
increased condom use with clients (over 96%), they fail to use condoms with casual partners (66% sometimes/never) and
sweethearts (75% sometimes/never). Prior to the recent mass brothel closures, an estimated 1/3 of FSW were brothel-based and
2/3 primarily worked as entertainment service workers, such as beer promoters, karaoke workers, casino and restaurant staff, and
masseuses. The 2007 BSS found that the median age of direct FSW is 25, half are divorced, nearly half have had no schooling,
they average over 100 clients per month (mean 4.4 per working day), they charge a median of US$1.80/client; (half of which may
to go to the owner), half have sweethearts and 85% used STI services in the last 3 months. ‘Sweethearts' can range from a
similar age boy/girlfriend relationship to a long-term client or ‘Ta-Ta' (literally grandfather, but actually ‘sugar daddy') who may not
specifically pay for sex but provides gifts and/or money.
Indirect FSW may earn US$20-30/night on top of their salary, and HIV prevalence is 12%. Sexual activity among entertainment
service workers varies widely, but on average they have less than 15 paying clients per year. Condom use with clients is over
85%, but condom use with sweethearts is 40-60%, and less than 40% visited an STI clinic in the past 3 months. Data from a
targeted survey among karaoke women with sweethearts reported that 83% have tried drugs, 7% have ever injected drugs, and
20% have more than one sweetheart.
2005 STI Survey indicated 70% of MSM had multiple male partners, 19% had multiple male partners in the past week, 15%
bought sex from men, 46% sold sex to men, 52% had unprotected sex with men, 41% have sex with women, 25% have
unprotected sex with women, 15% have unprotected sex with FSW, 10% had sex with female sweethearts, and 5% sold sex to
women. STI prevalence ranged from 7.4-9.7%. MSM are a diverse population many of whom who do not self-identify as MSM so
are difficult to reach. MSM serve as bridge populations to sweethearts/wives.
To staunch the transmission of HIV at its source, USG prevention activities target persons engaged in high risk behaviors
(MARPs), including MSM, sex workers, clients of sex workers, and DU/IDUs. Greater emphasis is being placed on male
responsibility by targeting men who purchase sex to increase their risk perception for HIV infection and decision making around
correct and consistent condom use.
In FY 2008, USG supported AB programs in ten priority provinces and municipalities. The program provided age-appropriate life
skills training (gender relations and sensitization, negotiation skills, and sexual/reproductive decision-making) that equipped them
with the knowledge, confidence and skills to remain abstinent and delay sexual debut for youth and OVC under 18. Fidelity and
partner reduction promotion are critical components of interventions that target out of school and sexually active youth, factory
workers, migrant populations, and individuals in stable relationships.
USG prevention activities targeting high-risk groups reached PLHA, FSW (brothel and non-brothel based), motor-taxi drivers,
casino workers, uniformed services, mobile populations, married men with sweethearts and/or buy sex, and youth. FSW were
reached with HIV/AIDS prevention education activities through outreach and peer education at entertainment establishments,
FSW's homes, and in drop-in centers. FSW were linked with health services. Capacity building for outreach workers working with
MSM was conducted using targeted information, education, and communication (IEC) materials that promote the use of STI and
VCT services.
In FY 09, USG activities will build on prior investments for both AB and Condoms and Other Prevention. AB activities are
implemented through indigenous FBOs (Buddhist, Christian and Muslim) and CBOs/NGOs through community outreach sessions
and integration with services provided through the Continuum of Care (CoC, see uploaded diagram) framework, including
voluntary counseling and testing (VCT), and care and treatment services. Activities focus on delay of sexual debut, secondary
abstinence, being faithful and partner reduction. Target populations include in and out of school youth, migrant workers, factory
workers and newly married couples. Activities address the broader social context in which AB interventions fit, such as gender
relations and safe migration. Prevention messages are also paired with anti-stigma messages.
Activities under Condoms and Other Prevention will continue to target MARPs as strong prevention programs have been critical to
the success of Cambodia's 100% condom use program (CUP). USG works with key stakeholders to identify MARPs, assess
relative risk among these groups, and understand disease transmission through strategic information efforts. Targeted behavior
change interventions to reduce STI/HIV/AIDS risks and vulnerabilities of MARPs include community outreach and venue-based
ABC communications; behavior change, condom and lubricant promotion through social marketing; and increasing access and
uptake of essential services, such as VCT, STI, and HIV/AIDS care and treatment.
Peer, outreach, and community-based education ensure the adoption and continued application of risk reduction/elimination
around sex and drug-taking behaviors. Outreach/peer education is being refined to better reach MARPs in their environments,
e.g. beer gardens and massage parlors, and to strengthen outreach as a means of identification, service provision, and referrals.
Education activities/messages seek to increase demand for appropriate sexual health services, reduce stigma associated with
their use, and change male behavior regarding multiple sexual partners and low condom use among SWs and sweethearts. USG
programs develop targeted behavioral communications messages and materials relevant for diverse MARPs. National health
networks, composed of sex workers or MSM, give voice to marginalized populations to advocate for better health.
Activities targeting Vietnamese customers and casino and other entertainment service workers (karaoke, discotheques, beer
gardens, etc.) will be continued in a free-trade zone along the Cambodia-Vietnam border and in larger cities with sizable
Vietnamese populations. Activities are implemented in partnership with PEPFAR/Vietnam and jointly funded by PEPFAR in
Cambodia and Vietnam. Activities include prevention, peer outreach and education, and health services for STI/HIV/AIDS and
reproductive health/family planning (RH/FP). In 2008 a joint clinic-drop-in center was opened near the 7 casinos along the
Cambodia-Vietnam border that provides HIV and RH/FP counseling, testing and treatment services in both Khmer and
Vietnamese. The clinic is funded by USG, with the Global Fund supporting pharmaceuticals and other commodities. Additionally,
all information, education and communications (IEC) materials targeting entertainment service workers are now being produced in
both Khmer and Vietnamese in collaboration with PEPFAR/Vietnam.
USG provides capacity building, technical, and other assistance to implementing partners and stakeholders to ensure the
relevance and long-term sustainability of HIV prevention initiatives. Capacity within military and police is being strengthened to
enable the Ministries of National Defense and Interior to assume full ownership of HIV prevention program. FSW and MSM
network organizations are being strengthened programmatically and managerially to enable them to manage and implement HIV
programs. Long term sustainability is dependant on continued donor funding and efforts to increase funding from the Royal
Government of Cambodia, which currently provides less than 3% of Cambodia's estimated budget need for HIV/AIDS.
Reductions in funding by donors, including USG, DFID and KfW in the near future, threaten the sustainability of our investments
and successes.
Challenges are centered around the low status of women which prevents them from speaking with their partners about sex
outside of marriage and their own protection from HIV/STIs. Although sex outside of marriage appears to be common practice
among males, the 2005 DHS reports that 89% of women ages 15-49 do not think it is acceptable for a man to have extramarital
sex. Other challenges persist around seasonal work and migration as it affects the availability of community members to
participate in activities and the program's ability to provide follow-up services. Poor education and limited employment
opportunities are also a challenge. ‘Good' garment factory jobs pay ~$60/month, which a FSW can earn in 2-3 nights. Social
norms and sexual behaviors among men need to change and must begin at the senior government leadership level. Access to
venues where men target women for sex - beer gardens, casinos, karaoke bars - is difficult as owners do not want their
establishment to be seen as selling sex. An additional barrier is police harassment of owners who visibly promote condom use or
sell condoms.
Additionally, in September 2007, the Minister of Interior undertook a campaign to close brothels. These closures increased
following the passage of a new Law on the Suppression of Human Trafficking and Sexual Exploitation in February 2008. Thus far,
the law has not been widely disseminated so there is limited understanding of its authorities or those of law enforcement officers.
Brothel closures have led to sex workers being improperly arrested and abused and has driven others underground where
community outreach workers can no longer reach them. Other sex workers have simply moved onto the streets where they are
more vulnerable and the 100% CUP cannot be enforced. Some FSW have moved into other entertainment industries, including
massage and karaoke, while others have established themselves as ‘independents' where several sex workers rent rooms
together in a house that is not a brothel. Following intense advocacy and awareness raising the RGC recognizes the improper
implementation of the law, thus is working with the USG (USAID and G/TIP) and other development partners to improve
implementation, including training of police with non-PEPFAR funds.
USG collaborates with the National AIDS Authority (NAA), National Center for HIV/AIDS, Dermatology and STDs (NCHADS),
National Authority for Combating Drugs (NACD), the UN family, and other donors. Many USG partners also receive USAID
reproductive health/family planning (RH/FP) funds which wraparound HIV/AIDS programming, these same partners also receive
Global Fund support which enables them to expand coverage of integrated HIV/AIDS-RH/FP activities. USG staff and
implementing partners are active on government-donor working groups and are members of the Global Fund Country
Coordinating Mechanism (CCM) and CCM-sub-committee. USG participates on multiple Royal Government of Cambodia
technical working groups and donor forums to strengthen collaboration/programming, including chairing the Development Partners
Forum for HIV/AIDS. USG community based activities leverage and complement Global Fund support in prevention, care, and
treatment to facility-based services. USG staff and partners assist in the development of Global Fund proposals. USG continues
to work closely with DFID and KfW on a jointly funded USAID-DFID social marketing/behavior change communications activity, to
which DFID and KfW provide condoms and other birth spacing commodities.
USG also works with the Ministry of Education, Youth and Sport. Through USAID's Education Program a revised National Basic
Education Curriculum has been developed which includes HIV/AIDS as a health topic; pre-service training on this curriculum is
also provided to future teachers. HIV/AIDS and other health topics are also included in the life skill programs under USAID's
‘Educational Support to Children in Underserved Populations' and ‘Schools for Life' projects. Under the leadership of the School
Health Department, HIV/AIDS will be included throughout the Education reform program.
Table 3.3.02:
Although Cambodia has observed a decline of HIV prevalence among the general population in recent
years, youth continue to be vulnerable. According to the Inter-Censal Population Survey, young people (10-
24 years) represent up to 36.5% of the total population of Cambodia (MoP, 2004). Social issues such as
illicit drugs and rape are important issues facing youth. The UN HIV/AIDS Joint Support Program 2006-
2010 for Cambodia acknowledged that HIV prevention education for young people remains an important
intervention.
RHAC will continue to provide HIV/AIDS education and promote positive behavioral change focusing on
abstinence and be faithful as well as providing medically accurate information about condoms to young
people in and out of schools in 34 schools and 521 villages in five provinces, covering approximately
300,000 youth. RHAC continues to mobilize trained peer educators (PEs) to educate their friends through
one-on-one communication, and conduct/organize other education events such as group discussions,
village edutainment, quiz shows and local drama. Educational materials such as booklets will be printed
and distributed to young people to reinforce AB messages. Youth centers will continue to serve as a venue
to provide counseling, education, vocational training and other social and recreational activities for young
people. RHAC is providing training to Youth Advisory Groups (YAGs) and Teacher Counselors, involving
them in developing creative activities that are organized by PEs and young people. RHAC is facing some
difficulty in getting young people to attend education events; however, it is aligning the program to meet
youth needs and interests. RHAC will provide medical services such as HIV counseling and testing, and
STI treatment in a friendly environment. Some clinics have established youth centers adjacent to clinics
which offer young people convenient access through a separate entry. PEs also refer young people who
need medical services to RHAC's clinics or health centers.
RHAC will promote gender equity by having gender-balanced peer educators so that girls and boys can
participate equally in any activity and no girl or boy will be socially excluded as a result of gender
differences. During the training of PEs, RHAC promotes discussion about the fact that men and women
should have equal opportunities and rights with regard to training and jobs. Appropriate roles and
responsibilities for brothers/husbands will be emphasized to support their sisters/wives to access social
services and health care and empower women. RHAC has extended its reporting form to enable the
program to collect the number of beneficiaries by gender and will closely monitor progress regarding gender
participation.
Resources for the AB program benefit from wraparound USAID support for reproductive health education
for young people, including birth spacing, unwanted pregnancies and nutrition. USAID supports staffing,
training, education events, supervision, monitoring and evaluation. Other donors including Global Fund,
UNFPA and Plan International (PLAN) have enable RHAC to expand to other geographic areas.
Estimated amount of funding that is planned for Human Capacity Development $60,850
Activities include provision of STI (Sexually Transmitted Infection) management through RHAC's clinics;
community HIV/AIDS education for women, men and married couples in villages; behavior change
communication (BCC); and education on HIV/AIDS for factory workers (including garment factories and
palm oil and rubber plantations), fishermen, construction workers and entertainment workers.
As of September 2008, under USG support, RHAC established 17 clinics, provided HIV/AIDS education to
communities covering 3,565 villages, and implemented BCC (Behavior Change Communication) on
HIV/AIDS in ten factories. During FY 2009, RHAC will establish three additional clinics (for a total of 20
clinics), continue and expand HIV/AIDS education in communities to 3,811 villages, and expand BCC on
HIV/AIDS in 43 factories, 17 construction companies, 10 entertainment establishments, and five fishing
communities. RHAC will graduate its community HIV/AIDS education activities from half of the currently
covered villages and shift to new villages. The BCC focus in villages will be more on mass education rather
than small group education in order to maximize coverage. BCC activities that target factory workers,
entertainment workers and other risk groups as mentioned above will expand to new factories and
establishments in current and new provinces and will remain focused on small group and on-on-one
approaches.
HIV prevalence has declined in recent years. The available data indicates that HIV prevalence among ANC
women has declined from 1.1% in 2006 to 0.8% and prevalence in the general population from 0.9% to
0.8% (NCHADS, 2007). However, strong HIV prevention interventions need to continue in order to prevent
a new wave of the epidemic.
RHAC will continue to provide STI diagnosis and treatment as part of integrated services through current
and newly established clinics. STI treatment services are provided to clients including men and women,
young people, factory workers, construction workers and other high risk groups such as direct and indirect
entertainment workers and MSM (Men having Sex with Men). RHAC's clinical services, including STI
treatment, will be provided free of charge for specific high risk groups such as entertainment workers to
promote high rates of service utilization and follow up. RHAC's clinics collaborate with community-based
and outreach peer education programs in order to strengthen client referrals. Laboratory services have
been upgraded to provide more accurate diagnosis and treatment based on national recommended
guidelines. RHAC promotes partner treatment for STIs in order to prevent re-infection and stresses re-visits
and follow-up to ensure that patients are cured. The clinics also have condoms available for sale to
encourage family planning as well as HIV/AIDS prevention (dual protection).
Spousal transmission continues to be a feature of the HIV/AIDS epidemic in Cambodia. Men/husbands in
rural areas are moving to the city especially during dry season in order to find jobs and usually return to
their village homes during the rainy season for rice planting and harvesting. While in the city many have
extra-marital sex. The BSS (Behavior Surveillance Survey) 2007 found that 61% of moto-taxi drivers had
sex with women other than their spouse and 47% had multiple sex partners during the past year. Among
these, 40% had sex with sex-workers. Without HIV/AIDS knowledge and appropriate behavior these men
could have unprotected sex which exposes them to HIV infection that may consequently infect their
wives/partners. Women and housewives remain at greater risk of HIV infection if they are not in the position
to talk about safe sex with their husbands. The RHAC community based program provides education on
HIV/AIDS for men on safe sexual behavior before leaving their family for the city, as well as for housewives
to know how to openly talk with their husbands about safer sex. RHAC works with an extensive
government network of health volunteers known as Village Health Support Groups (VHSGs) and mobilizes
them to provide HIV/AIDS education to people in the community, especially married couples. RHAC will
recruit and train more VHSGs especially in the new provinces, operational districts (ODs) and villages.
RHAC will put more emphasis on organizing large public gathering events such as community theater
(locally known as Lkhorn) which continues to be a popular and relevant approach in the rural context and a
component of the recommended national communication strategy. VHSGs will also continue to provide one
-on-one talks and conduct group discussion sessions as appropriate. In addition, VHSGs also play a role
as community-based family planning distributors for condom sales to rural couples as a dual protection
method. VHSGs meet on a daily basis with people in the community in their role as community-based
family planning distributors, also providing education about HIV/AIDS. The Cambodian Demographic and
Health Survey 2005 has found that general knowledge about HIV/AIDS is relatively high, therefore RHAC
will focus on giving specific education messages on PMTCT, VCT (Voluntary Counseling and Testing), and
other information related to care and treatment adherence and promotion of condom use among rural
couples.
Entertainment service workers are one of the nationally defined high-risk populations for which prevention
interventions should be targeted. Other groups such as factory workers and construction workers are quite
mobile, making them vulnerable to HIV infection and potentially contributing to fueling the HIV epidemic if
prevention activities are not implemented. These workers migrate from rural districts to search for jobs in
the city, mostly in the flourishing garment industry and construction. The majority are from poor families and
have lower literacy rates which put them under greater risk when exposed to city life. RHAC will address
the need for HIV/AIDS and RH (Reproductive Health) information among these groups by recruiting and
training Peer Educators (PEs) who provide education through one-on-one talks, group discussions, and
quiz shows. RHAC program staff will assist PEs in organizing education sessions/events. Education
materials will also be distributed to target groups. PEs will refer their friends to RHAC's clinics for clinical
services, especially STI treatment and VCT. Condoms will be distributed or sold to target groups through
the PEs, RHAC's clinics and in commercial and entertainment establishments. RHAC coordinates closely
with factory managers, establishment owners and relevant government institutions to mobilize their support
for prevention activities.
Sexual prevention activities are wrapped around by non-PEPFAR USAID maternal and child health and
reproductive health funds. Other funding sources include Global Fund and Ministry of Health. USAID
Activity Narrative: supports operating costs for clinics and operational costs for community and workplace programs. STI
drugs for all clinics are purchased under the Global Fund. The Ministry of Health provides condoms and
commodities for clinics and community-based programs. Condoms for outreach peer education in the
workplace are procured under Global Fund.
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $235,850
Table 3.3.03:
Under a sub-grant from RHAC, Angkor Hospital for Chidren (AHC) provides services to HIV infected chidren
both in the hospital and through home based care. AHC is one of 23 pediatric ART (Antiretroviral Therapy)
hospitals throughout the country which can provide ARV (Anti Retroviral) and OI (Opportunistic Infection)
treatment to HIV infected children and is the only pediatric ART site in Siem Reap province. All children
diagnosed with HIV will be provided with OI prophylaxis including Cotrimoxazol and Fluconazol to prevent
PCP (Pneumocystic Pneumonia) and crypotococcal meningitis. The hospital also provides OI treatment for
other illnesses such as diarrhea, TB, candidosis, herpes, etc.
AHC has a home care team which conducts home visits to follow up on HIV infected children under ART
and OI treatment to assess treatment adherence and overall health of the child. During the home visit, the
home care team assesses caregiver knowledge on administering medicine, conducting medical
assessments, and determining drug side effects as well as stressing the importance of keeping hospital
appointments. The team connects children and families to other available support services. AHC continues
to improve the skills and knowledge of staff to better provide effective and compassionate care for children
and families through training in areas such as psychosocial issues and attending meetings or workshops.
AHC recruits and involves PLHA (People Living with HIV/AIDS) in providing counseling and education to
caretakers and children and will continue to establish a pediatric peer educator and self-support group
education program for children as evidence shows that their peers are the best source of support for
children.
As a general pediatric hospital, AHC provides broad medical services and can serve as the entry point for
HIV counseling and testing and Continuum of Care (CoC) service for HIV infected children. Families are
more likely to participate in hospital activities since AHC provides the whole CoC in the hospital as well as in
the community.
The USG funded pediatric care service for HIV infected children is coordinated with funding in other
program areas including HIV counseling and testing, pedicatric ARV treatment, and OVC (Orphans and
Vulnerable Children). Individuals provide in-kind resources such as toys for children during home visits.
Estimated amount of funding that is planned for Human Capacity Development $16,188
Estimated amount of funding that is planned for Water $1,200
Table 3.3.10:
Under a sub-grant from RHAC, the Angkor Hospital for Children (AHC) provides comprehensive continuum
of care (CoC) services for HIV infected children from counseling and testing to OVC support. OI
(Opportunistic Infection) prophylaxis/management and home care service is addressed in the Pediatric Care
and Support program area; HIV counseling and testing activities are described in the Counseling and
Testing, and Orphans and Vulnerable Children program areas.
Pediatric ART (Antiretroviral Therapy) is distinct from adult ART in terms of medications, tools and methods
of education (especially for adherence), and the patient's ability to understand ART. Children who receive
HIV testing are followed up whether they are infected or not. CD4 cell counts are performed for all HIV
infected children identified through the counseling and testing process to determine which children need
ART. For children needing treatment, three ART preparation sessions are conducted to train the family and
the child in how to comply with treatment requirements, possible ART side effects and continuing adherence
to treatment over time. Infected children who are not in the ART program will receive a CD4 test every six
months. In some cases, ARV is also provided to HIV infected children with poor medical conditions
although they have high CD4 cell counts. Children under ART who live in Siem Reap will be followed up by
a home care team to monitor their medical condition and ensure they continue to take appropriate
medication.
AHC will strengthen collaboration with home-based care organizations to follow up with children who live in
remote districts or come from other provinces. The hospital arranges appointments with families or
caretakers of discharged children for routine medical check-ups and re-supply of ARVs. Children and
families are advised to come to the hospital anytime if the patient experiences any side effects. Disease
monitoring is regularly performed to evaluate the patients' health condition and to assess response to
medication. AHC has observed that increasing numbers of children whose health did not improve after
starting first line ART is probably the result of drug resistance. AHC now requests viral load and genotype
tests in order to determine if the patient is, in fact, drug resistant and therefore can begin appropriate
second line treatment. AHC has physicians and medical staff trained and qualified to deliver ART services
to children and will continue to provide updated training to enable them to continue to provide high quality
services.
As of July 2008, AHC has maintained the active cohort of 394 children who continue to receive ARV
treatment from the hospital. AHC expects the number of HIV infected children that need ART services to
increase to 474 by September 2010. AHC does not expect a larger increase of children since a number of
new pediatric sites are being established. The National Center for HIV/AIDS, Dermatology and STDs
(NCHADS) has requested that AHC transfer patients to ART sites near their homes, especially those from
outside of Siem Reap. However, some patients keep going back to AHC after being referred which
increases the number of children receiving ART services from AHC.
USG support covers approximately 50% of medical personnel salaries who provide ART services, lab tests
including CD4 counts, viral load and genotype tests and some office equipment and supplies. The facility
itself is supported by a private foundation (ABBOTT) and individual contributions. ARV drugs are provided
by MoH/NCHADS under Global Fund support. Transportation support for children is shared between
USAID, BTC (Belgium Technical Cooperation) and other NGOs.
Estimated amount of funding that is planned for Human Capacity Development $11,508
Table 3.3.11:
OVC activities will be carried out by the Angkor Hospital for Children (AHC) through a sub-grant. Often
abandoned by their families, many HIV affected children do not acquire enough skills to attain minimal
levels of livelihood security. They may also face stigma, discrimination, abuse, and exploitation. The AHC
supports both children living with HIV infected parents and those who lost parents due to AIDS and now live
in orphanages or with community caretakers. AHC provides school supplies to enable affected children to
attend school and supports family income generation activities to ensure food security and improve
nutrition. Formula is provided when needed for safe infant feeding to improve nutritional status. The
hospital conducts routine medical check-ups for children in orphanages, schools and the community.
Education about HIV/AIDS is provided to caregivers and the community to raise awareness and reduce
stigma and discrimination. AHC refers affected children to other organizations for legal aid, psychological
counseling and financial support. AHC will continue to collaborate with other NGOs to identify affected
children who need support.
The OVC program is integrated with other program areas (pediatric care and treatment, and counseling and
testing) and is also supported by AHC resources for general pediatric services.
Table 3.3.13:
HIV voluntary counseling and testing or VCT will be provided as an integrated service through 20 RHAC
clinics and a sub-grant to Angkor Hospital for Children (AHC). In 2008, RHAC managed 17 clinics (the
same clinics as mentioned in the PMTCT program area), established in eight of 24 provinces including
Battambang, Kampong Speu, Kampong Cham, Phnom Penh, Sihanoukville, Siem Reap, Svay Rieng and
Takeo, and covering 14 Operational Districts (ODs). RHAC will establish three additional clinics in FY 2009.
These clinics provide comprehensive reproductive health and HIV/AIDS related services including FP
(Family Planning), ANC (Antenatal Care), PNC (Postnatal Care), STI (Sexually Transmitted Infection)
treatment, cervical cancer screening, post-abortion care, PMTCT, VCCT and male circumcision. The target
groups for VCT services include the general population and other high risk groups, including pregnant
women (addressed in the PMTCT program area), young people, factory workers, sex workers,
entertainment and casino workers, and MSM (Men who have Sex with Men). The clinics collaborate within
different program components of RHAC as well as with other implementing partners to strengthen referrals
for VCT services. RHAC clinics provide free VCT services directly to sex and entertainment workers in
addition to those referred by other RHAC programs.
Clients receive HIV/AIDS information education provided by clinic staff while waiting for their appointments
and through TV education to promote demand for VCT services. RHAC's community-based outreach peer
education program provides education about HIV/AIDS, including VCT and information about the availability
of services, and refers people who need services to the clinics. Each clinic has a separate room for males
and male counselors/providers so that men feel more comfortable when receiving services. The clinics will
continue to improve or maintain quality services as this has been shown to increase the number of clients
overall and VCT clients in particular. All clinics are equipped with laboratory support services, including
qualified lab technicians and counselors to provide quality services to clients. Having the capacity to
perform on-site testing using the national recommended testing protocol promotes increased post-test
counseling. RHAC clinics provide post-test counseling to over 95% of clients tested. In order to further
ensure the quality of testing, RHAC will train clinic staff and lab technicians in External Quality Assurance
(EQA) and will start to implement EQA in its clinics/laboratories following the Standard Operation Procedure
(SOP) for VCT external quality control, in collaboration with the National Institute of Public Health (NIPH)
and the National Center for HIV/AIDS, Dermatology and STDs (NCHADS). RHAC will train staff on updated
VCT services to continue quality counseling and testing services, which will bring in more VCT clients.
Clients identified as HIV positive by RHAC clinics will be referred to appropriate services including TB,
OI/ART (Opportunistic Infection/Antiretroviral Therapy), and home-based care. Each clinic will improve
follow-up of referred clients to ensure that they receive the services they require. RHAC expects to expand
cervical cancer screening services for HIV infected women in additional clinics. This service is currently
provided in two clinics in Takeo and Siem Reap in collaboration with MSF-Belgium.
AHC is an official NCHADS VCT site for HIV counseling and testing for children. As a pediatric hospital
providing services for 300-600 sick children on daily basis, AHC is an entry point into the continuum of care
(CoC) program for HIV infected children. Staff conduct risk assessments of children and provide counseling
to caretakers and children about VCT, ART and conduct testing. The hospital provides HIV testing for 20-50
children per month. Two types of tests are provided, including antibody and PCR (Polymerase Chain
Reaction) for those less than18 months old. The PCR will be sent to a national laboratory for testing.
Children identified as HIV infected are provided with further services including OI and ART. AHC will
continue to build on its network with other partners providing child care support activities and with
communities to refer children for hospital services, including VCT.
RHAC clinics provide comprehensive integrated services, therefore funding for VCT services is integrated
with other USG funds for HIV/AIDS, and non-PEPFAR USAID reproductive health and maternal health
funds as well as Global Fund. USAID is funding core and operational costs of 17 clinics including staffing,
training, facilities and other associated costs. HIV tests for all clinics are procured under Global Fund.
Resources for VCT services provide by AHC are augmented by a private foundation (ABBOTT), and
donations by individuals. Belgium Technical Cooperation (BTC) and other NGOs share the cost of transport
for children.
Estimated amount of funding that is planned for Human Capacity Development $32,603
Table 3.3.14:
RHAC will have 20 fully-equipped laboratories, co-located in its clinics, that perform HIV testing on-site. In
addition to HIV testing, these laboratories perform other reproductive health and maternal health tests
including syphilis (RPR), vaginal smear, cervical smear, urethral smear, pregnancy, urine analysis, and
cervical cancer screening (PAP smear & VIA). One lab has been upgraded to perform comprehensive lab
tests including bio-chemical analyses.
RHAC will continue quality control measures in its laboratories to ensure the accuracy of testing, particularly
HIV. RHAC will build the capacity of laboratory technicians through training and provide HIV testing for the
Angkor Hospital for Children, its sole sub-grantee.
Estimated amount of funding that is planned for Human Capacity Development $15,271
Table 3.3.16:
