Cambodian Town A Model For AIDS Prevention
The quiet seaside town of Sihanoukville in Cambodia draws visitors on study tours from as far away as Indonesia and China. It is not the town's profitable port or the many tourists on the long stretches of cream-coloured beaches that are making waves, but a matter literally under the covers: HIV prevention in commercial sex.
Today in Sihanoukville (also known as Kampong Som), it is very difficult to purchase sex without a condom. Surveys indicate that 96% of sex workers use condoms with their clients. The common response to customers is: no condom, no sex.
Sihanoukville's success with condoms has earned its place in the annals of AIDS history. In the fight against this pandemic, which has left more than 40 million people infected and 20 million dead globally, there are not many success stories.
So the achievements of a small town in one of the poorest countries in Asia stand out. Its efforts caused controversy initially, but won approval after rates of HIV and other sexually transmitted infections (STIs) fell.
Sihanoukville's ""100% Condom Use Programme"" - which follows the programme that transformed Thailand's AIDS epidemic - has drawn several hundred visitors from other provinces as well as from other Asian nations. The World Health Organization even used Sihanoukville's experience to help produce guidelines on condom programmes.
This week, the town will again be highlighted at a meeting on the 100% condom use programme in Vientiane Lao People's Democratic Republic. Health officials from China, Mongolia and Viet Nam who have set up similar programmes in their countries, as well as the Lao People's Democratic Republic and the Philippines, which recently initiated pilot projects, are attending the meeting.
""One of the first human rights is to be protected from infection, from disease and death. And this programme prevents infection among sex workers and the spreading of HIV to their clients, then to the clients' wives and in the end to babies,"" says Dr Bernard Fabre-Teste, who heads the HIV and sexually transmitted infections (STI) unit at the World Health Organization's Western Pacific Regional Office in Manila.
Only a few years ago, AIDS cast a dark cloud over Sihanoukville. It seemed that the epidemic was spiralling out of control.
More than half of Sihanoukville sex workers were infected with HIV - 57% in 1998 - and at least one other sexually transmitted infection (STI). Roughly 16% of policemen and fishermen were HIV-positive in 1999. And only about 56% of sex workers were using condoms.
The provincial health director Kiv Bun Sany remembers: ""We were very worried. We could not wipe out prostitution from society. We saw this programme was successful in Thailand so we decided to try it.""
It was a brave decision. ""We had no government support, we were breaking the law and we had a lot of opposition from the community. We were very scared,"" he says.
The police were surprised at having to protect with sex workers. The relationship between these two groups had been characterized by arrests, violence and extortion. ""Before, when sex workers would see the police, they would run, because the police would arrest them, put them in prison and cut their hair,"" says the Chief of the metropolitan district of Sihanoukville Prum Sakhon.
He recalls how he first reacted to the programme: ""I didn't agree. It broke the law."" Later, he had to convince his staff. ""They didn't believe AIDS was a problem.""
In time, the police had more proof than they wanted: colleagues were dying of AIDS. In all, about 30 policemen have died, together with 20 family members - a sizeable number for a force of about 100. In 1999, Sihanoukville got official endorsement from Prime Minister Hun Sen, who encouraged other parts of Cambodia to follow the town's example. Since then, other provinces have adopted the programme, although not always as successfully.
Criticisms that the programme would encourage prostitution have been proved wrong. In fact, the reverse has happened. In 1997, 75% of military and police officers visited sex workers, whereas in 2001, only 32% did.
The welfare of sex workers, often young women bonded by debt, has also improved, although still far from perfect. Their health and relationships with the police are much better now, says health worker Chiam Samlot, who does outreach work in brothels. Sex worker visits to the local STI clinic for free check-ups, as encouraged by the programme, have increased 10-fold.
""Their biggest concern is money. Also, some of them, especially the older ones, do not like to use condoms with their sweethearts,"" she says. Chiam is close to many sex workers - literally. She lives in Phoum Thmey village, where many of the simple, blue-painted houses offer sex for sale. Young men, many rural migrants, seek refuge here after a long day's work at the industrial and shipping yards just a stone's throw away.
In these brothels, the walls are plastered with colourful condom posters, some with cartoon condoms, others depicting an embracing couple with a condom at hand.
A 20-year-old sex worker from the provinces, Sothea (not her real name), says she can't remember the last time when a client didn't want to use condoms. ""They are scared of AIDS too,"" she says.
Sothea entered the sex trade two year ago after her mother, a single parent who sold flowers and cakes on the street, fell ill. She is clear about using condoms: ""I don't want AIDS. I want to have a long life, to take care of my mother and brothers.""
For more information, please contact Mr Peter Cordingley at WHO's Western Pacific Regional Office, Manila, tel. (632) 5289991 or email: email@example.com