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Introduction and aims People who use drugs (PWUD) face several mental health problems. This report aims to examine the prevalence of and factors associated with psychological distress among Cambodian PWUD. Design and methods Data used in our analysis were from the national survey of 1626 PWUD recruited through respondent-driven sampling method in Cambodia in 2012 to 2013. Distress was measured through self-report by using the 10-item Kessler Psychological Distress Scale (K10). All analyses were weighted. Results Approximately half of PWUD had mild to severe psychological distress in the past four weeks (K10 ≥ 20). In the adjusted analysis, being female (odds ratio 1.60; 95% confidence interval 1.22, 2.12) and having experienced living in rehabilitation centres (odds ratio 2.46; 95% confidence interval 1.56, 3.87) were associated with a higher risk of having moderate or severe psychological distress (K10 ≥ 25). Discussion and conclusions Psychological distress was prevalent among Cambodian PWUD. PWUD who were female or experienced living in rehabilitation centres were more likely to report distress. Policy makers should consider shifting further from compulsory institutionalised treatment model to community-based treatment program. Mental health assessment and mental health care services should be included in drug treatment programs and should be gender-sensitive. Further research investigating other mental disorders among PWUD are also needed.

Background: In Cambodia, behavioral risks and subsequent new HIV infections in key populations, including female entertainment workers (FEWs), continue to be of great national concerns. This National Integrated Behavioral and Biological Survey was conducted to determine the prevalence of HIV, syphilis, and related risk behaviors among FEWs in the country. Methods: This cross-sectional survey was conducted in 2016 among 3,151 venue-based and non-venue-based FEWs recruited from the capital city and 17 other provinces using a two-stage cluster sampling design for structured-questionnaire interviews and HIV/syphilis testing. Descriptive statistical analyses were performed. Results: The mean age of FEWs in this survey was 26.2 (SD= 5.7) years. The prevalence of HIV and syphilis was 3.2% (95% CI= 1.75-5.75) and 0.8% (95% CI= 0.36-1.70), respectively. Only 25.1% of the respondents reported always using condoms with non-commercial partners, and 80.6% reported always using condoms with commercial partners in the past three months. About one-fifth (20.2%) reported having had at least one STI symptom in the past three months. Regarding substance use, 7.6% reported having used some form of illicit drugs in the past three months. The most common form of the drugs was amphetamine-type stimulants (86.1%), and 0.6% reported injecting drugs in the past three months. Of the total, 74.3% reported using some form of contraceptives, with condoms being the most common method (33.5%), and 33.7% reported having at least one induced abortion during the time working as an EW. Conclusions: This study surmises that the prevalence of HIV among FEWs in Cambodia remains stable, and these women remain at an increased risk of HIV infection. Sexual behaviors, notably inconsistent condom use and multiple partnership, may have exacerbated their vulnerability. These findings highlight the need for tailor-made interventions that focus on sexual and reproductive health education and access to needed services for this key population.

Background Hepatitis C virus (HCV) is a significant global health concern. Despite evidence of the relationship between injecting drug use and HCV, studies on HCV among people who inject drugs in developing countries remain scarce. To address this need, we conducted this study to explore the prevalence of and factors associated with HCV antibody positivity among people who inject drugs in Cambodia. Methods Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey among people who use and inject drugs conducted in 2017. We used the respondent-driven sampling method to recruit participants in 12 provinces for face-to-face interviews and HIV and HCV antibody testing. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with HCV antibody positivity. Results This study included 286 people who inject drugs with a mean age of 31.6 (SD = 7.5) years. The prevalence of HCV antibody among participants in this study was 30.4%, of whom 31.0% were co-infected with HIV. After adjustment for other covariates, the odds of HCV antibody positivity was significantly higher among participants who were in the older age group of 25 to 34 (AOR = 1.85, 95% CI = 1.06–7.92) and ≥ 35 (AOR = 2.67, 95% CI = 1.24–5.71), were in Vietnamese ethnic group (AOR = 5.44, 95% CI = 2.25–13.14), were living on the streets (AOR = 3.01, 95% CI = 1.29–704), had been sent to a drug rehabilitation center in the past 12 months (AOR = 2.67, 95% CI = 1.21–5.90), had received methadone maintenance therapy in the past 12 months (AOR = 3.02, 95% CI = 1.32–6.92), and were tested positive for HIV (AOR = 3.80, 95% CI = 1.58–9.12) compared to their respective reference group. Conclusion The prevalence of HCV antibody among people who inject drugs in Cambodia is high, particularly in older and more vulnerable subgroups. Tailor-made interventions are required to increase access to culturally sensitive harm reduction interventions to prevent primary HCV infection and reinfection. In addition, there is an opportunity to expand screening, diagnosis, and treatment with new directly acting antiviral agents.

Background Globally, the prevalence of HIV among transgender women is much higher than that of the general adult population. This can be explained by the persistently low rate of consistent condom use among this population. This study was therefore conducted to explore factors associated with consistent condom use among sexually-active transgender women in Cambodia, specifically with their non-commercial partners. Methods Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey 2016. Participants were recruited from the capital city of Phnom Penh and 12 other provinces with high burden of HIV using the Respondent-Driven Sampling (RDS) method. Face-to-face interviews were conducted using a structured questionnaire. Weighted multivariate logistic regression analysis was conducted to explore independent factors associated with consistent condom use. Results This study included 1202 transgender women who reported having anal sex with at least one male partner not in exchange for money or gifts in the past three months. The mean age of the participants was 26.0 (SD = 7.0) years. Of the total, 41.5% reported always using condoms with male non-commercial partners in the past three months. After adjustment, the likelihood of consistent condom use was significantly higher among participants who resided in an urban community (AOR = 1.7, 95% CI = 1.1–2.6), had attained at least 10 years of formal education (AOR = 1.8, 95% CI = 1.2–2.7), perceived that they were likely or very likely to be HIV infected (AOR = 2.9, 95% CI = 2.0–4.1), reported drinking alcohol two to three times per week (AOR = 3.1, 95% CI = 1.1–8.3), reported using amphetamine-type stimulants (AOR = 1.9, 95% = 1.1–3.8) or other drugs (AOR = 7.6, 95% CI = 1.5–39.5), and reported inconsistent condom use with male commercial partners in the past three months (AOR = 4.3, 95% CI = 1.8–10.4) compared to that of their respective reference group. Conclusions This study confirms the low rates of condom use, particularly in non-commercial relationship, among transgender women in Cambodia. To address these concerns, efforts towards education about effects of multiple, concurrent relationships, and inconsistent condom use should be reinforced among transgender women.

ObjectiveTo estimate the prevalence of HIV testing and examine factors associated with recent HIV testing among people who use drugs (PWUD) in Cambodia.DesignCross-sectional study.SettingTwelve major provinces with a high burden of HIV and drug use in Cambodia.ParticipantsThis study included 1677 PWUD recruited using a peer-based social network recruitment method. Participants’ selection criteria included being at least 18 years old and using any illicit drugs via any administration routes in the past 12 months.Primary outcome measureRecent HIV testing, defined as having an HIV test in the past 6 months.ResultsThe median age of the participants was 28 (IQR 22–34) years, and 56.6% were men. The prevalence of lifetime and recent HIV testing was 70.7% and 42.9%, respectively. After adjustment in multivariable logistic regression analysis, recent HIV testing remained positively associated with being female (adjusted OR (AOR) 1.55, 95% CI 1.18 to 2.04) or third gender identity (AOR 2.06, 95% CI 1.11 to 3.80), having ever been to a drug rehabilitation centre (AOR 1.60, 95% CI 1.13 to 2.29), having used any HIV services in the past 6 months (AOR 7.37, 95% CI 5.61 to 9.69), having received HIV education in the past 3 months (AOR 3.40, 95% CI 2.63 to 4.40) and having self-perception of higher HIV risk (AOR 1.81, 95% CI 1.19 to 2.73).ConclusionsRecent HIV test uptake among PWUD in Cambodia was suboptimal. This study highlights the roles of outreach HIV education and services in promoting regular HIV testing among PWUD. Strengthening the coordinated effort of government agencies and local civil society organisations to prioritise expanding community-based peer-driven interventions to reach out to this hidden population is warranted.

Background People who use drugs are at a disproportionately higher risk of mental disorders due to prolonged exposure to psychosocial challenges. However, studies on mental health among people who use drugs in resource-constrained countries are scarce. This study sheds light on the prevalence and correlates of psychological distress among people who use drugs in Cambodia. Methods We conducted this cross-sectional study in the capital city and 11 provinces in 2017. The Respondent Driven Sampling method was adapted to recruit 1677 people who used drugs for face-to-face interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12). A total score of GHQ-12 > 2 indicated high psychological distress. We performed a multiple logistic regression analysis to identify factors associated with psychological distress. Results We included 1598 participants in the analyses, with a mean age of 28.6 years (SD = 7.8). Of the total, 42% had high psychological distress – 50% in women and 37% in men. The adjusted odds of having high psychological distress were significantly higher among participants who were 25–34 years old and 35 years and above, had been to a drug rehabilitation center, had been insulted by family members, and had been sexually harassed/abused by someone when they were growing up. The odds of having high psychological distress were significantly lower among participants who were male, lived in their own dwelling, reported injecting as the mode of the first drug use, and had someone taking care of them when they got sick. Conclusions This study documents a high prevalence of psychological distress among people who use drugs in Cambodia. Intervention programs that attempt to address mental health problems among people who use drugs in resource-limited settings should be gender- and age-sensitive and target more marginalized subpopulations. Mental health services can be integrated into HIV and harm-reduction programs for people who use drugs.

This cross-sectional study explored the prevalence and correlates of syphilis infection among people who use and inject drugs (PWUD/PWID) in Cambodia. Data were collected in 2017 from 1,677 PWUD/PWID living in the capital city of Phnom Penh and 11 other major provinces using the respondent-driven sampling method. The SD Bioline HIV/Syphilis Duo test was used to determine human immunodeficiency virus (HIV) and current or past syphilis infection. A multivariable logistic regression analysis was conducted to identify risk factors associated with current or past syphilis infection. The prevalence of current or past syphilis infection was 3.8% (95% confidence interval = 2.4–4.6). After adjustment, current or past syphilis infection remained positively associated with being female, living on the streets, having an average monthly income of US$100–299, having transactional sex in the past three months, and having been to a rehabilitation centre in the past 12 months. Current or past syphilis infection was negatively associated with having attained at least high school level of formal education. The findings indicate vulnerability to syphilis infection among PWUD/PWID in Cambodia, particularly among subpopulations who are more marginalized. Syphilis prevention and control programmes should be systematically integrated into HIV and sexually transmitted infection policy and services in the country.

BackgroundGlobally, the prevalence of HIV among transgender women remains much higher than that of the general population, and a large proportion of them are unaware of their HIV status. Transgender women are exposed to gender-based violence and social stigma and discrimination in different settings that may create significant barriers to receiving HIV prevention and care services. This study aimed to identify factors associated with recent HIV testing among transgender women in Cambodia.MethodsWe conducted a cross-sectional survey in 2016 among 1375 transgender women recruited from 13 provinces using a peer-based social network recruitment method. We used a structured questionnaire for face-to-face interviews and performed rapid HIV/syphilis testing onsite. We used a multiple logistic regression analysis to identify factors associated with recent HIV testing.ResultsOf the total, 49.2% of the participants reported having an HIV test in the past six months. After controlling for other covariates, the odds of having an HIV test in the past six months was significantly lower among students (AOR 0.36, 95% CI 0.20-0.65), participants who perceived that they were unlikely to be HIV infected (AOR 0.50, 95% CI 0.32-0.78), and participants who reported always using condoms with male non-commercial partners in the past three months (AOR 0.65, 95% CI 0.49-0.85) relative to their respective reference group. The odds of having an HIV test in the past six months was significantly higher among participants who had been reached by community-based HIV services (AOR 5.01, 95% CI 3.29-7.65) and received HIV education (AOR 1.65, 95% CI 1.06-2.58) in the past six months relative to their respective reference group.ConclusionsDespite the widely available free HIV testing services, more than half of transgender women in this study had not received an HIV test in the past six months. Our findings suggest that a tailored and comprehensive combination prevention program, in which HIV testing is linked to care continuum and beyond, maybe an essential next step. Social media may have the potential to be promoted and utilized among transgender women populations in order to improve HIV testing and other prevention measures.

BackgroundCambodia has been well recognized for its success in the fight against the HIV epidemic. However, challenges remain in eliminating HIV infections in key populations, including women working in entertainment establishments, such as massage parlors, karaoke bars, or beer gardens. This study explored the prevalence of HIV and identified factors associated with HIV infection among female entertainment workers (FEWs) in Cambodia.MethodsThis national biological and behavioral survey was conducted in 2016 in Phnom Penh and 17 provinces. We used a two-stage cluster sampling method to recruit FEWs for HIV testing performed on-site and face-to-face interviews using a structured questionnaire. We investigated factors associated with HIV infection using multiple logistic regression.ResultsThis study included 3149 FEWs with a mean age of 26.2 years (SD 5.7). The adjusted prevalence of HIV was 3.2% (95% CI 1.76–5.75). In the multiple logistic regression model, the odds of HIV infection were significantly higher among FEWs in the age group of 31 to 35 (AOR 2.72, 95% CI 1.36–8.25) and 36 or older (AOR 3.62, 95% CI 1.89–10.55); FEWs who were not married but living with a sexual partner (AOR 3.00, 95% CI 1.16–7.79); FEWs who had at least ten years of formal education (AOR 0.32, 95% CI 0.17–0.83); FEWs who reported having abnormal vaginal discharge (AOR 3.51, 95% CI 1.12–9.01), genital ulcers or sores (AOR 2.06, 95% CI 1.09–3.17), and genital warts (AOR 2.89, 95% CI 1.44–6.33) in the past three months; and FEWs who reported using illicit drugs (AOR 3.28, 95% CI 1.20–4.27) than their respective reference group. The odds of HIV infection were significantly lower among FEWs working in karaoke bars (AOR 0.26, 95% CI 0.14–0.50) and beer gardens (AOR 0.17, 95% CI 0.09–0.54) than among freelance FEWs.ConclusionsThe prevalence of HIV among FEWs in Cambodia remains much higher than that in the general population. These findings indicate that differentiated strategies to address HIV and other sexually transmitted infections should be geared towards FEWs working as freelancers or in veiled entertainment venues such as massage parlors and freelance sex workers. Prevention efforts among venue-based FEWs should be sustained.

Background Globally, research on the co-infection of the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among people who inject drugs is growing. However, studies in resource-poor countries remain limited. Therefore, we conducted this study to explore factors associated with HIV/HCV co-infection among people who inject drugs in Cambodia. Methods This national survey was conducted in 2017 in the capital city and 11 provinces. We used a ‘peer-based social network recruitment’ method to recruit 286 participants for face-to-face interviews and HIV and HCV testing. A modified Cox proportional hazard model was used to identify risk factors associated with HIV/HCV co-infection. Results The prevalence of HIV and HCV was 15.4% and 30.4%, respectively. Of the total, 9.4% of the participants were HIV/HCV co-infected, and 61.4% of the HIV-infected participants were co-infected with HCV. About half (56.8%) of the participants tested HIV positive were aware of their HIV status; of whom, 83.3% were on antiretroviral therapy. Only 11.5% of the participants with HCV antibody positivity were aware of their HCV infection status; of whom, 50.0% were on HCV treatment. The adjusted prevalence ratio (APR) of HIV/HCV co-infection was significantly higher among women than among men and among participants who lived on the streets than among those living with their family or relatives. The APR of HIV/HCV co-infection was also significantly higher among participants who had received methadone maintenance therapy than those who had not received it. Conclusions The prevalence of HIV/HCV co-infection among people who inject drugs in Cambodia was considerably high. Intervention programs are required to increase access to harm-reduction interventions among most marginalized people who inject drugs to prevent HIV and HCV infection. HCV screening services should be expanded in this key population, given its small population size and the availability of directly-acting antiviral agents in the country.

Background Most of studies on the relationship between drug use and HIV have focused largely on people who inject drugs. Non-injecting drug use is much more common than injecting drug use, and although it can also predispose people to HIV infection, it is not widely explored. We therefore conducted this study to explore the prevalence of HIV and identify risk factors for HIV infection among people who use non-injecting drugs (PWUD) in Cambodia. Methods This cross-sectional study was conducted in 2017. The Respondent Driven Sampling method was used to recruit the study participants who were interviewed face-to-face using a structured questionnaire. Blood samples were collected for HIV and syphilis testing. A multivariable logistic regression analysis was conducted to identify risk factors associated with HIV infection. Results In total, 1367 PWUD were included in this study, whose mean age was 28.0 (SD = 7.7) years. The majority (95.1%) of the participants used methamphetamine. The prevalence of HIV was 5.7, and 35.2% of the identified HIV-positive PWUD were not aware of their status prior to the survey. After adjustment for other covariates, HIV infection remained significantly associated with being in the age group of ≥35 (AOR = 2.34, 95% CI = 1.04–6.11), having lower level of formal education of ≤ 6 years (AOR = 2.26, 95% CI = 1.04–5.15), living on the streets (AOR = 2.82, 95% CI = 1.10–7.23), perception that their HIV risk was higher as compared to that of the general population (AOR = 3.18, 95% CI = 1.27–8.62), having used injecting drugs in lifetime (AOR = 3.8, 95% CI = 1.36–4.56), and having cuts or sores around the genital area in the past 12 months (AOR = 3.42, 95% CI = 1.09–6.33). Conclusions The prevalence of HIV among PWUD in this study was more than 10 times higher than the prevalence in the general adult population. The findings reveal a higher vulnerability to HIV infection among specific sub-populations of PWUD, such as those who are homeless, who may benefit from tailored interventions that respond to their specific needs. To enhance HIV case finding, stratification of PWUD to facilitate HIV risk profiling based on socio-economic profiles and drug injection history is recommended.

BACKGROUND: With rapid expansion of antiretroviral therapy for HIV, there are rising life expectancies among people living with HIV. As a result, co-morbidity from non-communicable diseases in those living and aging with HIV is increasingly being reported. Published data on this issue have been limited in Cambodia. The aim of this study was to determine the prevalence of diabetes mellitus, hypertension and hypercholesterolemia and associated risk factors in adults living with HIV in Cambodia. METHODS: This cross-sectional study was conducted in five provinces of Cambodia from May-June 2015. Information was obtained on socio-demographic and clinical characteristics through face-to-face interviews using a structured questionnaire, and anthropometric and biochemical measurements were performed. Diabetes mellitus was diagnosed with fasting blood glucose ≥126 mg/dl, hypertension with systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and hypercholesterolemia with fasting blood cholesterol ≥190 mg/dl. Multivariable logistic regression analyses were used to explore risk factors. RESULTS: The study sample included 510 adults living with HIV; 67% were female, with a mean age of 45 (standard deviation = 8) years. Of these, 8.8% had diabetes mellitus, 15.1% had hypertension and 34.7% had hypercholesterolemia. Of the total participants with non-communicable diseases (n = 244), 47.8% had one or more diseases, and 75% were not aware of their diseases prior to the study: new disease was diagnosed in 90% of diabetes mellitus, 44% of hypertension and 90% of hypercholesterolemia. Single disease occurred in 81%, dual disease in 17% and triple disease in 2%. In adjusted analyses, those consuming 1 serving of fruit compare to 2 servings as significantly with diabetes mellitus, those eating 1 serving of fruit compare to 2 servings and using lard for cooking were significantly associated with hypertension, and those being unemployed, having monthly income less than 100 USD and being underweighted were significantly associated with hypercholesterolemia. CONCLUSIONS: The prevalence of diabetes mellitus, hypertension and hypercholesterolemia in adults living with HIV in this study was considerably high, with most of these diseases newly identified through active screening in the survey. These findings strongly suggest that screening of non-communicable diseases should be integrated into routine HIV care in Cambodia.

Background Transgender people are disproportionately affected by HIV. Despite their high vulnerability to HIV, lack of adequate epidemiological and surveillance data related to this population in many countries prevents provision of appropriate services. This paper summarizes descriptive findings from a national integrated biological and behavioral survey and discusses policy implications of the findings on HIV prevention among transgender women in Cambodia. Methods This cross-sectional study was conducted between December 2015 and February 2016. Participants were recruited from 20 sites in the capital city and 12 provinces of Cambodia using Respondent Driven Sampling (RDS) method. Behavioral data were collected through structured questionnaire interviews, and rapid finger-prick HIV testing was performed. Descriptive data analyses were conducted using STATA. Results This study included 1,375 transgender women with a mean age of 25.9 years (SD = 7.1). The overall prevalence of HIV was 5.9%. The prevalence of HIV was significantly higher among urban participants compared to their rural counterparts (6.5 vs. 2.6%, p = 0.02). Almost one in five (19.6%) had never been tested for HIV prior to the study. Overall, 45.0% reported ever using gender affirming hormones. More than one-third (39.1%) reported not using condoms in their last sex, 29.8% had engaged in sex in exchange for money/gifts, and 14.0% reported that they had experienced at least one symptom of sexually transmitted infections (STI) in the past year. About one in ten (10.1%) reported having used some form of amphetamine-type stimulant drugs, while 6.5% reported having sex during or after using illicit drugs. A significant number of participants experienced sexual abuse (39.2%), losing a job (24.3%), or physical abuse (23.6%) because of their transgender identity. In addition, 82.9 and 88.9% would be willing to use the HIV self-test and pre-exposure prophylaxis (PrEP), respectively, if they become available. Conclusions The high prevalence of HIV, STI, and related risk behaviors among transgender women in Cambodia is of great concern, suggesting an urgent need to further expand tailored prevention interventions for this key population focusing on individual, social, and structural drivers of HIV. HIV self-test and PrEP should be explored as a priority.

The study investigated whether clients of sex workers are a bridge for transmission of HIV to the general population of Cambodia. We interviewed and collected blood from 468 clients attending 30 randomly selected brothels in three provinces of Cambodia. The levels of HIV knowledge and condom use, and prevalence of HIV (9.2%) were high. Almost 40% of those interviewed had sex with women other than sex workers (wives, girlfriends, etc.), but rarely used condoms. Sexually transmitted disease (STD) rates were high, but most sought treatment from pharmacies. HIV infection was correlated with a history of STD, having had an HIV test, not living with one's wife, a high level of HIV/AIDS knowledge, and condom slippage/breakage. Clients are a major bridge for HIV transmission from sex workers. Current condom promotion programmes need to target non-sex worker intercourse. More effective, acceptable STD-control strategies need to be implemented and evaluated.

ObjectiveTo examine factors associated with HIV infection among transgender women in Cambodia.DesignCross-sectional study.SettingsHIV high-burden sites including the capital city and 12 provinces.ParticipantsThis study included 1375 sexually active transgender women with a mean age of 25.9 years (SD 7.1), recruited by using respondent-driven sampling for structured questionnaire interviews and rapid finger-prick HIV testing.Primary outcome measureHIV infection detected by using Determine antibody test.ResultsHIV prevalence among this population was 5.9%. After adjustment for other covariates, participants living in urban areas were twice as likely to be HIV infected as those living in rural areas. Participants with primary education were 1.7 times as likely to be infected compared with those with high school education. HIV infection increased with age; compared with those aged 18–24 years, the odds of being HIV infected were twice as high among transgender women aged 25–34 years and 2.8 times higher among those aged ≥35 years. Self-injection of gender affirming hormones was associated with a fourfold increase in the odds of HIV infection. A history of genital sores over the previous 12 months increased the odds of HIV infection by threefold. Transgender women with stronger feminine identity, dressing as a woman all the time, were twice as likely to be HIV infected compared with those who did not dress as a woman all the time. Having never used online services developed for transgender women in the past six months was also associated with higher odds of being HIV infected.ConclusionsTransgender women in Cambodia are at high risk of HIV. To achieve the goal of eliminating HIV in Cambodia, effective combination prevention strategies addressing the above risk factors among transgender women should be strengthened.