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Studies in drug use settings rarely use sex under the influence of drugs as an indicator of sexual risk behaviors. This study explored the prevalence of sex under the influence of drugs and its correlates among people who use drugs (PWUD) in Cambodia. We included 1147 PWUD from 12 provinces in this study. A multiple logistic regression analysis was conducted to identify factors associated with sex under the influence of drugs. Of the total, 39.7% reported having had sex under the influence of drugs in the past three months. After adjustment, sex under the influence of drugs was significantly associated with living in urban areas (AOR 2.97, 95% CI 1.68–5.27), having two to three (AOR 2.48, 95% CI 1.76–3.49) and four or more sexual partners (AOR 6.46, 95% CI 4.24–9.85), engaging in transactional sex (AOR 1.69, 95% CI 1.19–2.39), using methamphetamine (AOR 2.97, 95% CI 2.06–4.31), using drugs for three years or longer (AOR 1.67, 95% CI 1.15–2.41), having been to a drug rehabilitation center (AOR 1.77, 95% CI 1.18–2.41), having a network of ten or more PWUD (AOR 1.82, 95% CI 1.25–2.66), and having high psychological distress (AOR 1.66, 95% CI 1.25–2.22). This study documents the high prevalence of sex under the influence of drugs and its risk factors among male and female PWUD in Cambodia. These findings point to the need for integrating HIV and harm-reduction programs using innovative approaches to address the overlapping risks in this key population.

Approximately 34% of people with tuberculosis (TB) were undiagnosed in Cambodia in 2017. This study explored barriers in access to TB services and information gaps by genders and key populations in the Cambodian national TB programme. In 2017, we conducted a consensus and validation workshop, desk reviews, 19 in-depth interviews, and 30 focus group discussions with representatives of stakeholder groups, affected populations, and communities. Content analyses were performed for qualitative interviews. We employed the consensus development methods during the workshop to define and prioritise key populations. Key themes that inhibited access to TB services included the lack of knowledge, awareness, time and financial means, and gender-specific vulnerabilities. Systemic barriers included inconsistencies in policy and guideline implementation and lack of resources required for effective TB management. We did not find indications of coercive practices against women and key populations. However, stigma and discrimination did exist in healthcare institutions, the workplace, and the community. There were significant gaps in gender and key population-specific data and reporting systems at all levels. Data availability is vital for understanding gender and key population-specific gaps, and they should be duly utilised. Mechanisms to ensure equality and inclusivity are necessary to end TB in Cambodia.

BackgroundStudents go through a transition when they enter university, which involves major individual and contextual changes in every domain of life that may lead to several behavioral and health problems. This paper describes a wide range of health behaviors among male and female university students in Cambodia.MethodsA cross-sectional survey was conducted in 2015 among students randomly selected from the Royal University of Phnom Penh and University of Battambang. Health-related behaviors in different domains were collected using a structured questionnaire. Chi-square test, Fisher’s exact test, or independent Student’s t-test was used as appropriate to describe and compare the variables among male and female students.ResultsThis study included 1359 students, of whom 50.8% were male, and the mean age was 21.3 years (SD= 2.3). Of the total, 79.5% reported not having any vigorous-intensity activities, 25.9% not having moderate-intensity activities, and 33.5% not having walked continuously for 10 minutes during the past seven days. The prevalence of substance use was low with 38.3% currently drinking alcohol, 1.1% smoking tobacco, and 0.4% using an illicit drug during the past 12 months. About one in ten (10.6%) reported having sexual intercourse, with a mean number of partners of 2.1 (SD= 2.4) during the past 12 months, and 42.4% not using a condom in the last intercourse. Only 7.1% reported having been diagnosed with a sexually transmitted infection in the past 12 months; of whom, 60% sought for treatment. About one-third (33.6%) reported eating fast food once or twice, and 5.3% having it three times or more over the last week. More than half (55.6%) had one to two servings of fruits and vegetables daily, and 9.9% did not eat any fruits and vegetables over the last week.ConclusionsWe found that the prevalence of sexual risk behaviors and substance use was plausibly low among university students in this study. However, the rates of inactive lifestyle and unhealthy food consumption were concerning. Public policy and universities should promote healthy behaviors among the students. The interventions may take advantage of and expend upon the good health behaviors and consider gender differences.

Beyond the monopoly environment of the early 100% Condom Use Program in Cambodia, less is known about how current female entertainment workers negotiate condom use on their own, and what factors impact that negotiation. This study aims to understand the experiences of current female entertainment workers in negotiating condom use with clients in Cambodia. Data collection occurred over a period of 3 weeks (August–September 2017) with concurrent data transcription and translation. A total of 27 focus group discussions (FGDs) were conducted in the following groups: pilot FGD (5), karaoke bar (5), massage parlor (5), beer garden (5), on-call sex workers (3), cross-venue groups exploring parenting issues (2), and street-based sex workers (2). Female entertainment workers experience a range of control over negotiating condom use with clients. Participants reported times when they were able to take direct action and successfully insist on condom use, times when they agreed to participate in condomless sex for money in the face of economic insecurity, and times when male clients sabotaged their attempts to negotiate condom use with tricks, verbal threats or threats of violence. These experiences are influenced by alcohol use, economic shocks, trust between partners, and experiences with side effects. Our findings support the development of policies that re-invigorate the structural-level condom promotion programs while also acknowledging the many individual-level factors that shape condom use such as alcohol consumption, economic insecurity, trust, and side effects.

Background Female entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance abuse, and gender-based violence (GBV) than the general female population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status. Objective This study evaluated the efficacy of the Mobile Link intervention in improving FEWs’ health by engaging and connecting them to existing HIV, sexual and reproductive health, and GBV services. Methods A randomized controlled trial was conducted between March 2018 and June 2019 in the capital city and 3 other provinces in Cambodia. FEWs in the intervention arm received automated twice-weekly Short Message Service messages and voice messages with health information and direct links to outreach workers. The control group received the existing standard care, including free HIV and STI counseling and testing and a toll-free helpline staffed by trained counselors. We used a stratified random sampling method to select participants from 5 study sites in the 4 selected provinces. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group (18-24 and 25-30 years) and study site using a random number generator and enrolled them in person. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use assessed through a face-to-face structured interview. We also measured secondary outcomes, including contact with outreach workers, escorted referral service use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression. Results A total of 1118 participants were recruited and enrolled in the study. We included 218 FEWs in the intervention arm and 170 FEWs in the control arm in the per protocol analyses after removing 730 dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (at 30 weeks: adjusted odds ratio [AOR] 3.29, 95% CI 1.28-8.47), receiving an escorted referral (at 30 weeks: AOR 2.86, 95% CI 1.09-7.52; at 60 weeks: AOR 8.15, 95% CI 1.65-40.25), and never being forced to drink at work (at 60 weeks: AOR 3.95, 95% CI 1.62-9.60). Over time, no significant differences between intervention and control groups were observed for any primary outcomes in the fully adjusted models. Conclusions The Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals but did not show an effect on primary outcomes. Reduced forced drinking at work was also significantly more extensive in the intervention group than in the control group. Longer-term messaging may increase access to services and impact FEWs’ health outcomes in the future. Trial Registration Clinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842 International Registered Report Identifier (IRRID) RR2-10.1186/s13063-018-2614-7

Background Understanding the extent of viral hepatitis burden in specific subgroups, such as pregnant women and people living with HIV/AIDS (PLWHA), and their geographic distribution is essential for evidence-informed policy and mobilizing resources for targeted treatment and prevention efforts. However, in Cambodia, the epidemiology of hepatitis C remains uncertain. We estimated the hepatitis C virus (HCV) burden and transmission risk factors among PLWHA and pregnant women attending antenatal care (ANC) in Cambodia. Methods Between March and April 2016, we conducted a cross-sectional survey in four diverse geographical areas: the capital city of Phnom Penh and three provinces. We collected information on demographic characteristics and risk behaviors and performed HCV antibody (Anti-HCV) testing among pregnant women attending public ANC clinics and among those receiving HIV care at the hospitals. We computed the prevalence of HCV among the two population subsets and performed logistic regression analyses to identify risk factors associated with HCV antibody positivity. Results Of 935 participants enrolled, 510 (54.6%) were pregnant women and 425 (45.4%) were PLWHA. Anti-HCV prevalence was significantly higher in PLWHA than in pregnant women (29/425, 6.8% vs 5/510, 0.9%, P P = 0.031). There was no significant geographic difference in anti-HCV prevalence among pregnant women. In multivariable analyses (data subset to PLWHA), HCV infection was significantly associated with having a family member positive for HCV (OR = 7.6 [95% CI: 1.01–57.84], P = 0.048) and a history of intravenous medication injection in the last 5 years (OR = 7.1 [95% CI: 2.79–18.10], P Conclusions HCV infection is relatively common among Cambodian PLWHA, likely related to intravenous medication injection and intra-familial viral transmission. Systematic HCV testing and care among PLWHA (and possibly their family members) might be necessary. Setting up a surveillance system for HCV might also be beneficial for some geographical regions and populations.

The association between oral and overall health, and particularly between dental and immune health, in children living with HIV remains unclear. This study examined the association between the decayed, missing and filled teeth (DMFT) score and CD4+ cell counts in 142 children living with HIV aged 8–15 years (male, 51%) from Phnom Penh, Cambodia. Other indicators of oral health (e.g., debris index, salivary flow, salivary pH and oral health-related quality of life) and overall health (e.g., nutritional status and quality of life) were also evaluated. DMFT scores were negatively associated with the CD4+ cell count in male children (β: −0.13, 95% confidence interval [CI]: −0.25, −0.02). In all children, positive associations were observed between salivary pH and CD4+ count (β: −0.645, 95% CI: 0.02, 1.25) and between salivary flow and height-for-age Z-score (β: 1.22, 95% CI: 0.50, 1.95). The debris index was negatively associated with the height-for-age Z-score (β: −2.04, 95% CI: −3.38, −0.71). In summary, oral health was associated with immune and nutritional status. Oral health policies for children living with HIV should be emphasised, and further studies should evaluate the mechanism underlying the relationship between oral and overall health.

Background Globally, the prevalence of HIV among transgender women is more than 40 times higher than the prevalence in the general reproductive-age adults. They also face intersecting barriers to health, social, and legal services due to their hidden and stigmatized nature. Despite the particular needs, data regarding the access to services among transgender populations is scant globally. This study aims to identify characteristics of transgender women in Cambodia that may determine their accessibility to community-based HIV services. Methods In the National Biological and Behavioral Survey 2016, a structured questionnaire was used for face-to-face interviews with 1375 sexually active transgender women recruited from the capital city and 12 other provinces using the Respondent-Driven Sampling method. Weighted multivariate regression analysis was conducted to explore factors associated with access to community-based HIV services. Results The mean age of the participants was 25.8 years (SD = 7.1), and 45.0% reported having received at least one community-based HIV service in the past three months. Compared to participants who reported not having been reached by any community-based HIV programs, participants who reported having been reached by the programs were significantly more likely to reside in an urban setting (AOR = 1.41, 95% CI = 1.01–1.96), to have used gender-affirming hormones (AOR = 1.50, 95% CI = 1.17–1.92), to have been tested for HIV in the past six months (AOR = 7.42, 95% CI = 5.78–9.53), and to have been arrested by police or other authorities because of their transgender identity (AOR = 1.55, 95% CI = 1.03–2.33). Participants who reported having been reached by community-based HIV programs were significantly less likely to report being in a receptive role (AOR = 0.34, 95% CI = 0.15–0.82), to use condoms consistently with non-commercial male partners (AOR = 0.72, 95% CI = 0.55–0.94), and to perceive that their co-workers were not supportive regarding their transgender identity (AOR = 0.57, 95% CI = 0.44–0.98). Conclusions Despite the extensive expansion of community-based HIV programs, less than half of transgender women in this national survey had access to the services. Innovative strategies and culturally sensitive interventions should be put in place to reach and respond to the needs of sub-groups of transgender women who are less likely to be reached by the existing traditional approaches.

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.

Background Intravaginal practices (IVPs), methods used by women most often to manage vaginal hygiene and address perceived disruptions to vaginal health, may increase the risk of contracting human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This qualitative study explores the social, professional, and peer context surrounding IVPs, the experiences of self-cleaning or getting cleaned from a health professional, and the perceived impacts of IVPs among female entertainment workers (FEWs) in Cambodia. Methods In 2017, we conducted 27 focus group discussions from four provinces, and 16 follow-up semi-structured in-depth interviews with purposively selected participants in two provinces. Data collection occurred over three weeks, with concurrent data transcription and translation. The data from the transcripts were analyzed using Dedoose, an online, open-access qualitative analysis software. Two researchers independently labeled sections of transcripts associated with broader categories and subcategories based on the initial content analysis matrix and created codes. This process continued iteratively until a final coding schema and conceptual model was created. Results We found that IVPs are widely practiced among FEWs in Cambodia and are associated with internalized and enacted stigma. Stigma was an overarching theme that impacted the sub-themes of (1) messages about cleaning, (2) the cleaning process, and (3) the impact of cleaning. Experiences of enacted stigma and internalized stigma permeated conversations about IVP, including feeling pressured by peers to keep themselves clean, practicing internal cleaning after transactional sex, and being called dirty by health providers. Conclusions FEWs who practice IVP talk about it in the context of their lived experiences stigma and discrimination. Highly stigmatized practices such as IVP among FEWs may benefit from a harm reduction approach that emphasizes positive changes without judgment, coercion, or discrimination.

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.

HIV self-testing (HIVST) is recommended by the World Health Organization, but implementation remains limited. This cross-sectional study evaluated HIVST uptake among female entertainment workers (EWs), men who have sex with men (MSM), and transgender women in Phnom Penh, Cambodia, to inform national implementation.Between December 2018 and September 2019, individuals reached through community outreach or via online advertising were offered HIVST or referrals to facility-based testing. Participants opting for HIVST could choose between test kits employing oral-fluid or finger-prick-based sample collection; and between an "assisted" option in which outreach staff offered instructions and assistance and an "unassisted" option in which participants received a kit with instructions for use. A structured questionnaire was administered to facilitate descriptive statistics and tests for associations between participant characteristics and HIV testing preferences and outcomes.Among 1,241 eligible individuals; 1,210 (97.5%) provided responses for analysis. Of these, 1,203 (99.4%) were recruited through outreach; 7 (0.6%) through online advertising. Among those recruited by outreach, 1,186 (98.6%) opted for assisted HIVST, and 1,065 (88.5%) opted for oral-fluid versus finger-prick testing. All individuals recruited through online advertisements opted for unassisted oral-fluid testing. Among all participants, 455 (37.6%) were MSM, 325 (26.9%) were transgender women, 430 (35.5%) were female EWs, and overall, 71.7% reported never previously testing for HIV. A total of 84 participants (6.9%) received reactive screening results and 81 (97.5%) were linked to treatment.Uptake of HIVST was high, and most participants preferred oral-fluid over finger-prick-based testing. Many individuals (72%) who had never previously accessed HIV testing services participated in HIVST, with high rates of reactivity.

Women working in the entertainment industry are confronted with various forms of gender-based violence (GBV). However, their vulnerability remains understudied, particularly in resource-limited settings. This study aims to examine the prevalence of GBV among female entertainment workers (FEWs) in Cambodia and identify factors associated with victimization. We conducted a cross-sectional study in November 2018 for the impact evaluation of a randomized controlled trial. We used a stratified random sampling method to recruit 600 FEWs from different entertainment venues in the capital city and three other provinces. Female data collectors administered a structured questionnaire, and we performed multiple logistic regression analyses. Of the total, 60.5% had experienced a form of GBV during their lifetime; of whom, 37.5% experienced the GBV in the past 6 months. The prevalence of emotional abuse, forced substance use, physical abuse, and forced sex was 51.5%, 25.0%, 20.6%, and 2.9%, respectively. Forced substance use and forced sex were mainly perpetrated by clients, physical abuse by intimate partners, and emotional abuse by others such as entertainment establishment owners or managers. FEWs victimized by clients (relative risk ratio [RRR] = 0.19, 95% confidence interval [CI] = [0.07, 0.53]) and others (RRR = 0.11, 95% CI = [0.03, 0.44]) were less likely to be married compared with victims of intimate partner violence. Factors associated with sexual harassment were working in beer gardens (adjusted odds ratio [aOR] = 2.39, 95% CI = [1.20, 4.73]) and restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]), and having higher acceptance of violence against women (aOR = 1.12, 95% CI = [1.01, 1.24]). FEWs in Cambodia experience high levels and unique forms of GBV as they are confronted with different types of perpetrators. Interventions need to be tailored to fit the specific needs of FEWs. Interventions aimed at reducing client-perpetrated violence should specifically focus on forced substance use and forced sex, while physical abuse by intimate partners should also be addressed.

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.

Background Cambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia. Methods This mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed. Results The median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21–112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06–1.48); TB symptoms—cough (aHR: 1.52; 95% CI: 1.18–1.94), hemoptysis (aHR 1.32; 95% CI: 1.07–1.63), and night sweats (aHR: 1.24; 95% CI: 1.05–1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04–1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01–1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62–0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1–3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16–1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings. Conclusions TB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.

ObjectiveTo examine the relationship between gender-based violence, HIV risks, psychological distress and binge drinking among female entertainment workers (FEWs) in Cambodia.DesignCross-sectional study.SettingPhnom Penh and three other provinces in Cambodia.ParticipantsWe recruited 600 FEWs from entertainment venues using a stratified random sampling method. Participants were eligible if they were at least 18 years old, working in the selected entertainment venues and self-identified as a FEW.Primary outcome measureBinge drinking was defined as drinking more than five units of alcoholic drinks in 24 hours on at least one occasion in the past 3 months.ResultsThe prevalence of binge drinking was 76.7%. Adjusted odds of binge drinking were significantly higher among FEWs who earned >US$250 per month than those who earned ≤US$120 per month (adjusted OR (AOR) 2.96, 95% CI: 1.40 to 6.24), had been forced to drink more than once per month in the past 3 months than those who had never been forced to drink (AOR 5.66, 95% CI: 2.19 to 14.65), worked at karaoke bars than those working at a restaurants/café (AOR 1.85, 95% CI: 1.19 to 2.88) and experienced emotional abuse in the past 6 months than those who did not experience it (AOR 2.71, 95% CI: 1.22 to 6.02). The odds of binge drinking were significantly higher among FEWs with lower psychological distress than those with higher psychological distress (AOR 1.65, 95% CI: 1.09 to 2.49).ConclusionsThis study highlights a high prevalence of binge drinking among FEWs and its associations with working environments, conditions and contexts. Our findings suggest that individual-based behavioural intervention may not effectively reduce binge drinking among FEWs. Structural and occupational health policy interventions may be needed to change the working environment.

Background Currently, the number of children living with HIV is the highest ever. This has led to an increased focus on a healthy life expectancy in this population. Improving oral health status may contribute to improved immunity, which could in turn lead to greater overall health in this population. This study aims to evaluate the effectiveness of an oral health intervention in improving oral health and immune status among children living with HIV in Cambodia. Methods A randomized controlled trial will be conducted in Phnom Penh from May 2018 to April 2020. Among 520 dyads of children living with their respective caregivers, half will be randomly allocated to the intervention group and the other half to the control group. Children aged 3–15 years who are currently receiving antiretroviral therapy at the National Pediatric Hospital will be recruited. In addition, 260 HIV-uninfected children (age-matched to the intervention group) will be recruited from the communities. They, together with their caregivers, will comprise the second control group. The main components of the intervention will include oral health education sessions for the children, as well as daily oral self-care under the supervision of their caregivers. The primary study outcome will be the change in oral health status including the number of decayed, missing, or filled permanent teeth, and the secondary outcome will be CD4 count. The effects of the intervention will be assessed by comparing outcome indicators between the children in the intervention and those in the control groups. Discussion This trial will investigate the effects of an oral health intervention on the improvement of oral health and immune status among children living with HIV and determine the differences compared with the control groups. This intervention would encourage the promotion of oral health interventions among children living with HIV and thus contribute to delaying the onset of AIDS. Trial registration Current Controlled Trials, International Standard Randomized Controlled Trial Number Register, ISRCTN15177479. Registered on 17 January 2018. Electronic supplementary material The online version of this article (10.1186/s13063-018-3047-z) contains supplementary material, which is available to authorized users.

Background Traditional, complementary and alternative medicine (TCAM) is seen as a way to provide healthcare in both developed and developing countries across the world. In Cambodia, there is a long tradition of using TCAM. However, scant studies have been conducted on the extent of Cambodian TCAM use and how it interacts with allopathic health care to date. In this study, we examined the prevalence of and factors associated with utilization of herbal medicines among patients with chronic diseases in primary health care settings in Cambodia. Methods A cross-sectional survey was conducted in 2015 with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers purposively selected from Phnom Penh, Kampong Cham and Siem Reap. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. I-CAM-Q was used to measure TCAM use. A multivariate logistic regression model was constructed to identify factors associated with herbal medicine use. Results In total, 1602 patients were included in this study, of whom 77.7% were female, and 51.2% were recruited from urban primary health centers with a mean age of 46.5 years (SD = 15.2). Of total, 27.0% reported at least one consultation with a TCAM provider in the past 12 months. The most common modality of TCAM used was herbal medicine (89%). Herbs were obtained at drug or folk stores (36.9%), from herbalists directly (28.5%) or from their own gardens (18.6%). Of herb users, 55.2% reported that herbs were somewhat helpful. After adjustment, herb users were significantly more likely to be female (AOR = 1.42, 95% CI = 1.12–2.67), have completed less schooling (AOR = 0.66, 95% CI = 0.45–0.96), were unemployed or homemakers (AOR = 0.23, 95% CI = 0.13–0.52) and have a gastrointestinal illness (AOR = 0.49, 95% CI = 0.39–0.62). Conclusions Herbal medicines are broadly used among chronic disease patients in Cambodia. Understanding TCAM use in the general population will support health care practitioners and policy makers to make informed decisions about the use of TCAM. Integration of TCAM into the primary health system should be further explored.

Background Understanding the circumstances of adolescents living with HIV is critical in designing adolescent-friendly services that will facilitate successful transition from pediatric to adult care. This study describes access, utilization and ongoing social support needs among adolescents living with HIV aged 15–17 in transition from pediatric to adult HIV care in Cambodia. Methods A cross-sectional study was conducted among 328 adolescents, randomly selected from 11 antiretroviral therapy (ART) clinics across the country. Descriptive analyses were conducted to summarize their characteristics, access to social support and ongoing support needs among male and female adolescents. Results Mean age of the study participants was 15.8 (SD = 0.8) years. Just over half (55.2%) were male. Most had at least one deceased parent (mother 50.9%; father 60.5%), and majority were living with biological parents (40.8%) or relatives (49.3%). A third came from families with an ID poor card, and 21.0% were working for pay. Almost half (46.6%) reported that their family had received social support for their health care, including food support (76.5%), school allowance (62.1%), transport allowance to ART clinics (53.6%), psychosocial counseling (35.3%), vocational training (22.9%) or home visits (11.1%). Several ongoing social support needs were identified, including ongoing inability to cover health expenses unless they are supported by health insurance or health equity fund (55.0%). In addition, adolescents reported having been asked to come back earlier than their scheduled appointment (13.7%), having had to purchase their own drugs (2.7%), experiencing HIV stigma (32.0%), having been denied housing or food due to HIV (8.2%) or failing to attend school within the past month partly because of HIV (16.8%). Two-thirds did not have access to peer support groups. Conclusions Social protection mechanisms are reaching some adolescents in need, while other remain without social support due to discontinuities in health and social care. Multi-sectoral interventions, supporting school attendance, adolescent-friendly clinic scheduling, reductions in child employment, mitigation of HIV-related stigma and strengthening of peer-to-peer support are required to improve coverage of social protection interventions for adolescents in transition.

Background Early HIV diagnosis and initiation onto antiretroviral therapy may prevent ongoing spread of HIV. Risk Tracing Snowball Approach (RTSA) has been shown to be effective in detecting new HIV cases in other settings. The main objective of this study is to evaluate the effectiveness of RTSA in increasing the rate of newly identified HIV cases among high-risk populations. Our second objective was to evaluate the effectiveness of RTSA, as compared to the walk-in group, in increasing the number of HIV tests and early case detection. Methods This study was conducted from April 1 to September 30, 2016 at two NGO clinics in Phnom Penh, Cambodia. Respondent driven sampling method was adapted to develop RTSA to reach high-risk populations, including key populations and the general population who have social connections with key populations. Bivariate and multivariate logistic regression analyses were conducted. Results During the implementation period, 721 clients walked in for HIV testing (walk-in group), and all were invited to be seeds. Of the invited clients, 36.6% agreed to serve as seeds. Throughout the implementation, 6195 coupons were distributed to seeds or recruiters, and resulted in 1572 clients visiting the two clinics with coupons (RTSA group), for a coupon return rate of 25.3%. The rate of newly identified HIV cases among the RTSA group was significantly lower compared to that in walk-in group. However, the highest number of newly identified HIV cases was found during the implementation period, compared to both pre- and post-implementation period. Although statistically not significant, the mean CD4 count of newly identified HIV cases detected through RTSA was almost 200 cells/mm3 higher than that in the walk-in group. Conclusions Although the rate of newly identified HIV cases among the RTSA group was lower than that in the walk-in group, the inclusion of RTSA in addition to the traditional walk-in method boosted new HIV case detection in the two participating clinics. A higher mean CD4 count for the RTSA group may reveal that RTSA may be able to detect HIV cases earlier than the traditional walk-in approach. Further research is needed to understand whether RTSA is a cost-effective intervention to prevent ongoing spread of the HIV among high-risk populations in Cambodia.

Background Preparing adolescents for transition into adult care and supporting their acquisition of self-health care management skills is a critical determinant of their post-transition HIV care outcomes. However, there is a scarcity of research on effective transition strategies. This study explores factors associated with adolescent preparedness for transition into adult care in Cambodia. Methods In August 2016, a cross-sectional study was conducted among 223 adolescents living with HIV aged 15–17, randomly selected from 11 antiretroviral therapy clinics, utilizing a structured questionnaire. The level of preparedness was determined using a pre-existing scale, and adolescents were categorized as having a high- or low level of preparedness for transition. Bivariate and multivariate analyses were conducted. Results Of 223 adolescents, 55.2% were male, and their mean age was 15.8 years. Overall, 53.3% had a high level of preparedness for transition. As part of the transition protocol, 2.7% had completed a transfer form, 24.7% had a transition case manager, 29.6% had been counselled about the transition, and 19.7% had visited an adult ART clinic. In multivariate analysis, a higher level of preparedness for transition was independently associated with older age (AOR 2.44, 95% CI 1.34–4.46; p = 0.004), family having received social support for their health (AOR 5.32, 95% CI 1.97–14.36; p = 0.001), knowing the kind of treatment they received (ART) (AOR 12.67, 95% CI 2.91–15.19; p = 0.001), trust in friends or family for HIV treatment (AOR 7.82, 95% CI 1.13–8.89; p = 0.008), receiving counseling on transition (AOR 3.17, 95% CI 1.15–8.76; p = 0.03), having a ‘Case Manager’ identified to support them during the preparation process for transition (AOR 3.89, 95% CI 1.08–13.96; p = 0.04), and satisfaction with preparation process for transition in general (AOR 0.35, 95% CI 0.03–0.87; p = 0.01). Conclusions A range of individual, social and health system and services factors may determine successful transition preparedness among adolescents in Cambodia. Strengthening implementation of age-appropriate and individualized case management transition at all sites, while creating supportive family, peer, and healthcare environments for adolescent transition is required.

Background HIV/AIDS continues to be a major public health concern for children. Each day, worldwide, approximately 440 children became newly infected with HIV, and 270 children died from AIDS-related causes in 2018. Poor nutrition has been associated with accelerated disease progression, and sufficient dietary diversity is considered a key to improve children’s nutritional status. Therefore, this study aims to 1) examine nutritional status of school-age children living with HIV in Phnom Penh, Cambodia, and 2) identify factors associated with their nutritional status, especially taking their dietary diversity into consideration. Methods This cross-sectional study was conducted in May 2018 within the catchment area of the National Pediatric Hospital, Cambodia. Data from 298 children and their caregivers were included in the analyses. Using semi-structured questionnaires, face-to-face interviews were conducted to collect data regarding sociodemographic characteristics, quality of life, and dietary diversity. To assess children’s nutritional status, body weight and height were measured. Viral load and duration of antiretroviral therapy (ART) were collected from clinical records. Multiple logistic regression analyses were performed to identify factors associated with stunting and wasting. Results Of 298 children, nearly half (46.6%) were stunted, and 13.1% were wasted. The mean number of food groups consumed by the children in the past 24 h was 4.6 out of 7 groups. Factors associated with children’s stunting were age (adjusted odds ratio [AOR] 2.166, 95% confidence interval [CI]: 1.151, 4.077), household wealth (AOR 0.543, 95%CI: 0.299, 0.986), duration of receiving ART (AOR 0.510, 95%CI: 0.267, 0.974), and having disease symptoms during the past 1 year (AOR 1.871, 95%CI: 1.005, 3.480). The only factor associated with wasting was being male (AOR 5.304, 95%CI: 2.210, 12.728). Conclusions Prevalence of stunting was more than double that of non-infected school-age children living in urban areas in Cambodia. This highlights the importance of conducting nutritional intervention programs, especially tailored for children living with HIV in the country. Although dietary diversity was not significantly associated with children’s nutritional status in this study, the findings will contribute to implementing future nutritional interventions more efficiently by indicating children who are most in need of such interventions in Cambodia.

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: Compared to the general population, drug users are at increased risk of both poor mental health and HIV infection. The aim of this study was to determine the prevalence and correlates of high psychological distress among drug users in Cambodia. Methods: In April 2014, a two-stage cluster sampling method was used to randomly select 169 drug users from hotspots in Phnom Penh. Psychological distress was measured using General Health Questionnaire (GHQ-12). Bivariate and multivariable analyses were conducted to identify factors associated with levels of psychological distress among this population.Results: Our study found high prevalence of attempted suicide (15.3%), drug related arrests (46.2%), and incarceration (31.4%). Of the 169 participants, 42.0% were found to have high levels of psychological distress, indicating poor mental health. After adjustment, high levels of psychological distress were independently associated with suicidal ideation (p< 0.001), higher frequency of drug use (p= 0.02), sharing of needles or syringes (p= 0.005), and having been sent to a rehabilitation centre (p= 0.02). In addition, participants who perceived their overall health as being poor or very poor were more likely to have high levels of psychological distress (p= 0.002).Conclusions: Integration of mental health within HIV and needle and syringe exchange programmes is required to address psychological distress among drug users in Cambodia. Health system interventions, such as screening, referral, and training of health providers, need to be strengthened. In addition, interventions addressing social determinants of mental health and mitigation of frequent arrests and improving conditions in rehabilitation centres are required.

BackgroundEntertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this report is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.MethodsData used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.ResultsMost participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used condom with partner at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).ConclusionsThis information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety, and respectful employment.

Background Transgender women experience disproportionate social stigma that may lead to behavioral risks and poor psychological wellbeing. This study examines social and behavioral factors associated with binge drinking among transgender women in Cambodia. Methods A cross-sectional survey was conducted in 2016 among 1039 transgender women recruited from 13 provinces using the Respondent Driven Sampling method. A structured questionnaire was used for face-to-face interviews. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with binge drinking. Results The prevalence of binge drinking was 43.3 %. After adjustment, the odds of binge drinking were significantly higher among participants in the age group of 25–34 compared to those in the age group of 18–24 and lower among participants in job categories such as hairdresser or beautician, office workers, and self-employed compared to those who were unemployed. The odds of binge drinking were significantly higher in participants who dropped out of school and thought it was because of their transgender identity, had transactional sex in the past three months, used amphetamine-type stimulants in the past three months, and reported experience of verbal abuse by family members during childhood. Regarding mental health, the odds of binge drinking were significantly lower among participants who had depressive symptoms over the past week. Conclusions These findings highlight the intersections between social marginalization, gender-based violence, HIV risks, and alcohol abuse. We recommend further exploration of the structural factors that may be modifiable through workplace policies or occupational health interventions among transgender women.

Background With support of the national tuberculosis (TB) program, KHANA (a local non-governmental organization in Cambodia) has implemented an innovative approach using a seed-and-recruit model to actively find TB cases in the community. The model engaged community members including TB survivors as seed and newly diagnosed people with TB as recruiters to recruit presumptive TB cases in their social network in a snowball approach for screening and linkage to treatment. This study aimed to explore the acceptability of the active case finding with the seed-and-recruit model in detecting new TB cases and determine the characteristics of successful seeds. Methods This qualitative study was conducted in four provinces (Banteay Meanchey, Kampong Chhnang, Siem Reap, and Takeo) in Cambodia in 2017. Fifty-six in-depth interviews and ten focus group discussions (with a total of 64 participants) were conducted with selected beneficiaries and key stakeholders at different levels to gain insights into the acceptability, strengths, and challenges in implementing the model and the characteristics of successful seeds. Transcripts were coded and content analyses were performed. Results The seed-and-recruit active case finding model was generally well-received by the study participants. They saw the benefits of engaging TB survivors and utilizing their social network to find new TB cases in the community. The social embeddedness of the model within the local community was one of the major strengths. The success of the model also hinges on the integration with existing health facilities. Having an extensive social network, being motivated, and having good knowledge about TB were important characteristics of successful seeds. Study participants reported challenges in motivating the presumptive TB cases for screening, logistic capacities, and high workload during the implementation. However, there was a general consensus that the model ought to be expanded. Conclusions These findings indicate that the seed-and-recruit model is well-accepted by the beneficiaries and key stakeholders. Further studies are needed to more comprehensively evaluate the impacts and cost-effectiveness of the model for future expansion in Cambodia as well as in other resource-limited settings.

In Cambodia, HIV prevalence is concentrated in key populations including among female entertainment workers (FEWs) who may engage in direct or indirect sex work. Reaching FEWs with sexual and reproductive health (SRH) services has been difficult because of their hidden and stigmatized nature. Mobile-phone-based interventions may be an effective way to reach this population and connect them with the existing services. This article describes study design and implementation of a randomized controlled trial (RCT) of a mobile health intervention (the Mobile Link) aiming to improve SRH and related outcomes among FEWs in Cambodia.A two-arm RCT will be used to determine the effectiveness of a mobile-phone-based text/voice messaging intervention. The intervention will be developed through a participatory process. Focus group discussions and in-depth interviews have been conducted to inform and tailor behavior change theory-based text and voice messages. During the implementation phase, 600 FEWs will be recruited and randomly assigned into one of the two arms: (1) a control group and (2) a mobile phone message group (either text messages [SMS] or voice messages [VM], a delivery method chosen by participants). Participants in the control group will also receive a weekly monitoring survey, which will provide real-time information to implementing partners to streamline outreach efforts and be able to quickly identify geographic trends. The primary outcome measures will include self-reported HIV and sexually transmitted infections (STI) testing and treatment, condom use, contraceptive use, and gender-based violence (GBV).If the Mobile Link trial is successful, participants will report an increase in condom use, linkages to screening and treatment for HIV and STI, and contraception use as well as a reduction in GBV. This trial is unique in a number of ways. First, the option of participation mode (SMS or VM) allows participants to choose the message medium that best links them to services. Second, this is the first RCT of a mobile-phone-based behavior change intervention using SMS/VMs to support linkage to SRH services in Cambodia. Lastly, we are working with a hidden, hard-to-reach, and dynamic population with which existing methods of outreach have not been fully successful.Clinical trials.gov, NCT03117842 . Registered on 31 March 2017.

Background Adolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study investigated factors associated with viral non-suppression among adolescents living with HIV in Cambodia. Methods A cross-sectional study was conducted in August 2016 among 328 adolescents living with HIV aged 15–17 years who were randomly selected from 11 ART clinics in the capital city of Phnom Penh and 10 other provinces. Clinical and immunological data, including CD4 count and viral load, were obtained from medical records at ART clinics. Adolescents were categorized as having achieved viral suppression if their latest viral load count was 672 (AOR = 0.47, 95% CI 0.26–0.86), had a relative as the main daily caregiver (AOR = 0.37, 95% CI 0.17–0.80), and did not believe that there is a cure for AIDS (AOR = 0.40, 95% CI 0.21–0.75) compared to their reference group. The likelihood of having viral non-suppression also remained significantly higher among adolescents who had first viral load > 628 RNA copies/mL (AOR = 1.81, 95% CI 1.05–4.08) and among those who were receiving HIV care and treatment from an adult clinic (AOR = 2.95, 95% CI 1.56–5.59). Conclusions The proportion of adolescents living with HIV with viral suppression in this study was relatively high at 76.8%, but falls short of the global target of 90%. Programs targeting younger adolescents and adolescents in transition from pediatric to adult care with a range of interventions including psychosocial support and treatment literacy could further improve viral suppression outcomes.

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 Adolescents living with HIV experience worse HIV care outcomes compared to adults, especially during transition from pediatric to adult care. However, data regarding adolescents are limited. This paper describes and compares characteristics of male and female adolescents living with HIV preparing for transition from pediatric to adult care in Cambodia. Methods This cross-sectional study was conducted in August 2016 among 328 adolescents aged 15–17, randomly selected from 11 antiretroviral therapy (ART) clinics. Data were collected using a structured questionnaire, and descriptive analyses were conducted to compare characteristics of male and female adolescents. Results Of total, 55.2% were male, and 40.8% were living with parents. Majority (82.6%) got HIV infection from their mothers. Overall, adolescents had received ART for an average of 8.4 years, and HIV care for 9.5 years. Additionally, 82.4% were on first line ART regimen. Mean CD4 count from the most recent test was 672 cells/mm3, and viral load was 7686 copies/mL. Overall, 95.6% were adherent to ART on Visual Analogue Scale. About half (50.7%) had never disclosed their HIV status to anyone, while the remaining had disclosed it to their siblings (24.2%), friends (13.0%), schoolteachers (2.4%), or other (5.8%). A fifth reported having had boy or girlfriends, but few (2.1%) had ever had sexual intercourse. Females were more likely to have been engaged in sexual intercourse, and none reported having used a condom in their last intercourse. Few participants reported having ever used tobacco (1.8%), or any kind of illicit drugs (0.9%), but almost a fifth (20.7%) had a history of alcohol use. The majority (82.1%) were aware that they were receiving ART. HIV-related knowledge was suboptimal among the sample. Conclusions This study provides a snapshot of immunological, virological, adherence, and disclosure outcomes that should be tracked during and following healthcare transition to evaluate the effectiveness of the transition program. Findings showed high ART adherence, low likelihood of disclosure outside of family circles, sub-optimal condom use, and poor knowledge of HIV. To provide individualized support for healthcare transition, pediatric and adult clinics need to ensure that these characteristics are taken into account.

ObjectiveTo explore social and behavioural factors associated with depressive symptoms among university students in Cambodia.DesignCross-sectional study.SettingsTwo public universities—one in the capital city of Phnom Penh and another in Battambang provincial town.ParticipantsThis study included 1359 students randomly selected from all departments in the two universities using a multistage cluster sampling method for a self-administered questionnaire survey in 2015.Primary outcome measureDepressive symptoms measured by using the Center for Epidemiologic Studies Depression scale. All measures in the study were self-reported.ResultsThe proportion of students with depressive symptoms and severe depressive symptoms were 50.6% and 19.6%, respectively. After adjustment in multivariate logistic regression analysis, depressive symptoms remained significantly associated with poor academic performance (adjusted OR (AOR)=7.31, 95% CI 2.24 to 23.86), higher consumption of unhealthy food (AOR=1.72, 95% CI 1.08 to 2.76), a negative self-perception about body shape (AOR=0.54, 95% CI 0.29 to 0.99) and general health status (AOR=2.99, 95% CI 1.28 to 7.00), and limited physical activeness (AOR=0.30, 95% CI 0.16 to 0.58). Depressive symptoms also remained significantly associated with adverse childhood experiences including physical violence (AOR=1.39, 95% CI 1.04 to 1.86), psychological abuse (AOR=1.82, 95% CI 1.37 to 2.42) and lack of general and medical care (AOR=0.51, 95% CI 0.30 to 0.86) by family during childhood.ConclusionsThe key factors associated with depressive symptoms were family related and individual behaviours and attitudes. Thus, efforts should be invested in comprehensive screening and intervention programmes to diagnose those vulnerable students early, offer immediate treatment and cater appropriate support.

Background In Cambodian context, female entertainment workers (FEWs) are young women working at establishments such as karaoke bars, restaurants, beer gardens or massage parlors. FEWs may sell sex to male patrons and are considered a high-risk group for HIV. This study aimed to identify factors associated with recent HIV testing among FEWs in Cambodia to inform future prevention activities. Methods Data were collected in 2014 as part of the evaluation of a larger HIV prevention project. A two-stage cluster sampling method was used to select participants from Phnom Penh and Siem Reap for face-to-face interviews using a structured questionnaire. A logistic regression model was constructed to identify independent factors associated with recent HIV testing. Results Data were collected from 667 FEWs with a mean age of 25.6 (SD = 5.5). Of total, 81.7% reported ever having had an HIV test, and 52.8% had at least one test in the past six months. After adjustment for other covariates, factors independently associated with recent HIV testing included living in Phnom Penh (AOR = 2.17, 95% CI = 1.43–3.28), having received HIV education in the past six months (AOR = 3.48, 95% CI = 2.35–5.15), disagreeing with a statement that ‘I would rather not know if I have HIV’ (AOR = 2.15, 95% CI = 1.41–3.30), agreeing with a statement that ‘getting tested for HIV helps people feel better’ (AOR = 0.32, 95% CI = 0.13–0.81) and not using a condom in the last sexual intercourse with a non-commercial partner (AOR = 0.48, 95% CI = 0.26–0.88). Conclusions FEWs with greater knowledge and positive attitudes towards HIV testing got tested for HIV more frequently than those with lesser knowledge and less positive attitudes. These findings suggest that future interventions should focus on disseminating tailored health messages around testing practices as well as specific topics such as condom use with non-commercial partners.

Background There is a growing concern for an increasing burden of non-communicable diseases (NCDs) in people living with HIV. This concern is evident especially in developing countries where dietary and lifestyle risk factors associated with NCDs are becoming more prominent. This study explored the prevalence of diabetes mellitus, hypertension, and hyperlipidemia and related risk factors in men and women living with HIV in Cambodia. Methods This cross-sectional study was conducted among 510 adult people living with HIV randomly selected from one city and four provinces in Cambodia. A structured questionnaire was used to collect data on socio-demographic characteristics, health behaviors, medical history, and antiretroviral therapy (ART). Anthropometric and biological measurements were performed. Descriptive statistics were used to calculate proportions and means of the measured variables. An independent Student’s t-test was used for continuous variables. Chi square test or Fisher’s exact test was used for categorical variables to explore gender differences. Results Prevalence of diabetes mellitus, hypertension, and hyperlipidemia was 9.4, 15.1, and 33.7%, respectively. The prevalence of hyperlipidemia was significantly higher among men compared to women. Mean systolic and diastolic blood pressures were also significantly higher among men. Regarding risk factors, 17.3% of participants were overweight, and 4.1% were obese. Tobacco and alcohol use was common, particularly among men. Fruit and vegetable consumption was considerably low among both men and women. Physical activity levels were also low. About 40% of participants reported having a job that involved mostly sitting or standing; 46.3% reported engaging in moderate activities; and 11.8% reported engaging in vigorous activities during leisure time. A significantly higher proportion of men compared to women engaged in vigorous activities both at work and during leisure time. Conclusions The prevalence of diabetes mellitus, hypertension, and hyperlipidemia among men and women living with HIV in Cambodia is considerably high. Related risk factors were also common. Given the comorbidity of NCDs and HIV, policy and programmatic interventions are required, including integration of NCD screening into HIV programs. Distinctions in the levels of diseases and in health behaviors between men and women suggest that interventions need to be tailor-made and gender-specific, targeting their respective diseases and behaviors.

Background Harm reduction interventions in Cambodia face numerous obstacles because of conflicting understanding and interests and inconsistencies in the implementation by law enforcement officials. This study aims to examine how understanding and application of Drug Control Law (DCL) and Village/Commune Safety Policy (VCSP) affects harm reduction interventions in Cambodia from the standpoints of law enforcement officials, people who inject drugs and people who use drugs (PWID/PWUD), as well as other key stakeholders. Methods This qualitative study was conducted in the capital city of Phnom Penh in 2015. We held five focus group discussions (FGDs) with groups of PWID/PWUD, police officers, Sangkat/commune officers, and local non-governmental organization (NGO) field staff. We also conducted ten key informant interviews (KIIs) with representatives from government agencies, donor agencies, and NGOs. FGDs and KIIs with Cambodian participants were transcribed in Khmer and translated into English. KIIs with foreign participants were transcribed in English. Transcripts were read and re-read to identify emerging themes, which were reviewed and refined to develop common and divergent patterns. Results There was a huge gap between what the DCL and VCSP say and how law enforcement officers and PWID/PWUD understood them. The gap was also evident in how law enforcement officers implemented the DCL and VCSP. Harm reduction services, including health- and non-health-related interventions, were limited and challenged by unsupportive attitudes, misinterpretation of the DCL and VCSP, and the lack of full engagement with NGOs in the development of these instruments. The needs of PWID/PWUD in accessing health care services were not met due to misconduct of authorities while practicing the DCL and VCSP. Further, the misconduct and enforcement of the law and policy lead to increased social discrimination and physical abuses against PWID/PWUD. Conclusions There is a lack of common understanding of the drug-related law and policy and their implications to harm reduction services among both law enforcement officers and PWID/PWUD. Thus, there is a need to mainstream and simplify the law and policy for better comprehension among these actors. To improve the quality and coverage of harm reduction interventions, the gap of understanding and enforcement of laws and policies should be narrowed, and coordination between the government and NGOs and other key stakeholders should be strengthened.

Background People who use drugs are an important priority for HIV programs. However, data related to their utilization of HIV services are limited. This paper reports patterns of HIV testing, drug use, and risk and service perception among people who use drugs. Study participants were receiving HIV and harm reduction services from a community-based program in Phnom Penh, comprised of itinerant peer-led outreach and static drop-in centers. Methods This was a mixed-methods study conducted in 2014, comprising of a quantitative survey using a structured questionnaire, followed by two focus group discussions among a sub-sample of survey participants. Participants were recruited from hotspots in five HIV high-burden communes using a two-stage cluster sampling method. Quantitative descriptive analyses and qualitative thematic analyses were performed. Results This study included 151 people who use drugs with a mean age of 31.2 (SD = 6.5) years; 77.5% were male and 39.1% were married. The most common drugs used were methamphetamines (72.8%) and heroin (39.7%), and 38.0% injected drugs in the past 3 months. Overall, 83.3% had been tested for HIV in the past 6 months, of whom 62.5% had been tested by peers through community-based outreach. However, there were ongoing HIV risks: 37.3% were engaging in sex on drugs, only 35.6% used a condom at last sexual intercourse, and 10.8% had had a sexually transmitted infection in the last 6 months. Among people who reported injecting drugs in the past 3 months, 27.5% reported re-using needles/syringes. Almost half (46.5%) perceived themselves as being at lower risk of HIV compared to the general population. Qualitative results contextualized the findings of low perception of HIV risks and suggested that although services were often unavailable on weekends, at night, or during national holidays, peer-led community-based outreach was highly accepted. Conclusions A peer-led community-based approach was effective in reaching people who use drugs with HIV and harm reduction interventions. To mitigate ongoing HIV risks, expanding access to combination prevention interventions and implementing strategies to enable people who use drugs to objectively assess their HIV risks are required. Additionally, community-based programs should collect data along the care continuum, to enable decentralized tracking of progress towards 90–90–90 goals at local levels.

Background Despite the success in promoting condom use in commercial relationships, condom use with regular, noncommercial partners remains low among key populations in Cambodia. This study explores factors associated inconsistent condom use with sweethearts among unmarried sexually active female entertainment workers (FEWs). Methods In 2014, the probability proportional to size sampling method was used to randomly select 204 FEWs from entertainment venues in Phnom Penh and Siem Reap for face-to-face interviews. Multivariate logistic regression analysis was conducted to examine independent determinants of inconsistent condom use. Results Of total, 31.4% of the respondents reported consistent condom use with sweethearts in the past three months. After adjustment, respondents who reported inconsistent condom use with sweethearts remained significantly less likely to report having received any form of sexual and reproductive health education (AOR = 0.49, 95% CI = 0.22–0.99), but more likely to report having been tested for HIV in the past six months (AOR = 2.19, 95% CI = 1.03–4.65). They were significantly more likely to report having used higher amount of alcohol in the past three months (AOR = 1.29, 95% CI = 1.01–1.99) and currently using a contraceptive method other than condoms such as pills (AOR = 4.46, 95% CI = 1.34–10.52) or other methods (AOR = 9.75, 95% CI = 2.07–9.86). Conclusions The rate of consistent condom use in romantic relationships among unmarried FEWs in this study is considerably low. The importance of consistent condom use with regular, non-commercial partners should be emphasized in the education sessions and materials, particularly for FEWs who use non-barrier contraceptive methods.

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.

In Cambodia, despite great achievements in reducing the prevalence of HIV in the general population, reducing new HIV infections among young at-risk women remains a challenge. This study was designed to examine the prevalence of risky behaviors of sexually active female youth in Cambodia and to explore risk factors associated with engagement in transactional sex. We surveyed sexually active female youth aged 10-24 enrolled at risk "hotspots" in eight provinces in Cambodia. We collected data on demographic factors, sexual behavior, and factors hypothesized to be associated with transactional sex. Multivariable logistic regression was used to identify associations between demographic and sexual behavior and transactional sex. Of the 280 respondents, the mean age was 21.2, and 48.1% had been paid for sex in the past year. After adjustment, at-risk females who were never have been married (adjusted odds ratio (AOR) 3.40, 95% confidence interval (CI) = 1.65-6.97), have completed less than 6 years of school (AOR 3.26, 95% CI = 1.60-6.66), have 1 or more parents who had died (AOR 4.34, 95% CI = 2.00-9.38), be a heavy alcohol drinker (AOR 3.58, 95% CI = 1.78-7.18), have used a condom with their boyfriend during last sexual encounter (AOR 3.50, 95% CI = 1.68-7.32), and have ever had an HIV test (AOR 3.51, 95% CI = 1.68-7.32) were more likely to engage in sex work. Our findings suggest that prevention strategies for female youth at risk of engagement in sex work should include upstream structural interventions that aim to encourage girls' education and empowerment. In addition, tailored sex education and behavior change messaging about the risks of heavy drinking, condom use with romantic partners, and the importance of frequent HIV testing for at-risk youth and sex workers should be designed and delivered to youth currently engaging in sex work.

Background In Cambodia, there has been an increase in entertainment work as a result of the breakdown of the traditional brothel-based sex industry, presenting new challenges to addressing the health issues and needs of people working in the entertainment industry. This study aims to identify factors associated with psychological distress among female entertainment workers (FEWs) in Cambodia. Methods A two-stage cluster sampling method was used to randomly select 657 FEWs from entertainment establishments in Phnom Penh and Siem Reap in April and May 2014 for interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12), and multivariate logistic regression analysis was conducted. Results Almost half of FEWs (43.2 %) had a higher level of psychological distress (GHQ-12 > 3), while 19.5 % reported having suicidal thoughts, and 7.3 % reported having attempted to commit suicide in the past 3 months. Controlling for confounding factors, women with a higher level of psychological distress were significantly more likely to rate their overall health (AOR = 1.88, 95 % CI 1.20 to 2.94) and quality of life (AOR = 2.39, 95 % CI 1.47 to 3.87) as poor. They were also significantly more likely to have suicidal ideation (AOR = 2.41, 95 % CI 1.45 to 3.76), rate their HIV risk as higher than the general population (AOR = 0.48, 95 % CI 0.31 to 0.74), have been forced to drink at work (AOR = 1.77, 95 % CI 1.19 to 2.62), have had clients requesting not to use a condom (AOR = 3.48, 95 % CI 1.14 to 10.62), be not able to find condoms when they needed it (AOR = 0.64, 95 % CI 0.45 to 0.93), have had a family member who said hurtful things to them during childhood (AOR = 1.84, 95 % CI 1.24 to 2.75), and have had a parent or guardian who had been physically abused (AOR = 1.93, 95 % CI 1.34 to 2.82). Conclusions FEWs in Cambodia experience high levels of psychological distress, which likely stems from both past negative experiences and current working conditions. For women that are experiencing psychological distress, intervention programs aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk.

Background: Despite remarkable success in the fight against HIV, HIV prevalence in many countries remains high among key populations including men who have sex with men (MSM), and HIV testing rates is relatively low among this hard-to-reach population. This cross-sectional study explores factors associated with recent HIV testing among MSM in Cambodia. Methods: This study was conducted in 2014 and included 384 MSM randomly selected from two provinces of Battembang and Siem Reap, using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect data on socio-demographic characteristics, HIV testing history, sexual behaviors, HIV testing attitudes, and HIV knowledge. Multivariate logistic regression analysis was performed to identify factors independently associated with recent HIV testing. Results: Mean age of the participants was 23.4 (SD = 5.2). Of total, 83.6 % had been tested for HIV at least once in their lifetime, and 65.1 % had been tested for HIV in the past six months. After controlling for other covariates, MSM who had been tested for HIV in the past six months were significantly more likely to regard themselves as female (AOR = 2.29, 95 % CI = 1.06-5.37), have received some form of HIV education in the past six months (AOR = 3.97, 95 % CI = 1.91-8.26), perceive that they were at higher HIV risk compared to the general population (AOR = 2.48, 95 % CI = 1.14-4.86), have been diagnosed with an STI in the past six months (AOR = 3.19, 95 % CI = 1.02-9.24), report using a condom at last sexual intercourse with a man or woman (AOR = 2.24, 95 % CI = 1.06-3.13), and report using a condom at last sexual intercourse with a boyfriend (AOR = 2.17, 95 % CI = 1.04-5.31). Conclusions: This study highlights the common practices of risky sexual behaviors and relatively low rate of recent HIV testing among MSM in Cambodia. HIV education and social marketing should be expanded and tailored for MSM, specifically addressing the risk of unprotected anal inte rcourse and the importance of regular HIV testing for early enrolment in the care and treatment cascade.

Background Compared to general children, orphans and vulnerable children (OVC) are more exposed to negative outcomes in life such as abuse and neglect. Consequently, OVC are more susceptible to depression. This paper investigated factors associated with depressive symptoms among OVC in Cambodia. Methods In this cross-sectional study, data of 606 OVC from the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project were analyzed. The data were collected from five provinces and analyzed separately for boys and girls. Multiple linear regression analysis was used to identify factors independently associated with levels of depressive symptoms. Results Both boys and girls who reported having been too sick making them unable to attend school or go to work in the past six months (boys: B = 3.5; 95 % CI = 0.7, 6.2; girls: B = 5.7; 95 % CI = 2.9, 8.5) and who had witnessed violence in the family (boys: B = 5.6; 95 % CI = 1.6, 9.6; girls: B = 5.8; 95 % CI = 1.7, 9.9) had a higher level of depressive symptoms. Girls who were older (B = 8.5; 95 % CI = 3.0, 14.0), who did not have enough food in the past six months (B = −8.7; 95 % CI = −13.7, −3.7) and whose parents were separated, divorced or dead (B = 3.9; 95 % CI = 0.5, 7.2) had a higher level of depressive symptoms. Higher level of school attachment was negatively associated with depressive symptoms in both genders (boys: B = −1.4; 95 % CI = −2.0, −0.9; girls: B = −1.4; 95 % CI = −2.0,-0.9). Conclusions Factors such as physical health and exposure to violence may affect mental health of OVC in Cambodia. As health is of utmost importance, better healthcare services should be made easily accessible for OVC. Schools have the potential to act as a buffer against depressive symptoms. Therefore, efforts should be made to keep OVC in school and to improve the roles of school in Cambodia.

Objective: To explore risk factors associated with induced abortion among sexually active female entertainment workers (FEWs) in Cambodia. Design: Cross-sectional study. Setting: Phnom Penh and Siem Reap, Cambodia. Participants: This study included 556 FEWs aged 18–47 years randomly selected from entertainment establishments in the two cities in 2014 using a twostage cluster sampling method. Data were collected through face-to-face interviews using a structured questionnaire. Primary outcome measure: History of induced abortion during the time working as a FEW. Results: Of the total sample, 45.6% reported currently using a contraceptive method with condom (42.4%) being the most common method, followed by pills (25.6%). One-fourth (25%) of the respondents reported having been pregnant at least once, and 21.4% reported having at least one induced abortion during the time working as a FEW. After controlling for other covariates in a multivariate logistic regression model, FEWs with a history of induced abortion remained significantly more likely to be currently working in a karaoke bar (AOR=1.75, 95% CI 1.10 to 2.78), to have worked longer as a FEW (AOR=1.42, 95% CI 1.06 to 1.43), to have had a greater number of sexual partners in the past 12 months (AOR=1.86, 95% CI 1.02 to 1.54), to be currently using a contraceptive method (AOR=1.52, 95% CI 1.01 to 2.29), to be able to find condoms when they needed them (AOR=2.03, 95% CI 1.09 to 3.82), and to report inconsistent condom use with non-commercial partners in the past 3 months (AOR=1.62, 95% CI 1.06 to 3.44). Conclusions: This study highlights the high rates of unwanted pregnancies that ended in induced abortions among FEWs in Cambodia. Access of FEWs to quality sexual and reproductive healthcare services is deemed a high priority. Integrated interventions to improve sexual and reproductive health among these vulnerable women should be tailored to reach the most-at-risk groups.

Background In Cambodia, despite great successes in the fight against HIV, challenges remain to eliminating new HIV infections and addressing sexual reproductive health (SRH) issues in key populations including female entertainment workers (FEWs). To address these issues, the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project has been implemented since late 2009 using a community-based approach to integrate HIV and SRH services. This study evaluates the impact of the SAHACOM on sexual and healthcare-seeking behaviors among FEWs in Cambodia. Methods A midterm and endpoint comparison design was utilized. Midterm data were collected in early 2012, and endpoint data were collected in early 2014. A two-stage cluster sampling method was used to randomly select 450 women at midterm and 556 women at endpoint for face-to-face interviews. Results Compared to women at midterm, women at endpoint were significantly less likely to report having sexual intercourse in exchange for money or gifts in the past three months (OR = 2.1, 95 % CI = 1.6-2.7). The average number of commercial sexual partners in the past three months also decreased significantly from 5.5 (SD = 13.3) at midterm to 3.6 (SD = 13.9) at endpoint (p = 0.03). However, women at endpoint were significantly less likely to report always using condom when having sexual intercourse with clients in exchange for money or gifts (OR = 2.6, 95 % CI = 1.5-4.5). Regarding sexually transmitted infections (STIs), women at endpoint were significantly less likely to report having an STI symptom in the past three months (OR = 1.8, 95 % CI = 1.4-2.3) and more likely to seek treatment for the most recent STI symptom (OR = 1.6, 95 % CI = 1.1-1.9). Furthermore, women at endpoint were significantly more likely to be currently using a contraceptive method (OR = 1.4, 95 % CI = 1.1-1.8) and less likely to report having an induced abortion (OR = 1.4, 95 % CI = 1.1-1.7) during the time working as a FEW. Conclusions The overall findings of the study indicate that the SAHACOM is effective in reducing sexual risk behaviors and improving the access to SRH care services among FEWs in Cambodia. However, several unfavorable findings merit attention.

Background Compared to the general population, men who have sex with men (MSM) are at greater risk for HIV and less understood due to their more hidden and stigmatized nature. Moreover, the discrepancy in findings in the literature merits further investigations in MSM populations from different cultures and settings. We therefore conducted this study to explore factors associated with inconsistent condom use among high-risk MSM in Cambodia. Methods This cross-sectional study was conducted in 2014 among 367 MSM randomly selected from Battembang and Siem Reap using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect information on characteristics of respondents, HIV testing history, self-perception of HIV risk, substance use, sexual behaviors, mental disorders, and HIV knowledge. Multivariable logistic regression analysis was performed to identify factors independently associated with inconsistent condom use. Results On average, 62.3% of respondents reported that they always used condoms over the past three months. The rates varied with types of sexual partners; the proportion of respondents who reported always using condoms was 55.1%, 64.2%, 75.9%, 73.0%, 78.1%, and 70.3%, for sexual partners who were girlfriends, boyfriends, female sex workers, male sex workers, female clients, or male clients, respectively. After adjustment, inconsistent condom use was significantly associated with age of ≥25 (AOR = 1.77, 95% CI = 1.09–2.86), self-rated quality of life as good or very good (AOR = 4.37, 95% CI = 1.79–5.67), self-perception of higher HIV risk compared to the general population (AOR = 2.37, 95% CI = 1.35–4.17), illicit drug use in the past three months (AOR = 5.76, 95% CI = 1.65–10.09), and reported consistent lubricant use when selling anal sex to men in the past three months (AOR = 2.85, 95% CI = 1.07–8.12). Conclusions We found risky sexual behaviors to be considerably high among MSM in this study, especially among those who used illicit drugs or were older than 25. HIV education and social marketing should be expanded and specifically designed for MSM to better educate on the increased risk of HIV with unprotected anal sex and illicit drug use as risk factors, and the importance of the use of both condoms and lubricant during anal intercourse.

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.