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This study evaluated the impacts of the Sustainable Action against HIV and AIDS in Communities (SAHACOM) Project on health and quality of life of people living with HIV (PLHIV). Outcome indicators from baseline documentation (2010) were compared to those obtained at midterm (2012) and end line (2014). Results showed that HIV prevalence among pregnant women aged 15–24 attending antenatal care decreased from 0.5% at baseline to 0.3% at midterm and end line. Proportion of PLHIV who were on antiretroviral therapy (ART) 12 months after the initiation of the treatment increased from 85% at baseline and midterm to 89.5% at end line. Proportion of PLHIV in need for ART and currently on the treatment increased from 90.0% at baseline to 92.5% at midterm and to 96.0% at end line. Regarding their health status, proportion of PLHIV reporting their overall health as good increased from 52.0% at baseline to 78.3% and 80.2% at midterm and end line, respectively. Similarly, proportion of respondents reporting their overall quality of life as good increased sharply from 35.0% at baseline to 73.3% and 72.0% at midterm and end line, respectively. In conclusion, the SAHACOM is effective in improving health and quality of life of PLHIV in Cambodia.

BackgroundMobile Link is a mobile phone–based intervention to increase access to, and use of, health care services among female entertainment workers in Cambodia who face higher risks for specific diseases and gender-based violence. A multisite randomized controlled trial showed that Mobile Link connected female entertainment workers with outreach workers for information and escorted referrals after 6 months but did not lead to statistically significant improvements in HIV and sexually transmitted infection testing, contraceptive use, and condom use. ObjectiveThis study aims to conduct a 3-part economic evaluation of Mobile Link to understand its costs, value, and affordability. MethodsWe conducted cost, cost-effectiveness, and budget impact analyses of Mobile Link using cost and outcomes data from the Mobile Link trial and other sources. For the cost analysis, we estimated the total, per-person, and incremental costs of Mobile Link compared with usual care. Using probabilistic decision-analytic models, we estimated the 1-year cost-effectiveness of Mobile Link from payer and combined payer and patient perspectives by converting selected primary and secondary outcomes from the trial to disability-adjusted life years (DALYs) averted. Finally, we estimated the financial costs of scaling up Mobile Link’s messaging and outreach services to 70% of female entertainment workers in 5 years. ResultsThe incremental costs of Mobile Link were US $199 from a payer perspective and US $195 per person from a combined payer and patient perspective. With an average of 0.018 (95% predicted interval –0.088 to 0.126) DALYs averted, Mobile Link’s cost-effectiveness was US $10,955 per DALY from a payer perspective (US $10,755 per DALY averted from a payer and patient perspective). The costs of Mobile Link would have to decrease by 85%, or its effectiveness would have to be 5.56 times higher, for the intervention to meet the upper limit of recommended cost-effectiveness thresholds in Cambodia (US $1671 per DALY averted). The 5-year cost of scaling Mobile Link to 34,790 female entertainment workers was estimated at US $1.64 million or US $46 per person per year. ConclusionsThis study provided a comprehensive economic evaluation of Mobile Link. We found that Mobile Link is not likely to be cost-effective unless its costs decrease or its effectiveness increases. Scaling up Mobile Link to more female entertainment workers is estimated to cost less than the costs of the trial. Given the importance of linking female entertainment workers to essential services, future research should focus on enhancing the effectiveness of Mobile Link or developing new mobile health interventions for this population. Trial RegistrationClinicalTrials.gov NCT03117842; https://clinicaltrials.gov/study/NCT03117842

Abstract Background Understanding context-specific determinants of antiretroviral therapy (ART) adherence is crucial for developing tailored interventions for improving health outcomes and achieving the UNAIDS’ third 95% target. This cross-sectional study explores factors associated with ART adherence among stable people living with HIV on ART in Cambodia. Methods We used baseline survey data from a quasi-experimental study conducted in 2021. The participants were recruited from 20 ART clinics in nine provinces for face-to-face interviews. A structured questionnaire collected information on sociodemographic characteristics, ART adherence, perceived ART self-efficacy, mental health, quality of life, stigma, and discrimination. We conducted bivariate and multiple logistic regression analyses to identify factors associated with ART adherence. Results Out of the 4101 participants, 86.5% reported adhering to ART in the past two months. The adjusted odds of ART adherence were significantly higher among participants in older age groups than those aged 15–29, participants with elevated cholesterol than those without it, participants who exhibited strong self-efficacy in health responsibility to maintain life than those with poor self-efficacy in health responsibility, participants who scored 301 USD per month than those who earned ≤ 100 USD per month. Conclusion The ART adherence rate among stable people living with HIV in this study was comparable to that of the general people living with HIV in Cambodia. The results suggest the need for innovative interventions to further reduce stigma and discrimination and strategies to improve the self-efficacy and mental health of people living with HIV to improve ART adherence.

Abstract Background The COVID-19 pandemic pushed governments worldwide to implement unprecedented mitigation measures, including safe-distancing, lockdowns, disruption of non-essential services, border closures and travel restrictions, with both potential to affect rural and urban service-users differently and unintended consequences including reductions in sexual and reproductive health (SRH) services. We aimed to explore rural–urban differences in progress and challenges in SRH services provision in Cambodia, particularly during initial months of the COVID-19 pandemic. Methods We used a mixed-methods study design, including a household survey of 423 adolescents and women aged 18–49 and semi-structured interviews with 21 healthcare providers. We analysed survey data using multivariable logistic regression to identify associations between rural–urban setting and contraceptive perceptions or access. We analysed interview data thematically. Results Rural–urban residence was significantly associated with reported perceptions about and access to contraceptives. Rural participants had higher odds of stating it was possible to change contraceptive methods early in the COVID-19 pandemic, compared with urban participants. Qualitative data showed that although SRH services continued, health-workers faced differential challenges in rural and urban areas, e.g. service-users not attending due to job losses in urban areas and not complying with safe-distancing and mask-wearing requests in rural areas. Conclusions COVID-19 and inadequate mitigation responses differentially affected rural and urban SRH service providers and service-users, exacerbating existing socioeconomic stressors while adding new fears of infection, transport constraints, and reduced livelihoods. Added financial support could help mitigate challenges in both rural and urban areas.

Abstract Background Maintaining oral health is essential for improving overall health of children living with HIV. Therefore, we evaluated the effectiveness of an oral health intervention for improving their oral and overall health. In addition, we examined their longitudinal association between changes in oral and overall health. Methods We conducted a 2-year randomized controlled trial involving children living with HIV in Cambodia. Children aged 3–15 years and their caregivers were randomly allocated either to the intervention (group A) or control (group B) arm. A second control arm (group C) included children without HIV. The group A children received oral health education sessions and practiced home-based daily care. Results In the baseline survey, 482 children participated (group A: n = 160, group B: n = 168, group C: n = 154), and 350 completed the endline survey. An interaction effect in teeth brushing duration was observed in children in group A relative to group B (AOR = 2.69, 95% CI: 1.37–5.31) and group C (AOR = 3.78, 95% CI: 1.70–8.40). Longitudinal associations were observed between changes in oral hygiene and overall health, as presented by alterations in dental caries in permanent teeth with viral load detection (adjusted odds ratio = 3.58, 95% CI: 1.10 − 11.73), in salivary flow quantity with the overall quality of life (β = 0.07, 95% CI:

Abstract 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

Background Cambodia has achieved great success in tuberculosis (TB) control in the past decade. Nevertheless, people with TB are missed by the health systems at different stages of the care pathway. This programme review corroborated the care-seeking behaviours of people with TB and TB services availability and estimated the number of people completing each step of the TB disease and TB preventive treatment (TPT) care cascade.Methods Patient pathways and the care cascades for TB disease and TPT were constructed using data from the latest national TB prevalence survey, routine surveillance and programme, the global TB database and published studies. We also randomly selected TB survivors in the 2019 cohort to assess recurrence-free survival 1-year post-treatment. TPT care cascade was constructed for people living with HIV (PLHIV) and household contacts (children

Objectives We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia.Design Operational study; quantitative cohort data and cross sectional qualitative data.Setting Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia.Participants Pregnant women screened for syphilis; MCH health care providers and managers.Methods We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used.Outcome measures Syphilis testing and treatment results and perceptions regarding these services.Results A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019–2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners’ lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants.Conclusions Study results contributed to informing improvements to syphilis management in MCH services in Cambodia.

Abstract Background Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients’ and health facilities’ burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model’s effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. Methods We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD—a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers’ work burden, the model’s cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. Discussion This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. Trial registration ClinicalTrials.gov, NCT04766710 . Registered 23 February 2021, Version 1.

Abstract 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.

Abstract Background Oral health status is associated with the overall health among people living with human immunodeficiency virus (HIV) infection. However, it is unclear whether dental caries is associated with the viral load in this population. Particularly, dental caries among children living with HIV needs better understanding as this can affect their overall health and future well-being. This study assessed the association between dental caries and viral load among children living with HIV in Phnom Penh, Cambodia. Methods This cross-sectional study, conducted at the National Pediatric Hospital as a baseline survey of a randomized controlled trial, included 328, 3–15-year-old children living with HIV and their primary caregivers. Calibrated and trained examiners conducted oral examinations for dental caries (DMFT/dmft index) in the children and retrieved the latest HIV viral load data from the hospital’s patient information system. On the dental examination day, the children and their caregivers were invited to answer a questionnaire-based interview. Multiple logistic regression analysis was conducted to assess the association between dental caries and viral load. The cut-off point for undetectable viral load was set at 1000 copies/mL) (AOR: 1.12, CI: 1.03–1.23). Conclusions Dental caries was associated with viral load status detection among children living with HIV. This finding suggests that dental caries may affect their immune status. The oral health of children living with HIV should be strengthened, and further research is needed to clarify the causal relationship between viral load and oral health status.

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

Abstract 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.

Abstract 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.

Abstract Background Cambodia has made notable progress in the fight against tuberculosis (TB). However, these gains are impeded by a significant proportion of undiagnosed cases. To effectively reach people with TB, active case-finding (ACF) strategies have been adopted by countries affected by the epidemic, including Cambodia, alongside passive case finding (PCF). Despite increased efforts to improve case detection, approximately 40% of TB cases in Cambodia remained undiagnosed in 2018. In Cambodia, several community-based TB ACF modalities have been implemented, but their effectiveness has yet to be systematically assessed. Methods This pragmatic cluster randomized controlled trial will be conducted between December 2019 and June 2021. We will randomize eight operational districts (clusters) in seven provinces (Kampong Cham, Kampong Thom, Prey Veng, Thbong Khmum, Kampong Chhnang, Kandal, and Kampong Speu) to either the control group (PCF) or the intervention groups (ACF using a seed-and-recruit model, ACF targeting household and neighborhood contacts, and ACF targeting persons aged ≥ 55 years using mobile screening units). The primary endpoints will be TB case notification rates, additionality, and cumulative yield of TB cases. The secondary endpoints include treatment outcomes, the number needed to screen to find one TB case, and cost-effectiveness outcome measures. We will analyze the primary and secondary endpoints by intention to treat. We will compare cluster and individual-level characteristics using Student’s t test and hierarchical or mixed-effect models to estimate the ratio of these means. The incremental cost-effectiveness ratio per disability-adjusted life year averted will also be considered as a benchmark to determine whether the interventions are cost-effective. Discussion This study will build an evidence base to inform future scale-up, implementation, and sustainability of ACF strategies in Cambodia and other similar settings. Implementation of this study will also complement TB control strategies in Cambodia by conducting ACF in operational districts without active interventions to find TB cases currently. Those who are ill and might have TB will be promptly screened, diagnosed, and linked to care. Early diagnosis and treatment initiation will also benefit their community by interrupting transmission and prevent further infections. The experience gained from this project will inform future attempts in conducting pragmatic trials in low-resource settings. Trial registration ClinicalTrials.gov, NCT04094350. Registered on 18 September 2019.

Objective To examine the relationship between gender-based violence, HIV risks, psychological distress and binge drinking among female entertainment workers (FEWs) in Cambodia.Design Cross-sectional study.Setting Phnom Penh and three other provinces in Cambodia.Participants We 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 measure Binge 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.Results The 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).Conclusions This 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.

BackgroundFemale 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. ObjectiveThis 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. MethodsA 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. ResultsA 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. ConclusionsThe 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 RegistrationClinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842 International Registered Report Identifier (IRRID)RR2-10.1186/s13063-018-2614-7

Female entertainment workers (FEWs) are at higher risk of gender-based violence (GBV) than the general population. The prolonged stress and fear caused by GBV increase the likelihood of depression, a major mental health problem among FEWs. However, their mental health issue has received limited attention and remains poorly researched in the context of GBV. We examined the association between GBV and depressive symptoms among FEWs in Cambodia. We conducted this cross-sectional study in 2017. We used a two-stage cluster random sampling method to select FEWs from the municipality and six provinces for face-to-face interviews. We used the Centre for Epidemiologic Studies Depression Scale (CES-D) to measure depressive symptoms. We conducted a multivariable logistic regression analysis to identify factors associated with depressive symptoms. We included a total of 645 FEWs in data analyses. The proportions of FEWs experiencing emotional, physical, and sexual violence were 36.1%, 11.6%, and 17.2%, respectively. Of the total participants, 65.9% had high levels of depressive symptoms. The adjusted odds of having high levels of depressive symptoms were higher among FEWs who engaged in transactional sex (AOR 1.79, 95% CI 1.09-2.94), experienced emotional abuse (AOR 3.15, 95% CI 1.90-5.23), and experienced two (AOR 7.89, 95% CI 3.28-18.99) and three overlapping types of GBV (AOR 12.12, 95% CI 2.47-59.25) than those who did not. FEWs in this study experienced high levels and overlapping types of GBV associated with high levels of depressive symptoms. Policy interventions and services should be designed to prevent GBV and support the victims of GBV to mitigate depressive symptoms among FEWs in Cambodia.

Background HIV-positive children are at high risk for oral mucosal disorders. Additionally, their low immune status is associated with dental caries. However, little is known about how their dental caries and related risk factors, such as salivary flow, salivary pH level and oral health-related quality of life, differ from those of HIV-negative children. The study aimed to assess (1) dental caries and related risk factors in HIV-positive compared with HIV-negative children and (2) the association between these factors and HIV seropositive status in Phnom Penh, Cambodia.Methods This was a cross-sectional study conducted as a baseline survey of a randomised controlled trial. The study setting was the National Pediatric Hospital’s catchment area. The study population comprised 328 HIV-positive and 154 HIV-negative children aged 3–15 years and their caregivers. We collected clinical oral health data, questionnaire data to assess oral health-related quality of life and growth data.Results The mean number of decayed, missing or filled permanent teeth (DMFT) and deciduous teeth (dmft) among HIV-positive children was 4.0 (SD 3.6) and 7.0 (SD 4.9), respectively. Among HIV-negative children, the respective values were 3.3 (SD 3.7) and 7.1 (SD 4.6). Living with HIV was positively associated with DMFT (adjusted OR 1.85, 95% CI 1.14 to 3.01) and salivary flow (β=0.72, 95% CI 0.44 to 1.00) and negatively associated with salivary pH (β=−0.13, 95% CI −0.24 to –0.02). However, HIV-positive status was not significantly associated with dmft or oral health-related quality of life.Conclusions HIV-positive children had poorer oral health status regarding DMFT and salivary pH level. Specific strategies and further efforts are required to align their oral health status with that of HIV-negative children.

Abstract Background As elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia. Since 2016, the National Social Security Fund (NSSF) has implemented a social health insurance scheme with a contributory approach for formal sector workers. However, informal sector workers and dependents of formal sector workers are still not covered by this insurance because it is difficult to set an optimal amount of contribution for such individuals as their income levels are inestimable. The present study aims to develop and validate an efficient household income-level assessment model for Cambodia. We aim to help the country implement a financially sustainable social health insurance system in which the insured can pay contributions according to their ability. Methods This study will use nationally representative data collected by the Cambodia Socio-Economic Survey (CSES), covering the period from 2009 to 2019, and involving a total of 50,016 households. We will employ elastic net regression analysis, with per capita disposable income based on purchasing power parity as the dependent variable, and individual and community-level socioeconomic and demographic characteristics as independent variables. These analyses aim to create efficient income-level assessment models for health insurance contribution estimation. To fully capture socioeconomic heterogeneity, sub-group analyses will be conducted to develop separate income-level assessment models for urban and rural areas, as well as for each province. Discussion This research will help Cambodia implement a sustainable social health insurance system by collecting optimal amount of contributions from each socioeconomic group of the society. Incorporation of this approach into existing NSSF schemes will enhance the country’s current efforts to prevent impoverishing health expenditure and to achieve UHC.

Abstract Background Globally, people who inject drugs (PWID) continue to be among the most vulnerable populations to acquire infection of human immunodeficiency virus (HIV). The most recent national survey found that nearly a quarter of PWID in Cambodia were infected with HIV in 2012. The aim of this study is to estimate the current prevalence of and factors associated with HIV infection among PWID in Cambodia. Methods This national integrated biological and behavioral survey was conducted from June to December 2017. Participants were recruited from the capital city and 11 major provinces using the respondent driven sampling method. Face-to-face interviews were conducted using a structured questionnaire, and blood samples were collected for HIV, syphilis, and hepatitis C virus (HCV) testing. Multiple logistic regression analysis was conducted to identify risk factors for HIV infection. All analyses were estimated with sampling weights that corrected for non-response and sample design. Results A total of 310 PWID participated in the study, and the mean age was 31.8 years (SD = 7.8). The prevalence of HIV was 15.2%. More than half (57.4%) of the HIV-positive participants were co-infected with HCV, and 44.7% were not aware of their HIV status prior to this study. After adjustment for other covariates, HIV infection remained positively associated with being female (AOR = 1.88, 95% CI = 1.03–4.04), being in the older age group of ≥35 (AOR = 2.99, 95% CI 1.33–9.22), being widowed, divorced or separated (AOR = 2.57, 95% CI = 1.04–6.67), living on the streets (AOR = 2.86, 95% CI 1.24–4.37), and HCV infection (AOR = 3.89, 95% CI 1.86–1.15). The HIV infection remained negatively associated with having higher level of formal education of ≥10 years (AOR = 0.44, 95% CI 0.13–0.83) and higher average income of ≥US$200 per month (AOR = 0.20, 95% CI = 0.05–0.74). Conclusions The prevalence of HIV among PWID in Cambodia remains high, but is reducing compared with the 24.8% reported in the 2012 national survey. Findings from this study provide critical information for tailoring interventions based on identified vulnerabilities and risk factors for HIV. Our findings underline the importance of socio-structural factors in HIV epidemiology among PWID in Cambodia, which require mitigation.

Abstract 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.

Abstract 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.

Abstract 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.

Abstract 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.

Objective To estimate the prevalence of HIV testing and examine factors associated with recent HIV testing among people who use drugs (PWUD) in Cambodia.Design Cross-sectional study.Setting Twelve major provinces with a high burden of HIV and drug use in Cambodia.Participants This 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 measure Recent HIV testing, defined as having an HIV test in the past 6 months.Results The 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).Conclusions Recent HIV test uptake among PWUD in Cambodia was suboptimal. This study highlights the roles of outreach HIV education and services in promoting regular HIV testing among PWUD. Strengthening the coordinated effort of government agencies and local civil society organisations to prioritise expanding community-based peer-driven interventions to reach out to this hidden population is warranted.

Background and objectives The effects of active case finding (ACF) models that mobilise community networks for early identification and treatment of tuberculosis (TB) remain unknown. We investigated and compared the effect of community-based ACF using a seed-and-recruit model with one-off roving ACF and passive case finding (PCF) on the time to treatment initiation and identification of bacteriologically confirmed TB. Methods In this retrospective cohort study conducted in 12 operational districts in Cambodia, we assessed relationships between ACF models and: 1) the time to treatment initiation using Cox proportional hazards regression; and 2) the identification of bacteriologically confirmed TB using modified Poisson regression with robust sandwich variance. Results We included 728 adults with TB, of whom 36% were identified via the community-based ACF using a seed-and-recruit model. We found community-based ACF using a seed-and-recruit model was associated with shorter delay to treatment initiation compared to one-off roving ACF (hazard ratio 0.81, 95% CI 0.68–0.96). Compared to one-off roving ACF and PCF, community-based ACF using a seed-and-recruit model was 45% (prevalence ratio (PR) 1.45, 95% CI 1.19–1.78) and 39% (PR 1.39, 95% CI 0.99–1.94) more likely to find and detect bacteriologically confirmed TB, respectively. Conclusion Mobilising community networks to find TB cases was associated with early initiation of TB treatment in Cambodia. This approach was more likely to find bacteriologically confirmed TB cases, contributing to the reduction of risk of transmission within the community.

Abstract 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.

Abstract Background Although HIV prevalence in Cambodia has declined to 0.6% among the general population, the prevalence remains high among female sex workers (14.0%) and men who have sex with men (2.3%). Over the past 10 years, the number of people who use drugs (PWUDs) has increased considerably. PWUDs, especially people who inject drugs (PWIDs), who have multiple sex partners or unprotected sex contribute to a higher HIV prevalence. This paper aims to estimate the prevalence of HIV across PWUD groups and to identify factors associated with HIV infection. Methods Respondent-driven sampling (RDS) was used to recruit 1626 consenting PWUDs in 9 provinces in 2012. Questionnaires and blood specimens were collected. HIV prevalence estimates were calculated using RDSAT 7.1. Individual weightings for HIV were generated with RDSAT and used for a weighted analysis in STATA 13. Multivariate logistic regression was used to identify the independent factors associated with HIV prevalence. Results Most of the PWUDs were men (82.0%), and 7.3% were PWIDs. Non-PWIDs, especially users of amphetamine-type stimulants (ATS), represented the larger proportion of the participants (81.5%). The median age for of the PWUDs was 24.0 years (IQR: 20–29). The HIV prevalence among the PWUDs was 5.1% (95% CI: 4.1–6.2), 24.8%, among PWIDs and 4.0% among non-PWIDs. The HIV prevalence among female PWIDs was 37.5, and 22.5% among male PWIDs. Four factors were independently associated with HIV infection: female sex, with AOR = 7.8 (95% CI: 3.00–20.35); age groups 21–29 and older (AOR = 10.3, 95% CI: 1.2–20.4); and using drugs for ≥12 months (AOR = 4.0, 95% CI: 1.38–11.35). Finally, injecting drugs remained a strong predictor of HIV infection, with an AOR = 4.1 (95% CI: 1.53–10.96). Conclusion HIV prevalence remains high among PWIDs. Harm reduction efforts, such as needle and syringe provision programs, must improve their coverage. Innovative strategies are needed to reach sub-groups of PWUDs, especially women who inject drugs. Furthermore, the large proportion of non-PWIDs, especially ATS users, should not be ignored. Therefore, combined HIV prevention and harm reduction programs should integrate ATS users.

Abstract 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.

Abstract 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.

Abstract Background Transgender women are at significant risk of HIV, and they face intersecting barriers to health, social, and legal services. However, data regarding the unique needs and experiences of transgender women are globally scant. This study examined the relationship between gender-based violence and depressive symptoms among transgender women in Cambodia. Methods This cross-sectional study included 1375 sexually active transgender women recruited by using the respondent-driven sampling method in the capital city of Phnom Penh and 12 provinces between December 2015 and February 2016. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale (CES-D). Multivariate regression analysis was conducted to explore factors independently associated with depressive symptoms. Results Of total, 45.0% of the participants had depressive symptoms, and 21.8% had severe depressive symptoms. After controlling for potential confounders, transgender women with depressive symptoms remained significantly more likely to report several negative experiences of gender-based violence such as a feeling that co-workers or classmates were not supportive regarding their transgender identity (AOR = 2.00, 95% CI = 1.22–3.28), having difficulties in getting a job (AOR = 1.67, 95% CI = 1.29–2.16), having been denied or thrown out of housing (AOR = 1.53, 95% CI = 1.02–2.26), having difficulties in getting health services (AOR = 2.40, 95% CI = 1.50–3.82), having been physically abused (AOR = 1.54, 95% CI = 1.15–2.08), and having been fearful of being arrested by police or authorities (AOR = 2.18, 95% CI = 1.64–2.91) because of their transgender identity. Regarding their childhood experiences, transgender women with depressive symptoms remained significantly more likely to report that someone had tried to touch them or make them touch in a sexual way when they were growing up (AOR = 2.08, 95% CI = 1.61–2.68). Conclusions Transgender women in Cambodia experience high levels of gender-based violence and depressive symptoms. To address these concerns, a combination of service and policy interventions are required. These may include training and sensitization of trained and lay health providers in screening for depressive symptoms and integration of mental health services into facility- and community-based HIV services with enforcement of policies and laws that protect the rights of transgender women against gender-based violence.

Abstract 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.

Abstract Background 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. Methods 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). Discussion 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. Trial registration Clinical trials.gov, NCT03117842. Registered on 31 March 2017.

Abstract 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.

Abstract Background At-risk male youth in Cambodia who purchase sex are at greater risk for HIV compared to the general population. Factors associated with paying for sex among youth are poorly studied, both globally and in Cambodia. This study aimed to identify specific factors associated with transactional sex with women among most-at-risk male youth in Cambodia. Methods This cross-sectional questionnaire survey was conducted with 405 sexually active male youth aged 16–24 recruited at ‘hotspots’ in the capital city of Phnom Penh and seven provinces. We collected data on demographic factors, sexual behaviors, HIV testing and other potential factors. Multivariable logistic regression analysis was used to identify factors associated with transactional sex. Results In total, this study included 405 male youth with a mean age of 21.3 (SD = 2.2). Of the total respondents, 82.5% (n = 334) have ever paid for sex. After controlling for potential confounding, participants who purchased sex in the last 12 months remained significantly more likely to be older than 18 (AOR = 3.60, 95% CI = 1.26–10.62), reside in an urban area (AOR = 2.29, 95% CI = 1.24–4.20), never have been married (AOR = 9.58, 95% CI = 4.34–21.12), spend less than 2.55 USD per day (AOR = 2.22, 95% CI = 1.12–4.40), and have had more than 4.6 sexual partners in the past year (AOR = 16.73, 95% CI = 4.71–59.36). Conclusions This study highlights the high proportion of Cambodian male youth who paid for sex and the potential challenges to addressing this issue. While the majority of HIV prevention interventions surrounding sex work are aimed at female sex workers themselves, targeting the demand side of sex work, particularly the local demand, may be an important next step towards a sustainable HIV prevention.

Abstract 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.

Abstract 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.

Abstract Background Coping with chronic illnesses often involves major lifestyle changes that may lead to poor mental health. Furthermore, in order to treat the chronic conditions, many sufferers in Asia turn to traditional, complementary and alternative medicines (TCAM). This study explores prevalence of TCAM use and factors associated with anxiety and depressive symptoms among patients with chronic diseases in Cambodia. Methods In 2015, this cross-sectional study was conducted with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. Symptoms of anxiety and depression were assessed by using the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression models were constructed to explore factors associated with anxiety and depressive symptoms. Results The study participants included 1528 patients, of whom 77.2% were female, with a mean age of 46.5 years (SD = 15.3). After adjustment, patients with depressive symptoms remained significantly more likely to be in the age groups between 41 and 60 years old and to be married, separated/divorced or widowed compared to those without depressive symptoms. Regarding the use of TCAM, patients with depressive symptoms remained significantly more likely to report using an herbalist, practicing visualization and praying for own health, but less likely to report using vitamins or supplements in the past 12 months. For quality of life, patients with depressive symptoms remained significantly less likely to agree that they had enough energy for their everyday life and had enough money to meet their daily needs. Similar risk factors were also found to be significantly associated with anxiety symptoms. Conclusions Cambodian patients with chronic diseases who experienced symptoms of anxiety or depression were more likely to report reduced quality of life, greater chronic disease-related stigma and more TCAM use. Given the potential interaction of TCAM, mental health and other chronic conditions, a history of TCAM use and mental health should be elicited in clinical practices in primary health care settings, particularly in developing countries.

Abstract 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.

Abstract 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.

Abstract 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.

Abstract 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.

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.

Introduction This systematic review aims to determine if combination HIV prevention programmes include outcome measures for empowerment, inclusion and agency to demand equal rights and measure the relationship between empowerment and HIV prevention outcomes.Methods An electronic literature search of PubMed, POPLINE, Index Medicus and Google Scholar was conducted between August and October 2018. We included studies that evaluated combination prevention programmes that had all three types of intervention components and that specifically serve members of populations disproportionately affected by HIV published from 2008 to 2018. The selected studies were screened for inclusion, and relevant data abstracted, assessed for bias and synthesised.Results This review included a total of 15 studies. Findings indicate that combination HIV prevention programmes for marginalised populations have delivered a variety of theory-based behavioural and structural interventions that support improvements in empowerment, inclusion and agency. However, empowerment, inclusion and least of all agency are not measured consistently or in a standardised way. In addition, analysis of their relationships with HIV prevention outcomes is rare. Out of our 15 included studies, only two measured a relationship between an empowerment, inclusion or agency outcome and an HIV prevention outcome.Conclusion These findings suggest that policy-makers, programme planners and researchers might need to consider the intermediate steps on the pathway to increased condom use and HIV testing so as to explain the ‘how’ of their achievements and inform future investments in HIV prevention. This will support replication and expansion of programmes and ensure sustainability of the programmes.PROSPERO registration number CRD42018106909

Abstract Background The prevalence of HIV and sexually transmitted infections (STIs) among key populations in Cambodia continues to rise. To address this issue, KHANA, the largest national HIV organization in the country developed and implemented the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project. This study aims to determine the impacts of the SAHACOM on sexual behaviors and the uptake of HIV/STI services among men who have sex with men (MSM) in Cambodia. Methods We compared outcome indicators at midterm (n = 352) and endline (n = 394). Surveys were conducted in 2012 and 2014 in Battambang and Siem Reap provinces. A two-stage cluster sampling method was employed to select the study sample for structured interviews. Results The midterm and endline samples were similar. The average number of sexual partners in the past three months decreased significantly from 6.2 to 4.0 (p = 0.03). The proportion of MSM who reported paying for sex with men in the past three months also decreased significantly from 19.0 % to 9.7 % (OR = 2.0, 95 % CI = 1.3-3.0). No significant change was found in condom and lubricant use in all types of relationships. Regarding STIs, 28.1 % of MSM at midterm reported having at least one STI symptom in the past three months compared to 6.1 % at endline (OR = 4.6, 95 % CI = 2.9–7.4); out of them, 14.1 % of MSM at midterm sought treatment compared to 20.7 % at endline (OR = 2.6, 95 % CI = 1.1–6.9). The proportion of MSM who reported using illicit drugs in the past three months also decreased significantly from 12.2 % to 5.1 % (OR = 2.4, 95 % CI = 1.4–4.2). However, the proportion of MSM who reported having been tested for HIV in the past six months decreased significantly from 94.1 % to 77.1 % (OR = 2.9, 95 % CI = 1.8–3.6). Conclusions Findings from this study indicate that the SAHACOM was effective in improving sexual behaviors and related health outcomes among MSM under the project. However, it could not increase condom use and HIV testing rates among this key population. Tailored intervention programs are needed to improve condom use and HIV testing among MSM in Cambodia.

Background: Psychological and social problems are major concerns in this era of successful antiretroviral therapy. Although livelihood programs have been implemented extensively to improve the daily living conditions of people living with HIV in Cambodia, no studies have yet investigated the impacts of these programs on the mental health of this vulnerable population. Therefore, we examined the impact of a livelihood program on depressive symptoms and associated factors among people living with HIV in Cambodia. Design: A quasi-experimental, nonequivalent comparison group study was conducted in six provinces of Cambodia in 2014. Data were collected from an intervention group comprising 357 people living with HIV who had participated in the livelihood program and a comparison group comprising 328 people living with HIV who had not participated in this program. Multiple logistic regression analysis was carried out to examine the association between livelihood-program participation and depressive symptoms as measured by the depressive symptoms subscale of the 25-item Cambodian version of the Hopkins Symptom Checklist. A propensity score matching was used to examine the effect of the livelihood program on depressive symptoms while controlling for selection bias. Results: Overall, 56.0% and 62.7% of the participants in the intervention and comparison groups, respectively, met the Hopkins Symptom Checklist threshold for depressive symptoms. The multiple logistic regression analysis showed that the participants in the intervention group had significantly lower odds of having depressive symptoms (adjusted odds ratio 0.68, 95% confidence interval 0.52–0.88). The analysis from propensity score matching indicated that the livelihood program helped mitigate depressive symptoms among the participants in the intervention group (T=−1.99). Conclusions: The livelihood program appeared to help mitigate the burden of depressive symptoms among people living with HIV in Cambodia. Thus, this program should be scaled up and modified to better improve participants’ mental health.

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.

BACKGROUND:Entertainment 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 study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia. METHODS:Data 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. RESULTS:Most 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 a condom 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). CONCLUSIONS:This 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.