HIV Risk and Psychological Distress among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Background: In Cambodia, there has been an increase in entertainment work as a result of the breakdown of the traditional brothel-based sex industry, presenting new challenges to addressing the health issues and needs of people working in the entertainment industry. This study aims to identify factors associated with psychological distress among female entertainment workers (FEWs) in Cambodia. Methods: A two-stage cluster sampling method was used to randomly select 657 FEWs from entertainment establishments in Phnom Penh and Siem Reap in April and May 2014 for interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12), and multivariate logistic regression analysis was conducted. Results: Almost half of FEWs (43.2 %) had a higher level of psychological distress (GHQ-12 \u3e 3), while 19.5 % reported having suicidal thoughts, and 7.3 % reported having attempted to commit suicide in the past 3 months. Controlling for confounding factors, women with a higher level of psychological distress were significantly more likely to rate their overall health (AOR = 1.88, 95 % CI 1.20 to 2.94) and quality of life (AOR = 2.39, 95 % CI 1.47 to 3.87) as poor. They were also significantly more likely to have suicidal ideation (AOR = 2.41, 95 % CI 1.45 to 3.76), rate their HIV risk as higher than the general population (AOR = 0.48, 95 % CI 0.31 to 0.74), have been forced to drink at work (AOR = 1.77, 95 % CI 1.19 to 2.62), have had clients requesting not to use a condom (AOR = 3.48, 95 % CI 1.14 to 10.62), be not able to find condoms when they needed it (AOR = 0.64, 95 % CI 0.45 to 0.93), have had a family member who said hurtful things to them during childhood (AOR = 1.84, 95 % CI 1.24 to 2.75), and have had a parent or guardian who had been physically abused (AOR = 1.93, 95 % CI 1.34 to 2.82). Conclusions: FEWs in Cambodia experience high levels of psychological distress, which likely stems from both past negative experiences and current working conditions. For women that are experiencing psychological distress, intervention programs aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk

Prevalence and correlates of psychological distress among drug users in Phnom Penh, Cambodia

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

Factors Associated with Induced Abortion among Female Entertainment Workers: A Cross-Sectional Study in Cambodia

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

How Understanding and Application of Drug-Related Legal Instruments Affects Harm Reduction Interventions in Cambodia: A Qualitative Study

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

Factors Associated with Recent HIV Testing among High-Risk Men Who Have Sex with Men: A Cross-Sectional Study in Cambodia

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

Are Text Messages a Feasible and Acceptable Way to Reach Female Entertainment Workers in Cambodia with Health Messages? A Cross-Sectional Phone Survey

Background: Despite great achievements in reducing the prevalence of HIV, eliminating new HIV infections remains a challenge in Cambodia. Entertainment venues such as restaurants, karaoke bars, beer gardens, cafes, pubs, and massage parlors are now considered important venues for HIV prevention efforts and other health outreach interventions. Objective: The purpose of this study was to explore phone use and texting practices of female entertainment workers (FEWs) in order to determine if text messaging is a feasible and acceptable way to link FEWs to health services. Methods: This cross-sectional phone survey was conducted in May 2015 with 97 FEWs aged 18–35 years and currently working at an entertainment venue in Phnom Penh. Results: Of the 96 respondents, 51% reported sending text messages daily; of them, 47% used Khmer script and 45% used Romanized Khmer. Younger FEWs were more likely to report daily texting (P Conclusions: The findings from this study support the development of mHealth interventions targeting high-risk groups in urban areas of Cambodia. Our data suggest that mHealth interventions using texting may be a feasible way of reaching FEWs in Phnom Penh

Determinants of Inconsistent Condom Use among HIV Serodiscordant Couples in Cambodia

Background: Globally, heterosexual transmission within serodiscordant relationships is a significant source of new HIV infections. In 2012, there were an estimated 1,350 incident cases of HIV in Cambodia, of which 37% were between heterosexual couples and 30% among sex workers. In combination with antiretroviral therapy (ART), consistent condom use can significantly reduce HIV transmission risk among serodiscordant couples. This study explored determinants of inconsistent condom use among serodiscordant couples in Cambodia. Methods: A cross-sectional study was conducted in Battambang, Pursat and Takeo provinces in September 2013. A structured questionnaire was used to collect data on condom use and other HIV-related risk behaviors from HIV-positive partners of 262 serodiscordant couples. A two-stage cluster sampling method was used to randomly select participants from a list of serodiscordant couples who were receiving care and support services from community-based organizations in the selected sites. Multivariate logistic regression analysis was conducted to identify factors associated with inconsistent condom use. Results: In total, 239 respondents were included in the analysis with a mean age of 41.6 years [standard deviation (SD) = 6.7 years], of whom 60.2% were male and 80.3% were consistent condom users. The mean duration of living in the serodiscordant relationship was 13.4 years (SD = 7.8 years). After controlling for other covariates, inconsistent condom users were significantly more likely to be female (OR = 2.8; 95% CI = 1.261, 6.462), to have been living in a shorter HIV serodiscordant relationship (OR = 0.89; 95% CI = 0.902, 0.998), and to be frequent alcohol users (OR = 2.9; 95% CI = 1.323, 6.483). In addition, inconsistent condom users were significantly more likely to agree that ART prevents transmission of HIV (OR = 2.7; 95% CI = 1.344, 5.443). Conclusions: Gender-sensitive interventions to promote consistent condom use and to mitigate alcohol-associated risky sexual behaviors, especially unprotected sex, should form part of HIV prevention interventions for serodiscordant couples in addition to early ART initiation. Further research is required to explore the role of pre-exposure prophylaxis among this population

Transition into Adult Care: Factors Associated with Level of Preparedness among Adolescents Living with HIV in Cambodia

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

Social Return on Investment: A Cost-Benefit Analysis of the HIV Integrated Care and Prevention Programs in Cambodia

Background: KHANA’s HIV Integrated Care and Prevention (ICP) project provided comprehensive care and support to HIV-affected communities through home and community-based care teams from 2007 to 2011. The aim of this study was to use Social Return on Investment (SROI) methodology to evaluate the social, health, and economic impacts of the ICP project, enabling the calculation of a ratio cost-to-benefit for the community in terms of HIV care, support, and treatment. Methods: The SROI methodology is a social cost-benefit analysis framework that measures and accounts for the values created by a program or series of initiatives. Values were mapped to common outcomes of the project, which were defined by key beneficiaries during a community consultation exercise. Five stages were used to calculate the SROI: establishing scope and identifying key stakeholders, mapping project outcomes, assigning a financial value to project outcomes, establishing project impact, and calculating inputs. Results: A combined five-year investment of approximately US$2,406,000 from the European Commission (EC), plus US$1,957,934 from the World Food Programme (WFP) and community inputs, generated total benefits worth US$10,894,835, after adjusting for the discount rate and Purchasing Power Parity (PPP). Monetized outcome values ranged from$30, avoided cost of informal school fees paid by orphans and vulnerable children (OVC), to $1,200, avoided burden of debt and asset loss caused by health costs prior to diagnosis. Beneficiaries gaining the most outcome value were people living with HIV (PLHIV), OVC, and their families (food security outcome 51$1 invested in the ICP generated a return of approximately $2 worth of social, health, and economic value. Conclusions: The ICP program yielded substantial impacts in food security, wellbeing, improved health, and improved productive capacity, which enabled greater economic returns for the households. Results of this study have been used to inform project management, implementing partners, and policy-makers to further explore areas of benefit for PLHIV, OVC, and their families