New report finds Cambodia's HIV/AIDS fight at critical crossroads in funding, prevention

Despite Cambodia's remarkable history in driving down HIV infections, a report released today on the future of AIDS in the country argues that future success is not guaranteed and the government needs to focus increasingly on wise prevention tactics and assume more of the financing of its AIDS program.

The report, called The Long-Run Costs and Financing of HIV/AIDS in Cambodia, written by Cambodian experts working closely with staff of the Results for Development Institute (R4D), based in Washington, D.C., finds that Cambodia, in a best-case scenario, could reduce the infections to 1,000 people a year in 2031 – a half-century after AIDS was first identified. That is down from an estimated 2,100 infections last year and from the peak of 15,000 a decade ago.

But the report's authors also say that if Cambodia's AIDS efforts stall and current coverage of key services declines, especially in carefully targeted prevention, the number of infections could climb to 3,800 a year in 2031 – nearly a four-fold increase over the best-case scenario. The report concludes that the government's successful track record will only be maintained if it scales up prevention services for the most at-risk populations, such as sex workers, men having sex with men, and injecting drug users.

"We welcome this in-depth and forward-looking report for our country," said Cambodia's Minister of Health H.E. Dr. Mam Bunheng. "Cambodia has a long history of fighting HIV/AIDS head-on, with effective prevention strategies, and we believe that this report will help us sharpen our strategies. Our goal is to further prevent the number of HIV infections in our country and we will continue on that path."

In Cambodia, HIV/AIDS was first identified in 1991. Only a few years later, experts warned that the epidemic had taken off rapidly and that Cambodia risked becoming the Asian country with the worst AIDS problem. In response, the country attacked the epidemic vigorously, earning international recognition for its success. Between 1998 and last year, Cambodia dramatically reduced new infections and made anti-retroviral treatment widely available. By 2009, an estimated 93 percent of those eligible for AIDS drugs were receiving them.

Still, Cambodia's AIDS epidemic, fueled largely by unprotected heterosexual sex between men and female sex workers, remains volatile and could spread rapidly without targeted prevention efforts, the new report says.

The cost of the national AIDS program also has grown from US$21 million in 2003 to US$51.8 million in 2008, raising some concerns among government and donor officials about their ability to sustain a growing level of spending to fight the epidemic over the years to come. Donors now fund 90 percent of Cambodia's AIDS program.

The report is the third in a series of studies done by the financing group of aids2031, an international initiative that has brought together some of the world's experts on AIDS. The group also issued a report on the global trends in financing the AIDS fight, which was summarized in a paper published earlier this year in The Lancet, and a report on South Africa's epidemic, which was released in mid-November.

Robert Hecht, managing director of R4D and overall coordinator of the series of reports, said that the Cambodian study has particular significance for countries in Asia, Latin America, and Eastern Europe that are fighting AIDS epidemics largely confined to specific at-risk groups.

"Cambodia is an important example of a country that was facing a possible catastrophe a decade ago and has averted that thanks to bold actions," Hecht said. "But there's no room for complacency. This is the moment for Cambodia to strike a bargain with its outside funders such as the Global Fund, Australia, and the U.S. If these funders maintain a modest level of financial support to help preserve Cambodia's gains to date, the government can gradually step in to assume fuller and more sustainable funding of its AIDS program."

H.E. Dr. Mean Chhi Vun, Director of the National Centre for HIV/AIDS, Dermatology and STD, said that the report comes at an important time for the Cambodian government as it begins to assume more of the cost of AIDS programs from donors. "This report will play a key role in our discussions on how to move forward," Dr. Vun said. "We are committed to finding the most cost-efficient solutions as well as the most effective programs. We will draw upon our own experiences over the last decade and more, but we will also use these important findings to help guide us."

The report examines the costs in fighting Cambodia's epidemic under various strategies, ranging from US$ 1.4 billion during 2009 to 2031 under the current plan, to US$2.3 billion over the 22-year period in a dramatically stepped-up prevention plan – a differential of $900 million, or nearly 40 percent. The report's authors recommend a third course that stops nearly as many new infections as the most expensive approach, but costs much less because it emphasizes spending selectively on the highest impact prevention services, such as promoting consistent condom use in high risk settings.

"Cambodia has many choices in front of it," said Dr. Vonthanak Saphonn, the lead Cambodian author of the report and Deputy Director of the National Institute of Public Health. "Our recommendation is that Cambodia needs to focus investments on HIV/AIDS in those areas that are most cost-effective. This may mean that the country has to evaluate each intervention and focus on those that are contributing the most to the national program in a cost-effective manner."

Richard Skolnik, a professor of public health at George Washington University and the lead technical adviser to R4D on the project, said he believes the country's past history of success in fighting AIDS bodes well for the future. But he said difficult financial decisions will have to be made now.

"We have every reason to believe Cambodia can continue its effective fight against the epidemic," Skolnik said. "But Cambodia is very dependent on its external partners on financing, and if they don't put enough government money into the program and focus on the wisest investments, even this outstanding program could be threatened."

Tony Lisle, UNAIDS Country Coordinator for Cambodia, welcomed the report and said he hoped it would make a strong contribution to the country's ongoing fight against AIDS. "I hope this provides an opportunity for Cambodian officials to intensify their already strong efforts against AIDS with the kind of vigor it has shown in the past," Lisle said. "Cambodia has been a shining example around the world when it comes to lowering HIV infections, and I believe it can now make further adjustments that will allow it to remain a leader."