CAMBODIA: Focus on MSM and the spread of HIV/AIDS

CAMBODIA: Focus on MSM and the spread of HIV/AIDS
30 Jan 2007 08:26:51 GMT
Source: IRIN

PHNOM PENH, 30 January (IRIN) - As dusk falls along the banks of the
Tonle Sap River, opposite the Royal Palace in Phnom Penh, the
Cambodian capital, Noun, 35, a married engineer, stops at his
favourite vantage point on his route home each evening, a popular
cruising site for Cambodian gays, where last month alone he met seven
different partners.

Noun's world is a complex one, riddled with deception and hypocrisy in
this otherwise conservative Khmer society. "I'm not gay," he said. "I
just like having sex with men."

Such an assertion is not unusual in many South East Asian nations,
including Cambodia. In less than an hour's time he will return to his
wife and two children about a kilometre away - none of whom are any
the wiser about his activities.

Men who have sex with men (MSM) could well prove a pivotal part of
Cambodia's bid to mitigate the spread of HIV/AIDS. "This is the hidden
MSM population, who not only have sex with men, but also have sex with
female partners," Tony Lisle, Country Coordinator for the Joint United
Nations Programme on HIV/AIDS (UNAIDS) in Cambodia, told IRIN.

Penetrating Noun's world, and others like it, could be the most
difficult challenge, but failing to do so could accelerate the spread
of the pandemic among the country's 14.5 million people.

CURRENT PREVALENCE RATES

Cambodia has the highest HIV/AIDS prevalence in South East Asia, but
has also made significant inroads against the disease since it first
appeared in 1991. According to UNAIDS, the estimated level of
infection among adults has dropped from a high of 3 percent in 1997 to
1.6 percent in 2006, which can be partly attributed to increasing HIV
mortality as those infected during the period of peak HIV incidence
move into AIDS.

Current surveillance data also suggest that the epidemic, largely
driven by the continued patronage of commercial sex workers by
Cambodian men, is changing: behavioural data now show consistently
higher rates of condom usage in the sex industry, largely the result
of enhanced public information campaigns and an assertive effort to
promote 100 percent condom usage.

HIV incidence among sex workers and their clients appears to have been
dramatically reduced, as corroborated by a reduction in the prevalence
of other sexually transmitted infections (STIs) among them, but sexual
networking continues to shift towards casual sex, making MSM as a risk
group all the more important.

MSM PREVALENCE RATES

Prevalence in the general population has also declined in recent
years, but health workers warn there is little room for complacency.
According to the latest survey by the Cambodian National Centre for
HIV/AIDS Dermatology and STDs (sexually transmitted diseases), the HIV
prevalence rate among MSM in Phnom Penh is 8.7 percent, and their
networking behaviour has become a serious source of concern.

Of the 58 percent of men surveyed in three provinces - Phnom Penh, in
the south, and Batdambang and Siem Riep in the northwest - who
reported having sex with female partners in the past year, almost 25
percent also reported having sex with female sex workers, with 16.6
percent having had sex with casual female partners in the past month.

"When you have a very dense network, and when you have crossovers in
the network between males and females, in the presence of high risk of
STIs and in the presence of very low condom usage, then you have a
potential for an explosive epidemic," Lisle warned.

"You're looking at multipartner behaviour," the UNAIDS official said,
pointing out that not only were the men putting themselves at risk,
but also the women they slept with.

MSM - A GLOBAL PHENENOMENON

Male-to-male sex is found in every culture and society, and is often
defined as a social and behavioural phenomenon rather than a specific
group of people. Although the description may include men who identify
themselves as being homosexual or gay, bisexual or transgender, it can
also include men who identify themselves as exclusively heterosexual
and are often married, particularly where discriminatory laws or
social stigma exist.

The manner in which Cambodian MSM define themselves blurs this
distinction even more: according to a 2004 study of 1,306 MSM by
Family Health International (FHI), 'Men Who Have Sex with Men in Phnom
Penh, Cambodia: Population Size and Sex Trade', there are four times
more of what are described locally as 'short-haired MSM' (masculine-
acting MSM who have sex with each other) than 'long-haired
MSM' (transgender MSM whose masculine sexual partners identify
themselves as being from either group).

Relations between the two groups are not always cordial. Short-haired
MSM enjoy a degree of privacy by being less visible than long-haired
MSM, who tend to be more conspicuous, have a great deal of difficulty
in securing employment and are often thrown out of their homes.

A recent report on 'MSM and HIV/AIDS Risk in Asia', by Therapeutics
Research Education AIDS Training Asia (TREAT Asia), found that short-
haired MSM were more likely to receive money for sex (20 percent
regularly and 41 percent occasionally).

RISK AND AWARENESS

In terms of HIV risk, male-to-male intercourse is significant in that
it can involve anal sex, which, when unprotected, carries a risk 10
times greater than unprotected vaginal intercourse does for the
receptive partner. At least 5 percent to 10 percent of HIV infections
worldwide are estimated to occur via MSM but, according to UNAIDS,
this figure varies considerably between countries and regions.

(table width="250" border="0" cellspacing="2" cellpadding="2"
align="right")(tr)(td)(table width="100%" border="0" cellspacing="2"
cellpadding="2" style="border: 1px solid #cccccc")(tr)(td)(img
src="http://www.irinnews.org/images/200611721.jpg"; height="188"
width="250" border="1" alt="")(br)(font size="1" face="Arial,
Helvetica, sans-serif")Sou Sothevy, 67, began working as a transgender
sex worker when she was 14, even selling sex during the Pol Pot
regime. Today she is one of Cambodia's leading advocates on issues of
HIV.(br)Credit: David Swanson/IRIN(/font)

(/td)(/tr)(/table)(/td)(/tr)(/table)Many Cambodian men are unaware of
these obvious risks. "It can be very difficult to reach MSM," Lisle
said, particularly those who might be classified as short-haired MSM
and therefore do not necessarily identify themselves as homosexual.

A government report, 'Turning the Tide - Cambodia's Response to HIV/
AIDS 1991-2005', identified the need to promote better understanding
of risks and behaviour change, encourage consistent condom use among
MSM, and to consider them not only a high-risk target group, but to
involve them in the planning and implementation of prevention
interventions.

A study of sexual behaviours, STIs and HIV among MSM in Phnom Penh,
undertaken by FHI in 2000, documented an alarming HIV prevalence rate
of 14.4 percent - approximately equivalent to the rate among informal
sex workers at the time - aggravated by drug use among 24 percent of
the sample population.

Although the government has begun to acknowledge MSM in its
intervention efforts, the researchers found that NGOs and community-
based organisations had only recently started implementing programmes
to reach this group.

ACCESS TO HEALTH CARE

Men's Health Cambodia (MHC) in Phnom Penh, established in 2002 and
funded by FHI, was the first NGO dedicated to addressing the health
needs of short-haired MSM in its drop-in centre and outreach
programme.

According to UNAIDS, fewer than one in 20 MSM have access to the HIV
prevention and care services they need - a figure largely in line with
global indicators.

Of the 30 men visiting the MHC centre weekly, most are concerned about
STIs and HIV testing, while others seek counselling to deal with their
sexual identity in a country that frowns on homosexuality.

After successful awareness interventions, condom usage overall appears
to be increasing, but the Executive Director of MHC, Mao Kimrun, 32,
said much more needed to be done. "Not everyone understands the risks
- there are still misconceptions that MSM are not at risk," he
asserted. "Condom usage is still not widespread, and many men cannot
afford them."

MHC runs a daily outreach programme in parks and other locations that
MSM might frequent. "They usually ask me about HIV/AIDS or STIs, and
they want to know about safe sex practices," Thavro Dum, an MHC
outreach member, told IRIN/PlusNews as he readied his motorcycle to
make his evening rounds.

He said MSM were often aware of HIV transmission and prevention, but
did not always know how to apply this knowledge to their own behaviour
to avoid risking infection.

As confirmed by the TREAT Asia report, condoms are imported and
expensive, which limits access, except when offered in social
marketing programmes; secrecy exacerbated the situation - some MSM
even based their HIV-risk assessment on whether a potential partner
appeared to have good personal hygiene or not; male sex workers were
often unable to negotiate condom use and generally did not use
lubricant, because clients "would know for sure that they are non-
female".

"I'm afraid of HIV/AIDS," said Eam Vanndy, 27, a male sex worker who
arrived in the capital three years ago in search of a job. He told
IRIN/PlusNews his customers paid between $5 and $10, and he always
used a condom. "Many of my friends are pretty boys [long-haired MSM].
Some use condoms; many do not."

Such stories are not unusual in a country where poverty is rife and
drives a growing number of people to work in the sex trade.

Sou Sothevy, 67, who has been a transgender sex worker since she was
14 and still works occasionally, commented, "Although MSM are aware of
the risks, they don't always use condoms with their partners. Some
male sex workers forego the usage of the condom for more money."

She spends most of her time as a local team leader in a network of
some 5,000 sex workers - the Women's Network for Unity - and also
serves on the national steering committee as an elected
representative. Sothevy, who has been living with HIV for over 10
years, believes most people have some awareness of the risk factors,
but remain careless. "Many use drugs, including heroin," she said.

"Cambodia is a very conservative country and there is discrimination
towards MSM, not just from the family, but society as a whole," she
pointed out. As a team leader, she monitors members' needs and keeps
an eye out for new sex workers in her local area. Nationally, the
network advocates for access to medicines and undertakes research for
NGOs, United Nations agencies and the government by sex workers and
the HIV-positive community.

Changing people's perceptions would not be easy said Sear Young Tan,
39, of the recently established National MSM Network, which aims to
eliminate stigma and discrimination against MSM, and promote equal
access to HIV- and MSM-related information and services.
"Discrimination against MSM is very much part of Cambodian life, both
in the family and society at large," the clothes-maker and makeup
artist noted.

"This makes the fight against HIV/AIDS all the more difficult," he
said, reiterating the fact that many MSM do not think of themselves as
MSM - even when they have sex with men. "It's just for pleasure and
means nothing."

But with many short-haired MSM engaging in more sexual encounters than
long-haired MSM - some having up to five different partners a week -
he said, getting the message out to this group should be an integral
part of the country's intervention efforts.

Most Cambodians are unaware of how many masculine-acting - and often
married - men are sexually active with other men, heightening the risk
of spreading the virus among the general population.

One MSM focus group participant in rural Cambodia cited in the TREAT
Asia report remarked: "I had a lot of friends, but my friends who have
sex with the same gender ... are all dead. Now it is only me here."

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