1

Kingdom of Cambodia Nation Religion King

Comprehensive report on HIV/AIDS activities in Cambodia

Quarter 1 2006

1. HIV/AIDS prevention activities Of the 30 specialized STI clinics, 24 (80.0%) are upgraded with laboratory support to perform RPR testing and basic microscopy (Annex: STI indicator 1). Of those, 11 are functioning and 13 are equipped but not yet functioning. This laboratory support enables specialized clinics to use refined algorithms for the syndromic management of STIs in high-risk populations. In the first quarter 2006, a total of 6,345 STI consultations were provided to sex workers of which 6,214 were monthly follow-up visits. Of the 6,214 sex workers who attended specialized clinics for monthly follow-up visits, 792 (12.8%) were diagnosed with a STI. 2. Comprehensive care for people living with HIV/AIDS (PLHA) 2.1. Availability of services To date, 27 Operational Districts (OD) in 17 provinces have established a Continuum of Care (Annex: CoC indicator). These CoC have been established in ODs that have OI/ART sites at the exception of Phnom Penh ODs. 2.1.1. VCCT Three new VCCT services have been opened in March 2006. These are Ksach Kandal in Kandal province and Chhlong and Snuol in Kratie province. Of the current 112 VCCT sites, 89 are supported directly by the Government, 19 by NGOs and 5 are private. Thus, a total of 107 VCCT sites operate in the public sector (Annex: VCCT indicator 1). 2.1.2. Health facility-based care (HFBC) services OI and ART services

Seven new OI/ART sites have been opened in the first quarter 2006. Those are Memut, Tbong Khmum, Choeung Prey located in Kampong Cham province, Kampong Chnang, Poipet in Bantey Manchey, Koh Thom in Kandal and Kampot RH. Of those new OI/ART sites, Kampong Chnang, Poipet and Kampot have started providing ART. Ang Roka RH has also started ART provision during this quarter. To date, 39 health facilities offer OI

Ministry of Health

National Center for HIV/AIDS, Dermatology and STD

2

x x x

x

OI/ART site (35 sites)

X OI Only site (4 sites) O CD4 Count Available 6 OI Only site (4 sites)

and ART services in 17 provinces. These OI and ART services are supported by the government and by partner NGOs. Of the total 39 OI/ART sites, 12 already provide pediatric care. 26 ODs have at least one facility that provides ART services (Annex: HFBC indicator 1). Five additional ODs have facilities that provide OI services and will start ART soon (Figure 1). Laboratory support The four leased CD4 FACScounts are still operational in 4 provinces (Takeo, Kompong Cham, Battambang and at NIPH in Phnom Penh). CD4 count is also available at Pasteur Institute in Phnom Penh and in Sisophon Banteay Manchey (US CDC) (Figure 1). A total of 7,953 CD4 counts have been conducted in Q1 2006 in the 4 provinces with the leased FACScounts.

Figure 1: Location of facility-based OI/ART sites and CD4 count services as of 31/03/06 Prevention of mother-to-child transmission (PMTCT) services Nine new PMTCT services (6 in Svay Rieng and 3 in Kampong Thom) have been opened in Q1 2006. To date Cambodia has 37 facilities that provide PMTCT services (Figure 2). A total of 23 ODs have at least one health facility providing PMTCT services (Annex: HFBC indicator 2 and PMTCT indicator 1).

OI/ART Sites

3

Figure 2: Location of facilities providing PMTCT services as of 31/04/06 2.1.3. Community-based services Home-based care (HBC) To date, there are 261 HBC teams in Cambodia (Annex: HBC indicator 1) (Figure 3). A total of 383 (about 40 %) health centers are linked to HBC teams (Annex: HBC indicator 4) within the CoC.

Figure 3: Trend in number of HBC teams form Q1 2005 to Q1 2006

250 248258 261 261

180

200

220

240

260

280

300

Q1 05 Q2 05 Q3 05 Q4 05 Q1 06

Year

Num

ber o

f HB

C te

ams

New PMTCT sites: - Svay Rieng 6: OD Svay Rieng: Chek HC and Svay Chrum HC OD Chiphu: HC Prey Angkunch and Chiphou RH OD Romeas Hek (RMH): Kampong Trach HC and RMH RH - Kg. Thom 3: OD Kg. Thom: Sro Yov HC OD Stoung: Stoung HC and Stoung RH

4

These HBC teams are currently supporting a total of 15,912 PLHA (Annex: HBC indicator 2). The 2006 target of 16,000 PLHA supported by HBC teams is nearly achieved. PLHA support groups (SG) Ninety new PLHA SG have been created in Q1 2006. To date 562 PLHA SG are active in Cambodia. These PLHA support groups are currently established in 14 provinces (source: CPN+ report). The number of active PLHA supported by these support groups increased from 15,753 in Q 4 2005 to 20,919 in Q1 2006 (Figure 4).

Figure 4: Trend in number of people supported by PLHA support groups

from Q1 2005 to Q1 2006 2. 2. Patient coverage

2.2.1. VCCT

A total of 50,137 persons have been tested for HIV at VCCT services in Q 1 2006 (Table 1). Of the total number of people tested, the vast majority (90.6%) were adults aged 15-49 and 27,161 (54.2%) were female. The HIV prevalence among VCCT clients was 8.7%, similar among men and women.

13,960 14,515 14,790 15,753

20,919

0

5,000

10,000

15,000

20,000

Q1 05 Q2 05 Q3 05 Q4 05 Q1 06

Quarter

Num

ber o

f PLH

A s

uppo

rted

5

People tested for HIV N= 50,137 No. (%)

People tested HIV positive N=4,370 No. (%)

Age ≤14 years 2,008 (4.0) 364 (8.3) 15-49 years 45,416 (90.6) 3,634 (83.2) > 49 years 2,713 (5.4) 372 (8.5) Sex

Male 22,976 (45.8) 2,001 (45.8) Female 27,161 (54.2) 2,369 (54.2) HIV status

HIV positive 4,370 (8.7) HIV negative or indeterminate 45,767 (91.3)

Table 1: Characteristics of clients tested at VCCT sites, Q1 2006 In Q1 2006, 99.7% (range: 63.8%-100% across sites) of VCCT clients who had a pre-test counseling were effectively tested for HIV and 97.7% (range: 88.6- 100 % across sites) of those tested received their result through post-test counseling (Figure 5). The target of 98% of people tested receiving post-test counseling is still nearly achieved (Annex: VCCT indicator 3).

Figure 5: VCCT cascade in Q 1 2006 This quarter, 2,391 VCCT clients were referred from the TB program. This data will be recorded over time to monitor progress of joint TB/HIV activities, in particular the efforts of HBC teams to ensure transportation of TB patients from the community to the nearest VCCT site.

(97.7%)48,966

50,137

50,298

48,000 48,500 49,000 49,500 50,000 50,500

Post-test

Tested

Pre-test

Number of pregnant women

(97.7%)

(99.7%)

6

The HIV prevalence among VCCT clients is still decreasing significantly over time with 8.7% of VCCT clients found HIV-infected in Q1 2006 compared with 9.7 % in Q4 2005 (figure 6).

Figure 6: Trend in HIV prevalence among VCCT clients from Q1 2005 to Q1 2006

2.2.2. OI and ART A total of 2,319 new patients were started on ART during the Q1 2006. To date, a total of 14,310 active patients, including 13,101 adults and 1,209 children are receiving ART, compared to 12,247 (1) in Dec 2005 (Figures 7, 8) (Annex: HFBC indicator 3).

1 The total number of people on ART at the end of 2005 was revised from 12,355 to 12,247 after corrections of some facility reports

7,3898,470

10,537

12,247

14,310

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006

Quarters

Num

ber o

f act

ive pa

tient

s on

ART

7,3898,470

10,537

12,247

14,310

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006

Quarters

Num

ber o

f act

ive pa

tient

s on

ART

12.5 1311.7

9.78.7

0

2

4

6

8

10

12

14

Q1 05 Q2 05 Q3 05 Q4 05 Q1 06

Quarters

HIV

pre

valle

nce

(%)

2006 target

7

Figure 7: Trend in number of active patients on ART from Q1 2005 to Q1 2006

Figure 8: Trend in number of active adult and child patients from Q3 2005 to Q1 2006 Gender equity in ARV treatment is still achieved, as female patients accounted for 48.4% of all patients. At OI/ART sites, 3,709 new patients started OI prophylaxis and 2,319 new patients started on ART in Q1 2006 (Figure 9). An average of 1,236 new patients was enrolled for OI prophylaxis and management each month and an average of 773 OI patients were enrolled on ART each month of Q1 06. The speed of ART scaling up is similar to that of the last semester 2005.

Figure 9: Trend in number of new patients on OI and ART from Q1 2005 to Q1 2006

9,62711,168

13,101

910 1,079 1,2090

2,0004,0006,0008,000

10,00012,00014,000

Q3 05 Q4 05 Q1 06

Quarter

Num

ber o

f act

ive

patie

nts

on A

RT

Adults Children

3205 3052

4225

32933709

1196

1867

24692134

2319

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Q1 05 Q2 05 Q3 05 Q4 05 Q1 06

New patients on OI care New patients on ART

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There were a total of 7,380 active OI adult patients not yet eligible for ART at the end of Q1 06. Of those, 4,829 (65.4%) were female, representing mostly spouses of male patients put on ART some years ago. Nation wide, 2,876 adult patients and 181 child patients enrolled in OI care were eligible for ART (WHO stage 4 and/or CD4 <200/mm3) but not yet on ART at the end of Q1 06. For all these patients to be included on ART in Q2 2006, there is a need to include more adults and children than the current rate. When we compare the data by site, a few sites have > 200 patients waiting to be started on ART and may have difficulties to catch up. These sites are namely Battambang RH, Takmao, Preah Bat Norodom Sihanouk hospital, Kossamak and Social Health clinic in Phnom Penh. Patient mobility across services

During Q1 2006, a total of 117 ART patients were transferred out to new ART sites located closer to their home residence. More than half of them were transferred from Siem Reap to Bantey Manchey and from Takeo to K. Trach in Kampot province. Survival

Some ART sites, namely Takeo, Siem Reap, Sotnikum, SH Center of Hope, Smach Manchey and Sisophon have been able to provide information on the status of their patients at the start of ART and on survival at 12 months. Most adult patients who started ART before January 2006 were WHO clinical stage III and IV at the start of ART (Table 2). At ART initiation the median CD4 count was < 60/mm3 at all sites. The proportion of patients diagnosed with tuberculosis (TB) at baseline varied from 29% to 54% across sites. The proportion of patients with ART experience at baseline varied from 1.4% to 8.1% across sites. All patients were started on first line regimen.

Takeo N=1,296 No. (%)

Siem Reap N=1,201 No. (%)

Sotnikum N=285 No. (%)

SH Center of Hope N=867 No. (%)

Smach Meanchey (Koh Kong) N=70 No. (%)

Sisophon (BM) N=289 No. (%)

WHO clinical stage I 55 (4.2) 52 (4.3) 12 (4.2) 0 1 (1.4) - II 121 (9.3) 181 (15.1) 17 (6.0) 42 (4.7) 2 (2.9) - III 629 (48.5) 618 (51.5) 102 (25.8) 273 (30.6) 28 (40.0) - IV

491 (38.0) 350 (29.1) 154 (54.0) 578 (64.7) 39 (55.7) -

Median CD4 count (IQR)

50 (14-137) 58 (17- 137) 55 (18 – 121) 55 (14-161) 21 (7-59) 57

TB diagnosed at baseline

645 (49.8) 524 (43.6) 118 (41.4) 281 (31.3) 20 (28.6) 155 (53.6)

ART experienced

41 (3.2) 97 (8.1) 22 (7.7) 69 (7.7) 1 (1.4)

-

Started on first line regimen 1,296 (100) 1,201 (100) 285 (100) - 57 (100) 289 (100)

Table 2: Baseline characteristics of adult patients started on ART before January 2006

At site providing pediatric care, the median CD4 % ranged from 7.6 to 9.2% across sites (Table3). The proportion of children with ART experience at baseline varied was 1.5% at Takeo. All children were started on first line regimen.

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Takeo N= 132 No. (%)

Siem Reap N=265 No. (%)

Median CD4 % (IQR) 7.6% (4-13.7)

9.2% (4.3-14.9)

ART experienced 2 (1.5)

-

Started on first line regimen 132 (100) 265 (100)

Table 3: Baseline characteristics of children patients started on ART before January 2006. At sites that provide adult care, the proportion of adult patients still alive and on ART after 12 months varies from 80.4% to 90.1% across sites (Tables 4, 5). Adult patient survival at 12 months is good and similar to that found in other countries (2). At the four sites with> 100 adult patients on ART, at least 80% of patients were still on first line regimen after 12 months. In the absence of viral load monitoring, this can be used as a proxi to estimate that the proportion of patients with HIV drug resistance (DR) suppression after 12 months on ART is probably ≥80%, meaning that the level of DR at these sites is low. Takeo

N=714 No. (%)

Siem Reap N=726 No. (%)

Sotnikum N=191 No. (%)

SH Center of Hope N=335 No. (%)

Transferred out (3) 64 17 2 0

(n=650) (n=709) (n=189) (n=335) Died

67 (10.3) 62 (8.7) 20 (10.6) 20 (5.9)

Lost to follow up

22 (3.4) 30 (4.2) 17 (9.0) 13 (3.9)

Still alive and on ART at same site

561 (86.3) 617 (87.0) 152 (80.4) 302 (90.1)

Still on first line regimen 561 (86.3) 612 (86.3) 151 (79.9) 288 (86.0)

Table 4: Outcome of adult patients who initiated ART before January 2005, at 12 months after ART start

2 Ferradini L, Jeannin A et al. Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment. Lancet 2006; 367:1335-42. Coetzee D, Hildebrand K, et al. Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa. AIDS 2004;18:887-95. Severe P, Leger P,et al. Antiretroviral therapy in a thousand patients with AIDS in Haiti. N Engl J Med. 2005 ;353:2392-4. 3 The patients transferred out to other sites were removed from the denominator since follow up and outcome data were not available at the same site

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Smach Manchey (Koh Kong) N=70 No. (%)

Sisophon N= 57 No. (%)

Transferred out 2 0

(n=68) (n=57) Died

15 8

Lost to follow up

4 1

Still alive and on ART at same site 49 (72.1) (4) 48 (84.2)

Still on first line regimen

48 (70.6) 47 (82.5)

Table 5: Outcome of adult ART patients for whom 12 months follow up data is available to date

At sites that provide pediatric care, the proportion of children still alive and on ART after 12 months was 93.2%, similar to that found in other countries (5) (Tables 6). Takeo

N=134 No. (%)

Siem Reap N=265 No. (%)

Transferred out 1 1

(n=133) (n=264) Died 9 (6.8) 8 (3.0)

Lost to follow up 0 10 (3.8)

Still alive and on ART at same site 124 (93.2) 246 (93.2)

Still on first line regimen 123 (91.8) 245 (92.8)

Table 6: Outcome of child ART patients for whom 12 months follow up data is available to

date 4 For patients who were started on ART in 2005 for whom we have 12 months follow up (n= 35), the survival rate at 12 months was 85.7%. 5 Chearskul S, Chotpitayasunondh T, et al . Survival, disease manifestations, and early predictors of disease progression among children with perinatal human immunodeficiency virus infection inThailand. Pediatrics.2002 Aug;110:e25

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2.2.3. PMTCT In Q1 2006, of 8,824 first ANC attendees at ANC clinics with PMTCT services, 5,510 (62.4%) were tested for HIV (Annex: PMTCT indicator 2). Of the total of women who came for their first ANC visit at PMTCT sites, 5,189 (58.8%) received their test result through post- test counseling (Annex: PMTCT indicator 3). Of the total number of couples in which the woman attended ANC clinics with PMTCT services for their first ANC visit, 1,353 (15.3%) husbands/partners also received post-test counselling (Annex: PMTCT indicator 4). Among women tested for HIV, 86 (1.7%) were HIV positive. Of 51 infants of HIV-infected mothers identified through PMTCT services who delivered in Q1 06, 49 (96.1%) received ARV prophylaxis, all of them single dose Nevirapine only, (Annex: PMTCT indicator 5) (Figure 10).

Figure 10: PMTCT cascade at ANC clinics with PMTCT services in Q 1 2006

2.2.4. TB/HIV collaboration In December 2005, 100 health centers have been selected in 12 ODs in 7 provinces, namely Svay Rieng, Prey Veng, Takeo, Kampot, Sihanoukville, Kandal and Siem Reap, to intensify TB/HIV collaborative activities. In particular, health centers with HBC teams facilitate the transportation of TB patients from the community to the nearest VCCT site for HIV testing. NCHADS and CENAT have just started collecting data on cross referrals from TB to HIV services. In Q1 2006 in the seven selected provinces, of the 4,015 newly diagnosed TB cases, 862 (21.5%) attended VCCT services for HIV testing (Table 7). Of those, 314 (7.8%) were actually transported by HBC teams from their community (HBC indicator 3). HBC teams reported that 94

49

86

5,189

5,510

8,824

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

ARV to mother and infant

HIV-positive

Test result given

HIV tested

First ANC visit

Number of pregnant women

12

(29.9%) of the 314 TB patients they transported to VCCT were found HIV-infected and referred to OI/ART services.

7 provinces N=4,015 No. (%)

Kampot N=288 No. (%)

Kandal N=828 No. (%)

Prey Veng N=788 No. (%)

Siem Reap N=726 No. (%)

Sihanoukville N=115 No. (%)

Svay Rieng N=625 No. (%)

Takeo N=645 No. (%)

Seen at VCCT services

862 (21.5)

49 (17.0) 121 (14.6) 355 (45.1) 77 (10.6) 13 (11.3) 93 (14.9) 154 (23.9)

Transported by HBC teams

314 (7.8) 29 (10.1) - 221 (28.0) 18 (2.5) - 24 (3.8) 22 (3.4)

Table 7: Referral of newly diagnosed TB patients to VCCT for HIV testing in 7 provinces

with specific TB/HIV collaborative activities during Q1 2006

3. Training

3.1. VCCT

During Q1 2006 29 nurse counselors and 25 laboratory technicians had refresher training. 3.2. OI/ART

The initial training for OI/ART teams include a five month initial in-service course for clinicians, a 3 week course for counselor nurses, a 3 week course for drug and logistic managers, and short training activities for auxiliary staff. OI/ART teams also receive “secondment” training which consists in an extensive visit of an existing and running OI/ART before they actually start their new site. Since 2004, 96 clinicians (Annex: HFBC indicator 4), 57 nurse counselors and 30 drug and logistic managers have been trained. 3.3. PMTCT

In 2005, 114 health care workers (midwives and nurses) were trained on counseling for PMTCT (Annex: PMTCT indicator 7). 3.4. Provincial data management

Data managers for the five provinces of Siem Reap, Sihanoukville, Pursat, Prey Veng and Battambang have been trained on HIV/AIDS data management in Q1 2006.

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4. Drug and logistic support To date, none of the OI/ ART sites had stock-outs of essential ARVs (Annex: HFBC indicator 5) In Q1 2006, all ART sites were able to report the number of patients on each ART regimen. Most prescribed regimens were d4t+3TC+NVP, d4t+3TC+EFV and AZT+3TC+NVP, whereas 1.5% of adults and 1.1% of children were on PI-based regimens (Table 8). ARV drug regimen

Adults N= 13,341(6) No. (%)

Children N= 1,233 (6) No. (%)

d4t+3TC+NVP 7,355 (55.1) 942 (76.4) d4t+3TC+EFV 2,244 (16.8) 241 (19.5) AZT+3TC+NVP 2,346 (17.6) 30 (2.4) AZT+3TC+EFV 995 (7.5) 5 (0.4) PI-based regimens 205 (1.5) 13 (1.1) Other regimens 196 (1.5) 2 (0.2) Table 8: Distribution of antiretroviral drug regimens prescribed for HIV infected patients in Cambodia, 31 March 2006

6 More regimen data are available than actual the number of active patients on ART because some sites probably still report ARV regimen of patients who have died or were lost to follow-up

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ANNEX: Monitoring and Evaluation indicators STI Indicators (NCHADS) 2006 target

No. (%) Q1 2006 score No. (%)

1 Number and percent of specialized STI clinics with laboratory support to perform RPR and basic microscopy

29 24 (80.0%) including 11 functioning and 13 equipped but not yet functioning

2 Proportion of DSWs diagnosed with cervicitis during monthly follow up consultations at specialized STI clinics

< 25% Not yet available

3 STI prevalence among DSWs ( N Gonorrhea and/or Chlamydiae trachomatis)

<25% Results not yet disseminated

Continuum of Care Indicators (NCHADS) 2006 target

No. (%)

Q1 2006 score No. (%)

1 Total number of Operational Districts with a Continuum of Care 30 27 VCCT indicators (NCHADS) 2006 target

No. (%) Q1 2006 score No. (%)

1 Number of licensed VCCT sites operating in the public and non-profit sectors

125 107

2 Number and percentage of adults (aged 15-49) who received HIV counseling and testing ++

169,000? (2.6%) at year end

45,416

3 Percentage of those tested who received their result through post-test counseling

98% 97.7%

4 Number (%) of VCCT clients that were referred from TB program - 2,391 (4.8%)

Health Facility Based Care Indicators (NCHADS) 2006 target

No. (%) Q1 2006 score No. (%)

1 Number (%) OD (7) with at least one center that provides ART services

30 26

2 Number (%) OD with at least one center that provides PMTCT services

23 19

3 Number of AIDS cases on HAART 11,999 adults

13,101 adults including 6,343 (48.4%) female + 1,209children 14,310 total

4 Cumulative number clinicians trained to provide ARVs 75 96

5 Number (%) OI/ ART sites with one or more stock-outs of essential ARVs

0% 0%

6 % people on ART alive 12 months after initiation >80% >80%

7 Cambodia has 24 provinces, 76 ODs, including 68 ODs with referral hospitals.

Home Based Care Indicators (NCHADS) 2006 targetNo. (%)

Ql 2006 scoreNo. (%)

I Total number of HBC teams actively providing home-based careand support services to PLHA

270 261

aL Number of PLHA supported by HBC teams 15,000 15,912

aJ Number of TB patients referred by HBC to VCCT 5,000 314

4 Number (percent) of HC with HBC teams35%:o of 942HC

383 (40.7%)

PMTCT Indicators (NMCHC) 2096targetNo. (%)

Ql 2006 scoreNo. (%)

# PMTCT sites 3 5 J I

2 # (%) ODs with at least one facility offering the minimumoackase of PMTCT services

LJ^ 1

J % ANC I women who received HIV testine at PMTCT sites 62.4%A? % ANC I women who receive post-test counsellins 58.8%5 % husbands and/or partners that receive post-test counselling

throush PMTCT prosramt53%

6 # (%) children born to HIV positive mothers, identifiedthrough PMTCT program that received a complete course ofantiretrovi ral orophylaxi s

4e (e6.1%)with SD NVP

7 # (%) children born to HIV infected mothers who receivedARV prophylaxis at birth and are HIV infected at l8 months

Not available

Seen and ApprovedDirector of NCHADS

Data Management Unit

Mr. Mam Sovatha

Phnom Penh, [] June 2006

Dr. Nicole Seguy