Cambodia has an estimated population of 13.8 million (2010), and epidemiological data show that the country’s HIV epidemic is concentrated and has particularly affected sex workers, people who inject drugs and men who have sex with men. According to the most recent estimates, about 63 000 people were living with HIV in the country in 2009.
Despite a fragile health care system debilitated by decades of civil war and despite being a low-income country (annual gross national income per person of US$ 710 (51)), Cambodia has been able to implement a comprehensive and effective national HIV response. The prevalence of HIV infection has declined from an estimated 2.0% among people 15–49 years old in 1998 to a projected 0.7% in 2010, and it has been able to achieve universal access targets for antiretroviral therapy, with close to 43 000 people receiving antiretroviral therapy, or 92% of adults and children who need it (Table 5.7). Cambodia has achieved this by leveraging high-level political support to develop an evidence-informed, integrated and decentralized national response.
Antiretroviral therapy was introduced on a small scale in 2001, but rapid scale-up was hampered by the uncoordinated efforts of multiple actors, limited capacity and poor infrastructure of local health facilities and a high level of stigma and discrimination against people living with HIV. To address these constraints and create a comprehensive and sustainable national antiretroviral therapy programme, the National Center for HIV/AIDS, Dermatology and STD (NCHADS) led the establishment of the Continuum of Care Framework in 2003, based on district-level services that emphasized teamwork, community links, including through home-based care, and a public health approach to service delivery.
HIV health services were progressively expanded in a coordinated way to cover most of the country’s operational districts. In 2008, NCHADS and the National Maternal and Child Health Center introduced a collaborative strategy called the “Linked Response”, which provided a comprehensive approach to preventing mother-to-child transmission, including HIV testing and counselling at the health centre level.
Similarly, NCHADS and the National Center for Tuberculosis and Leprosy Control accelerated TB and HIV collaborative activities, including HIV testing and counselling for people with TB in health centers and the three I’s for HIV and TB (section 5.4.2) at the operational district level.
National policies have also been put in place to provide a continuum of prevention to care and treatment services for key populations at higher risk of HIV infection, including sex workers, men who have sex with men and people who inject drugs. Access to health services has been improved by enhancing links and referral mechanisms between community outreach programmes and HIV testing and counselling, HIV care and treatment and sexual and reproductive health services.
Attention is also given to measuring and improving the quality of the HIV care and treatment programme. Coordination meetings are held regularly, mentoring is provided to district and health centre staff and national and regional network meetings for clinicians and counsellors facilitate the exchange of experiences and best practices. A strategy for tackling HIV drug resistance has been adopted, including monitoring for early-warning indicators, and a strategy for continuous quality improvement is currently being rolled out. Each operational district is supported in collecting indicators that measure the quality of management of health service users across the continuum of care and to implement appropriate corrective measures.
Table 5.7 Selected national indicators of HIV care and treatment, Cambodia, 2010
Number of people receiving antiretroviral therapy 43 000 (39 000 adults and 4 000 children)
% of people on antiretroviral therapy among those who need it 92% [68%–>95%]
Adults alive and receiving antiretroviral therapy at 12, 24 and 60 months 86% (12 months), 84% (24 months) and 78% (60 months) Median CD4 county at pre-antiretroviral therapy enrolment 197 per mm3
% newly registered in pre-antiretroviral therapy care screened for TB 64%
% of pregnant women who were tested for HIV and received the test result 57%
5.3.2 Access to antiretroviral therapy among women and children
A total of 136 low- and middle-income countries reported data disaggregated for adults and children.
About 456 000 children 0–14 years old were receiving antiretroviral therapy at the end of 2010, up from 354 600 at the end of 2010, a 29% increase from 2009 (Chapter 7 provides an in-depth analysis of treatment of and policy on children living with HIV).
Overall antiretroviral therapy coverage among children was lower than among adults in low- and middle-income countries. Children represented 7% of the people receiving antiretroviral therapy and 14% of the people who needed it. Of the 2 020 000 [1 800 000–
2 300 000] children estimated to need antiretroviral therapy, only 23% [20–25%] had access to treatment versus 51% of adults [48–54%].1 One of the main reasons is that sub-Saharan Africa accounts for 91% of the children who need treatment but has an estimated coverage rate of about 21% (Table 5.8). Indeed, only in Europe and
1 The coverage rates observed in 2010 decreased compared with 2009 because the estimated number of children who need antiretroviral therapy increased (see box 7.19).
Central Asia is the coverage among children higher than among adults, a fact that may be partly explained by the scale up of services for preventing mother-to-child HIV transmission in the region and robust links with treatment and care services.
Data disaggregated by sex on the number of people receiving and needing antiretroviral therapy are available from 109 low- and middle-income countries, representing 95% of the 6.65 million people receiving treatment in 2010.2 Women represented 58% of the people receiving antiretroviral therapy and 51% of those who need it. Overall, antiretroviral therapy coverage was higher among women, estimated at 53%, versus 40%
among men. However, this pattern does not apply to all regions (Table 5.9). Women are especially advantaged compared with men in East, South and South-East Asia and in sub-Saharan Africa. In contrast, in Latin America and Caribbean, coverage of antiretroviral therapy is higher among men than women.
2 Some countries provided disaggregated data only for a proportion of the people receiving antiretroviral therapy in the country. For the countries with incomplete data sets, treatment data by sex were obtained by applying male–female ratios from existing data to the total numbers of people receiving treatment. Similarly, for seven countries that could supply data by sex in 2008 or 2009 but not in 2010, the available male–
female ratios from 2008 or 2009 were applied to the 2010 data.
Table 5.8 Number of children 0–14 years old receiving and estimated to need antiretroviral therapy and percentage coverage
among children and adults in low- and middle-income countries, by region, December 2010
aGeographical region
Number of children receiving antiretroviral therapy,
December 2010
Estimated number of children needing antiretroviral
Sub-Saharan Africa 387 500 1 840 000
[1 600 000–2 100 000]
Latin America and the
Caribbean 16 300 41 400
Latin America 13 600 30 600
[25 000–38 000]
44%
[36–55%]
65%
[58–75%]
Caribbean 2 700 10 800
[8 700–13 000]
North Africa and the
Middle East 840 18 500
middle-income countries 456 000 2 020 000
[1 800 000–2 300 000]
23%
[20–25%]
51%
[48–54%]
Note: some numbers do not add up because of rounding.
a For an explanation of the methods used, see the explanatory notes for Annex 4 and 5, and Box 5.9.
b The coverage estimate is based on the unrounded numbers of people receiving and needing antiretroviral therapy.
5.3.3. Availability of antiretroviral therapy The number and distribution of health facilities providing antiretroviral therapy are important indicators of the scaling up of and access to treatment services.
In 2010, 128 low- and middle-income countries reported a total of 22 369 health facilities providing antiretroviral therapy. Of these facilities, 78% were in the public sector and 8% in the private sector (14%
were unspecifi ed).
A total of 109 countries provided data for both 2009 and 2010. In these countries, the reported number of health facilities providing antiretroviral therapy
increased from 18 386 to 21 641, or an 18% increase in one year. It increased by 22% in sub-Saharan Africa (from 8462 to 10 359 in 39 countries); 10% in Latin America and the Caribbean (from 2759 to 3048 in 24 countries); 12% in East, South and South-East Asia (from 6015 to 6741 in 21 countries) and 33% in Europe and Central Asia (from 1033 to 1369 in 17 countries).
In North Africa and the Middle East, the number of facilities providing antiretroviral therapy increased from 117 in 2009 to 124 in 2010 across 8 reporting countries, an increase of 6%.
The average number of people receiving antiretroviral therapy per health facility in the subset of 109 countries Table 5.9 Comparison of estimated antiretroviral therapy coverage levels among men and women, in low- and middle-income
countries by region, December 2010
Geographical region
who need it Coveragea
Number receiving
Latin America and the
Caribbean (20/29) 64% 322 900 500 000 62% 177 600 280 000
Latin America (16/20) 64% 292 800 455 000 64% 147 800 230 000
Caribbean (4/9) 64% 30 100 47 000 56% 29 800 53 000
East, South and
South-East Asia (20/34) 34% 521 800 1 600 000 48% 399 700 830 000
Europe and Central Asia
(18/26) 20% 27 100 140 000 20% 20 600 100 000
North Africa and the
Middle East (7/14) 9% 7 600 86 000 9% 5 600 61 000
Total (109/149) 40% 2 631 300 6 600 000 53% 3 663 500 6 900 000
a The coverage estimate is based on the unrounded numbers of people receiving and needing antiretroviral therapy.
Table 5.10 Number of facilities providing antiretroviral therapy in 2009 and 2010, countries reporting in both years
Geographical region
Number of countries reporting in both 2009
and 2010
Sub-Saharan Africa 39 10 359 8 462 22% 484
Latin America and the
Caribbean 24 3 048 2 759 10% 153
East, South and
South-East Asia 20 6 741 6 015 12% 132
Europe and Central Asia 17 1 369 1 033 33% 34
North Africa and the
Middle East 8 124 117 6% 66
Total 109 21 641 18 386 18% 297
reporting data in both years increased from 277 in 2009 to 297 in 2010. The average fi gure in sub-Saharan Africa is substantially higher than in the rest of the world, with 484 people receiving antiretroviral therapy per health facility versus 457 in 2009. Although sites cannot be directly compared across regions because of their different structures, it is necessary to ensure facilities are adequately distributed, staffed and equipped to cope with growing cohorts, as the workload of health care providers can signifi cantly infl uence the quality of service delivery.
5.3.4 Outcomes at the programme level:
retention on antiretroviral therapy
Adequately measuring retention on antiretroviral therapy (the proportion of people started on lifelong antiretroviral therapy who survive and continue it over time) is paramount to monitor the quality of service delivery and ensure the long-term success of antiretroviral therapy programmes. However, gaining a
broader perspective of the effectiveness of national care programmes also requires reinforcing the monitoring of the people living with HIV throughout the continuum of care, especially those enrolled in care but not yet receiving antiretroviral therapy.
Although limited country data are available on retention rates throughout the cascade of interventions, a recent analysis has shown very low rates of retention between testing and treatment initiation for people living with HIV (Box 4.3). In Viet Nam, the comparison of cumulative cases reported for HIV case-reporting and enrolment in HIV care and antiretroviral therapy identifi ed major gaps between services, leading to the implementation of changes in programme management (Box 5.12).
In December 2010, 92 low- and middle-income countries provided data on retention at 12 months, a decrease from the 115 that reported retention data as
Box 5.12