Andrey Rylkov Foundation
for Health and Social Justice
Русский

Providing Harm Reduction on the streets of Phnom Penh

Author: Ivan Varentsov

Whilst in Phnom Penh this January (capital of Cambodia) I was put in contact with colleagues from KHANA – a local non-governmental organization dealing with HIV prevention in the country including provision of harm reduction services. I was lucky enough to be invited to visit KHANA’s drop-in center for people who use drugs and even to join the outreach team. This was a very interesting and useful experience. These guys are doing great work out there, despite being limited both in funds and in support from the government. I decided to document my experiences in order to inform the public more about HR in Cambodia, as I believe not much is known about the situation beyond the region.

General info

I would like to start by giving a general picture of HIV situation in the country as well as access to treatment and HR services.

The population of Cambodia is just over 15 mln. The estimated prevalence of HIV among the adult general population is 0.7% (UNAIDS, 2012). Estimated number of PLHIV is 76 000 (UNAIDS, 2012). 46 134 of them are on ART (2013, NCHADS). ARV-treatment is available for free and is accessible for those needed (even provided on a base of some licensed NGOs). Most-at-risk populations (MARPS) are entertainment workers (EW), drug users (IDU/DUs) and men who have sex with men (MSM).

The estimated number of people who use drugs in Cambodia is between 13 000 and 28 000. 10% of them are injection drug users (IDUs). Almost all of IDUs (1 085) live in PP. HIV prevalence among IDUs is high – 24,8 % (IDU size estimated study in Cambodia 2012 done by NCHADS, NACD, KHANA).

The most popular drug is methamphetamine. Heroin is used almost only by those IDUs living in PP (it is not affordable in regions) and also they often mix it with valium.

HR projects in Cambodia were started by non-governmental organizations (NGOs) in 2004 but NSP guidelines on HIV prevention among IDUs were issued only in 2006. At the moment there are only three NGOs providing HR services in PP and only two of them have a NSP license to do syringe exchange – KHANA is one of them.

The first and only methadone clinic in Cambodia was opened in Phnom Penh in July 2010. By the end of 2013 there were 136 people on methadone treatment (118 of them were Khana’s clients including 22 females).

According to estimates about 80% of all IDUs are HCV positive (56% among methadone patients).

There is no local Harm Reduction Network in Cambodia but there is an MSM network, PLHIV network (CPN+), network of NGOs working in HIV prevention and few others. But there is a peer support group of IDUs under KHANA program existing in PP and maybe when it becomes stronger it could give grounding for a HR network.

KHANA

The organization I was connected with – KHANA – is the largest national NGO providing integrated HIV prevention, care and support services at the community level in Cambodia. Initially established in 1996 as a project of the International HIV/AIDS Alliance, KHANA became an independent NGO in 1997, and has been officially registered in Cambodia since 2000. KHANA is one of the leading organizations focusing on HIV and AIDS in Cambodia today. It has a main office in Phnom Penh with about 80 personnel working in it (including volunteers) and is working in 20 out of 24 provinces and municipalities in the country contributing to the national response through HIV prevention, care, and support and impact migration programs. Unfortunately, government in Cambodia doesn’t support NGOs working in HIV prevention, hence KHANA as well as all other NGOs is totally dependent on funding from external donors such as AusAID, USAID, Global Fund, EU and UN World Food Program.

Mondul Meanchey (MMC)

Upon my arrival to the place I was met by Kimhai, KHANA’s harm reduction demonstration center manager, and Kiry, outreach officer – I was put in touch with these colleagues before my visit. We went to the office where Kimhai introduced me about goal, objectives and key intervention activities to prevent HIV and other blood borne infection among people who injecting drugs and then he and his colleagues showed me the center.

Mondul Meanchey (MMC) drop-in center is one of the KHANA’s projects targeted on HIV prevention among IDU/DUs in Phnom Penh. MMC was opened in July 2010. In 2012 it moved to its current location (to replace drop-in center operated by other NGO which was moved to other location recently) to continue the provision of HR services for IDUs in this area. It is mainly funded by AusAID-HAARP and its annual operating budget is about 100 000 USD. Unfortunately due to circumstances at the moment the center has funding available only for next 12 months till December 2014 and its future is uncertain.

MMC is operated by 4 staff personnel (center manager, outreach officer, medical doctor and nurse) and also there is an outreach team which consists of 10 community representatives.

Community center is located in a private two-floored building and is opened 5 days a week from 7.30 a.m. till 5 p.m for drop-in-center and from Monday to Sunday for methadone case management. An average 30 clients visit MMC every day. On a first floor there is a big hall where people can come to get health information/education session, safe space, entertainment including TV and also a small library is available with story books and education materials. If needed there are also facilities available to take a shower. Next door to the hall there is a staff office and medical room with a doctor and nurse available upon a request. Doctor could provide primary health care, first aid help, simple surgery help. But as MMC does not have a special license to operate as clinic patients with serious conditions are referred to relevant governmental health facilities and NGO based clinics if needed.

d

d

d

d

d

d

d

Sometimes the organization has to pay for its clients to get medical help in clinics and hospitals. But in Cambodia they do have such a thing as ID Poor – special ID provided within the Identification of Poor Households Program. This program is to determine which households are poor and the poverty level of these individual households in the villages. The purpose of identification of individual households is to directly target services and development assistance to the poorest households in a village in order to help lift them out of poverty and to protect them from the impact of shocks (e.g. serious illness, crop failure) which may deepen their poverty. HIV positive IDU/DUs automatically get this ID Poor which authorized by NGOs clinic as soon as registered and could have an access to all medical help needed for free. The main barrier for homelessness IDU/DU who is not living with HIV – the person needs to have a registration in order to get ID Poor.

KHANA has a permission from MoH to conduct rapid testing on HIV and this service is also available (as well as syphilis testing) in MMC and during outreach activity through lay counselors who have trained properly.

On the second floor there is a counseling room, meeting room and computer training class which focuses on computer basics and design. MMC conducts seminars for its clients on many issues including safe injecting, vein care, overdose prevention, HIV prevention, how to reduce harm from using drugs, how to get and use ID Poor etc.

d

d

d

d

d

d

d

In the yard besides the house, there is a special metal safety box for the disposal of used syringes which are collected during outreach visits and/or brought to MMC by IDUs. As Kiry explained to me MMC has an agreement with certain medical facility according to which people from this medical facility periodically collect the syringes from this box and take away for safe disposal. To find such a partner which has the ability to destroy the used syringes – this is what we really lack in our ARF HR project in Moscow and that is why we don’t collect the used syringes on the streets.

Outreach experience

After I interrogated Kimhai, Kiry and their colleagues for about one hour with my questions regarding the organization and HIV situation in country they proposed me to join the outreach team which was ready to go and to continue conversation after we return back if needed.

The outreach team consisted of Kiry himself, two peer outreach workers, motor rickshaw (tuk-tuk) driver and myself. The motor rickshaw used for outreach visits is an MMC property. While driving to a place Kiry introduced me to peer outreach workers – Mr. X and Mr. Y. They both are former drug users and client of MMC. Mr. Y is a client of methadone program at the moment and Mr. X is a very important person among drug user community and the leader of IDUs’ peer support group.

в

в

в

в

в

в

в

After about 15 minutes drive we came to some district located nearby Bassac River. This definitely was not a tourist area, as I haven’t seen any Europeans there except me. The driver turned from the main road to some side lane and we arrived to a very poor-looking street with mostly barracks instead of houses and plenty of rubbish all around with children playing among it. People around were looking at me with an interest as not many Europeans (if any) come to see them I believe. We stopped in the middle of the street, took all the equipment and went into one of the gateways leading us almost to the bank of the river. There was a small hovel located among other barracks with people sitting inside of it. That was our target. This was the place where people traded and used drugs. After a conversation during which I suppose my colleagues were questioned about me and the purpose of my presence, I was allowed to take some photos of the hovel from outside but not from inside and was asked not to photograph people shooting up. Then colleagues started to do their work – they took the used syringes from people and also collected some more from the area around. Instead, they gave them hygiene kits with new ones. The outreach team distributed NSP kit to IDUs which includes clean need and syringe, sterilize water, alcohol swap and key message to promote safe injecting and HIV, HBV and HCV prevention, and also a contact address/phone number if they need further information. Besides NSP kit they also distribute hygiene kits which include some other supplies like ribbons, shampoo soap, toothpaste, toothbrush, condoms and info note on hygiene promotion and health care messages. According to Kiry, many of the clients in this hovel were on methadone but some of them also continue to use heroin and other drugs – the reason could be the insufficient dosage of methadone prescribed or need to get high, which is impossible with a prescribed methadone.

It is important to mention here that Naloxon is not available in Cambodia due to its exclude from the local list of essential drugs – it is neither used by ambulances nor available in pharmacies. NGOs doing outreach work do not distribute it and there is no Naloxon available in methadone clinic either. So overdose and its prevention is a great issue in Cambodia.

в

в

в

в

в

в

в

While we were standing near the hovel some more people came up to take clean syringes and other stuff. Kiry told me that normally they arrive and stay at one place for couple of hours so people from the area could come and access the service.

The average price for one dose (unfortunately I didn’t get how much is it in grams) is 5 USD. Average monthly income in Cambodia is about 70 USD. And sometimes drug users have to spend a few hundred dollars per month to get the needed amount of drugs for personal use.

After that street we drove to another place – an abandoned house used by drug users as a place to live. This squat was located at the ordinary street and surrounded even by a few fashionable houses. When we arrived we only found a few people there including one woman with a child. Kiry said that everybody is out in the city trying to earn money. But sometimes it is possible to meet up to 30 people at once here. The guys collected the used syringes inside and outside the building and left some hygiene kits with clean ones.

By the way Kiry told me that the police know about all these places and about what is going on there. But they come only if they are searching for any particular person who has stolen something or committed other criminal activities of interest. As I understood it is not beneficial for the police to close such squats as they also have some personal interest in it. But what is important is that police does not touch outreach workers because as the organization has the NSP license to do the needle exchange their work is legal and they have relevant documents with them to show the police if needed.

в

в

в

в

в

в

в

That was the end of the outreach for that day. We returned back to the office and I made some more photos of the center and the team. On the way back to the hotel Kiry showed me some more squats in the center of the city not far from the place where I lived. We didn’t enter them because as Kiry told that even outreach team is not allowed to enter so they usually stay on the nearest street and people come to them themselves.

Epilogue

When listening to Kimhai and Kiry telling me about challenges they face in their work I was comparing it with the situation in Russia we have – same restrictive drug policies, no government funding for NGOs, HIV epidemic among IDUs and only few harm reduction projects working. But there is one very important difference – although the government doesn’t provide financial support to NGOs doing harm reduction at the same time it doesn’t prevent them to do their job using the external funding from foreign donors and do not introduce barriers at the legislative level. That is why there is an access to OST in Cambodia, legal needle exchange programs, ID Poor and drop-in centers for IDUs available. And that gives hope that as soon as economic situation in country improves government could be able to start support and expand all these services itself. In Russia unfortunately there isn’t any hope for that at the moment.

в

в

в

в

в

в

в

Acknowledgement

Would like to thank here all those who helped me to prepare this article: Shona Schonning and Greg Gray for contacting me with KHANA, Narek Sargsyan for editing the text and of course Kimhai, Kiry and all other MMC colleagues for their hospitality and time spent with me.



Category Categories: Other EECA countries | Tag Tags: , , , , , | Comments No comments »

Leave a comment: