How Cambodia became the first Asian country to hit an elusive HIV target

Only 11 countries in the world can say this:

Ninety-five percent of people living there who are HIV positive know their status.

Ninety-five percent of HIV-positive people are taking medication that lowers the amount of the virus in their body.

And 95% of people on HIV medication have a viral load so low, they're considered virally suppressed. This means they have an almost zero risk of passing HIV on to their partners.

In June, Cambodia became the first country in the Asia-Pacific region to reach this milestone, which the U.N. has set as a goal for every country to achieve by the year 2030. The 95-95-95 targets were called ambitious and daunting when UNAIDS set them in 2020.

But since then, 11 nations, most of which are in Africa, have achieved them. Denmark is the one European nation on the list.

Many Asian countries — including wealthy ones like Japan and South Korea — have struggled to make these gains, says Dr. Annette Sohn, director of amfAR's TREAT Asia program, a network of clinics and researchers serving people with HIV.

"Sometimes people will think — why is it that we are not able to manage HIV control?" Sohn says. "The No. 1 challenge continues to be stigma."

That stigma might be a feeling of shame that keeps a person from getting tested for HIV or from visiting a clinic for treatment.

People living with HIV also face discrimination, which can make navigating the healthcare system a struggle.

Sohn says this is how Cambodia succeeded: Advocates recognized that people seek healthcare where they feel accepted and used this strategy to save lives.

"I moved to the countryside ... to die"

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At the peak of the AIDS crisis, as many as 15,000 people in Cambodia were dying each year from a virus that had no cure and no vaccine. Before 1998, there was no medication to prevent HIV from destroying a patient's immune system, leaving them vulnerable to infections and rare cancers.

"We heard it was a strange, deadly virus," recalls Sophal Seum. "People were scared of HIV."

The virus tore through brothels and nightclubs but quickly reached the general public. By 1999, about 2% of adults between the ages of 15 and 49 had contracted HIV. At the time, Seum was a young hotel worker near Angkor Wat, an ancient Hindu temple that attracts millions of visitors each year. He says he lost his job after testing positive for HIV in 2000 and struggled to find a new one. Many jobs at the time required blood tests, he says. The practice was banned in 2002.

"In 2006, I moved to the countryside — to die, you know," Seum told NPR. His wife and children joined him.

But with medication, and the help of a program providing home-based care, Seum recovered. Today, he is a national advocate for people living with HIV. Seum organizes community meetings for people living with HIV, making sure their needs are met, and offers counseling, especially to young people.

"It's not a full recovery, but I try to ride my bicycle to work," he says. "I can survive, because I have hope."

Cambodia had the political will

Cambodia's HIV epidemic peaked in the late 1990s and early 2000s, when about 180,000 people had contracted the virus. Today, the national rate has dipped from more than 2% to below 0.5%, and the vast majority of Cambodia's estimated 76,000 citizens living with HIV are on medication.

Chamreun Chob Sok is the executive director of KHANA, the Khmer HIV/AIDS NGO Alliance. It's Cambodia's largest network of nonprofits working to prevent HIV and support people living with the virus. Sok has worked on HIV prevention for almost the entirety of his career.

He says the country's response succeeded thanks to three main factors.

First, Sok says, Cambodia had the political will to do this.

Cambodia is a constitutional monarchy. In the '90s, both the king and the elected government wanted to prioritize HIV prevention efforts. In 1999, the country launched a public health campaign encouraging couples to use condoms 100% of the time, under the slogan "No condom, no sex." During those early years, more than 80% of sex workers reported using condoms.

Later, in 2003, the Cambodian government made HIV medication free with an $11.2 million grant provided by the Global Fund. Based in Geneva, the international financing group provides grants to countries for HIV, tuberculosis and malaria relief. The United States is the fund's largest donor.

Early programs in Cambodia focused on groups of people who had heightened rates of HIV: the military, police, garment factory workers and sex workers. As HIV rates shrank among the general population, Sok says, the epidemic became more concentrated among high-risk groups, who were harder to reach.

"What we call it now, is that Cambodia is under a concentrated epidemic. This means HIV transmission is occurring among a key and vulnerable population," Sok says.

To tackle the concentrated epidemic, Cambodian community health workers had to get creative.

Sok's perspective is that the best solutions are created by people with lived experience. Proudly, he lists off KHANA's programs:

There is SmartGirl, an intervention organized by women who previously worked in nightclubs, bars or other places where sex work is common. (Sok prefers the term female entertainment worker in an effort to reduce stigma.) Through KHANA, the women organized HIV finger-prick testing drives in their former workplaces. Then, they offered counseling and helped women who were HIV positive get medical care and other support.

"They became lay counselors. They became the people who go and conduct outreach," Sok says. "They're run by themselves, reaching their peers."

Men who sleep with men are another demographic with a high risk of HIV in Cambodia. Through KHANA, they created their own outreach, Sok says — including community hubs with coffee shops and internet access.

For a third project, transgender counselors created a program called Srey Sros: "Beautiful Woman" in the Khmer language, which signaled acceptance and safety.

"This is a way that can bring people to come to services early," Sok says. "And importantly, they're involved in ensuring the services are friendly."

This focus on key populations — demographic groups with the highest rates of HIV, and the highest risk of contracting it — is considered a gold standard of epidemic control. However, after U.S. funding delays and cuts to global HIV prevention, these programs have been among the first on the chopping block in other countries.

"Life with HIV is possible"

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Cambodia's achievement also rests on the shoulders of people willing to tell their stories. Dalish Prum is a program manager and community health worker for CPN+, one of Cambodia's largest support networks for people living with HIV.

When she was 15 years old, Prum was abducted and trafficked to the Thai border. Although she was quickly rescued, she fell sick months later. When she tested positive for HIV in 2003, she was still in high school.

"I cried almost every day for three years," Prum recalls. "I thought I will die soon, I cannot learn, I cannot study, I cannot graduate or make a family."

Prum drew strength from her supportive parents. She finished her studies and began working for HIV prevention programs, speaking at international conferences and becoming a leader in the country's efforts. She fell in love, married and had a little girl in 2018.

Today, Prum takes medication to keep her HIV to undetectable levels in her body, preventing health complications. She says people living with HIV in Cambodia still face challenges, especially in healthcare settings. But the 95-95-95 achievement signals that the work she and her colleagues are doing makes a difference.

And this is what she often tells the clients she counsels: Life with HIV is possible.

"Honestly, please love yourself," she says. "You have dignity."

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