Sex Under the Influence of Drugs Among People Who Use Drugs in Cambodia: Findings From a National Survey.

Studies in drug use settings rarely use sex under the influence of drugs as an indicator of sexual risk behaviors. This study explored the prevalence of sex under the influence of drugs and its correlates among people who use drugs (PWUD) in Cambodia. We included 1147 PWUD from 12 provinces in this study. A multiple logistic regression analysis was conducted to identify factors associated with sex under the influence of drugs. Of the total, 39.7% reported having had sex under the influence of drugs in the past three months. After adjustment, sex under the influence of drugs was significantly associated with living in urban areas (AOR 2.97, 95% CI 1.68-5.27), having two to three (AOR 2.48, 95% CI 1.76-3.49) and four or more sexual partners (AOR 6.46, 95% CI 4.24-9.85), engaging in transactional sex (AOR 1.69, 95% CI 1.19-2.39), using methamphetamine (AOR 2.97, 95% CI 2.06-4.31), using drugs for three years or longer (AOR 1.67, 95% CI 1.15-2.41), having been to a drug rehabilitation center (AOR 1.77, 95% CI 1.18-2.41), having a network of ten or more PWUD (AOR 1.82, 95% CI 1.25-2.66), and having high psychological distress (AOR 1.66, 95% CI 1.25-2.22). This study documents the high prevalence of sex under the influence of drugs and its risk factors among male and female PWUD in Cambodia. These findings point to the need for integrating HIV and harm-reduction programs using innovative approaches to address the overlapping risks in this key population.

Prevalence and correlates of HIV infection among people who use drugs in Cambodia: a cross-sectional survey using respondent driven sampling method.

BACKGROUND: Most of studies on the relationship between drug use and HIV have focused largely on people who inject drugs. Non-injecting drug use is much more common than injecting drug use, and although it can also predispose people to HIV infection, it is not widely explored. We therefore conducted this study to explore the prevalence of HIV and identify risk factors for HIV infection among people who use non-injecting drugs (PWUD) in Cambodia. METHODS: This cross-sectional study was conducted in 2017. The Respondent Driven Sampling method was used to recruit the study participants who were interviewed face-to-face using a structured questionnaire. Blood samples were collected for HIV and syphilis testing. A multivariable logistic regression analysis was conducted to identify risk factors associated with HIV infection. RESULTS: In total, 1367 PWUD were included in this study, whose mean age was 28.0 (SD = 7.7) years. The majority (95.1%) of the participants used methamphetamine. The prevalence of HIV was 5.7, and 35.2% of the identified HIV-positive PWUD were not aware of their status prior to the survey. After adjustment for other covariates, HIV infection remained significantly associated with being in the age group of ≥35 (AOR = 2.34, 95% CI = 1.04-6.11), having lower level of formal education of ≤ 6 years (AOR = 2.26, 95% CI = 1.04-5.15), living on the streets (AOR = 2.82, 95% CI = 1.10-7.23), perception that their HIV risk was higher as compared to that of the general population (AOR = 3.18, 95% CI = 1.27-8.62), having used injecting drugs in lifetime (AOR = 3.8, 95% CI = 1.36-4.56), and having cuts or sores around the genital area in the past 12 months (AOR = 3.42, 95% CI = 1.09-6.33). CONCLUSIONS: The prevalence of HIV among PWUD in this study was more than 10 times higher than the prevalence in the general adult population. The findings reveal a higher vulnerability to HIV infection among specific sub-populations of PWUD, such as those who are homeless, who may benefit from tailored interventions that respond to their specific needs. To enhance HIV case finding, stratification of PWUD to facilitate HIV risk profiling based on socio-economic profiles and drug injection history is recommended.

Access to community-based HIV services among transgender women in Cambodia: findings from a national survey.

BACKGROUND: Globally, the prevalence of HIV among transgender women is more than 40 times higher than the prevalence in the general reproductive-age adults. They also face intersecting barriers to health, social, and legal services due to their hidden and stigmatized nature. Despite the particular needs, data regarding the access to services among transgender populations is scant globally. This study aims to identify characteristics of transgender women in Cambodia that may determine their accessibility to community-based HIV services. METHODS: In the National Biological and Behavioral Survey 2016, a structured questionnaire was used for face-to-face interviews with 1375 sexually active transgender women recruited from the capital city and 12 other provinces using the Respondent-Driven Sampling method. Weighted multivariate regression analysis was conducted to explore factors associated with access to community-based HIV services. RESULTS: The mean age of the participants was 25.8 years (SD = 7.1), and 45.0% reported having received at least one community-based HIV service in the past three months. Compared to participants who reported not having been reached by any community-based HIV programs, participants who reported having been reached by the programs were significantly more likely to reside in an urban setting (AOR = 1.41, 95% CI = 1.01-1.96), to have used gender-affirming hormones (AOR = 1.50, 95% CI = 1.17-1.92), to have been tested for HIV in the past six months (AOR = 7.42, 95% CI = 5.78-9.53), and to have been arrested by police or other authorities because of their transgender identity (AOR = 1.55, 95% CI = 1.03-2.33). Participants who reported having been reached by community-based HIV programs were significantly less likely to report being in a receptive role (AOR = 0.34, 95% CI = 0.15-0.82), to use condoms consistently with non-commercial male partners (AOR = 0.72, 95% CI = 0.55-0.94), and to perceive that their co-workers were not supportive regarding their transgender identity (AOR = 0.57, 95% CI = 0.44-0.98). CONCLUSIONS: Despite the extensive expansion of community-based HIV programs, less than half of transgender women in this national survey had access to the services. Innovative strategies and culturally sensitive interventions should be put in place to reach and respond to the needs of sub-groups of transgender women who are less likely to be reached by the existing traditional approaches.

Factors associated with condom use with non-commercial partners among sexually-active transgender women in Cambodia: findings from a national survey using respondent-driven sampling.

BACKGROUND: Globally, the prevalence of HIV among transgender women is much higher than that of the general adult population. This can be explained by the persistently low rate of consistent condom use among this population. This study was therefore conducted to explore factors associated with consistent condom use among sexually-active transgender women in Cambodia, specifically with their non-commercial partners. METHODS: Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey 2016. Participants were recruited from the capital city of Phnom Penh and 12 other provinces with high burden of HIV using the Respondent-Driven Sampling (RDS) method. Face-to-face interviews were conducted using a structured questionnaire. Weighted multivariate logistic regression analysis was conducted to explore independent factors associated with consistent condom use. RESULTS: This study included 1202 transgender women who reported having anal sex with at least one male partner not in exchange for money or gifts in the past three months. The mean age of the participants was 26.0 (SD = 7.0) years. Of the total, 41.5% reported always using condoms with male non-commercial partners in the past three months. After adjustment, the likelihood of consistent condom use was significantly higher among participants who resided in an urban community (AOR = 1.7, 95% CI = 1.1-2.6), had attained at least 10 years of formal education (AOR = 1.8, 95% CI = 1.2-2.7), perceived that they were likely or very likely to be HIV infected (AOR = 2.9, 95% CI = 2.0-4.1), reported drinking alcohol two to three times per week (AOR = 3.1, 95% CI = 1.1-8.3), reported using amphetamine-type stimulants (AOR = 1.9, 95% = 1.1-3.8) or other drugs (AOR = 7.6, 95% CI = 1.5-39.5), and reported inconsistent condom use with male commercial partners in the past three months (AOR = 4.3, 95% CI = 1.8-10.4) compared to that of their respective reference group. CONCLUSIONS: This study confirms the low rates of condom use, particularly in non-commercial relationship, among transgender women in Cambodia. To address these concerns, efforts towards education about effects of multiple, concurrent relationships, and inconsistent condom use should be reinforced among transgender women.

Prevalence of and risk factors for hepatitis C virus antibody among people who inject drugs in Cambodia: a national biological and behavioral survey.

BACKGROUND: Hepatitis C virus (HCV) is a significant global health concern. Despite evidence of the relationship between injecting drug use and HCV, studies on HCV among people who inject drugs in developing countries remain scarce. To address this need, we conducted this study to explore the prevalence of and factors associated with HCV antibody positivity among people who inject drugs in Cambodia. METHODS: Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey among people who use and inject drugs conducted in 2017. We used the respondent-driven sampling method to recruit participants in 12 provinces for face-to-face interviews and HIV and HCV antibody testing. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with HCV antibody positivity. RESULTS: This study included 286 people who inject drugs with a mean age of 31.6 (SD = 7.5) years. The prevalence of HCV antibody among participants in this study was 30.4%, of whom 31.0% were co-infected with HIV. After adjustment for other covariates, the odds of HCV antibody positivity was significantly higher among participants who were in the older age group of 25 to 34 (AOR = 1.85, 95% CI = 1.06-7.92) and ≥ 35 (AOR = 2.67, 95% CI = 1.24-5.71), were in Vietnamese ethnic group (AOR = 5.44, 95% CI = 2.25-13.14), were living on the streets (AOR = 3.01, 95% CI = 1.29-704), had been sent to a drug rehabilitation center in the past 12 months (AOR = 2.67, 95% CI = 1.21-5.90), had received methadone maintenance therapy in the past 12 months (AOR = 3.02, 95% CI = 1.32-6.92), and were tested positive for HIV (AOR = 3.80, 95% CI = 1.58-9.12) compared to their respective reference group. CONCLUSION: The prevalence of HCV antibody among people who inject drugs in Cambodia is high, particularly in older and more vulnerable subgroups. Tailor-made interventions are required to increase access to culturally sensitive harm reduction interventions to prevent primary HCV infection and reinfection. In addition, there is an opportunity to expand screening, diagnosis, and treatment with new directly acting antiviral agents.

Recent HIV testing and associated factors among people who use drugs in Cambodia: a national cross-sectional study.

OBJECTIVE: To estimate the prevalence of HIV testing and examine factors associated with recent HIV testing among people who use drugs (PWUD) in Cambodia. DESIGN: Cross-sectional study. SETTING: Twelve major provinces with a high burden of HIV and drug use in Cambodia. PARTICIPANTS: This study included 1677 PWUD recruited using a peer-based social network recruitment method. Participants' selection criteria included being at least 18 years old and using any illicit drugs via any administration routes in the past 12 months. PRIMARY OUTCOME MEASURE: Recent HIV testing, defined as having an HIV test in the past 6 months. RESULTS: The median age of the participants was 28 (IQR 22-34) years, and 56.6% were men. The prevalence of lifetime and recent HIV testing was 70.7% and 42.9%, respectively. After adjustment in multivariable logistic regression analysis, recent HIV testing remained positively associated with being female (adjusted OR (AOR) 1.55, 95% CI 1.18 to 2.04) or third gender identity (AOR 2.06, 95% CI 1.11 to 3.80), having ever been to a drug rehabilitation centre (AOR 1.60, 95% CI 1.13 to 2.29), having used any HIV services in the past 6 months (AOR 7.37, 95% CI 5.61 to 9.69), having received HIV education in the past 3 months (AOR 3.40, 95% CI 2.63 to 4.40) and having self-perception of higher HIV risk (AOR 1.81, 95% CI 1.19 to 2.73). CONCLUSIONS: Recent HIV test uptake among PWUD in Cambodia was suboptimal. This study highlights the roles of outreach HIV education and services in promoting regular HIV testing among PWUD. Strengthening the coordinated effort of government agencies and local civil society organisations to prioritise expanding community-based peer-driven interventions to reach out to this hidden population is warranted.

Social marginalization, gender-based violence, and binge drinking among transgender women in Cambodia.

BACKGROUND: Transgender women experience disproportionate social stigma that may lead to behavioral risks and poor psychological wellbeing. This study examines social and behavioral factors associated with binge drinking among transgender women in Cambodia. METHODS: A cross-sectional survey was conducted in 2016 among 1039 transgender women recruited from 13 provinces using the Respondent Driven Sampling method. A structured questionnaire was used for face-to-face interviews. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with binge drinking. RESULTS: The prevalence of binge drinking was 43.3 %. After adjustment, the odds of binge drinking were significantly higher among participants in the age group of 25-34 compared to those in the age group of 18-24 and lower among participants in job categories such as hairdresser or beautician, office workers, and self-employed compared to those who were unemployed. The odds of binge drinking were significantly higher in participants who dropped out of school and thought it was because of their transgender identity, had transactional sex in the past three months, used amphetamine-type stimulants in the past three months, and reported experience of verbal abuse by family members during childhood. Regarding mental health, the odds of binge drinking were significantly lower among participants who had depressive symptoms over the past week. CONCLUSIONS: These findings highlight the intersections between social marginalization, gender-based violence, HIV risks, and alcohol abuse. We recommend further exploration of the structural factors that may be modifiable through workplace policies or occupational health interventions among transgender women.

Syphilis infection among people who use and inject drugs in Cambodia: a cross-sectional study using the respondent-driven sampling method.

This cross-sectional study explored the prevalence and correlates of syphilis infection among people who use and inject drugs (PWUD/PWID) in Cambodia. Data were collected in 2017 from 1,677 PWUD/PWID living in the capital city of Phnom Penh and 11 other major provinces using the respondent-driven sampling method. The SD Bioline HIV/Syphilis Duo test was used to determine human immunodeficiency virus (HIV) and current or past syphilis infection. A multivariable logistic regression analysis was conducted to identify risk factors associated with current or past syphilis infection. The prevalence of current or past syphilis infection was 3.8% (95% confidence interval = 2.4-4.6). After adjustment, current or past syphilis infection remained positively associated with being female, living on the streets, having an average monthly income of US$100-299, having transactional sex in the past three months, and having been to a rehabilitation centre in the past 12 months. Current or past syphilis infection was negatively associated with having attained at least high school level of formal education. The findings indicate vulnerability to syphilis infection among PWUD/PWID in Cambodia, particularly among subpopulations who are more marginalized. Syphilis prevention and control programmes should be systematically integrated into HIV and sexually transmitted infection policy and services in the country.

Prevalence and social determinants of psychological distress among people who use drugs in Cambodia.

BACKGROUND: People who use drugs are at a disproportionately higher risk of mental disorders due to prolonged exposure to psychosocial challenges. However, studies on mental health among people who use drugs in resource-constrained countries are scarce. This study sheds light on the prevalence and correlates of psychological distress among people who use drugs in Cambodia. METHODS: We conducted this cross-sectional study in the capital city and 11 provinces in 2017. The Respondent Driven Sampling method was adapted to recruit 1677 people who used drugs for face-to-face interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12). A total score of GHQ-12 > 2 indicated high psychological distress. We performed a multiple logistic regression analysis to identify factors associated with psychological distress. RESULTS: We included 1598 participants in the analyses, with a mean age of 28.6 years (SD = 7.8). Of the total, 42% had high psychological distress - 50% in women and 37% in men. The adjusted odds of having high psychological distress were significantly higher among participants who were 25-34 years old and 35 years and above, had been to a drug rehabilitation center, had been insulted by family members, and had been sexually harassed/abused by someone when they were growing up. The odds of having high psychological distress were significantly lower among participants who were male, lived in their own dwelling, reported injecting as the mode of the first drug use, and had someone taking care of them when they got sick. CONCLUSIONS: This study documents a high prevalence of psychological distress among people who use drugs in Cambodia. Intervention programs that attempt to address mental health problems among people who use drugs in resource-limited settings should be gender- and age-sensitive and target more marginalized subpopulations. Mental health services can be integrated into HIV and harm-reduction programs for people who use drugs.

Risk factors associated with HIV and hepatitis C virus co-infection among people who inject drugs in Cambodia.

BACKGROUND: Globally, research on the co-infection of the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among people who inject drugs is growing. However, studies in resource-poor countries remain limited. Therefore, we conducted this study to explore factors associated with HIV/HCV co-infection among people who inject drugs in Cambodia. METHODS: This national survey was conducted in 2017 in the capital city and 11 provinces. We used a 'peer-based social network recruitment' method to recruit 286 participants for face-to-face interviews and HIV and HCV testing. A modified Cox proportional hazard model was used to identify risk factors associated with HIV/HCV co-infection. RESULTS: The prevalence of HIV and HCV was 15.4% and 30.4%, respectively. Of the total, 9.4% of the participants were HIV/HCV co-infected, and 61.4% of the HIV-infected participants were co-infected with HCV. About half (56.8%) of the participants tested HIV positive were aware of their HIV status; of whom, 83.3% were on antiretroviral therapy. Only 11.5% of the participants with HCV antibody positivity were aware of their HCV infection status; of whom, 50.0% were on HCV treatment. The adjusted prevalence ratio (APR) of HIV/HCV co-infection was significantly higher among women than among men and among participants who lived on the streets than among those living with their family or relatives. The APR of HIV/HCV co-infection was also significantly higher among participants who had received methadone maintenance therapy than those who had not received it. CONCLUSIONS: The prevalence of HIV/HCV co-infection among people who inject drugs in Cambodia was considerably high. Intervention programs are required to increase access to harm-reduction interventions among most marginalized people who inject drugs to prevent HIV and HCV infection. HCV screening services should be expanded in this key population, given its small population size and the availability of directly-acting antiviral agents in the country.

HIV risks and recent HIV testing among transgender women in Cambodia: Findings from a national survey.

BACKGROUND: Globally, the prevalence of HIV among transgender women remains much higher than that of the general population, and a large proportion of them are unaware of their HIV status. Transgender women are exposed to gender-based violence and social stigma and discrimination in different settings that may create significant barriers to receiving HIV prevention and care services. This study aimed to identify factors associated with recent HIV testing among transgender women in Cambodia. METHODS: We conducted a cross-sectional survey in 2016 among 1375 transgender women recruited from 13 provinces using a peer-based social network recruitment method. We used a structured questionnaire for face-to-face interviews and performed rapid HIV/syphilis testing onsite. We used a multiple logistic regression analysis to identify factors associated with recent HIV testing. RESULTS: Of the total, 49.2% of the participants reported having an HIV test in the past six months. After controlling for other covariates, the odds of having an HIV test in the past six months was significantly lower among students (AOR 0.36, 95% CI 0.20-0.65), participants who perceived that they were unlikely to be HIV infected (AOR 0.50, 95% CI 0.32-0.78), and participants who reported always using condoms with male non-commercial partners in the past three months (AOR 0.65, 95% CI 0.49-0.85) relative to their respective reference group. The odds of having an HIV test in the past six months was significantly higher among participants who had been reached by community-based HIV services (AOR 5.01, 95% CI 3.29-7.65) and received HIV education (AOR 1.65, 95% CI 1.06-2.58) in the past six months relative to their respective reference group. CONCLUSIONS: Despite the widely available free HIV testing services, more than half of transgender women in this study had not received an HIV test in the past six months. Our findings suggest that a tailored and comprehensive combination prevention program, in which HIV testing is linked to care continuum and beyond, maybe an essential next step. Social media may have the potential to be promoted and utilized among transgender women populations in order to improve HIV testing and other prevention measures.

Prevalence and correlates of amphetamine-type stimulant use among transgender women in Cambodia.

BACKGROUND: The use of amphetamine-type stimulants (ATS) is associated with increases in HIV infections and other negative health outcomes. Globally, transgender women are among the most vulnerable to HIV. In this paper, we report the prevalence and correlates of ATS use among transgender women in Cambodia. METHODS: In 2016, 1375 transgender women were recruited for the National Integrated Biological and Behavioural Survey using respondent-driven sampling method. Participants were recruited from the capital city of Phnom Penh and 12 other provinces. A structured questionnaire was used to collect information on demographic characteristics, sexual behaviours, ATS and other substance use, depressive symptoms, gender-based violence, adverse childhood experiences, stigmatization, and social support. Weighted multivariable logistic regression analyses were conducted to identify risk factors associated with ATS use in the past three months. RESULTS: Overall, the most commonly reported illicit drug used by the survey participants was ATS (10.4%). ATS use was more likely to occur among participants who: (1) were urban dwellers, (2) were 25 to 34 years old, 3) had low levels of education, (4) engaged in transactional sex, (5) inconsistently used condoms with commercial partners, (6) reported binge drinking, (7) had depressive symptoms, (8) had a feeling that co-workers/classmates were not supportive regarding their transgender identity, and (9) had experienced emotional abuse during childhood. CONCLUSION: ATS were the most commonly reported illicit drugs among transgender women in this study. To mitigate potential negative outcomes, developing and implementing additional harm reduction strategies tailored to ATS use among transgender women is needed. Integration of HIV and mental health interventions into harm reduction programs is required.

Prevalence and risk factors of HIV infection among people who inject drugs in Cambodia: findings from a national survey.

BACKGROUND: Globally, people who inject drugs (PWID) continue to be among the most vulnerable populations to acquire infection of human immunodeficiency virus (HIV). The most recent national survey found that nearly a quarter of PWID in Cambodia were infected with HIV in 2012. The aim of this study is to estimate the current prevalence of and factors associated with HIV infection among PWID in Cambodia. METHODS: This national integrated biological and behavioral survey was conducted from June to December 2017. Participants were recruited from the capital city and 11 major provinces using the respondent driven sampling method. Face-to-face interviews were conducted using a structured questionnaire, and blood samples were collected for HIV, syphilis, and hepatitis C virus (HCV) testing. Multiple logistic regression analysis was conducted to identify risk factors for HIV infection. All analyses were estimated with sampling weights that corrected for non-response and sample design. RESULTS: A total of 310 PWID participated in the study, and the mean age was 31.8 years (SD = 7.8). The prevalence of HIV was 15.2%. More than half (57.4%) of the HIV-positive participants were co-infected with HCV, and 44.7% were not aware of their HIV status prior to this study. After adjustment for other covariates, HIV infection remained positively associated with being female (AOR = 1.88, 95% CI = 1.03-4.04), being in the older age group of ≥35 (AOR = 2.99, 95% CI 1.33-9.22), being widowed, divorced or separated (AOR = 2.57, 95% CI = 1.04-6.67), living on the streets (AOR = 2.86, 95% CI 1.24-4.37), and HCV infection (AOR = 3.89, 95% CI 1.86-1.15). The HIV infection remained negatively associated with having higher level of formal education of ≥10 years (AOR = 0.44, 95% CI 0.13-0.83) and higher average income of ≥US$200 per month (AOR = 0.20, 95% CI = 0.05-0.74). CONCLUSIONS: The prevalence of HIV among PWID in Cambodia remains high, but is reducing compared with the 24.8% reported in the 2012 national survey. Findings from this study provide critical information for tailoring interventions based on identified vulnerabilities and risk factors for HIV. Our findings underline the importance of socio-structural factors in HIV epidemiology among PWID in Cambodia, which require mitigation.