Mobile-health intervention for smoking cessation among Cambodian people living with HIV: A mixed-methods pilot study.

This mixed methods study aimed to evaluate the feasibility and preliminary efficacy of a fully automated, interactive smartphone-delivered intervention for smoking cessation among people living with HIV in Cambodia. We used the explanatory sequential design, with a pilot two-group single-blind randomized controlled trial (N = 50) followed by in-depth interviews with all trial participants. In the trial, participants were randomized to Standard Care (SC) or Automated Messaging (AM) group. SC comprised brief advice to quit and self-help materials. AM consisted of the SC components plus a fully automated smartphone-based treatment program that involved interactive and tailored proactive messaging for 2 months. Results showed that the AM approach was highly feasible and efficacious. Feasibility was supported by high rates of treatment engagement (e.g., 81% of delivered messages and assessments were read or completed) and high retention (96%) through the 2-month follow-up. Biochemically verified point prevalence abstinence at follow-up was 40% for the AM group and 8% for the SC group (relative risk: 5.0, 95% confidence interval: 1.2, 20.5). Being able to avoid other smokers, having coping skills, and having social/familial support contributed to successful abstinence. The AM program has the potential for wide-scale implementation in Cambodia and other low-income countries.

HIV prevalence, related risk behaviors, and correlates of HIV infection among people who use drugs in Cambodia.

BACKGROUND: Although HIV prevalence in Cambodia has declined to 0.6% among the general population, the prevalence remains high among female sex workers (14.0%) and men who have sex with men (2.3%). Over the past 10 years, the number of people who use drugs (PWUDs) has increased considerably. PWUDs, especially people who inject drugs (PWIDs), who have multiple sex partners or unprotected sex contribute to a higher HIV prevalence. This paper aims to estimate the prevalence of HIV across PWUD groups and to identify factors associated with HIV infection. METHODS: Respondent-driven sampling (RDS) was used to recruit 1626 consenting PWUDs in 9 provinces in 2012. Questionnaires and blood specimens were collected. HIV prevalence estimates were calculated using RDSAT 7.1. Individual weightings for HIV were generated with RDSAT and used for a weighted analysis in STATA 13. Multivariate logistic regression was used to identify the independent factors associated with HIV prevalence. RESULTS: Most of the PWUDs were men (82.0%), and 7.3% were PWIDs. Non-PWIDs, especially users of amphetamine-type stimulants (ATS), represented the larger proportion of the participants (81.5%). The median age for of the PWUDs was 24.0 years (IQR: 20-29). The HIV prevalence among the PWUDs was 5.1% (95% CI: 4.1-6.2), 24.8%, among PWIDs and 4.0% among non-PWIDs. The HIV prevalence among female PWIDs was 37.5, and 22.5% among male PWIDs. Four factors were independently associated with HIV infection: female sex, with AOR = 7.8 (95% CI: 3.00-20.35); age groups 21-29 and older (AOR = 10.3, 95% CI: 1.2-20.4); and using drugs for ≥12 months (AOR = 4.0, 95% CI: 1.38-11.35). Finally, injecting drugs remained a strong predictor of HIV infection, with an AOR = 4.1 (95% CI: 1.53-10.96). CONCLUSION: HIV prevalence remains high among PWIDs. Harm reduction efforts, such as needle and syringe provision programs, must improve their coverage. Innovative strategies are needed to reach sub-groups of PWUDs, especially women who inject drugs. Furthermore, the large proportion of non-PWIDs, especially ATS users, should not be ignored. Therefore, combined HIV prevention and harm reduction programs should integrate ATS users.

Characteristics, risk behaviors and factors associated with abortion among female entertainment workers in Cambodia.

BACKGROUND: Linkages between HIV and reproductive health (RH) among female entertainment workers (EWs) have not been addressed well in most developing countries. In Cambodia, there has been considerable research on HIV epidemiology among EWs. However, there have been limited studies on RH and specifically factors related to abortion. We examine socio-behavioral characteristics, and RH practices as determinants of abortion among Cambodian EWs. METHODS: A survey was conducted in Siem Reap and Battambang and Phnom Penh provinces/city among EWs in September 2012. Trained female interviewers administered the survey to 595 EWs. Two-stage cluster sampling was used to select EWs. Bivariate associations were examined using chi-squares; univariate and multivariate logistic regression were used to assess factors independently associated with reporting having at least one abortion while working as an EW. RESULTS: Three-quarters (75 %) of EWs were sexually active, of which nearly one third reported at least one abortion while working as an EW. About 40 % of EWs reported recent an abortion in the past six months. Contraceptive use in the past year was low. Factors found to be independently associated with reporting a recent abortion included: ages 25-29 (OR = 2.2, 95 % CI: 1.2-4.0), living with spouse/cohabitated partner (OR = 2.2, 95 % CI: 1.1-4.2), longer duration of entertainment work (OR = 4.8, 95 % CI: 2.5-9.2), higher number of partners (OR = 4.4, 95 % CI: 2.2-8.7) and being a karaoke worker (OR = 2.2, 95 % CI: 1.1-4.4). CONCLUSION: This study highlights a high proportion of EWs reporting abortion. While HIV vulnerability of EWs has been clearly established, broader RH needs have gone largely unrecognized and not prioritized. Though HIV/RH integrated initiatives have been introduced by the HIV program, challenges for EWs with multiple risks from professional and partners are profound. Therefore, there is an urgent need for practical programmatic approaches to help address their RH needs.

Clinical Presentation, Risk Factors, and Comparison of Laboratory Diagnostics for Seasonal Influenza Virus Among Cambodians From 2007 to 2020.

Background: Despite its global significance, challenges associated with understanding the epidemiology and accurately detecting, measuring, and characterizing the true burden of seasonal influenza remain in many resource-poor settings. Methods: A prospective observational study was conducted in Cambodia at 28 health facilities between 2007 and 2020 utilizing passive surveillance data of patients presenting with acute undifferentiated febrile illness (AUFI) to describe the prevalence of influenza A and B and characterize associated risk factors and symptoms using a questionnaire. A comparison of rapid influenza diagnostic tests (RIDTs) and real-time reverse transcription polymerase chain reaction (rRT-PCR) results was also conducted. Results: Of 30 586 total participants, 5634 (18.4%) tested positive for either influenza A or B, with 3557 (11.6%) positive for influenza A and 2288 (7.5%) positive for influenza B during the study. Influenza A and B were strongly associated with the rainy season (odds ratio [OR], 2.30; P < .001) and being from an urban area (OR, 1.45; P < .001). Analysis of individual symptoms identified cough (OR, 2.8; P < .001), chills (OR, 1.4; P < .001), and sore throat (OR, 1.4; P < .001) as having the strongest positive associations with influenza among patients with AUFI. Analysis comparing RIDTs and rRT-PCR calculated the overall sensitivity of rapid tests to be 0.492 (95% CI, 0.479-0.505) and specificity to be 0.993 (95% CI, 0.992-0.994) for both influenza type A and B. Conclusions: Findings from this 14-year study include describing the epidemiology of seasonal influenza over a prolonged time period and identifying key risk factors and clinical symptoms associated with infection; we also demonstrate the poor sensitivity of RIDTs in Cambodia.

Overweight and obesity among women at reproductive age in Cambodia: Data analysis of Cambodia Demographic and Health Survey 2014.

Overweight and obesity increase the risk of cardiovascular disease, type 2 diabetes mellitus, hypertension, stroke, and some type of cancers, and maternal health globally. In Cambodia, the prevalence of overweight and obesity among women aged 15-49 years increased from 6% in 2000 to 18% in 2014, becoming a public health burden. We examined socio-demographic and behavioral factors associated with overweight and/or obesity among women of reproductive age (WRA) in Cambodia. We analyzed data from the 2014 Cambodia Demographic and Health Survey (CDHS) that used a two-stage stratified cluster sampling design. Data analysis was restricted to non-pregnant women, resulting in an analytic sample of 10,818 women. Multivariable logistic regressions were performed using STATA V16 to examine factors associated with overweight and obesity. Prevalence of overweight and obesity among non-pregnant women of reproductive age were 15.2% and 2.8% respectively. Factors independently associated with increased odds of overweight and/or obesity including women aged 20-29 years with adjusted odds ratio [AOR = 2.4; 95% CI: 1.6-3.6], 30-39 years [AOR = 4.6; 95% CI: 3.0-6.9], and 40-49 years [AOR = 6.6; 95% CI: 4.3-10.1], married women [AOR = 1.8; 95% CI: 1.3-2.7], urban residence [AOR = 1.3; 95% CI: 1.1-1.5], and women having at least 4 children [AOR = 1.7; 95% CI: 1.2-2.5]. The factors were associated with decreased odds of overweight and obesity: completed at least secondary education [AOR = 0.7; 95% CI: 0.6-0.8], agricultural work [AOR = 0.7; 95% CI: 0.5-0.8], and manual labor work [AOR = 0.7; 95% CI: 0.6-0.9]. Increased age, married women, living in urban residence, and having at least four children were the main risk factors associated with overweight and/or obesity. Conversely, higher education, working in agriculture, and working in manual labor were negatively associated with overweight and/or obesity. Cambodia's non-communicable disease (NCD) public health programs should consider these characteristic for targeting interventions to further reduce overweight and/or obesity in the coming years.

Anemia among pregnant women in Cambodia: A descriptive analysis of temporal and geospatial trends and logistic regression-based examination of factors associated with anemia in pregnant women.

Anemia is a major public health problem for thirty-two million pregnant women worldwide. Anemia during pregnancy is a leading cause of child low birth weight, preterm birth, and perinatal/neonatal mortality. Pregnant women are at higher risk of anemia due to micronutrient deficiencies, hemoglobinopathies, infections, socio-demographic and behavioral factors. This study aimed to: 1) assess temporal and geospatial trends of anemia in Cambodia and 2) identify factors associated with anemia among pregnant women aged 15-49 years old in Cambodia. We analyzed data from the Cambodia Demographic and Health Survey (CDHS) for 2005, 2010, and 2014. Data were pooled across the three survey years for all pregnant women aged 15-49 years. Survey weights were applied to account for the complex survey design of the CDHS. Descriptive statistics were estimated for key sociodemographic characteristics of the study population. We used logistic regressions to assess factors associated with anemia among pregnant women aged 15-49 years old. Anemia in pregnant women aged 15-49 in Cambodia decreased from 56% in 2005 to 53% in 2014. With the highest in Preah Vihear and Stung Treng provinces (74.3%), in Kratie province (73%), and in Prey Veng (65.4%) in 2005, 2010, and 2014 respectively. Compared to pregnant women from the wealthiest households, women from poorest households were more likely to have anemia (AOR = 2.8; 95% CI: 1.6-4.9). Pregnant women from coastal regions were almost twice as likely of having anemia (AOR = 1.9; 95% CI: 1.2-3.0). Pregnant women were more likely anemic if they were in their 2nd trimester (AOR = 2.6; 95% CI: 1.9-3.6) or 3rd trimester (AOR = 1.6 95% CI: 1.1-2.3). Anemia remains highly prevalent among pregnant women in Cambodia. Public health interventions and policies to alleviate anemia should be prioritized and shaped to address these factors.

Etiology and risk factors for diarrheal disease amongst rural and peri-urban populations in Cambodia, 2012-2018.

Diarrheal diseases are a leading cause of mortality and morbidity, disproportionally affecting persons residing in low and middle-income countries. Accessing high-resolution surveillance data to understand community-level etiology and risk remains challenging, particularly in remote and resource limited populations. A multi-year prospective cohort study was conducted in two rural and two peri-urban villages in Cambodia from 2012 to 2018 to describe the epidemiology and etiology of acute diarrheal diseases within the population. Suspected diarrheal episodes among participants were self-reported or detected via routine weekly household visits. Fresh stool and fecal swabs were tested, and acute-illness and follow-up participant questionnaires collected. Of 5027 enrolled participants, 1450 (28.8%) reported at least one diarrheal incident. A total of 4266 individual diarrhea case events were recorded. Diarrhea incidence rate was calculated to be 281.5 persons per 1000 population per year, with an event rate of 664.3 individual diarrhea events occurring per 1000 population per year. Pathogenic Escherichia coli, Aeromonas spp., and Plesiomonas shigelloides were the most prevalent bacterial infections identified. Hookworm and Strongyloides stercoralis were the predominant helminth species, while Blastocystis hominis and Giardia lamblia were the predominant protozoan species found. Norovirus genotype 2 was the predominant virus identified. Mixed infections of two or more pathogens were detected in 36.2% of positive cases. Risk analyses identified unemployed status increased diarrhea risk by 63% (HR = 1.63 [95% CI 1.46, 1.83]). Individuals without access to protected water sources or sanitation facilities were 59% (HR = 1.59 [95% CI 1.49, 1.69]) and 19% (HR = 1.19 [95% CI 1.12, 1.28]) greater risk of contracting diarrhea, respectively. Patient-level surveillance data captured in this long-term study has generated a unique spatiotemporal profile of diarrheal disease in Cambodia. Understanding etiologies, together with associated epidemiological and community-level risk, provides valuable public health insight to support effective planning and delivery of appropriate local population-targeted interventions.

Ending Tobacco Use Through Interactive Tailored Messaging for Cambodian People With HIV (Project EndIT): Protocol for a Randomized Controlled Trial.

BACKGROUND: The prevalence of smoking remains high in many low- and middle-income countries (LMICs), including the Southeast Asian nation of Cambodia. Smoking is especially hazardous for people with HIV. In Cambodia, approximately 43%-65% of men with HIV and 3%-5% of women with HIV smoke cigarettes. Thus, there is a critical need for cost-effective smoking cessation interventions for Cambodian people with HIV. This paper describes the design, methods, and data analysis plans for a randomized controlled trial assessing the efficacy of a theory-based mobile health smoking cessation intervention in Cambodian people with HIV. OBJECTIVE: This 2-group randomized controlled trial compares the efficacy of a mobile health-based automated messaging (AM) intervention versus standard care (SC) in facilitating smoking cessation among Cambodian people with HIV. METHODS: Cambodian people with HIV who currently smoke and are receiving antiretroviral treatment (target, N=800) will be randomized to (1) SC or (2) the AM intervention. SC participants will receive brief advice to quit smoking, written self-help materials, nicotine patches, and will complete weekly app-delivered dietary assessments for 26 weeks. AM participants will receive all SC components (but will complete smoking-related weekly assessments instead of dietary assessments), in addition to a fully automated tailored messaging program driven by the weekly assessments to facilitate smoking cessation. In the Phase-Based Model of smoking cessation, the cessation process is partitioned into 4 phases: motivation, preparation (precessation), cessation (quit date to 2 weeks post quit), and maintenance (up to 6 months post quit). Our AM program targets processes within these phases, including increasing motivation to quit, enhancing self-efficacy, obtaining social support, skills to cope with nicotine withdrawal symptoms and stress, and skills to maintain abstinence. All participants will complete baseline and 3-, 6-, and 12-month in-person follow-up assessments. The primary outcome is biochemically confirmed abstinence at 12 months, with 3- and 6-month abstinence as secondary outcomes. Potential mediators and moderators underlying treatment effects will be explored, and cost-effectiveness will be assessed. RESULTS: This study was approved by all relevant domestic and international institutional and ethical review boards. Participant recruitment commenced in January 2023. Data collection is expected to conclude by the end of 2025. CONCLUSIONS: By demonstrating the greater efficacy and cost-effectiveness of AM relative to SC, this study has the potential to transform HIV care in Cambodia and prevent tobacco-related diseases. Furthermore, it may be adapted for use in other Cambodian populations and in other low- and middle-income countries. Ultimately, the AM approach to smoking cessation could greatly improve public health in the developing world and beyond. TRIAL REGISTRATION: ClinicalTrials.gov NCT05746442; https://clinicaltrials.gov/ct2/show/NCT05746442. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/48923.

Potential for community based surveillance of febrile diseases: Feasibility of self-administered rapid diagnostic tests in Iquitos, Peru and Phnom Penh, Cambodia.

Rapid diagnostic tests (RDTs) have the potential to identify infectious diseases quickly, minimize disease transmission, and could complement and improve surveillance and control of infectious and vector-borne diseases during outbreaks. The U.S. Defense Threat Reduction Agency's Joint Science and Technology Office (DTRA-JSTO) program set out to develop novel point-of-need RDTs for infectious diseases and deploy them for home use with no training. The aim of this formative study was to address two questions: 1) could community members in Iquitos, Peru and Phnom Penh, Cambodia competently use RDTs of different levels of complexity at home with visually based instructions provided, and 2) if an RDT were provided at no cost, would it be used at home if family members displayed febrile symptoms? Test kits with written and video (Peru only) instructions were provided to community members (Peru [n = 202]; Cambodia [n = 50]) or community health workers (Cambodia [n = 45]), and trained observers evaluated the competency level for each of the several steps required to successfully operate one of two multiplex RDTs on themselves or other consenting participant (i.e., family member). In Iquitos, >80% of residents were able to perform 11/12 steps and 7/15 steps for the two- and five-pathogen test, respectively. Competency in Phnom Penh never reached 80% for any of the 12 or 15 steps for either test; the percentage of participants able to perform a step ranged from 26-76% and 23-72%, for the two- and five-pathogen tests, respectively. Commercially available NS1 dengue rapid tests were distributed, at no cost, to households with confirmed exposure to dengue or Zika virus; of 14 febrile cases reported, six used the provided RDT. Our findings support the need for further implementation research on the appropriate level of instructions or training needed for diverse devices in different settings, as well as how to best integrate RDTs into existing local public health and disease surveillance programs at a large scale.

Determinants of Exclusive Breastfeeding of Infants under Six Months among Cambodian Mothers.

INTRODUCTION: Practicing exclusive breastfeeding (EBF) in an infant's first six months of life is recommended by the World Health Organization because of its proven effectiveness as a method to support the infant's short- and long-term physical and cognitive development. However, many countries, including Cambodia, face contextually driven challenges in meeting this optimum standard of breastfeeding. The recent declining EBF rate in Cambodia is a concerning indicator of the impact of these challenges. METHODS: We used existing data from the 2014 Cambodian Demographic and Health Survey (CDHS) to analyze 717 Cambodian mother-infant pairs. CDHS 2014 used a two-stage stratified cluster sampling approach to select samples. A multivariable logistic regression analysis was used to assess determinants of EBF, taking into account the sampling weight in the analysis. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated, and significance level was considered at p value < 0.05. RESULTS: Our findings indicate that among mothers with infants under six months, EBF was more likely if they resided rurally (AOR = 2.28; 95% CI 1.23-4.23) and if they delivered at a public hospital (AOR = 2.64; 95% CI 1.28-5.47). On the other hand, mothers of middle wealth index practiced EBF less than mothers of low wealth index (AOR = 0.58; 95% CI 0.34-0.99). And as expected, our analysis confirmed that the older the infants grew, the less likely they were to be exclusively breastfed than those younger than one month old (2-3 months: AOR = 0.49; 95% CI 0.26-0.92; 4-5 months: AOR = 0.25; 95% CI 0.15-0.43). CONCLUSION: The findings emphasize the need to address these determinants adequately by appropriate interventions to halt the declining trend of EBF practice. We recommend a multifaceted approach to improve EBF rates in Cambodia. Advocacy around EBF at public hospitals should continue, and private hospital staff should receive training to provide EBF counselling and support to mothers.

Psychological distress among Cambodian people who use drugs.

INTRODUCTION AND AIMS: People who use drugs (PWUD) face several mental health problems. This report aims to examine the prevalence of and factors associated with psychological distress among Cambodian PWUD. DESIGN AND METHODS: Data used in our analysis were from the national survey of 1626 PWUD recruited through respondent-driven sampling method in Cambodia in 2012 to 2013. Distress was measured through self-report by using the 10-item Kessler Psychological Distress Scale (K10). All analyses were weighted. RESULTS: Approximately half of PWUD had mild to severe psychological distress in the past four weeks (K10 ≥ 20). In the adjusted analysis, being female (odds ratio 1.60; 95% confidence interval 1.22, 2.12) and having experienced living in rehabilitation centres (odds ratio 2.46; 95% confidence interval 1.56, 3.87) were associated with a higher risk of having moderate or severe psychological distress (K10 ≥ 25). DISCUSSION AND CONCLUSIONS: Psychological distress was prevalent among Cambodian PWUD. PWUD who were female or experienced living in rehabilitation centres were more likely to report distress. Policy makers should consider shifting further from compulsory institutionalised treatment model to community-based treatment program. Mental health assessment and mental health care services should be included in drug treatment programs and should be gender-sensitive. Further research investigating other mental disorders among PWUD are also needed.

Factors Associated With Sexual Risk Behaviors Among People Who Use Drugs in Communities in Cambodia.

In Cambodia, HIV prevalence at 4% remains high among people who use drugs (PWUD). Complex and overlapping risk behaviors may enhance sexual transmission risk beyond PWUD. This study, therefore, aims to assess the factors associated with sexual risk behaviors among PWUD. Respondent Driven Sampling was used to recruit 1626 PWUD. Univariate and multivariate logistic regression analyses were used to identify factors associated with transmission risk including that high mental disorder scores were a strong predictor of sexual risk behaviors (odds ratio [OR] ranged from 1.9 to 2.8). Factors associated with sexual risk behaviors varied by gender: for men, these included geographical regions, non-married status, and heroin use; and for women, factors were age ≤20 years (OR = 5.4), living with friends (OR = 6.4), living in Central coastal region (OR = 6.1), and heroin use (OR = 4.8).

Potential Use of Community-Based Rapid Diagnostic Tests for Febrile Illnesses: Formative Research in Peru and Cambodia.

In 2012, the U.S. Defense Threat Reduction Agency Joint Science and Technology Office initiated a program to develop novel point-of-need diagnostic devices for surveillance of emerging infectious diseases including dengue, malaria, plague, and melioidosis. Prior to distribution of devices to observe their correct use among community members in Iquitos, Peru, and Phnom Penh, Cambodia, research was conducted to: 1) assess acceptability of use, including the motivation to use a rapid diagnostic test (RDT) before or instead of seeking care at a health facility, 2) explore comprehension of RDT use instructions, and 3) examine possible strategies for large scale RDT distribution and use at each site. In February 2014, 9 focus group discussions (FGD) with community members and 5 FGD with health professionals were conducted in Iquitos, and 9 FGD with community members and 9 in-depth interviews with health professionals in Phnom Penh. In both places, participants agreed to use the device themselves (involving finger prick) or could identify someone who could do so in their home or neighborhood. The main incentive to RDT use in both sites was the ability for device results to be used for care facilitation (post confirmatory tests), specifically reduced wait times to be seen or obtain a diagnosis. Comprehension of RDT use instructions was assessed in Iquitos by asking some participants to apply the device to research team members; after watching a short video, most steps were done correctly. In Phnom Penh, participants were asked to describe each step after reading the instructions; they struggled with comprehension. Health professionals' main concerns in both sites were their community's ability to accurately use the test, handle complicated instructions, and safety (i.e., disposal of lancets). Health system structure and ability to use home diagnostic devices varied in the two disease endemic sites, with substantial challenges in each, suggesting the need for different strategies for RDT large scale community use, and illustrating the value of formative research before deployment of novel technologies.

Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% Condom Use Programme.

BACKGROUND: Cambodia's 100% Condom-Use Programme (CUP), implemented nationally in 2001, requires brothel-based female sex workers (FSWs) to use condoms with all clients. In 2005, we conducted a sexually transmitted infection (STI) survey among FSWs. This paper presents the STI prevalence and related risk factors, and discusses prevalence trends in the context of the 100% CUP in Cambodia. METHODS: From March-May, 1079 FSWs from eight provinces consented to participate, provided specimens for syphilis, chlamydia, and gonorrhoea testing, and were interviewed. Univariate and multivariate logistic regression analysis was used to determine factors associated with STIs. STI prevalence was compared with data from the 1996 and 2001 STI surveys. RESULTS: Most FSWs were young (55% aged 15-24) and new to sex work (60% had worked 12

Low birth weight of institutional births in Cambodia: Analysis of the Demographic and Health Surveys 2010-2014.

BACKGROUND: Low birth weight (LBW), an important risk factor for early childhood mortality and morbidity, is a major public health concern in developing countries including Cambodia. This study examined the prevalence of LBW across provinces in Cambodia and changes over time, and identified the factors associated with such condition. METHODS: We used children datasets from Cambodia Demographic and Health Survey (CDHS) 2010 and 2014. There were 3,522 children and 4,991 children in both surveys. Maps illustrating provincial variation in LBW prevalence were constructed. Then, multivariate analyses were conducted to assess factors independently associated with LBW in CDHS 2014. RESULTS: LBW prevalence remained stable between 2010 and 2014, at around 7.0% 95% CI: 5.8-8.1). all institutional births, but within significant variation across provinces. Factors independently associated with LBW included mother's no education compared with those whose mothers had secondary or higher education (AOR = 1.6, 95% CI: 1.0-2.6), babies born to mothers with < 4 antenatal care (ANC) visits during the pregnancy compared with those whose mothers had at least 4 ANC visits (AOR = 2.0, 95% CI: 1.5-2.8). Also, first-born babies were at greater risk of LBW compared with second-born babies (AOR = 1.4, 95% CI: 1.0-2.0). CONCLUSION: The study points to key sub-populations at greater risk and regions where LBW is particularly prevalent. Programs should target provinces where LBW prevalence remains high. Illiterate women, especially those pregnant for the first time should be the program priority. The current national program policy, which recommends that pregnant women have ≥ 4 ANC visits during pregnancy should be further reinforced and implemented. Program design should consider ways to communicate the importance of making the recommended number of ANC visits among women with no formal education.

Proportion and predictors of loss to follow-up in a longitudinal cohort study of female entertainment and sex workers in Cambodia.

We examined the proportion and correlates of loss to follow-up (LTFU) among female entertainment and sex workers (FESWs) in a longitudinal HIV prevention intervention trial in Cambodia. The Cambodia Integrated HIV and Drug Prevention Intervention trial tested a comprehensive package of interventions aimed at reducing amphetamine-type stimulant use and HIV risk among FESWs in ten provinces. The present study estimated the proportion of women LTFU and assessed factors associated with LTFU. Logistic regression analyses were used. Of a total 596 women enrolled, the cumulative proportion of LTFU was 29.5% (n = 176) between zero- and 12-month follow-up. In multivariate analyses, women with no living children (adjusted odds ratio [AOR] 1.6; 95% confidence interval [CI]: 1.1, 2.3) and those who experienced recent food insecurity (AOR 1.7; 95%CI: 1.1, 2.7) were more likely to be LTFU. Women who were members of the SMARTgirl HIV prevention programme for ≥ 6 months compared to non-members were less likely to be LTFU (AOR 0.3; 95%CI: 0.2, 0.6). LTFU was moderately high in this study and similar to other studies, indicating a need for strategies to retain this population in HIV prevention programmes and research. Interventions aimed at stabilizing women's lives, including reducing food insecurity and creating communities of engagement for FESWs, should be considered.

Current HIV/AIDS/STI epidemic: intervention programs in Cambodia, 1993-2003.

In the past decade, Cambodia has been experiencing the most serious HIV/AIDS epidemic in Southeast Asia. With full support from the top policy makers, good leadership in program management, and the commitment of the public health program officers, the HIV/AIDS prevention and care program in Cambodia has been successful, despite its resource constraints. Available data from surveillance and other studies in Cambodia indicate a downward trend in HIV prevalence and incidence among high-risk groups, an increase in condom use among commercial sex workers and their clients, and a declining trend of sexually transmitted infections. Although these findings reflect the success of programs to prevent transmission, the incidence of HIV infections is still high in high-risk populations, and transmission among the general population continues. Cambodia therefore needs to increase its efforts to reduce transmission. More research and prevention programs should focus on the vulnerable populations. HIV/AIDS modeling indicates that Cambodia needs to prepare for increasingly large numbers of AIDS patients who will require expensive medical care.

Distribution of HIV in Cambodia: findings from the first national population survey.

OBJECTIVES: A limited number of studies in Asia have investigated HIV transmission in the general population in order to better guide preventive efforts. We examine HIV prevalence patterns in men and women aged 15-49 years in Cambodia. METHODS: The first national population-based survey was conducted in 2005, including HIV-related questionnaires and HIV test. Data were analysed separately for men and women. Logistic regression analysis, adjusted by age, was used to determine factors associated with HIV. To estimate the HIV prevalence, it was standardized by age, sex and place of residence. RESULTS: Among 6514 men and 8188 women, HIV prevalence was 0.61% [95% confidence interval (CI) 0.2-1.8] and 0.62% (95% CI 0.3-2.1), respectively. The prevalence in urban areas was approximately three times higher than in rural settings. The likelihood among women of being HIV positive increased with increasing age differentials between spouses. HIV among men increased with household wealth (odds ratio 5.7; 95% CI 2.0-16.4) and education (odds ratio 3.7; 95% CI 0.8-17.8). About 10% of men reported multiple partners, a behaviour strongly associated with HIV (odds ratio 4.0; 95% CI 1.3-12.5). CONCLUSION: This study revealed HIV prevalence to be relatively low in the general population and substantially below previous estimates. Multiple observations were consistent with the hypothesis that the bulk of infections among men are related to sex work and most women are infected in marriage. Intervention should be focused on reducing the transmission among spouses and empower women with better access to information, education and care while sustaining preventive efforts related to sex work.

Community action for preventing HIV in Cambodia: evaluation of a 3-year project.

The 'Community Action for Preventing HIV/AIDS Project' was implemented in four provinces in Cambodia (2001-04) to support a comprehensive set of HIV prevention efforts. Implementation was strictly monitored in terms of inputs, outputs and outcomes. We examine changes in these variables during the project period to assess the extent to which they were related to the project. Inputs and outputs were monitored regularly by supervision and quarterly project reports. Baseline and follow-up surveys were conducted on 10 target groups to measure changes in outcome indicators related to sexual risk behaviours, uses of HIV voluntary counselling and testing (VCT), self-reported sexually transmitted infections (STIs) and other indicators. The analyses use data from surveys and from project monitoring. Spending on HIV-related work at provincial level increased markedly, including investments in VCT, STI facilities and staff training. Yearly expenditure increased about 7-fold compared with years immediately preceding the project. VCT centres increased from 3 to 12, numbers of counsellors from 10 to 27, and numbers of client visits more than doubled. STI laboratory facilities increased from 0 to 6 with coverage of STI check-ups among sex workers increasing from 70% to 93% and a decline in men attending STI clinics. The survey results indicate significant changes in a number of major outcome indicators such as consistent condom use related to sex work (>80%), HIV testing and counselling after HIV tests, especially among police (42 to 72%, P < 0.001) and brothel-based sex workers (48 to 89%, P < 0.001). Self-reported STIs declined in most groups. Finally, the programmatic systems for planning, managing and monitoring implementation of activities at both central and provincial level, as well as technical guidelines, developed under the project have become the standard for the national programme. In conclusion, the project appears to have been comprehensive and a number of favourable changes in output and outcome indicators occurred. It seems likely that the project made a substantial contribution to these positive outcomes, though the extent is not clear. The project is likely to have powerful long-term effects through strengthening of capacity and establishment of systems for the national programme.

HIV-related risk behaviors in Cambodia and effects of mobility.

OBJECTIVES: To study HIV risk behaviors in different population groups, linkages to bridge populations, and to examine factors affecting such behaviors and links. METHODS: Ten population groups in 4 provinces were surveyed. Stratified random cluster sampling was used, and interviews were conducted to provide information on sociodemographic characteristics, mobility, and risk behaviors. The groups surveyed were female sex workers (FSWs), household men and women, youths in vocational training, and men with high-mobility occupations (fishermen, mototaxi drivers, police, military, casino workers, and deminers). The total number surveyed was 3848. RESULTS: The proportion reporting sex in the past year with FSWs differed sharply between male groups ranging from 20% to 51% in the high-mobility groups and 5% to 10% in the other groups. Noncommercial sex varied less by group. Consistent condom protection (always used condoms in the past 3 months) with FSWs was high (>85% for most groups). However, condom use was significantly less with noncommercial partners, a high proportion of whom complained about a lack of condom availability. For the different male groups, travel away from home >1 month in the past year was a strong independent determinant of both sex with FSWs and noncommercial sex. Casual sex was more common in young unmarried men. Women in the general population did not report casual sex, but 41% of them were "worried about being infected by their husbands." CONCLUSIONS: The results suggest mobility is a strong determinant of casual sex. Although FSWs may still act as an important bridge for HIV transmission in Cambodia, noncommercial sex is becoming increasingly important due to the relatively low condom use in such relationships.