Climate change impacts and disaster resilience among micro businesses in the tourism and hospitality sector: The case of Kratie, Cambodia.

Cambodia is considered extremely vulnerable to climate change due to high poverty, limited infrastructure, and weak adaptive capacity. Kratie province, in particular, has suffered from climate-induced disasters, including floods, droughts, storms, lightning, and heatwaves. To date, climate change interventions in the province have primarily focused on impacts on agriculture. However, enhancing the climate resilience of micro businesses in the tourism and hospitality sector is also crucial since the provincial economy increasingly depends on the interlinkage between agriculture, tourism and related enterprises. This article examines how climate change has impacted micro businesses in Kratie Town, and how they responded to the impacts. This study is based on semi-structured interviews with micro entrepreneurs randomly selected in the town. Results show that businesses have been predominantly affected by floods and storms. Business exposures and locations, types of business, production and supply chains, and client bases determined different impacts of and responses to these climate-related hazards. Businesses adopted primarily temporary and reactive responses rather than long-term systematic measures. Strengthening adaptive infrastructure, both physical and informational, will improve businesses' capability to prepare for and cope with these disasters.

Social-support needs among adolescents living with HIV in transition from pediatric to adult care in Cambodia: findings from a cross-sectional study.

BACKGROUND: Understanding the circumstances of adolescents living with HIV is critical in designing adolescent-friendly services that will facilitate successful transition from pediatric to adult care. This study describes access, utilization and ongoing social support needs among adolescents living with HIV aged 15-17 in transition from pediatric to adult HIV care in Cambodia. METHODS: A cross-sectional study was conducted among 328 adolescents, randomly selected from 11 antiretroviral therapy (ART) clinics across the country. Descriptive analyses were conducted to summarize their characteristics, access to social support and ongoing support needs among male and female adolescents. RESULTS: Mean age of the study participants was 15.8 (SD = 0.8) years. Just over half (55.2%) were male. Most had at least one deceased parent (mother 50.9%; father 60.5%), and majority were living with biological parents (40.8%) or relatives (49.3%). A third came from families with an ID poor card, and 21.0% were working for pay. Almost half (46.6%) reported that their family had received social support for their health care, including food support (76.5%), school allowance (62.1%), transport allowance to ART clinics (53.6%), psychosocial counseling (35.3%), vocational training (22.9%) or home visits (11.1%). Several ongoing social support needs were identified, including ongoing inability to cover health expenses unless they are supported by health insurance or health equity fund (55.0%). In addition, adolescents reported having been asked to come back earlier than their scheduled appointment (13.7%), having had to purchase their own drugs (2.7%), experiencing HIV stigma (32.0%), having been denied housing or food due to HIV (8.2%) or failing to attend school within the past month partly because of HIV (16.8%). Two-thirds did not have access to peer support groups. CONCLUSIONS: Social protection mechanisms are reaching some adolescents in need, while other remain without social support due to discontinuities in health and social care. Multi-sectoral interventions, supporting school attendance, adolescent-friendly clinic scheduling, reductions in child employment, mitigation of HIV-related stigma and strengthening of peer-to-peer support are required to improve coverage of social protection interventions for adolescents in transition.

Sex with sweethearts: Exploring factors associated with inconsistent condom use among unmarried female entertainment workers in Cambodia.

BACKGROUND: Despite the success in promoting condom use in commercial relationships, condom use with regular, noncommercial partners remains low among key populations in Cambodia. This study explores factors associated inconsistent condom use with sweethearts among unmarried sexually active female entertainment workers (FEWs). METHODS: In 2014, the probability proportional to size sampling method was used to randomly select 204 FEWs from entertainment venues in Phnom Penh and Siem Reap for face-to-face interviews. Multivariate logistic regression analysis was conducted to examine independent determinants of inconsistent condom use. RESULTS: Of total, 31.4% of the respondents reported consistent condom use with sweethearts in the past three months. After adjustment, respondents who reported inconsistent condom use with sweethearts remained significantly less likely to report having received any form of sexual and reproductive health education (AOR = 0.49, 95% CI = 0.22-0.99), but more likely to report having been tested for HIV in the past six months (AOR = 2.19, 95% CI = 1.03-4.65). They were significantly more likely to report having used higher amount of alcohol in the past three months (AOR = 1.29, 95% CI = 1.01-1.99) and currently using a contraceptive method other than condoms such as pills (AOR = 4.46, 95% CI = 1.34-10.52) or other methods (AOR = 9.75, 95% CI = 2.07-9.86). CONCLUSIONS: The rate of consistent condom use in romantic relationships among unmarried FEWs in this study is considerably low. The importance of consistent condom use with regular, non-commercial partners should be emphasized in the education sessions and materials, particularly for FEWs who use non-barrier contraceptive methods.

Non-communicable diseases and related risk behaviors among men and women living with HIV in Cambodia: findings from a cross-sectional study.

BACKGROUND: There is a growing concern for an increasing burden of non-communicable diseases (NCDs) in people living with HIV. This concern is evident especially in developing countries where dietary and lifestyle risk factors associated with NCDs are becoming more prominent. This study explored the prevalence of diabetes mellitus, hypertension, and hyperlipidemia and related risk factors in men and women living with HIV in Cambodia. METHODS: This cross-sectional study was conducted among 510 adult people living with HIV randomly selected from one city and four provinces in Cambodia. A structured questionnaire was used to collect data on socio-demographic characteristics, health behaviors, medical history, and antiretroviral therapy (ART). Anthropometric and biological measurements were performed. Descriptive statistics were used to calculate proportions and means of the measured variables. An independent Student's t-test was used for continuous variables. Chi square test or Fisher's exact test was used for categorical variables to explore gender differences. RESULTS: Prevalence of diabetes mellitus, hypertension, and hyperlipidemia was 9.4, 15.1, and 33.7%, respectively. The prevalence of hyperlipidemia was significantly higher among men compared to women. Mean systolic and diastolic blood pressures were also significantly higher among men. Regarding risk factors, 17.3% of participants were overweight, and 4.1% were obese. Tobacco and alcohol use was common, particularly among men. Fruit and vegetable consumption was considerably low among both men and women. Physical activity levels were also low. About 40% of participants reported having a job that involved mostly sitting or standing; 46.3% reported engaging in moderate activities; and 11.8% reported engaging in vigorous activities during leisure time. A significantly higher proportion of men compared to women engaged in vigorous activities both at work and during leisure time. CONCLUSIONS: The prevalence of diabetes mellitus, hypertension, and hyperlipidemia among men and women living with HIV in Cambodia is considerably high. Related risk factors were also common. Given the comorbidity of NCDs and HIV, policy and programmatic interventions are required, including integration of NCD screening into HIV programs. Distinctions in the levels of diseases and in health behaviors between men and women suggest that interventions need to be tailor-made and gender-specific, targeting their respective diseases and behaviors.

Transition into adult care: factors associated with level of preparedness among adolescents living with HIV in Cambodia.

BACKGROUND: Preparing adolescents for transition into adult care and supporting their acquisition of self-health care management skills is a critical determinant of their post-transition HIV care outcomes. However, there is a scarcity of research on effective transition strategies. This study explores factors associated with adolescent preparedness for transition into adult care in Cambodia. METHODS: In August 2016, a cross-sectional study was conducted among 223 adolescents living with HIV aged 15-17, randomly selected from 11 antiretroviral therapy clinics, utilizing a structured questionnaire. The level of preparedness was determined using a pre-existing scale, and adolescents were categorized as having a high- or low level of preparedness for transition. Bivariate and multivariate analyses were conducted. RESULTS: Of 223 adolescents, 55.2% were male, and their mean age was 15.8 years. Overall, 53.3% had a high level of preparedness for transition. As part of the transition protocol, 2.7% had completed a transfer form, 24.7% had a transition case manager, 29.6% had been counselled about the transition, and 19.7% had visited an adult ART clinic. In multivariate analysis, a higher level of preparedness for transition was independently associated with older age (AOR 2.44, 95% CI 1.34-4.46; p = 0.004), family having received social support for their health (AOR 5.32, 95% CI 1.97-14.36; p = 0.001), knowing the kind of treatment they received (ART) (AOR 12.67, 95% CI 2.91-15.19; p = 0.001), trust in friends or family for HIV treatment (AOR 7.82, 95% CI 1.13-8.89; p = 0.008), receiving counseling on transition (AOR 3.17, 95% CI 1.15-8.76; p = 0.03), having a 'Case Manager' identified to support them during the preparation process for transition (AOR 3.89, 95% CI 1.08-13.96; p = 0.04), and satisfaction with preparation process for transition in general (AOR 0.35, 95% CI 0.03-0.87; p = 0.01). CONCLUSIONS: A range of individual, social and health system and services factors may determine successful transition preparedness among adolescents in Cambodia. Strengthening implementation of age-appropriate and individualized case management transition at all sites, while creating supportive family, peer, and healthcare environments for adolescent transition is required.

HIV prevalence, risky behaviors, and discrimination experiences among transgender women in Cambodia: descriptive findings from a national integrated biological and behavioral survey.

BACKGROUND: Transgender people are disproportionately affected by HIV. Despite their high vulnerability to HIV, lack of adequate epidemiological and surveillance data related to this population in many countries prevents provision of appropriate services. This paper summarizes descriptive findings from a national integrated biological and behavioral survey and discusses policy implications of the findings on HIV prevention among transgender women in Cambodia. METHODS: This cross-sectional study was conducted between December 2015 and February 2016. Participants were recruited from 20 sites in the capital city and 12 provinces of Cambodia using Respondent Driven Sampling (RDS) method. Behavioral data were collected through structured questionnaire interviews, and rapid finger-prick HIV testing was performed. Descriptive data analyses were conducted using STATA. RESULTS: This study included 1,375 transgender women with a mean age of 25.9 years (SD = 7.1). The overall prevalence of HIV was 5.9%. The prevalence of HIV was significantly higher among urban participants compared to their rural counterparts (6.5 vs. 2.6%, p = 0.02). Almost one in five (19.6%) had never been tested for HIV prior to the study. Overall, 45.0% reported ever using gender affirming hormones. More than one-third (39.1%) reported not using condoms in their last sex, 29.8% had engaged in sex in exchange for money/gifts, and 14.0% reported that they had experienced at least one symptom of sexually transmitted infections (STI) in the past year. About one in ten (10.1%) reported having used some form of amphetamine-type stimulant drugs, while 6.5% reported having sex during or after using illicit drugs. A significant number of participants experienced sexual abuse (39.2%), losing a job (24.3%), or physical abuse (23.6%) because of their transgender identity. In addition, 82.9 and 88.9% would be willing to use the HIV self-test and pre-exposure prophylaxis (PrEP), respectively, if they become available. CONCLUSIONS: The high prevalence of HIV, STI, and related risk behaviors among transgender women in Cambodia is of great concern, suggesting an urgent need to further expand tailored prevention interventions for this key population focusing on individual, social, and structural drivers of HIV. HIV self-test and PrEP should be explored as a priority.

How understanding and application of drug-related legal instruments affects harm reduction interventions in Cambodia: a qualitative study.

BACKGROUND: Harm reduction interventions in Cambodia face numerous obstacles because of conflicting understanding and interests and inconsistencies in the implementation by law enforcement officials. This study aims to examine how understanding and application of Drug Control Law (DCL) and Village/Commune Safety Policy (VCSP) affects harm reduction interventions in Cambodia from the standpoints of law enforcement officials, people who inject drugs and people who use drugs (PWID/PWUD), as well as other key stakeholders. METHODS: This qualitative study was conducted in the capital city of Phnom Penh in 2015. We held five focus group discussions (FGDs) with groups of PWID/PWUD, police officers, Sangkat/commune officers, and local non-governmental organization (NGO) field staff. We also conducted ten key informant interviews (KIIs) with representatives from government agencies, donor agencies, and NGOs. FGDs and KIIs with Cambodian participants were transcribed in Khmer and translated into English. KIIs with foreign participants were transcribed in English. Transcripts were read and re-read to identify emerging themes, which were reviewed and refined to develop common and divergent patterns. RESULTS: There was a huge gap between what the DCL and VCSP say and how law enforcement officers and PWID/PWUD understood them. The gap was also evident in how law enforcement officers implemented the DCL and VCSP. Harm reduction services, including health- and non-health-related interventions, were limited and challenged by unsupportive attitudes, misinterpretation of the DCL and VCSP, and the lack of full engagement with NGOs in the development of these instruments. The needs of PWID/PWUD in accessing health care services were not met due to misconduct of authorities while practicing the DCL and VCSP. Further, the misconduct and enforcement of the law and policy lead to increased social discrimination and physical abuses against PWID/PWUD. CONCLUSIONS: There is a lack of common understanding of the drug-related law and policy and their implications to harm reduction services among both law enforcement officers and PWID/PWUD. Thus, there is a need to mainstream and simplify the law and policy for better comprehension among these actors. To improve the quality and coverage of harm reduction interventions, the gap of understanding and enforcement of laws and policies should be narrowed, and coordination between the government and NGOs and other key stakeholders should be strengthened.

Improving prevention and care for HIV and sexually transmitted infections among men who have sex with men in Cambodia: the sustainable action against HIV and AIDS in communities (SAHACOM).

BACKGROUND: The prevalence of HIV and sexually transmitted infections (STIs) among key populations in Cambodia continues to rise. To address this issue, KHANA, the largest national HIV organization in the country developed and implemented the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project. This study aims to determine the impacts of the SAHACOM on sexual behaviors and the uptake of HIV/STI services among men who have sex with men (MSM) in Cambodia. METHODS: We compared outcome indicators at midterm (n = 352) and endline (n = 394). Surveys were conducted in 2012 and 2014 in Battambang and Siem Reap provinces. A two-stage cluster sampling method was employed to select the study sample for structured interviews. RESULTS: The midterm and endline samples were similar. The average number of sexual partners in the past three months decreased significantly from 6.2 to 4.0 (p = 0.03). The proportion of MSM who reported paying for sex with men in the past three months also decreased significantly from 19.0 % to 9.7 % (OR = 2.0, 95 % CI = 1.3-3.0). No significant change was found in condom and lubricant use in all types of relationships. Regarding STIs, 28.1 % of MSM at midterm reported having at least one STI symptom in the past three months compared to 6.1 % at endline (OR = 4.6, 95 % CI = 2.9-7.4); out of them, 14.1 % of MSM at midterm sought treatment compared to 20.7 % at endline (OR = 2.6, 95 % CI = 1.1-6.9). The proportion of MSM who reported using illicit drugs in the past three months also decreased significantly from 12.2 % to 5.1 % (OR = 2.4, 95 % CI = 1.4-4.2). However, the proportion of MSM who reported having been tested for HIV in the past six months decreased significantly from 94.1 % to 77.1 % (OR = 2.9, 95 % CI = 1.8-3.6). CONCLUSIONS: Findings from this study indicate that the SAHACOM was effective in improving sexual behaviors and related health outcomes among MSM under the project. However, it could not increase condom use and HIV testing rates among this key population. Tailored intervention programs are needed to improve condom use and HIV testing among MSM in Cambodia.

When parents are not present: Decision-making dynamics for young children's health and illness in migrant-sending households in rural Cambodia.

As migration rates increase globally, an increasing proportion of children in low- and middle-income countries live apart from their parents. In particular, skipped-generation households are becoming more common, with grandparents serving as primary caregivers for young grandchildren whose parents migrate and provide remittance support. Yet, how families living apart make decisions for young children's healthcare is not well understood. Processes of care seeking for children's health are examined in Cambodia, which has high rates of internal and international migration, and an increasing number of skipped-generation households. We conducted semi-structured in-depth interviews with grandparents who are primary caregivers for children under ten in skipped-generation households in rural migrant-sending areas. Respondents discussed their family's migration history, care seeking and decision making for grandchildren, dynamics with absent migrant parents, and sources of support. Decisions for children's care are intimately tied to the availability of migrant remittances, which are the modality of the relationship between grandparents and parents. Additional remittance support allows grandparents to make decisions for grandchildren's health based on convenience rather than cost, given the burdens of caring grandparents have taken on a result of the parent's migration. Instrumental supports such as in-kind assistance and informational supports further facilitated children's access to healthcare. This qualitative study informs and explains findings from recent quantitative studies of migration and child health.

Social and behavioural factors associated with depressive symptoms among university students in Cambodia: a cross-sectional study.

OBJECTIVE: To explore social and behavioural factors associated with depressive symptoms among university students in Cambodia. DESIGN: Cross-sectional study. SETTINGS: Two public universities-one in the capital city of Phnom Penh and another in Battambang provincial town. PARTICIPANTS: This study included 1359 students randomly selected from all departments in the two universities using a multistage cluster sampling method for a self-administered questionnaire survey in 2015. PRIMARY OUTCOME MEASURE: Depressive symptoms measured by using the Center for Epidemiologic Studies Depression scale. All measures in the study were self-reported. RESULTS: The proportion of students with depressive symptoms and severe depressive symptoms were 50.6% and 19.6%, respectively. After adjustment in multivariate logistic regression analysis, depressive symptoms remained significantly associated with poor academic performance (adjusted OR (AOR)=7.31, 95% CI 2.24 to 23.86), higher consumption of unhealthy food (AOR=1.72, 95% CI 1.08 to 2.76), a negative self-perception about body shape (AOR=0.54, 95% CI 0.29 to 0.99) and general health status (AOR=2.99, 95% CI 1.28 to 7.00), and limited physical activeness (AOR=0.30, 95% CI 0.16 to 0.58). Depressive symptoms also remained significantly associated with adverse childhood experiences including physical violence (AOR=1.39, 95% CI 1.04 to 1.86), psychological abuse (AOR=1.82, 95% CI 1.37 to 2.42) and lack of general and medical care (AOR=0.51, 95% CI 0.30 to 0.86) by family during childhood. CONCLUSIONS: The key factors associated with depressive symptoms were family related and individual behaviours and attitudes. Thus, efforts should be invested in comprehensive screening and intervention programmes to diagnose those vulnerable students early, offer immediate treatment and cater appropriate support.

Sexual behaviors, HIV knowledge, HIV testing attitudes and recent HIV testing among female entertainment workers in Cambodia: A cross-sectional study.

BACKGROUND: In Cambodian context, female entertainment workers (FEWs) are young women working at establishments such as karaoke bars, restaurants, beer gardens or massage parlors. FEWs may sell sex to male patrons and are considered a high-risk group for HIV. This study aimed to identify factors associated with recent HIV testing among FEWs in Cambodia to inform future prevention activities. METHODS: Data were collected in 2014 as part of the evaluation of a larger HIV prevention project. A two-stage cluster sampling method was used to select participants from Phnom Penh and Siem Reap for face-to-face interviews using a structured questionnaire. A logistic regression model was constructed to identify independent factors associated with recent HIV testing. RESULTS: Data were collected from 667 FEWs with a mean age of 25.6 (SD = 5.5). Of total, 81.7% reported ever having had an HIV test, and 52.8% had at least one test in the past six months. After adjustment for other covariates, factors independently associated with recent HIV testing included living in Phnom Penh (AOR = 2.17, 95% CI = 1.43-3.28), having received HIV education in the past six months (AOR = 3.48, 95% CI = 2.35-5.15), disagreeing with a statement that 'I would rather not know if I have HIV' (AOR = 2.15, 95% CI = 1.41-3.30), agreeing with a statement that 'getting tested for HIV helps people feel better' (AOR = 0.32, 95% CI = 0.13-0.81) and not using a condom in the last sexual intercourse with a non-commercial partner (AOR = 0.48, 95% CI = 0.26-0.88). CONCLUSIONS: FEWs with greater knowledge and positive attitudes towards HIV testing got tested for HIV more frequently than those with lesser knowledge and less positive attitudes. These findings suggest that future interventions should focus on disseminating tailored health messages around testing practices as well as specific topics such as condom use with non-commercial partners.

Health and behavioral factors associated with binge drinking among university students in nine ASEAN countries.

BACKGROUND: Heavy drinking among university students has been globally recognized as a major public health burden. In the Association of Southeast Asian Nations (ASEAN) region, studies on this issue have been scant, country-specific and in different time frames. The aim of this study was to identify social and behavioral factors associated with binge drinking among university students in nine ASEAN countries. METHODS: This cross-sectional study was conducted in 2015 among 8809 undergraduate university students from 13 universities in Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand and Vietnam using self-administered questionnaire. Multivariate logistic regression analyses were conducted to explore the associated factors. RESULTS: More than half (62.3%) of the study sample were female with a mean age of 20.5 (SD = 2.0) years. Of total, 12.8% were infrequent (

Patterns of HIV testing, drug use, and sexual behaviors in people who use drugs: findings from a community-based outreach program in Phnom Penh, Cambodia.

BACKGROUND: People who use drugs are an important priority for HIV programs. However, data related to their utilization of HIV services are limited. This paper reports patterns of HIV testing, drug use, and risk and service perception among people who use drugs. Study participants were receiving HIV and harm reduction services from a community-based program in Phnom Penh, comprised of itinerant peer-led outreach and static drop-in centers. METHODS: This was a mixed-methods study conducted in 2014, comprising of a quantitative survey using a structured questionnaire, followed by two focus group discussions among a sub-sample of survey participants. Participants were recruited from hotspots in five HIV high-burden communes using a two-stage cluster sampling method. Quantitative descriptive analyses and qualitative thematic analyses were performed. RESULTS: This study included 151 people who use drugs with a mean age of 31.2 (SD = 6.5) years; 77.5% were male and 39.1% were married. The most common drugs used were methamphetamines (72.8%) and heroin (39.7%), and 38.0% injected drugs in the past 3 months. Overall, 83.3% had been tested for HIV in the past 6 months, of whom 62.5% had been tested by peers through community-based outreach. However, there were ongoing HIV risks: 37.3% were engaging in sex on drugs, only 35.6% used a condom at last sexual intercourse, and 10.8% had had a sexually transmitted infection in the last 6 months. Among people who reported injecting drugs in the past 3 months, 27.5% reported re-using needles/syringes. Almost half (46.5%) perceived themselves as being at lower risk of HIV compared to the general population. Qualitative results contextualized the findings of low perception of HIV risks and suggested that although services were often unavailable on weekends, at night, or during national holidays, peer-led community-based outreach was highly accepted. CONCLUSIONS: A peer-led community-based approach was effective in reaching people who use drugs with HIV and harm reduction interventions. To mitigate ongoing HIV risks, expanding access to combination prevention interventions and implementing strategies to enable people who use drugs to objectively assess their HIV risks are required. Additionally, community-based programs should collect data along the care continuum, to enable decentralized tracking of progress towards 90-90-90 goals at local levels.

Utilization of traditional, complementary and alternative medicine and mental health among patients with chronic diseases in primary health care settings in Cambodia.

BACKGROUND: Coping with chronic illnesses often involves major lifestyle changes that may lead to poor mental health. Furthermore, in order to treat the chronic conditions, many sufferers in Asia turn to traditional, complementary and alternative medicines (TCAM). This study explores prevalence of TCAM use and factors associated with anxiety and depressive symptoms among patients with chronic diseases in Cambodia. METHODS: In 2015, this cross-sectional study was conducted with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. Symptoms of anxiety and depression were assessed by using the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression models were constructed to explore factors associated with anxiety and depressive symptoms. RESULTS: The study participants included 1528 patients, of whom 77.2% were female, with a mean age of 46.5 years (SD = 15.3). After adjustment, patients with depressive symptoms remained significantly more likely to be in the age groups between 41 and 60 years old and to be married, separated/divorced or widowed compared to those without depressive symptoms. Regarding the use of TCAM, patients with depressive symptoms remained significantly more likely to report using an herbalist, practicing visualization and praying for own health, but less likely to report using vitamins or supplements in the past 12 months. For quality of life, patients with depressive symptoms remained significantly less likely to agree that they had enough energy for their everyday life and had enough money to meet their daily needs. Similar risk factors were also found to be significantly associated with anxiety symptoms. CONCLUSIONS: Cambodian patients with chronic diseases who experienced symptoms of anxiety or depression were more likely to report reduced quality of life, greater chronic disease-related stigma and more TCAM use. Given the potential interaction of TCAM, mental health and other chronic conditions, a history of TCAM use and mental health should be elicited in clinical practices in primary health care settings, particularly in developing countries.

Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: To facilitate provision of pre-exposure prophylaxis (PrEP) in low- and middle-income countries (LMIC), a better understanding of potential demand and user preferences is required. This review assessed awareness and willingness to use oral PrEP among men who have sex with men (MSM) in LMIC. METHODS: Electronic literature search of Cochrane library, Embase, PubMed, PsychINFO, CINHAL, Web of Science, and Google Scholar was conducted between July and September 2016. Reference lists of relevant studies were searched, and three authors contacted for additional data. Non-peer reviewed publications were excluded. Studies were screened for inclusion, and relevant data abstracted, assessed for bias, and synthesized. RESULTS: In total, 2186 records were identified, of which 23 studies involving 14,040 MSM from LMIC were included. The proportion of MSM who were aware of PrEP was low at 29.7% (95% CI: 16.9-44.3). However, the proportion willing to use PrEP was higher, at 64.4% (95% CI: 53.3-74.8). Proportions of MSM aware of PrEP was <50% in 11 studies and 50-70% in 3 studies, while willingness to use PrEP was <50% in 6 studies, 50-70% in 9 studies, and over 80% in 5 studies. Several factors affected willingness to use PrEP. At the individual domain, poor knowledge of PrEP, doubts about its effectiveness, fear of side effects, low perception of HIV risk, and the need to adhere or take medicines frequently reduced willingness to use PrEP, while PrEP education and motivation to maintain good health were facilitators of potential use. Demographic factors (education, age, and migration) influenced both awareness and willingness to use PrEP, but their effects were not consistent across studies. At the social domain, anticipated stigma from peers, partners, and family members related to sexual orientation, PrEP, or HIV status were barriers to potential use of PrEP, while partner, peer, and family support were facilitators of potential use. At the structural domain, concerns regarding attitudes of healthcare providers, quality assurance, data protection, and cost were determinants of potential use. CONCLUSIONS: This review found that despite low levels of awareness of PrEP, MSM in LMIC are willing to use it if they are supported appropriately to deal with a range of individual, social, and structural barriers.

HIV prevalence and factors associated with HIV infection among transgender women in Cambodia: results from a national Integrated Biological and Behavioral Survey.

OBJECTIVE: To examine factors associated with HIV infection among transgender women in Cambodia. DESIGN: Cross-sectional study. SETTINGS: HIV high-burden sites including the capital city and 12 provinces. PARTICIPANTS: This study included 1375 sexually active transgender women with a mean age of 25.9 years (SD 7.1), recruited by using respondent-driven sampling for structured questionnaire interviews and rapid finger-prick HIV testing. PRIMARY OUTCOME MEASURE: HIV infection detected by using Determine antibody test. RESULTS: HIV prevalence among this population was 5.9%. After adjustment for other covariates, participants living in urban areas were twice as likely to be HIV infected as those living in rural areas. Participants with primary education were 1.7 times as likely to be infected compared with those with high school education. HIV infection increased with age; compared with those aged 18-24 years, the odds of being HIV infected were twice as high among transgender women aged 25-34 years and 2.8 times higher among those aged ≥35 years. Self-injection of gender affirming hormones was associated with a fourfold increase in the odds of HIV infection. A history of genital sores over the previous 12 months increased the odds of HIV infection by threefold. Transgender women with stronger feminine identity, dressing as a woman all the time, were twice as likely to be HIV infected compared with those who did not dress as a woman all the time. Having never used online services developed for transgender women in the past six months was also associated with higher odds of being HIV infected. CONCLUSIONS: Transgender women in Cambodia are at high risk of HIV. To achieve the goal of eliminating HIV in Cambodia, effective combination prevention strategies addressing the above risk factors among transgender women should be strengthened.

Acceptability Study on HIV Self-Testing among Transgender Women, Men who Have Sex with Men, and Female Entertainment Workers in Cambodia: A Qualitative Analysis.

BACKGROUND: In Cambodia, HIV prevalence is high while HIV testing rates remain low among transgender women (TG women), men who have sex with men (MSM), and female entertainment workers (FEW). Introducing self-testing for HIV to these key populations (KPs) could potentially overcome the under-diagnosis of HIV and significantly increase testing rates and receipt of the results, and thus could decrease transmission. Therefore, this study aimed to determine the acceptability of HIV self-testing (HIVST) among these three categories of KPs. METHODS: This study was conducted through focus group discussions (FGDs) with TG women, MSM, and FEW in Phnom Penh city, Kampong Cham, Battambang, and Siem Reap provinces of Cambodia. Convenience sampling was used to recruit the participants. Two FGDs (six participants in each FGD) were conducted in each target group in each study site, totaling 24 FGDs (144 participants). Thematic analysis was performed to identify common or divergent patterns across the target groups. RESULTS: Almost all participants among the three groups (TG women, MSM, and FEW) had not heard about HIVST, but all of them expressed willingness to try it. They perceived HIVST as confidential, convenient, time-saving, and high-tech. Barriers to obtaining HIVST included cost, access, administration technique, embarrassment, and fear of pain. The majority preferred counseling before and after testing. CONCLUSIONS: Participants showed high willingness to use and acceptability of HIVST due to its confidentiality/privacy and convenience even if it is not linked to a confirmatory test or care and treatment. Notwithstanding, to increase HIVST, the target groups would need affordable self-test kits, education about how to perform HIVST and read results, assurance about accuracy and reliability of HIVST, and provision of post-test counseling and facilitation of linkage to care and treatment.