Research Article: HIV treatment cascade among female entertainment and sex workers in Cambodia: impact of amphetamine use and an HIV prevention program

Date Published: September 5, 2017

Publisher: BioMed Central

Author(s): Sokunny Muth, Aynar Len, Jennifer L. Evans, Maly Phou, Sophal Chhit, Yuthea Neak, Song Ngak, Ellen S. Stein, Adam W. Carrico, Lisa Maher, Kimberly Page.


HIV prevalence remains high in Cambodia among female entertainment and sex workers (FESW), and amphetamine-type stimulant (ATS) use significantly increases risk of infection. A successful continuum of care (CoC) is key to effective clinical care and prevention. This study aimed to describe the HIV CoC in HIV-positive FESW. We examined CoC outcomes among HIV-positive FESW participating in the Cambodia Integrated HIV and Drug Prevention Implementation (CIPI) study, being implemented in ten provinces. CIPI is a trial aimed at reducing ATS use concomitant with the SMARTgirl HIV prevention program.

From 2013 to 2016, 1198 FESW ≥ 18 years old who reported multiple sex partners and/or transactional sex were recruited. We identified 88 HIV-positive women at baseline. We described linkage to care as 12-month retention and viral suppression (<1000 copies/mL). Logistic regression analyses were conducted to examine correlates of retention in care at 12 months, and viral suppression. Median age of the 88 HIV-positive women was 32 years [interquartile range (IQR) 28, 35]; 50% were working in entertainment venues and 50% as freelance sex workers; 70% reported SMARTgirl membership. In the past 3 months, women reported a median of 15 sex partners, 38% reported unprotected sex, and 55% reported using ATS. Overall, 88% were receiving HIV care, 83% were on antiretroviral therapy, 39% were retained in care at 12 months, and 23% were virally suppressed. SMARTgirl membership was independently associated with fourfold greater odds of 12-month retention in care (AOR = 4.16, 95% CI 1.38, 12.56). Those at high risk for an ATS use disorder had 91% lower odds of 12-month retention in care (AOR = 0.09, 95% CI 0.01, 0.72). Viral suppression was independently associated with SMARTgirl membership, older age, reporting of STI symptoms, worse symptoms of psychological distress, and greater numbers of sex partners. This is the first study to characterize the HIV CoC in Cambodian FESW. While most women were successfully linked to HIV care, retention and viral suppression were low. Tailored programs like SMARTgirl, targeting the broader population of HIV-positive FESW as well as interventions to reduce ATS use could optimize the clinical and population health benefits of HIV treatment.

Partial Text

HIV risk remains high in Cambodia among FESW. High numbers of sexual partners and non-injection ATS use are associated with elevated HIV risk and infection rates in this population [1–3]. Cambodia has achieved substantive progress in reducing the spread of HIV at a population level; the estimated number of new infections has fallen 95% from a peak of 24,348 in 1995 to 651 in 2015 [4]. Comprehensive deployment of basic HIV prevention programs including condom promotion, HIV voluntary counseling and testing, and high coverage of HIV antiretroviral treatment (ART), have contributed to these declines [5]. However, women engaged in entertainment and sex work remain disproportionately impacted [3]. In addition to individual risks, structural factors present challenges for HIV prevention among FESW. Anti-trafficking legislation aimed at suppressing human trafficking and sexual exploitation amplified HIV risks: brothel closures and migration of working women to entertainment venues and street-based sex work had negative impacts on access to HIV and STI prevention and health services [6]. Stigma, discrimination and violence further contribute to risk and negative health outcomes [7–9].

Between June 2013 and May 2016, 88 (7.3%) women were identified with HIV infection among the 1198 who completed a baseline CIPI study visit. Their median age was 32 years (IQR 28, 35); 70.45% (n = 62) women reported being HIV infected at study entry, and 49 of these did not elect to be re-tested for HIV by the study. Twenty-six women who were identified as HIV positive on record linkage had self-reported either being HIV negative (N = 23) or never tested (N = 3), most (n = 18) also did not wish to be tested by the study. All women were aware that the study was working with NCHADS to obtain HIV results from testing conducted external to the CIPI Study. HIV-positive women were identified in all ten provinces participating in the CIPI study, but almost half (n = 41) were from two provinces: Phnom Penh (25%; n = 22) and Battambang (21.6%; n = 19). Over one-third (35%) reported never having attended school. Table 1 shows participant characteristics and risk exposures. Women were equally divided (50%) in reporting their primary work setting as either an entertainment venue or as freelance/brothel based FESW. A majority (70%) were members of SMARTgirl, and 15% of members had attended a SMARTgirl club in the past month. All women (99%) reported multiple sex partners in the past 3 months. Unprotected sex in the past 3 months was reported by 38% of women. Twenty-eight women (32%) tested positive for PSA, indicating unprotected sex in the past 48 h. ATS use was prevalent by both self-report (55%) and urine screening (42%; indicating use in the past 48–72 h). We found 81% agreement between self-reported ATS use and ATS urine screening results. On the ASSIST, 51% scored moderate to high-risk for an ATS use disorder, and 51% were classified as being at similarly elevated risk for an alcohol use disorder. There were 27 (31%) participants that scored moderate or high-risk for clinically significant psychological distress on the K-10.Table 1Characteristics of HIV-positive FESW enrolled in the CIPI Study (N = 88)Characteristic or exposureN/median(%)/IQRAge (years) <201(1) 20–2927(31) 30–3955(63) ≥405(6)SMARTgirl member (yes)62(70)Length of time participant has been SMARTgirl member (months) (N = 62) <625(40) 6–2414(23) >2423(37)SMARTgirl Club visit frequency in the past year (N = 58a) ≥1 time/month9(15) <1 time/month35(60) Never14(24)Education (total years of school) None31(35) Primary (1–6)44(50) Secondary (7+)13(15)Age of first sexual intercourse [median (IQR)]18(16–19)Time since HIV diagnosis at baseline 0, new infectionb29(33) 1–12 month18(20) >1–5 year19(22) >5 year22(25)Work setting (location worked most days in past month) Entertainment venue44(50) Brothel/Freelance44(50)Currently work for manager or boss (yes)42(48)Income last month ($US)c <10032(36) 100–25036(41) >25020(23)Experienced food insecurity (last 3 months) Never54(61) Rarely16(18) Sometimes8(9) Often9(10)Experienced any physical or emotional violence (past 3 months)47(53)Number of sexual of partners (last 3 months) <520(23) 6–1527(31) 16–4019(22) 41–15014(16) >1508(9)Number of sexual partners [last 3 months; median (IQR)]15(6, 42.5)Self-reported any unprotected sex (last 3 months)33(38)PSA positive test28(32)Self-reported use of ATS (past 3 months)48(55)Tested for positive for ATS use at study visit37(42)ATS ASSIST score <437(42) 4–2642(48) 27+9(10)Alcohol ASSIST score <1137(42) 11–2633(38) 27+18(20)K10 Psychological distress (depression and anxiety) Low or No risk37(43) Mild risk23(26) Moderate risk13(15) Severe risk14(16)Self-reported symptoms of sexually transmitted infection (last 3 months)19(22)aRestricted to the n = 58 SG members with non-missing databTime since diagnosis was determined by NCHADs records or as the date of testing from CIPI baseline for newly identified infectionscAverage monthly household income in Cambodia in 2012 was US$56.53; in 2013, US$71.5; in 2014, US$89.98, and in 2015, US$91.14 ( This is the first study to characterize the HIV CoC in a group of Cambodian FESW. Although a high proportion of women were successfully linked and enrolled into HIV care, there were precipitous declines in the proportion who remained in care after initiating ART and achieving viral suppression: 43% of women who initiated ART were lost to follow up. These results are in stark contrast to estimates for the general Cambodian population, where 95% of those diagnosed and on ART are retained in care at 12 months [4]. Only one in four (23%) of the HIV-positive women in this study were virally suppressed. The proportion of women on ART who were virally suppressed (59%), however is not dissimilar to estimates in the general Cambodian population (64%) [4]. In contrast to other studies which include female sex workers, our results show that a high proportion were engaged in care and initiated treatment: 94% of those who enrolled in care initiated ART, compared to 28% in a recently published study of CoC outcomes in a South African FSW cohort [33]. Mountain et al. [17] show similar low rates of ART initiation in a meta-analysis of studies of FSW, with a pooled estimate of 39% ART initiation among ART eligible FSW in low and middle income countries. The proportion of virally suppressed participants in our study (59% of women retained) was similar (57%) to the pooled estimate in that study [17]. There are several potential reasons that FESW in Cambodia have poorer retention in care compared to the general population in Cambodia. Women working in the entertainment industry are very mobile, often moving between provinces, which likely impacts retention. Sex work is highly stigmatized in addition to being illegal in Cambodia, and some women may not feel that they can access care that is non-judgmental or responsive to their needs. That viral suppression in women in our sample who are engaged in care is comparable to that seen general population is encouraging. Expanded efforts targeting Cambodian FESW are clearly needed to optimize CoC indicators, especially the goal of successful engagement in care, which would contribute to reductions in HIV morbidity and mortality as well as decreased risk of onward HIV transmission in this high priority population. In Phnom Penh, there are currently two HIV clinics that serve key high-risk groups including FESW, and provide tailored services to women like space for their children during clinic visits. Expanding services that facilitate treatment engagement by FESW could will result in a higher proportion of women who achieve successful viral suppression.   Source:


Leave a Reply

Your email address will not be published.