How Harm Reduction Programs Work in The Context of Village and Commune Safety Policy: Lessons Learned from A National Non-Governmental Organization in Cambodia

Cambodia is no exception to the global rise in the use of illicit drugs. After more than a decade of civil war and isolation, Cambodia opened its borders and introduced a free market economy in 1993. Since then, the developing country has become a transit point along regional drug trafficking routes between middle-income countries of Thailand and Vietnam. In turn, Cambodia experienced a sharp rise in drug seizures, arrests, and an emerging wave of drug use ^{1, 2}. In 1995, as a response to the increasing drug problems, the government formed the National Authority for Combating Drugs (NACD) to manage and coordinate all aspects of drug control in the country ³.

Since the organization’s inception, no consensus has been reached on the number of people who use drugs (PWUD) and people who inject drugs (PWID) in Cambodia. According to NACD, the estimated number of PWUD ranged from 6,000 to 40,000, of which 600 to 1,000 were PWID. Another study in 2007 suggested that there were about 9,000 to 20,000 PWUD, of which about 2,000 were PWID ². UNAIDS estimated about 46,300 PWUD, of whom 23,150 were using amphetamine types stimulant (ATS), and more than 2,000 were PWID ^{2, 4}.

Although HIV prevalence in the general population in Cambodia has substantially decreased over the last two decades from around 2% in 1998 to only 0.28% in 2014 ^{5, 6}, HIV among PWUD and PWID remains particularly high with a prevalence of 24.4% among PWID and 1.1% among PWUD in 2010 ² and 24.8% among PWID and 4.0% among PWUD in 2012 ⁷. While their practices increase their risk for HIV, their access to HIV prevention, treatment, and care services are limited. In 2010, only 40% of PWID were exposed to HIV prevention, which is far behind Cambodia’s Universal Access target of 80% ⁸. One out of five PWID have access to needles and syringes programs (NSP), particularly in the capital city of Phnom Penh ³; about 40-45% have received HIV testing and counseling services in the past six months ⁹. Since 2003, the Cambodian government has recognized the importance of harm reduction in targeting HIV prevention among PWUD and PWID and their sexual partners ¹⁰. A pilot harm-reduction program was conducted in 2004, which granted Mith Samlanh, a local non-governmental organization (NGO), a license to distribute needles and syringes to street-based children in Phnom Penh. In 2005, the harm-reduction program was extended to Korsang, a community-based NGO.

For over a decade as the largest HIV NGO, KHANA responds to the challenges of HIV in Cambodia by providing HIV prevention, care, and support services at the community level targeting key populations including PWUD and PWID. As of 2012, KHANA collaborated with local community-based organizations in the capital city and 11 provinces to foster the access and delivery of services to PWUD and PWID.

In June 2010, Mondul Meanchay, hereafter referred to as “the Center,” was established by KHANA in Meanchey District of the capital city of Phnom Penh as a center of excellence. By 2011, the NACD granted the Center a license to provide needles and syringes to PWID within the Center’s scope of coverage. From May 2012 to April 2013, the Center’s scope with provision of needles and syringes was expanded through outreach services. With the recognition from the NACD and local authority, the Center demonstrates best practices in harm reduction and provides capacity building and training while documenting case studies and monitoring trends related to HIV and drug use. The Center aims to engage its local community through programs delivered in partnership with KHANA’s network of community-based NGOs.

The Center’s staff members are directly managed by KHANA, which consist of a center manager, a medical doctor, a nurse, an outreach assistant, two peer counselors, and ten peer outreach workers (four of whom are women) who are former or occasional PWUD and PWID.

The Center’s facility provides onsite services as well as community-based services. The services are based on international best practices informed by evidence- based findings for effectiveness in achieving the 16 key interventions of harm reduction that contribute to the improvement of the HIV, health, and development status of PWUD and PWID based on the World Health Organization (WHO) and the International HIV/AIDS Alliance good practice guide, and adapted as KHANA Standard Package of Activities (SPA) ^{11, 12}.

A wide range of interventions are implemented at the Center, including peer outreach (i.e. condom distribution and group education) and networks, referrals to methadone maintenance treatment (MMT), and voluntary HIV counseling and testing (VCT), education sessions, psycho-social counseling about drug use problems, provision of a space to rest, and primary health care services. Also, it serves as the center for information, education, and communication with the provision of capacity building to support community-based organizations ¹³.

In late 2010, NACD initiated the Village and Commune Safety Policy (VCSP) nationwide. The policy focuses on removing five elements from communities, which include the following: drug use, human trafficking, gangs, domestic violence, and gambling. This policy involves all local authorities and police at all levels ensuring that these problems are removed from communities ¹⁴.

Since its implementation, the VCSP has impacted harm-reduction programs with additional challenges in providing accessible services to the key target populations. Conflicts between law enforcement and harm-reduction programs for PWUD and PWID are a common occurrence under the provisions of the VCSP. A recent study found that 15% of PWUD and PWID have been arrested at least once by police during the implementation of VCSP ⁹. Also, 75% of interviewed had been questioned by the police (Personal communication with the Center staff, April 2012). In another study, about 75% of police reported conducting body searches on suspected members of the key populations ¹⁵. Consequently, key populations are weary of possessing needles and syringes (67%) and condoms (23%) to incriminate themselves of drug use and prostitution. Overall, 19% of the key population was discouraged from seeking health services to avoid unwanted attention from law enforcement. In the same study, 58% of law enforcement officers reported arresting key populations within in a six-month period of the implementation of the VCSP with the following reasons for arrest: drug use (64%), distribution of drugs (36%), and displaying violence (13%) ¹⁵. As high as 94% of law enforcement officers believe their reasons for arrest were justifiable and valid in controlling drugs and preventing HIV ¹⁵. Therefore, this paper aims to examine the challenges and implications of the VCSP on harm-reduction programs and describe lessons learned from a harm-reduction program within the context of the VCSP in Cambodia.

This study used a combination of quantitative and qualitative methods within fieldwork conducted from March to April 2012. The quantitative method refers to the collection and analyses of the Center’s monitoring and evaluation database to determine the trends of service uptake, characteristics of PWUD and PWID, and coverage. The qualitative study was conducted in tandem to gain a comprehensive understanding of the issues. In addition, desk reviews and consultative meetings were conducted to collect additional information and different perspectives about the program.

Monitoring and evaluation data were retrieved from the Center’s database and program reports. These data were used to understand the characteristics of PWUD and PWID reached by the Center, to quantify the number of the beneficiaries, and to identify trends overtime. Types of drugs used, specific age groups, and gender stratifications were analyzed.

For qualitative data, a purposive sampling method was used to select participants for key informant interviews (KIIs) and focus group discussions (FGDs). Based on the characteristics of the key population and purposes of the study, eight in-depth interviews with key informants as well as four FGDs, and 26 interviews with PWUD and PWID were conducted within the scope of the Center’s coverage.

Key informants included an outreach assistant, a nurse, a Center manager, and a medical doctor along with other stakeholders and local authorities that had been working with the Center (nurses at the referred health centers, village chief, commune council, and MMT staff).

FGDs and in-depth interviews were conducted with PWUD and PWID who used illicit drugs either regularly or occasionally. Occasional drug use was defined as using illicit drugs, as defined in Cambodian Drug Control Law, two times per week or less in the past month ¹⁶. Regular drug use was defined as using illicit drugs, as defined in Cambodian Drug Control Law, three or more times per week in the past month ¹⁶.

The FGDs and in-depth interviews were conducted at the Center with trained qualitative researchers. The interviews with key informants were held at a time and location convenient for them. Qualitative data were analyzed using thematic analyses. Some themes were pre-identified and some were explored during the analyses. Available documents and reports related to harm-reduction programs were reviewed. These included the concept note of the Center Aide Memoire, the Annual Reports 2011, the Community Need Assessment Report 2010 before the establishment of the Center, Cambodian Drug Control Law, the Needle Syringe Program Guidelines, and a standard package of activities for PWUD and PWID.

A number of consultative meetings were conducted with staff in different departments of KHANA. This study was based on the secondary data from the Center’s database. Names and clients’ identities were removed during the data analysis phase to maintain confidentiality. All qualitative interviews were conducted with verbal informed consent with anonymity, confidentiality, and privacy ensured throughout the process. Participants who required either health or non-health services were referred to the Center for treatment or referred to other appropriate government service facilities with their consent.

After two years of implementing the harm-reduction program, the Center appears to have achieved its objectives of delivering services to PWUD and PWID in the communities through different services, such as high uptake of PWUD and PWID access to services within the Center and different referrals. However, some challenges remain including the failure of the NSP program due to competitive priorities between the law enforcement and harm-reduction programs particularly NSP given the complexity of the VCSP. Results from the field using former PWUD and PWID as peer outreach workers proved to be effective for the drug use community-based programs because it built trust and credibility among PWUD and PWID. However, it is likely to fail using conventional drug treatment based approach like the former initially setting up, in the northwestern provinces of Cambodia ¹. This community-based peer outreach approach allows participants to support each other in various ways such as filling in report forms, helping each other during health education sessions. Despite this, challenges remained relating to jealousy among the group due to their limited education level, stigma, and discrimination especially among female PWUD and PWID involved with sex work. Also, group peer outreach attracted unwanted attention from local police. As a result, many PWUD and PWID are afraid to attend their peer education sessions at the Center. The active referral system is a unique feature of the Center, which ensured that PWUD and PWID received appropriate services. However, in the long term, it becomes costly in terms of expanding reach-out. Once the program becomes well established and stable, this approach needs to be revisited to minimize the dependency from the group and ensure long-term sustainability of services. Comprehensive services that are available at the Center (i.e. counseling, primary health care, drug use group education) and referrals (i.e. SRH, VCCT, MMT) should be well maintained linkages. It is clear that the vocational training program has to be redesigned to meet the needs of PWUD and PWID through coordination and their thorough participation at the initial design stage to avoid the waste of resource and time. A successful lesson from Croatia related to comprehensive services and referrals using multidisciplinary teams were documented. The approach resulted in a high retention rate of up to 85% ¹⁷. A systematic review suggested that a combined intervention that addressed socio-environmental factors to be more effective than the stand-alone strategies ¹⁸. Distribution of sterile needles and syringes is a key component of harm reductions as well as HIV prevention intervention efforts ¹⁹. However, a very low coverage of NSP was found given that only 16% of PWID reported accessing NGO drop-in centers ⁹. Epidemiologically, at least up to 60% coverage would be needed to meet the threshold that could halt and decrease HIV epidemic among PWID. Another concern is the shifting pattern from ATS users to PWID since less than 5% of those visited at the

Center were originally PWID (Personal communication with the Center staff). Therefore, it raises great concerns about what triggers PWUD to become PWID. More studies are needed for a better understanding about this link. Therefore, it is really important to focus work on both PWUD and PWID to reduce the potential for transitions from snorting to injecting. The complexity of the VCSP significantly affects the NSP at the community level where more than half of PWUD and PWID were hidden with lower coverage. Lack of understanding, stigma, discrimination, and a prevailing negative attitude and behaviors towards PWUD and PWID remain high from local communities. In addition, the location of drop-in centers may contribute to challenging accessibility issues for the NSP ¹⁰. Also, this policy discourages PWUD and PWID to disclose their status. Consequently, many PWUD and PWID did not want to carry needles, syringes, or condoms. Thus, the key population remains hidden or has moved to other locations in search of safety and employment. Globally, there is a strong evidence to suggest that harm-reduction intervention is effective in preventing the spread of HIV among PWUD and PWID. However, at each country level, the successful harm reduction programs have to be designed to fit and adapt well with the local context in terms of socio-economic, political, and cultural issues ^{10, 20}. Working with PWUD and PWID is politically complex because of the subtle line that separates a PWUD and PWID from a drug distributor or a drug dealer. Therefore, it is quite challenging to maintain a high level of support from authorities and police because government and police have different priorities - reducing crime; whereas our priority - reducing HIV transmission - results in a clash of approaches. The recent update from the Center after the study was conducted reported that there has been a positive sign of distribution of sterile needles and syringes in the community through peer outreach activities without any major distraction from police. However, more work and understanding are required to ensure that crime reduction efforts do not undermine HIV prevention. This study is subject to a number of limitations. First, the monitoring and evaluation data available at the Center were limited to a program performance report rather than information for a specific research purpose. Double counting may have occurred between the peer outreach activities, services within the Center, referrals, and coverage overlapping. However, this concern has been addressed through regular coordination meetings to update and share information. The unique identifier for PWUD and PWID is in the process of discussion to improve data quality and duplication issue. Secondly, findings were based on the secondary data available at the Center and desk reviews combined with additional qualitative interviews. Therefore, it represents the picture of the harm-reduction implementation at the Center only. However, experiences, challenges, and lessons learned from this model are worth-sharing and documenting.

In conclusion, many of the key harm-reduction interventions appear to have achieved its objective of delivering services to PWUD and PWID in the communities though challenges remain except the NSP in the community that need to be more advocated with the government. Moreover, other aspects of the harm-reduction intervention package need to be strengthened and improved including referral to MMT and ensuring access to ART for PWUD and PWID living with HIV. A proper formative assessment should be conducted prior to the setting up of any vocational training and the network link to private pharmacies on the NSP to better guide a program planning and to increase relevant and flexible strategies to ensure the value of money. The further success of The Center’s harm-reduction programs should be reviewed to fit well with the current socio-economic, political, and cultural contexts. Though there were some clashes between the police, government, and harm-reduction implementation particularly NSP, there is a need to have a common way to work together with mutual understanding, coordination, and collaboration with all parties involved exhibiting a degree of flexibility with a common goal toward the successful NSP implementation as part of the NACD national strategic plan 2011-2015 ^{21, 22}.

This work was supported by AusAID-HAARP-Cambodia through KHANA. We thank Mr. Kimhai So and his staff members at Mondul Meanchey Demonstration Center, for their facilitation and coordination during the study. The contents of this article do not necessarily reflect the views of the AusAID or the authors’ host institutions.

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