Randal G. Tonks
Camosun College,
Victoria, B.C. Canada
In making my comments from the International Health Perspective I would like to review the global perspective on health and HIV/AIDS as outlined by Aboud (1998) and Hynie (1998). In conjunction with that review I will address the work presented at this symposium (Lubec & Wong, 2003) insofar as it addresses the problem of HIV/AIDS from the perspective of International Health. Following that I will focus on some current research that parallels and complements this project in one way or another along with a few final comments about this project on HIV/AIDS in Cambodia.
The Symposium:
Intersection on Globalisation and HIV/AIDS in Cambodia: Multiple sub-disciplinary views on interventions for women and children at risk. Lubec, I. & Wong, M.L. (2003).
HIV/AIDS, beer, sex-tourism and women’s safety: Trans-cultural, multi-sector community health challenges in Cambodia. Lubec, I., Wong, M.L., Nosworthy, G., Tan, A., Dy, B.C., Kros, S.P., Chhit, M., Touch, S., Lee, N.L., Chew, K. and Mok, V. (2003).
Grassroots empowerment and trans-cultural workshops: Some strategies for HIV/AIDS prevention among Beer Promotion Women” in Cambodia. McCourt, M. (2003).
The child vendors of Angkor Wat: Facing Cambodia’s future, its HIV/AIDS epidemic, and the risk of sexual exploitation from sexual tourists.. McNeil, A. (2003).
“It just wouldn’t do, now to have ‘prostitutes’ selling the beer of our ‘national icon’: Moral, organizational and business dilemma for international beer companies and their “throwaway” workers. Stevanov, D., Tribble, K., Traut, P., Candy, E., McCourt, M., McNeil, A., Wong, M.L. & Lubec, I. (2003).
Aboud (1998) points out that in considering health from and international perspective one must recognize several layers at which health issues can be addressed. She identifies the environmental, institutional and psychological (attitudes & behaviours) as being of importance when working in the area of international health. The local culture must also be taken into consideration where local understanding of disease etiology and prognosis is important to consider when planning interventions. It also plays an important role for researchers in navigating the local community and political structure when establishing rapport and carrying-out any research or reparative health measures. This approach is built upon the bio-psycho-social model of health and healthcare where the biological disease or condition is seen within a co-constitution of the personal psyche or state of mind as well as the social-politico historical circumstance in which one exists.
In considering the research that Dr. Lubec and his colleagues have been doing in Siem Reap, it is clear that they are performing a project broadly grounded in the International Health perspective outlined by Aboud (1998). To begin, they have considered the physical and socio-historical environment by addressing the location of Siem Reap as being in Cambodia, a country that is both beautiful and lush, with great historico-cultural sites as well as being a nation that has been mired in slaughter and political upheaval. On the one hand, tourism has brought foreign currency and international attention to Siem Reap with the local Angkor Wat temples, however it also fosters the sex-trade and is largely responsible for the current crisis with HIV/AIDS. This international attention has also brought positive influences such as Les Medicine Sans Frontier, and socially minded researchers like Dr. Lubec and his team.
They have also examined the infrastructure of the country, where local services and facilities for health and other social programmes are minimal. In combating this social health crisis, Lubec et al. have been working with local institutions and officials as well as those from international organizations. Here they have promoted education and understanding of the disease and its transmission through community billboard information, condom and t-shirt campaigns, as well as community action focus groups. Recognising various limitations to the existing information and education resources, Lubec at al. have made the information visible through the placement of billboards, promotion of education among the youth (i.e., condom education), and through the consciousness raising and changing of social standards of talking about sex among housewives and their husbands.
In carrying out these information and education campaigns Ian Lubec and his team have been sensitive to the socio-cultural standards of behaviour among men, both married and un married, as well as these “Beer Girls” and how they end up in the sex-trade. Addressing not only the men whose patronage of the Beer Houses leads them to engaging in unprotected sex with Beer Girls where they may become infected or spread infection to others, Lubec’s team has also addressed the wives of those men and prospective Beer Girls. Here they have broken down of the historical cultural barriers that surround the talking about sex; helping women to become empowered about condom use and proactive in combating the spread of HIV/AIDS.
Beyond these actions, the Lubec Team has also addressed issues around povertry as it leads to the introduction of women to the Beer Girl life and subsequently to the sex-trade. On this and other aspects of their community action research I applaud Ian Lubec and his team on their fine work. Clearly representative of an International Health perspective, their work is broadly minded and addresses the issue of HIV/AIDS in Cambodia’s Siem Reap at numerous levels.
Hynie (1998) addresses several facts about HIV & AIDS in the international realm that I would like to summarise and comment on as they pertain to the work of Lubec and colleagues on the Siem Reap team, as presented in this symposium.
To begin, she points out that there are several types of HIV grouped around teo Major types: HIV1 & HIV2 . A summary of these two types is found in Table 1 below.
|
HIV1 |
HIV2 |
|
10 genetic subtypes |
Less easily transmitted |
|
M – (a-j) + (O-outliers heterogeneous) |
Longer incubation period |
|
B in Americas, Japan, Australia, Caribbean & Europe (Ivory Coast-both) A + D sub-Saharan Africa |
Heterosexual & blood transfusion |
|
C South Africa + India E Central African Republic |
Equally distributed among males & females |
|
Others very low prevalence & highly localized |
More prevalent in West Africa (some in Cameroon & Angola) |
Risk of transmission
Hynie also addresses the risk of transmission where she points out that a single act of unprotected sex with an HIV-infected partner is estimated at .0004%-1% chance of contracting HIV. While the one-time risk is relatively low of contracting HIV, it is also pointed out that 75%-85% of HIV infections through unprotected sex. Further risk factors for the transmission of HIV must thus be considered.
Duration of sexual relationships important where the longer the duration the greater the risk of contracting HIV. For the Beer Girls, the longer they involved in the sex-trade trade the greater their risk for contracting and transmitting HIV/AIDS. This is also closely linked with the frequency of contact as an important factor as was found by Gomes do Espirito and Etheredge (2003).
Gender has also been identified where women are generally at a greater risk than men, Hynie (1998) also address the following factors related to gender and the risk for transmission of HIV/AIDS. Circumcision is associated with increased risk for females but a decreased risk for males. Also considered are the presence of genital ulceration (charancoid, syphilis or herpes sores) which may go undetected for a longer period in women as well as the presence of other nonulcerative STDs, and sex during menses all of which increase the risk for transmission. Other factors that are also important to consider, but may not be as relevant in Siem reap are: donated organs and blood as well as Intravenous Drug Use(IDU).
Because infected individuals are usually without symptoms, except for minor flu-like symptoms at time of transmission, HIV/AIDS is easily spread far and wide without any knowledge that it has been. It is usually not until something more serious is evident such as Karposi Sarcoma or candidiasis of the esophagus, trachea or bronchi of the lungs that it becomes evident that infection has occurred. As a result of this, it is crucial that testing of individuals is performed, particularly those involved in the sex-trade, in order that the slowing of transmission can occur. Hynie reports that 1980s US Centers of Disease Control established diagnostic criteria, yet more than 50% of cases are missed until other more precise tests can be done. These are contingent on facilities that often are not available. (i.e. ELISA – immunoabsorbant assays). Lubec et al have addressed the issue of need for testing and medical facilities and continue to promote the investment in health care infrastructure in Siem Reap
Hynie points out that the most commonly prescribed prevention strategy is ABC: Abstinence, Be true to your lover, Condoms – this is most effective method. Working through various methods, Lubec and his team have been promoting at least one of these approaches, the others may be difficult to promote where the local cultural and economic situation works against them.
Hynie also reports that the Roles of men & women in society are important, as Lubec has identified the socio-culural background to the current epidemic in Siem Reap. They have also addressed the Social Norms for sexual behaviour, Attitudes towards condom use, Sensitivity to frank discussion of sex which are important factors outlined but Hynie, who also addresses Social exclusion (difficulty in reaching groups who display risky behaviours) as a factor.
Sexual Networking
Sexual networking is another factor addressed by Hynie where she identifies the establishment of multiple relationships often with companionship & domestic services, not money. She give the examples of migrant workers (urban/rural wives), long distance truckers, as well as widows/ divorcees as some who may be susceptible to infection. It has been identified that women’s partners are the main source of HIV infections and that the problem of condom use requests (suggesting infidelity) are major factors.
Lubec et al. have identified both of these types of situations where many men appear to use the Beer Girls as a primary or secondary source of sex, often also infecting their wives at home. Lubec et al.’s work on targeting the wives and Beer Girls together to establish an understanding of the transmission of the disease as well as methods for it’s prevention. For many of the wives this has been a source of empowerment where they can confront the challenges of raising the issue of condom use with their husband, having ready made answers and skills to deal with the possibly negative reaction of their husbands.
Many challenges exist in considering the pandemic of HIV/AIDS, Hynie indicates that two questions stand front and centre: Who to target? and How to identify high risk groups and behaviours? She points out that a lack of knowledge and incorrect perceptions of personal risk or misconceptions of transmission (i.e., handshaking, food, kissing, breathing) may be at play. Lubec and colleagues have addressed a number of these challenges and targeted a number of players including the international beer companies and multinational drug companies as having a responsibility to the Beer Girls and citizens of Siem Reap.
Multi-level and multinational interventions are suggested by Hynie (1998) and Aboud (1998) including: school & community education, couple education & counseling, the role of community healers as well as various community interventions (i.e., brothel owners saving money with “condom only” policy- spoke to each client prior to initiation of the sexual encounter. As mentioned above, Lubec et al. have carried out a number of these interventions including small group interventions that give information plus peer support. In particular the groups with Beer Girls and wives has exemplified this approach where they each have reported empowerment in talking about and negotiation of condom use while they also understand and support each other as part of the system of individuals involved.
I would like to commend Dr. Lubek and his team for the work they are doing where they are clearly working at a number of these different levels in order to combat the problem of HIV/AIDS among the people of Siem Reap. Ranging from educational to supportive they also have addressed local and national government, the United Nations and multinational corporations in the role they currently (or potentially can) play in the fight against HIV/AIDS. In particular they have been lobbying the beer companies to take amore active role in the safety of their employees (Beer Girls) and take some responsibility for their wellbeing. Additionally, partially through the co-operation of Les Medicine Sans Frontier, Dr. Lubec’s team has also been lobbying governmental officials and multinational drug companies to make available, at cost, drugs that will help to save lives of those infected in Siem Reap.
In this final section I will address some current research and review a few publications on HIV/AIDS that are relevant to this project in Siem Reap. The themes visited include: alcohol, barriers in the sex trade, relationship power, access, and adherence.
Bagby et al. (2003) report that alcohol abuse, particularly binge drinking will compromise the immune system. This has been demonstrated in primates with the simian SIV. Obviously this applies to the Siem reap project where those involved in heavy drinking at the Beer Houses will have their immune systems compromised and the course of action of HIV/AIDS will be expected to be more rapid than in others. Ian Lubec and colleagues have also pointed out that the consumption of alcohol may alter one’s judgment with respect to having unprotected sex. These two mitigating features of alcohol, along with expected nutritional deficiencies associated with chronic alcoholism indicate that an important attack on HIV/AIDS in Siem Reap ought to be to reduce alcohol consumption and also address the social and economic contributions to the phenomena of Beer Houses in Cambodia.
Barriers to leaving the sex trade have also been described in some recent research by Manopaiboon, Bunnell, Kilmarx, Chaikummao, Limpakarnjanarat, Supawitkul, St. Louis and Mastro (2003). In looking at the situation for women in Northern Thailand they found that most common barriers to leaving the sex trade were 1. Economic, 2. relationship with partner, 3. attitudes towards sex work, and 4. HIV/AIDs experience. They reported that women often go through cycles of quitting and returning. Of these factors, Ian Lubec et al. have considered the issues around economics and the relationship that the women have with their partners, including the cultural norms and expectations. Clearly one aspect of a solution to the crisis of HIV/AIDS in Siem Reap is to establish a better standard of living for the women in order that they won’t be forced into the sex trade even on an occasional basis.
Pulerwitz, Amaro, De Jong, Gortmaker and Rudd (2003) examined the negotiation of condom use as an important factor in stopping the spread of HIV/AIDS. They found that relationship power was critically important in condom negotiation and use in a study controlled for socio-economic-status. Additionally Noar, Morokoff and Harlow (2003) found that sexual assertiveness, self efficacy and partner communication were all important characteristics of women who were able to successfully negotiate the use of condoms. It was also reported (Hynie, 1998) that brothel owners in Chiang Mai Thailand had adopted “condom only” policies after recognizing that it was more economically viable to keep their women healthy. They raised the pre-intervention 42% condom use to 92% two months following the intervention with 80% at one year follow-up.
Education and interventions that were found to be most successful in studies were peer group discussions where women could talk with other women. DeMarco, Johnsen (2003) for example engage women with HIV/AIDS to take action based upon their life experiences to help themselves and others through intergenerational education. Others have focused on youth education, such as Perez and Dabis, (2003) who identify multi-level approaches as best that include both community education and interpersonal communication of information and support. Thiis follows what Hynie (1998) suggests, that they serve a dual function of both education and social support. As with the Siem Reap tam’s work, this multilevel approach to educational and social intervention is most effective.
Various studies have reported that access to antiretroviral drugs and treatment is contingent on one’s ethnic and socio-economic status in the United States (Oggins, 2003). As Ian Lubek has pointed out, in addition to Stephen Lewis in Africa, many people in these places will not get adequate access to medication for HIV. As a result it is those marginalized people, like the “throw-a-way” Beer Girls who don’t receive treatment and are left to die quick and undignified deaths (McCourt, 2003). If the difficult task of access to adequate testing, treatment and health care were completed, the challenge of adherence to medical regimens would also arise.
Adherence to treatments may also be a problem for those who adopt avoidant coping styles or may be involved with alcohol or other drugs that lead them to miss dosages or motivation to take their medication (Halkitis, Parsons, Wolitski & Remien, 2003). They also found that difficulty in communicating with one’s partner also may lead to missed medication and failure to follow treatment regimen.
In summary, The Siem Reap team has done an good job of addressing the problem of the spread of HIV/AIDS within the international perspective. They have addressed the environmental and historical circumstance in which the current crisis lies and have considered the social, political and economic factors at play. They have developed a multi-faceted approach to understanding and stemming the spread of HIV/AIDS. Integrating international and national lobbying, community information and action as well as individual and community educational prevention programmes has resulted from the work of this team. Hopefully through their continued efforts and those of other within the Cambodian and international communities there will be a slowing and reversal of the grown and spread of HIV/AIDS in Cambodia and elsewhere throughout the world.
Aboud, F.E. (1998). Health psychology in global perspective. Thousand Oaks, Sage.
Hynie, M. (1998). The AIDS/HIV pandemic. In F.E. Aboud’s Health psychology in global perspective, pp. 94-122. Thousand Oaks, Sage.
Lubec, I. & Wong, M.L. (2003). Intersection on Globalisation and HIV/AIDS in Cambodia: Multiple sub-disciplinary views on interventions for women and children at risk. Symposium presented at the Canadian Psychological Association annual conference, Hamilton, Ont. June 12, 2003.
Lubec, I., Wong, M.L., Nosworthy, G., Tan, A., Dy, B.C., Kros, S.P., Chhit, M., Touch, S., Lee, N.L., Chew, K. and Mok, V. (2003). HIV/AIDS, beer, sex-tourism and women’s safety: Trans-cultural, multi-sector community health challenges in Cambodia. Paper presented to the Canadian Psychological Association annual conference, Hamilton Ont, June, 12, 2003.
McCourt, M. (2003). Grassroots empowerment and trans-cultural workshops: Some strategies for HIV/AIDS prevention among Beer Promotion Women” in Cambodia. Paper presented to the Canadian Psychological Association annual conference, Hamilton Ont, June, 12, 2003.
McNeil, A. (2003). The child vendors of Angkor Wat: Facing Cambodia’s future, its HIV/AIDS epidemic, and the risk of sexual exploitation from sexual tourists. Paper presented to the Canadian Psychological Association annual conference, Hamilton Ont, June, 12, 2003.
Stevanov, D., Tribble, K., Traut, P., Candy, E., McCourt, M., McNeil, A., Wong, M.L. & Lubec, I. (2003). “It just wouldn’t do, now to have ‘protitutes’ selling the beer of our ‘national icon’: Moral, organizational and business dilemma for international beer companies and their “throwaway” workers. Paper presented to the Canadian Psychological Association annual conference, Hamilton Ont, June, 12, 2003.
Bagby, Stoltz, Zhang, Kolls, Brown, Bohm, Rockar, Purcell, Jeanette, Murphey-Corb, N. (2003). The effect of chronic binge ethanol consumption on the primary stage of SIV infection in rhesus macaques. Alcoholism: Clinical & Experimental Research, Vol 27(3),Mar 2003. pp. 495-502. Journal URL: http://www.alcoholism-cer.com/
DeMarco, & Johnsen (2003). Taking action in communities: Women living with HIV/AIDS lead the way. Journal of Community Health Nursing, Vol 20(1), Spr 2003. pp. 51-62. Journal URL: http://www.erlbaum.com/Journals/journals/JCHN/jchn.htm
Halkitis, Parsons, Wolitski, & Remien, (2003) Characteristics of HIV antiretroviral treatments, access and adherence in an ethnically diverse sample of men who have sex with men. AIDS Care, Vol 15(1), Feb 2003. pp. 89-102. Journal URL: http://www.tandf.co.uk/journals/carfax/09540121.html
Manopaiboon, Bunnell, Kilmarx, Chaikummao, Limpakarnjanarat, Supawitkul, St. Louis, & Mastro, (2003). Leaving sex work: Barriers, facilitating factors and consequences for femal sex workers in northern Thailand. AIDS Care, Vol 15(1), Feb 2003. pp. 29-52. Journal URL: http://www.tandf.co.uk/journals/carfax/09540121.html
Noar, Morokoff, & Harlow, (2003). Condom negotiation in heterosexually active men and women: Development and validation of a condom influence strategy questionnaire. Psychology & Health, Vol 17(6), Dec 2002. pp. 711-735. http://www.tandf.co.uk
Oggins,J. (2003). Notions of HIV and medication among multiethnic people living with HIV. Health & Social Work, Vol 28(1), Feb 2003. pp. 53-62. http://www.naswpress.org
Pulerwitz, Amaro, De Jong, Gortmaker, Rudd, (2003). Relationship power, condom use and HIV risk among women in the USA. AIDS Care, Vol 14(6), Dec 2002. pp. 789-800. Journal URL: http://www.tandf.co.uk/journals/carfax/09540121.html
http://dx.doi.org/10.1080/0954012021000031868
Perez, Dabis, (2003). HIV prevention in Latin America: Reaching youth in Colombia. AIDS Care, Vol 15(1), Feb 2003. pp. 77-87. Journal URL: http://www.tandf.co.uk/journals/carfax/09540121.html
Gomes do Espirito, M. E & Etheredge, G. D., (2003). HIV prevalence and sexual behaviour of male clients of brothels' prostitutes in Dakar, Senegal. AIDS Care, Vol 15(1), Feb 2003. pp. 53-62. Journal URL: http://www.tandf.co.uk/journals/carfax/09540121.html