All is not well at Angkor Wat: One Cambodian community's

reactions to HIV/AIDS, sexual tourists, international "beer girls",

partying husbands and their wives and newborns.

Ian Lubek

Psychology Department

University of Guelph

and Mee Lian Wong

Department of Community,

Occupational and Family Medicine,

National University of Singapore

Abstract

While restoration work on the Temples of Angkor Wat progresses, attracting almost 200,000 tourists this year, the citizens of Siem Reap are unprepared to face the HIV/AIDS pandemic amongst them, with approximately 10,000 of the 140,000 citizens conservatively estimated to now be sero-positive. Following in-depth interviews conducted in Siem Reap and Phnom Penh, during February 2000, with a sample of 16 citizens and 3 medical practitioners (aged 30-59), strategies were designed to help particularly vulnerable women in the community reduce the risk of HIV transmission. All of the sample in 2000 reported disrupted and uprooted lives as they survived the Pol Pot regime. Among men who had not yet formed their own family units, some reported high risk behaviours, including abuse of alcohol with related road accidents and unprotected sex with various sex-trade workers, who arrived with the UN forces in the early 1990s, both direct (brothel prostitutes) and indirect sex-workers (discotheque dancers, Karioke singers, and young "beer-serving girls") . The latter are hired by beer distributors and wear costumes with the trademarks of international brands such as Labatt's Ice Beer, Fosters, Heineken, Tiger, ABC, San Miguel, Stella Artois, Alain Delon, Budweiser, Anchor, etc; they use "playful" sexuality to sell their quotas of beer for a salary of $2 per day. Each must sell about a case of beer per day, with beer being sold at from US $1.80 to $4.50 per can. To meet this quota, some "beer girls" monopolize one client and drink a case with him. To support children and families, these indirect sex workers may sometimes offer sex for money to their clients, when both are inebriated and condom use is often neglected. Local Married men also reported using the indirect sex-workers, but less frequently.

Educational campaigns about condom use aimed at high schools may be protecting younger Cambodians, but the men in the orphaned or battered generation of genocide survivors, may be engaged in unprotected sex and other risky behaviours. Young, often underage and illiterate beer-girls, some sold by their families to recruiters, enter the sex-work arena without information about HIV/AIDS (and sexually transmitted disease) prevention. Some sexual tourists often specifically request unprotected sex with the younger beer-girls, in the belief they are less likely to be sero-positive. However, rates of HIV/AIDS infections in Siem Reap, among the highest in Cambodia, have climbed during the past three years for indirect and direct sex-workers, and varied from 19% to 55%, depending on the sources and sampling methods. Local Siem Reap men are now transmitting the HIV virus to their wives (5% sero-positive) and newborn children. All interviewees in 2000 could name friends who had died in the HIV/AIDS epidemic; in 2001, all 15 beer-girls in two focus groups could name fellow beer-girls who had died that year. Only 2 beer companies seemed to have established any sort of minimal, but voluntary, annual health-information seminar for their women employees.

After feeding back a summary of the initial interview findings in Siem Reap, a small grass-roots citizens' action committee (local NGO) was formed of citizens and doctors. In 2000, they generally agreed on insufficient medical facilities, the lack of treatments for even opportunistic infections and believed medications, both antibiotic and anti-retroviral, were not affordable. Extended HIV/AIDS education and sex-worker outreach programs were also stressed, along with preparation of orphanages for "HIV/AIDS babies".

In 2001, with a small grant from the Elton John AIDS Foundation, educational materials were prepared, based upon those successfully used in Singapore and Malaysia by Mee Lian Wong. These booklets and cassettes, to be used by local peer educators, were translated into Khmer, and offer practical strategies for negotiating condom compliance by the "beer-girls" and the wives of local men who frequent them. They were pilot-tested in February, 2001 and revisions are expected shortly to be sent back for circulation in the community. With the help of local health workers, questionnaires about condom use and cervical gonorrhea testing has commenced at one health centre. After a small round-table conference was organized in early March, 2001 in Siem Reap to allow all local agencies, government departments and NGOs concerned with HIV/AIDS and women's health issues to interact about their programmes, a community "needs assessment" was carried out concerning the creation of an all-in-one "Wellness" clinic to bring together, equip and better co-ordinate all aspects of HIV/AIDS (and STD) prevention, education, acute care, diagnosis, treatment, long-term care and follow-up. This project is being developed in conjunction with the input from the local NGO/ community members, medical personnel, and will first seek the aid of international donors for startup assistance and then seek sustaining contributions from local community industry leaders (e.g., major hotels, tourism businesses, beer companies, etc.) . We are currently monitoring HIV rates and administering a behavioural questionnaire concerning condom use among sex workers and married women.