Research Helps Reduce HIV/AIDS in Siem Reap

U of G students participate in Cambodian NGO

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Street vendors gather around Guelph student Trisha Pagnutti, back right, and Australian intern Brett Dickson, left, after an HIV/AIDS workshop at Angkor Wat.

Almost overnight, Prof. Ian Lubek’s planned two-month research stay in Australia turned into a 13-year-long commitment to improving the health and working conditions of women in northwestern Cambodia. The U of G psychology professor never imagined a four-day stopover at Cambodia’s Angkor Wat temple complex early in 1999 would change the direction of his career and that of female “beer-sellers” in the adjacent town of Siem Reap.

“One local Cambodian took me aside and quite determinedly said, ‘You’re a professor; you’re smart. We’re dying of AIDS here and we can’t figure out what to do. Surely you can come back and help us confront AIDS!’ That presented quite a challenge to me,” says Lubek, whose area of study at the time was gender imbalance in scientific productivity.

“I knew next to nothing about HIV/AIDS. I was an armchair psychologist exploring philosophical and epistemological questions about the history of the social sciences, and knew little about health psychology.

“The situation in Cambodia was complex, starting with the fact that many young men had lost their parents in the 1970s during the Pol Pot genocide, when 25 per cent of the population died. Their culture required that parents arrange marriages,” Lubek adds. “As a result, a large cohort of young Cambodian men remained single, frequenting brothels.

“Meanwhile, young Cambodian women denied primary education were relegated to working in the entertainment industry, selling beer, giving massages or singing karaoke. Their salaries were never enough to make ends meet, so they occasionally accepted propositions for sex – about three times a month according to our research.”

Lubek’s research shows that a person in Cambodia needs about $213 a month to get by, but beer-sellers were only paid an average of $83 a month in 2011 and 2012. “Since 2002, I’ve been calling for beer companies to pay a living wage,” he says. “Many entertainment workers are labelled ‘indirect sex workers’ and remain unmarried because of the social stigma attached to that label. Yet, on average, they must support three or more dependents.

He explains that condom use has been required in Cambodian brothels since 2000, but beer-sellers are at risk for non-condom use: their job is to promote one particular brand of beer, so they drink about six beers nightly with their heavy-drinking customers. When Lubek’s research began in 2000, there were no anti-retroviral medications available, and 21 per cent of the beer-sellers were found to be HIV positive between 1995 and 2003.

“Mortality was high among the beer-sellers,” he says. “With compromised immune systems, other infections take a worse, often fatal, toll. The women’s average age at death was 25 years.”

Lubek returned to Cambodia in 2000 to conduct a “needs assessment.” He interviewed 23 people – a cross-section comprising sex workers, housewives, medical staff, educators and tour guides.

“I needed to find out how the virus was being spread through the community and what kind of prevention program was possible. I knew the brothel-based sex workers were a high-risk group and the beer-sellers and women in the entertainment industry were another vector for transmission.”

Lubek says epidemiological work done by the local government showed 42 per cent of sex workers and 20 per cent of the indirect sex workers were HIV positive, as were eight per cent of monogamous married women and their non-monogamous husbands. The first official case of HIV/AIDS was recorded in 1991, the year the United Nations sent peacekeeping forces to help Cambodia prepare for democratic elections in 1993.

“Many of those soldiers came from sub-Saharan Africa, where the rate of HIV/AIDS was in the range of 30 to 40 per cent among the military,” he explains. “Much of their ‘danger pay’ was spent on rest and recreation in beer halls, brothels and discotheques.”

Government statistics showed that about one quarter of single Cambodian men were using commercial sex workers; surprisingly, the same number of married men were doing likewise. The risk of acquiring HIV was high for both married men and their wives. By 2003, about 33 per cent of all the monogamous married women who volunteered to be tested at free health centres were found to be HIV positive.

“I was very worried to find out how sex-tourism had contributed to the spread of HIV/AIDS through the community,” Lubek remembers.

When he presented feedback from the needs assessment in 2000, many people in Siem Reap agreed to become HIV/AIDS peer educators if proper training and resources were provided. They formed a grassroots Cambodian non-governmental organization (NGO) called SiRCHESI (Siem Reap Citizens for Health Education and Social Issues) and set three goals: to help end HIV/AIDS, to change the male gender bias in education (because only boys received an education, girls could not get well-paid jobs), and to improve the subsistence pay rate, which was far below the actual cost of living. The first community groups targeted for health education outreach were married women and beer-sellers.

By 2008, the percentage of Siem Reap sex workers who were infected by HIV/AIDS had dropped from 42 per cent in 2000 to zero. Today, the HIV/AIDS rate among beer-sellers is less than two per cent.

Lubek credits community, NGO and government efforts – perhaps even an audio tape about condom use that was developed by SiRCHESI in 2002 and 2003. The tape was widely circulated among beer-sellers and used by peer educators for married women. The tape also surfaced in brothels, where clients had to listen to it before they were allowed “upstairs.”

An anti-trafficking law implemented by the Cambodian government in 2009 prohibited prostitution, including soliciting and selling sex. Lubek says all the brothels were officially closed down, followed by an abrupt end to HIV/AIDS testing and education for sex workers. “That entire at-risk group disappeared. Some of them resurfaced as restaurant hostesses, but there were no education programs for them until SiRCHESI began workshops.”

Australian teacher Neela Grifiths volunteers with the Siem Reap Citizens for Health Education and Social Issues to provide English lessons for former beer-sellers; new skills will help them secure safer better-paying jobs.

Lubek also notes that two of the world’s biggest brewers – Carlsberg and Heineken, who together control 80 per cent of the Cambodian market – formed an industry association (Beer Selling Industry Cambodia) to address the problem. That group maintains that beer-sellers now receive sufficient income, are not forced to engage in sex work and do not drink with customers. The industry group also defers the provision of anti-retroviral medications to government-sponsored programs. But Lubek says these points have all been refuted by SiRCHESI’s data, collated by Guelph research students and made available at www.fairtradebeer.com.

“Despite industry interventions after 2006, about 83 per cent of the beer-sellers still drink with their customers,” says Lubek. “In 2011-2012, our research found that they drank about six glasses of beer nightly, while hostesses employed by the restaurants to sit and drink with customers were drinking 11 glasses of beer a night. The women drank 27 nights a month.”

Meanwhile, SiRCHESI founded a school that taught literacy and skills to women, enabling former beer-sellers to land less risky, better-paid jobs and regain social acceptance. The NGO is now considering launching a daycare facility for working moms and an impaired-driving awareness program.

Student interns from U of G and other universities still work with SiRCHESI in Cambodia, participating in the NGO’s health interventions, re-interviewing hotel apprenticeship students, collecting data through questionnaires, analyzing data and writing reports. As part of the SiRCHESI team, they co-author and publish papers and conference presentations.

SiRCHESI accommodates up to four student interns at a time – 12 per year – in February, April and August. The interns live in a hotel and are provided with meals, a translator, a car and driver, and academic supervision.

Serendipity led Lubek’s career in unpredictable directions, but he says every day has been fulfilling. And many of the students who have worked on the project over the past 13 years have also found new directions for their careers. He concludes: “Keeping an open mind is key.”

Interested students can read more at www.fairtradebeer.com/miscdocs/brochure2013.pdf or email Lubek directly at ilubek@uoguelph.ca.

Psychology professor Ian Lubek, left, and Australian intern Kristy Forshaw meet with pediatrician Beat Richner, who has founded five private hospitals in Cambodia. Photos courtesy SiRCHESI