Cambodia HIV/AIDS Policy Assessment and Audit. Cambodia HIV/AIDS Policy Assessment and Audit. Report

Cambodia HIV/AIDS Policy Assessment and Audit Report National AIDS Authority June 2007

Table of Contents ACRONYMS... I ACKNOWLEDGEMENTS... II EXECUTIVE SUMMARY... III RECOMMENDATIONS MATRIX...V 1: TERMS OF REFERENCE, METHODOLOGY AND DEFINITIONS... 1 TERMS OF REFERENCE... 1 METHODOLOGY... 1 DEFINITIONS... 3 2. THE CONTEXT... 5 THE HIV EPIDEMIC IN CAMBODIA... 5 NATIONAL STRATEGIC PLAN AND UNIVERSAL ACCESS TARGETS... 5 THE HIV/AIDS LAW... 7 NATIONAL AIDS AUTHORITY... 7 3. OVERVIEW OF THE HIV/AIDS LAW, POLICIES AND RELATED DOCUMENTS... 9 4. NINE KEY THEMATIC FINDINGS... 13 5: AREAS FOR LAW REFORM, POLICY DEVELOPMENT AND IMPROVED IMPLEMENTATION. 17 THE HIV/AIDS LAW IMPLEMENTATION ISSUES... 17 THE HIV/AIDS LAW PENALTIES... 21 THE HIV/AIDS LAW POSSIBLE REFORMS OF GENERAL PROVISIONS... 21 EDUCATION, YOUTH AND SPORT... 23 HEALTH: BLOOD SUPPLY... 23 HEALTH: COUNSELLING, TESTING AND CONFIDENTIALITY... 24 HEALTH: PREVENTION OF MOTHER-TO-CHILD TRANSMISSION... 26 HEALTH: COMPLAINTS AGAINST HEALTH CARE WORKERS AND FACILITIES... 27 HEALTH: POST-EXPOSURE PROPHYLAXIS FOR NON-HEALTH EXPOSURE... 27 HEALTH: STD PREVENTION AND CONTROL... 27 HEALTH: SURVEILLANCE... 28 ILLICIT DRUGS... 28 LAW ENFORCEMENT AGENCIES... 29 LABOUR... 30 MEDIA LAWS... 31 MEN WHO HAVE SEX WITH MEN... 31 NATIONAL DEFENCE... 32 PUBLIC WORKS AND TRANSPORT... 33 RURAL DEVELOPMENT... 33 SOCIAL AFFAIRS AND VETERANS AND YOUTH REHABILITATION... 33 WOMEN S AFFAIRS... 34 6. LOOKING TO THE FUTURE... 35 WHO INITIATES POLICY DEVELOPMENT?... 35 DOES POLICY MATTER?... 35 APPENDIX 1: CAMBODIA HIV/AIDS POLICY ASSESSMENT AND AUDIT POLICY SURVEY... 37 APPENDIX 2: CAMBODIA HIV/AIDS POLICY ASSESSMENT AND AUDIT: GUIDE TO COMPLETING THE POLICY SURVEY... 40 APPENDIX 3: SUMMARY OF POLICY SURVEY RESPONSES BY MINISTRY... 42

Acronyms ART anti-retroviral therapy CENAT National Centre for Tuberculosis and Leprosy Control HCW health care worker IEC information, education and communication ILO International Labour Organisation LPWG Legal and Policy Working Group ( of the NAA) MoCR Ministry of Cults and Religions MoEYS Ministry of Education, Youth and Sport MoH Ministry of Health MoI Ministry of Interior MoLVT Ministry of Labour and Vocational Training MoND Ministry of National Defence MoPWT Ministry of Public Works and Transport MoRD Ministry of Rural Development MoSVY Ministry of Social Affairs, Veterans and Youth Rehabilitation MoWVA Ministry of Women s and Veteran s Affairs MSM men who have sex with men NAA National AIDS Authority NACD National Authority for Combating Drugs NCHADS National Centre for HIV/AIDS, Dermatology and STDs NBTS National Blood Transfusion Service NGO non-government organisation NMCHC National Maternal and Child Health Centre NRHP National Reproductive Health Program NSP II National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS, 2006-10 OD Operational District OVC orphans and vulnerable children PBTC Provincial Blood Transfusion Centre(s) PHD Provincial Health Department PITC provider initiated testing and counselling PLWHA person living with HIV/AIDS PMTCT Prevention of mother-to-child transmission RGC Royal Government of Cambodia SOP standard operating procedures STI sexually transmissible infection TB tuberculosis UA universal access VCCT voluntary confidential counselling and testing i

Acknowledgements First of all, the National AIDS Authority would like to express out great thanks to Mr David Lowe short term consultant to NAA for developing and conducting the Cambodia HIV/AIDS Policy Assessment and Audit with technical recommendation provided by Mr Tony E. Lisle, the UNAIDS country director to Cambodia. The NAA would also appreciates all His Excellencies, ladies and gentlemen who are members of the law and policy working group to NAA, that work very hard to provide all useful information to make this assessment and audit fruitfully. Last but not least, the special thanks to Dr Sou Sophy, official in charge of the law and policy of the NAA and Dr Hor Bun Leng, deputy secretary general of the NAA, who took all their effort to coordinate this task successfully. Finally, our special thanks to UNADS and US/CDC to Cambodia on their financial support to conduct this assessment and audit as well as publication and dissemination. Phnom Penh, July 2007 Secretary General H.E. Dr Teng Kunthy ii

Executive summary The purpose of the assessment and audit was to identify all existing national level HIV/AIDS policies, to determine the strengths and weaknesses of these policies, their implementation status, and to identify the need for revisions and new policies to fill gaps. An HIV/AIDS Policy Inventory has been developed which contains a brief description of all existing policy and related documents. A total of ten Ministries have developed an HIV/AIDS sectoral strategy and/or HIV/AIDS policies. A total of 8 sectoral strategies and 26 policy documents have been developed. The number of Ministries with an articulated strategy and/or policies reflects the multisectoral nature of the Cambodian response to HIV/AIDS. The majority of policy development has, however, not surprisingly occurred within the health sector. Most policy development commitments contained in NSP II have already been fulfilled or policy development is under way. Relevant policies exist for most universal access indicators. The high level of policy development in relation to NSP II commitments and UA indicators suggests that the major focus of work needs to be not so much in policy development but more in implementation. The Law on the Prevention and Control of HIV/AIDS is one of the key instruments for creating an enabling environment for HIV/AIDS programs. The provisions of the Law can be classified into three types: public health policy provisions, social policy provisions, and program commitments. Many of the provisions in the Law are reasonably broad statements which require further elaboration in policy statements or guidelines to facilitate implementation. Development of supporting policies and guidelines has occurred in most, but not all, areas covered by the HIV/AIDS Law. The development of policies and guidelines does not necessarily mean that implementation of the Law is occurring. It is, however, a first step. Implementation of the HIV/AIDS Law is variable. Provisions relating to public sector health policies and services are reasonably well implemented, within the context of available resources. The private health sector and other parts of the public sector are not as far advanced in implementation. Some policies to facilitate implementation have only recently being developed. Education about the provisions of the HIV/AIDS Law and improved enforcement has been proposed by NSP II. Key thematic findings of this policy assessment and audit are: 1. Formal policy development followed program development in Cambodia. Programs were developed in the 1990s in the absence of a written policy framework. However, program design involved at least some implicit policy decisions. 2. Policies are largely consistent with international best practice. 3. Strategies and guidelines contain a lot of policy content. That is, policies can be found in a range of documents. 4. All policies are consistent with the HIV/AIDS Law. 5. A significant amount of new policy development and policy revision is taking place. Six new policies were developed in 2006. A total of 16 policies, strategies or guidelines are currently being developed or are under review. This constitutes a dynamic policy environment. iii

6. Policy development has been driven by the need for policies and guidelines to implement the HIV/AIDS Law; policy commitments in NSP II; universal access targets; a maturing national HIV/AIDS response where policy is catching-up with program development; and a new trend for policy to drive program development. 7. While most policies are HIV/AIDS specific, there is an increasing number of mainstream policies with HIV/AIDS content. 8. Policy linkages within and between sectors are actively being developed. 9. While there has been some good progress, some policy gaps remain. 10. Implementation of policies is variable and needs to be improved. The main areas where policy gaps exist are: - Workplace policies in the public sector. - Policy on the approach of law enforcement agencies to working with HIV harm reduction programs. - A government policy statement on MSM and HIV/AIDS/STIs. - Provision of penalties for HIV/AIDS-related discrimination in employment. (The HIV/AIDS Law contains penalties for discrimination in other areas, but not employment.) - Policy on availability of post-exposure prophylaxis for non-occupational cases, (especially for rape victims). Other areas for reform of the HIV/AIDS Law, needed policy development, and improved implementation are set out in the recommendations matrix (see next page). iv

Recommendations matrix For more details on recommendations contained in this matrix, refer to section 5, Areas for law reform, policy development and improved implementation. Ministry/Authority Policy area Law reform Policy/guideline development needed NAA Policy dissemination Discrimination Information standards Deliberate transmission Compulsory testing Public sector HIV workplace policy MSM Provide penalties for HIV/AIDS-related discrimination in employment. Establish RGC Human Rights Commission or Ombudsperson to investigate breaches of HIV/AIDS Law. (Broader than HIV/AIDS focus) Amend deliberate transmission offence to: - Provide for intentionally exposing another person to a real risk of HIV infection. - Provide for a defence or mitigating factor of consent or use of safe sex Establish standards for information regarding: - HIV/AIDS Law provision re misleading information on preventing and treating HIV/AIDS. - HIV/AIDS Law provision that sale or distribution of condoms and needles be accompanied by printed information on proper use. Develop guidelines for court officials on use of deliberate transmission provisions (with Ministry of Justice and Ministry of Interior) Develop an operational guideline for Judges hearing applications for conducting a compulsory HIV test and disclosure to a court of medical records re a persons HIV status (with MoJ) Development of a public sector HIV/AIDS workplace policy Develop a Government policy statement on MSM and HIV/AIDS/STIs Education: Human resources HIV/AIDS human resources policy Addressing implementation Place Policy Inventory on NAA web site and update regularly. Place electronic copies of policies on NAA web site or provide links to Ministry web sites. Additional dissemination and education relating to the HIV/AIDS Law. v

Ministry/Authority Policy area Law reform Policy/guideline development needed MoEYS School health Develop implementation guidelines for the School Health Policy Addressing implementation Conduct a situation analysis of all school health initiatives to develop an action plan to harmonise current and planned interventions. Health Blood supply Develop additional guidelines on the clinical use of blood, CPA, and donor selection. Establish policies on institutional development of the NBTC and its financing. Notification of HIV test results Contact tracing HIV testing PMTCT Post exposure prophylaxis Sex worker interventions Surveillance Create a positive duty on HIV testing centres to provide data (coded and confidential) to the government s epidemiologic monitoring program Consider whether contact tracing guidelines are needed Provide additional policy guidance on HIV testing of children Consider the potential role for provider initiated testing and counselling in Cambodia. Issue new policy and guidelines, incorporating opt-out testing and standard operating procedures Consider developing guidelines for making PEP available for nonoccupational exposures Evaluation of 100% condom use program, outreach and peer education programs, and STI case management, and related policies Consider the feasibility of improvements to the HIV surveillance strategy Improve policy implementation regarding voluntary blood collection, blood screening and QA and optimal use of blood products. Improved implementation of PMTCT services through more effective intrasectoral coordination of services Health Commission Create a health commission to mediate disputes between providers and consumers and legal redress where disputes cannot be resolved (applies to entire health sector, not just HIV/AIDS) NACD Harm reduction Scale-up of harm reduction interventions Ministry of Interior Law enforcement agencies Develop national policy on the approach of law enforcement agencies to working with HIV/AIDS prevention programs vi

Ministry/Authority Policy area Law reform Policy/guideline development needed Ministry of Media law Changing the Press Law to prohibit Information publishing information which incites discrimination against PLWHAs MoND Defence policies Consideration of developing policies in the following areas: A workplace HIV/AIDS policy for MoND/RCAF personnel. Provision of health services for PLWHAs in the military, including coordination between MoND health services and civilian health services, and referral policy and guidelines to ensure full access to the continuum of care. Infection control policy and guidelines for MoND health services. Provision of HIV/AIDS-related and STI services to the wives and families of military personnel, including prevention, VCCT, family planning, and PMTCT. Impact mitigation policies for affected families of military personnel, including widows and OVC. Sentinel, anonymous and de-linked screening of military recruits and/or existing personnel as part of national surveillance. The policy approach to take to testing and/or screening of military recruits. MoPWT Mobility and public works projects MoRD Rural development policies Review existing MoRD policies and guidelines in support of poverty alleviation, enhancing food security, improving living standards, and reducing gender inequality, to reduce vulnerability of rural communities to HIV/AIDS. Addressing implementation Fully implement the policy for 1% of the budget of major infrastructure contracts to be set aside for HIV prevention programs for infrastructure workers and the surrounding community vii

Ministry/Authority Policy area Law reform Policy/guideline development needed MoSVY Policy on Issue guidelines to assist with Alternate Care for implementation of the policy. Children Strengthen the policy by addressing: Mobilisation and support for community-based responses for children affected by HIV/AIDS. Developing specific measures for family reintegration. MoWA Policy on Women and Girls Spousal transmission Develop an action plan to implement the Policy on women, girls and STI/HIV/AIDS, based on a clear understanding of MoWA's mission and role Addressing implementation Promoting an integrated multisectoral approach to the issue of spousal transmission viii

1: Terms of reference, methodology and definitions Terms of reference The National AIDS Authority (NAA) decided to undertake a comprehensive audit and assessment of the HIV/AIDS policy environment in Cambodia. The purpose of the assessment and audit was to identify all existing national level HIV/AIDS policies, to determine the strengths and weaknesses of these policies, their implementation status, and to identify the need for revisions and new policies to fill gaps. Key tasks Key tasks were: - Undertake a review of previous relevant policy assessments or mapping undertaken in Cambodia. - Undertake a desk review of all policies to establish existing policies and whether they meet international best practice standards and are in line with the Cambodian Law on the Prevention and Control of HIV/AIDS and support the implementation of the National Strategic Plan for a Comprehensive and Multisectoral Response to HIV/AIDS, 2006-10 (NSP II). - Assess the completeness of existing policies; determine strengths and weaknesses; identify those policies which require strengthening and revision; and determine key policy gaps that need to be addressed. - Assess policy implementation and determine which policies are being effectively implemented and the reasons for effective implementation, or where policies are not being implemented, the reasons or barriers. - Analyse overall findings, outline policy gaps and develop a set of key recommendations for the NAA Policy Board and its partners on those policies that need to be strengthened or modified, new policies to be developed, as well as recommendations for complementary operational frameworks, guidelines and procedures that may require development for different sectors and thematic areas. - Develop an inventory of national HIV/AIDS policies that can be regularly updated by the NAA Secretariat on an annual basis and available on the NAA web site as a public document. Methodology The key components of the methodology were: - A review of previous policy assessments. - A review of all policies in relation to consistency with international best practice and compliance with the Cambodian HIV/AIDS Law and NSP II. - An HIV/AIDS policy survey of Ministries and UN agencies to collect qualitative information on existing policies. - Interviews with stakeholders in relation to policy strengths and weaknesses, implementation, the need for policy revisions, and key policy gaps. - Analysis of data and formulation of recommendations. The Policy Survey The purpose of the survey was to collect information in a time-efficient and consistent way on the adequacy and extent of implementation of existing RGC HIV/AIDS policies in Cambodia. Ministries and UN agencies were asked to jointly complete the survey. A guide to completing the survey was developed and sent to all Ministries and UN agency HIV/AIDS focal points, along with the survey 1

instrument. A copy of the survey instrument and the guide to completing the survey is at appendices 1 and 2, respectively. The survey and guide were translated from English to Khmer by the NAA. Policy Inventory An National HIV/AIDS Policy Inventory was developed. This is in a separate document to this report. The Inventory contains a brief description of all current national level RGC HIV/AIDS-related policies that were in force as of November 2006. The Inventory also includes the HIV/AIDS Law, strategies and guidelines, as these type of documents also have substantial policy content. Where strategies, policies and guidelines were being developed, this is indicated. The Inventory does not, however, contain a description of draft policies as their content may change in the process of development. The Inventory contains the following information for each policy: - Document title - Issuing authority - Document type - (i.e. law, strategy, policy or guidelines) - Current status date of issue, any planned review, and any specified expiry date. - Core contents a brief description of the policy - Target populations - Implementing organisations by type of organisation - Related documents the title of any directly related documents An advantage of the Inventory is that it provides a single, easily available resource to anyone wanting to check whether a policy exists, its currency and contents. It will be important for the NAA to update the Inventory regularly. While annual revisions have been proposed, it would be preferable if this could be done progressively through the year, as new policies are developed. This would increase the utility of the Inventory as it would become a known source of how to access new policies. As the NAA web site develops, it would be useful to also include electronic copies of policies and related documents to provide ease of access. Alternatively, links to Ministry web sites could be provided. Scope The scope of the policy assessment and audit was deliberately limited to RGC national level HIV/AIDS policies. Policies developed by provincial governments, the private sector and NGOs were not within the scope of this work. Both HIV/AIDS specific policies and mainstream policies that address HIV/AIDS in a broader context were within the scope of this assessment and audit. Most RGC policies on HIV/AIDS deal only with HIV/AIDS. There are, however, some policies that deal with HIV/AIDS within a broader context. The Law on Prevention and Control of HIV/AIDS, 2002 ( the Law ) provides legal force to RGC policies in a range of areas. The Law was within the scope of the policy assessment and audit. Limitations and constraints The Policy Survey The focus of the survey was intended to be policy specific. The guide to completing the survey stated that it was not intended to collect information about strategies or guidelines unless they contained substantive policy content. The guide provided definitions of the terms strategy, policy, guidelines, and 2

standard operating procedures to assist people in determining what came within the scope of the term policy. The utility of the survey was limited by two factors. - A low return rate. Twelve useable surveys relating to policies in eight Ministries were received. This is a poor return rate compared to the total of 26 existing HIV/AIDS policies or guidelines, and nine HIV/AIDS strategies with some policy content. The deadline for completing the surveys was extended on a number of occasions and reminder notices were sent out. This resulted in some additional returns. - Most of the surveys received related to documents with the word policy in the title. It would appear that HIV/AIDS focal points in the Ministries and UN agencies did not read the guide to completing the survey. They appear to have assumed that survey returns for guidelines and strategies with substantive policy content were not needed. In addition a number of completed surveys relating to the establishment of Ministry-specific HIV/AIDS committees were received. These surveys were excluded from analysis as they did not relate to policies. The broad scope of work, coupled with a relatively limited time-frame, did not allow for a detailed assessment of the extent to which particular policies were being implemented or specific barriers to implementation. To do this would have required a significantly longer project that would have had some similarities to a comprehensive evaluation of the national response. It is important to stress that the assessment and audit was not intended to be a quasi evaluation of implementation of NSP I or II. Prior to the development of the National HIV/AIDS Policy Inventory, there was no consolidated list of HIV/AIDS policy-related documents in Cambodia. HIV/AIDS policies and related documents were identified through multiple strategies. These included Policy Survey returns, web sites, requests to Ministries and UN agencies to forward copies of HIV/AIDS policies, circulation of a list of policies to key informants to check for omissions, checking for missing documents in stakeholder interviews, and following-up references to policies in other documents. This multiple cross-checking should have identified all existing HIV/AIDS policies, although it is possible that there may be some policies that have not been identified. Definitions Policy documents have a distinct purpose and function, compared to other types of documents such as strategies, guidelines and standard operating procedures. Definitions of the terms policy, strategy, guidelines, and standard operating procedures are set out below. In Cambodia it is common for the distinctions between strategies, policies and guidelines to be blurred. In practice, this means that policy content often appears in strategies and guidelines, and not just policy documents. So as to capture the full range of Cambodian HIV/AIDS-related policies, this assessment and audit has included the policy content of strategies and guidelines. Another reason for including strategies and guidelines is that some Ministries have HIV/AIDS strategies and/or guidelines but no separate policy documents. Standard operating procedures are not included in the scope of the policy assessment and audit as they are primarily focussed on how to implement policies and programs and rarely have additional policy content, beyond what appears in related documents. The following definitions have been used in relation to strategies, policies, guidelines and standard operating procedures. 3

Strategies define problems or issues, set out measurable high level goals and objectives and determine the type of action needed to achieve the goals. A strategy is usually implemented over a number of years, with defined start and finish dates. Strategies can be whole-of-government (eg HIV/AIDS National Strategic Plan), or specific to a particular Ministry or issue. Strategies are high level documents which set out broad programmatic directions. Policies are documents officially endorsed by governments (including Ministries and Authorities) which adopt a course of action to be pursued in relation to a specific issue. Compared to strategies, policies usually have a narrower focus. Policy documents set out the choices made by government on particular issues. For example, governments may choose between voluntary, mandatory and compulsory HIV testing for different populations and settings. A policy on HIV testing will set out the government s policy decision. Policy documents can take the form of laws, decrees and sub-decrees, or a government endorsed statement setting out policy directions. Guidelines usually provide more detailed information on how to go about implementing a policy. For example, a law could define the Government s policy approach to HIV testing (e.g., voluntary, pre- and post-test counselling and confidentiality). Guidelines would contain more detailed information on the policy, with a focus on implementation. Guidelines promote implementation of policies by providing practical advice. In Cambodia, it is common for guidelines to be a combination of both policy statements and implementation guidelines. The term guidelines implies that they are intended to give guidance which is not mandatory. However, it would appear that the intention of RGC Ministry s is for guidelines to have a mandatory effect, at least in relation to government services. Standard Operating Procedures (SOPs) are intended to provide clear, standardised, transparent systems for decision-making and details on how to go about program implementation, disbursement of funds, regular monitoring, reporting, etc. They are focussed on procedures. They are usually more detailed than guidelines and may be more prescriptive. 4

2. The context The HIV epidemic in Cambodia The Cambodian HIV/AIDS epidemic is generalised, driven by high risk behaviours in commercial sex, male to male sex, and emerging cases of sharing injecting equipment. There has been a high level of political commitment and leadership from the Royal Government of Cambodia in responding to HIV/AIDS. Cambodia has been one of the few developing countries in the world that has been successful in turning the tide of a generalised HIV/AIDS epidemic. HIV prevalence in the adult population peaked at 3% in 1997 and fell to 1.9% in 2003. The high number of PLWHAs, estimated to be 123,000 gives rise to a wide range of support and care and treatment needs. National Strategic Plan and Universal Access Targets NSP II has 3 goals: 1. To reduce new infections of HIV; 2. To provide care and support to people living with and affected by HIV/AIDS; and 3. To alleviate the socio-economic and human impact of AIDS on the individual, family, community, and society. NSP II strategies of direct relevance to policies are - Increased coverage of effective prevention, care and support, and impact mitigation interventions and additional interventions developed; - A supportive legal and public policy environment for the HIV/AIDS response; and - Increased availability of information for policy makers and program planners through monitoring, evaluation and research. Based on the lessons learnt from NSP I, the primary policy-related opportunity for an enhanced response identified by NSP II was the need to enforce the National HIV/AIDS Law. The need to scale-up prevention services for at risk populations has policy implications in areas where policy development had not occurred. This includes policies on harm reduction for injecting drug use and HIV prevention in MSM. Similarly, the need to scale-up impact mitigation services highlighted the need for policies to guide and support program development. While NSP II identifies the need to scale-up care and support services, this did not have policy implications as this area was already well served by policies and guidelines developed under NSP I. Specific policy related commitments in NSPII are summarised in Table 1 along with the Universal Access (UA) indicators which have been developed for Cambodia. The current status of policy development for each NSP commitment and UA indicator is also listed. Analysis of Table 1 indicates that most policy development commitments for NSP II have already been fulfilled or policy development is under way. Relevant policies exist for most UA indicators. These policies were developed under either NSP I or II. The high level of policy development in relation to NSP II commitments and UA indicators suggests that the major focus of work needs to be not so much in policy development but more in implementation. 5

Table 1: List of NSP II policy commitments and Universal Access Indicators in relation to current status of policy development NSP II policy commitment Universal Access Indicator Current policy development status NAA & MOSVY to provide leadership in developing national policies, guidelines and strategies for impact mitigation. Improve the coordination mechanisms for impact mitigation policies and programs Percentage of households with OVC that are accessing livelihood opportunities. Percentage of communes with at least 1 organisation providing care and support to households with OVC. Policy on Alternate Care for Children issued by MoSVY, April 2006. Minimum Standard for Substitute Care for Children drafted. National Orphans and Vulnerable Children Multisectoral Action Plan being developed by OVC Task Force MoEYS to develop HIV/AIDS-related policies MoLVT to develop workplace policies and programs MoPWT to support creation of an enabling policy environment to reduce mobility and migrant worker vulnerability to HIV. Review, update and implement national policies on internal and crossborder migration and HIV/AIDS vulnerability Supportive legal and public policy environment for harm reduction. MoI will develop policies and programs for HIV. Work with religious leaders to ensure dissemination and implementation of MoCR s HIV/AIDS policy Number of large employers that have workplace policies and interventions. Percentage of IDUs who are exposed to HIV prevention interventions. Percentage of ATS users who are exposed to HIV prevention interventions. Percentage of respondents who say that an HIV+ teacher who is not sick should be allowed to continue teaching Number of Ministries actively implementing an HIV/AIDS plan School Health Policy issued Aug 2006 Youth Policy in draft Life Skills Education Policy in draft Prakas on Creating HIV/AIDS Committees in Enterprises and Establishments and Managing HIV/AIDS in the Workplace issued September 2006. Public sector HIV/AIDS workplace policy recommended by this report (current policies relate to private sector). Policy on HIV/AIDS and Prevention in the Public Works and Transport Sectors issued August 2006 MoLVT Prakas on Education of HIV/AIDS, Safe Migration, and Labour Rights for Cambodian Workers Abroad issued August 2006. Following policies being developed by NACD Policies and Guidelines for Needle and Syringe Programs in Cambodia. Policies and Guidelines for Opiate Substitution Therapy. Clinical Guidelines and Protocols for Methadone Maintenance Services in Cambodia. National Drug Treatment and Rehabilitation Policy. Minimum Standards for Residential Drug Treatment and Rehabilitation Centres. Operational Framework for Access by Drug Users to HIV Voluntary Counselling and Testing in Closed Settings. No plans for legislative reform at this stage. HIV/AIDS policy for law enforcement agencies recommended by this report. Further dissemination to be undertaken by MoCR and UNICEF. Covered by HIV/AIDS Law provisions re education of general public Revised plans under development in a number of Ministries. 6

NSP II policy commitment Universal Access Indicator Current policy development status Number and percentage of operational districts with the continuum of care. Number of CoC sites operating with minimum package of services. Percentage of PLWHA with access to CoC OI and ART services. Number of home based care teams. Continuum of Care Framework developed under NSP I Policies and programs on OI and ART access developed under NSP I. Percentage of married women who report consistent condom use Percentage of men who report consistent condom use with commercial sex partners. Percentage of direct female sex workers who report consistent condom use. Percentage of indirect female sex workers who report consistent condom use. Percentage of visible MSM who are exposed to HIV prevention interventions Number and percent of ODs with at least one PMTCT site offering the minimum package of services. Percentage of pregnant women attending ANC who are HIV tested. Number of VCCT sites offering counselling and testing Number of health centres providing support to TB patients for HIV testing Number of condoms sold MoWA policy developed under NSP I. Improved multisectoral approach to spousal transmission needed. 100% Condom Use, outreach and peer education policies and programs developed under NSP I. Possible evaluation flagged by NCHADS. Policy statement on MSM and HIV/AIDS recommended by this report PMTCT policy developed under NSP I. To be reissued to incorporate an opt-out approach to HIV testing Policy developed under NSP I. PITC being considered as a supplementary strategy to VCCT. Policy developed under NSP I. HIV/AIDS Law requires the sale or distribution of prevention devices (eg condoms) be accompanied by printed information on proper use. Standards should be established by NAA The HIV/AIDS Law The Law on Prevention and Control of HIV/AIDS was passed by the National Assembly in 2002. The scope of the Law s provisions is outlined in the next section and more detail is provided in the HIV/AIDS Policy Inventory. Recommended legislative reform and improvements to implementation and enforcement of the Law are outlined in section 5. The law is largely consistent with international best practice, particularly in relation to antidiscrimination, privacy and confidentiality, and voluntary testing and counselling protections. National AIDS Authority The National AIDS Authority (NAA) is mandated by the HIV/AIDS Law to lead, coordinate and monitor Cambodia s national multisectoral response to HIV/AIDS. The NAA consists of senior officials, a Secretariat, representatives from Government Ministries, Institutions and Provinces and Municipalities, and the Cambodian Red Cross. The functions of the NAA are set out in the Law and a sub-decree. They include policy development, advocating for legislative support, strengthening relationships with stakeholders, and mobilising resources from national and international bodies. The NAA Policy Board ensures that policy development in specific sectors is consistent with the national policy framework and supports the enactment and enforcement of appropriate laws and policies related to HIV/AIDS. The 7

NAA also advocates for the implementation of the HIV/AIDS Law with government, non-government and the private sector and advocates with Government partners, through the Policy Board, for development and implementation of relevant policies and plans. The NAA has established a Legal and Policy Working Group (LPWG) The LPWG has the following tasks: 1. Develop principles, procedures, internal rules, TOT guide books, and legal documents for the implementation of the HIV/AIDS Law. 2. Develop and review training document materials for promotion of the Law, policies, and other relevant guidelines on HIV/AIDS. 3. Promote the Law, policies and guidelines on HIV/AIDS through selected media (general media networks, drama, public forum, etc). 4. Provide training on the HIV/AIDS Law to the Technical Board, NGOs, civil society, AIDS committees, Provincial AIDS Secretariats, districts, communes, police, local authorities, etc. 5. Develop systems for strengthening implementation, monitoring and evaluation of the Law. The LPWG is developing a work plan. 8

3. Overview of the HIV/AIDS Law, policies and related documents This section provides a broad overview of the areas covered by the HIV/AIDS Law, policies and related documents. 1 A summary of the contents of HIV/AIDS legal provisions, policies and related documents is provided in the HIV/AIDS Policy Inventory (see separate document). A total of ten Ministries have developed HIV/AIDS policies or related documents. This reflects the multisectoral nature of the Cambodian response to HIV/AIDS. The majority of policy development has, however, not surprisingly occurred within the health sector. Given the importance and breadth of the health sector s response, this is seen as appropriate. NCHADS has developed 15 (58%) of all policy and related documents. As Table 2 indicates, some Ministries have developed sectoral HIV/AIDS strategies, with some policy content, but have no separate HIV/AIDS policies (e.g. Ministry of Rural Development). Most of the 26 documents listed under the Policies and guidelines column have the title guideline in their title. These documents are in fact a combination of policies and guidelines. Ministry Table 2: Overview of HIV/AIDS legal provisions, policies and related documents by Ministry 2 HIV/AIDS legal provisions Sectoral HIV/AIDS Strategy Policies and guidelines Strategies & policies under review or development Cults and Religions 1 Education, Youth and Sports 1 1 1 3 Health: - National Blood Transfusion Serv 1 1 1 - NCHADS 4 1 15 2 - CENAT (TB) 1 - CENAT/NCHADS 1 - Maternal Child Health/NCHADS 2 2 - National Reproductive Hlth Prog 1 Nat Auth for Combating Drugs 1 1 5 National Defence 1 1 Labour and Vocational Training 2 2 Public Works and Transport 1 1 Rural Development 1 Social Affairs and Youth Rehab 1 1 2 Women s Affairs 1 Totals 10 8 26 16 A total of 16 policy and related documents (including sectoral strategies) were either under review or being developed for the first time, as at November 2006. This is indicative of the current dynamism in HIV/AIDS policy development in Cambodia. What is covered by the general provisions in the HIV/AIDS law? The Law on Prevention and Control of HIV/AIDS is made up of general provisions that apply to society as a whole and provisions that relate to the functions of specific Ministries. The general provisions of the law cover: - development of a multisectoral response 1 The term related documents refers to strategies and guidelines with significant HIV/AIDS policy content. 2 This table does not include general legal provisions. That is, legal provisions that do not relate to a particular Ministry. 9

- confidentiality - discrimination - education and information provision - monitoring of the epidemic and the national response - transmission offences Strategic frameworks In addition to NSP II, the following sectors have developed either HIV/AIDS specific sectoral strategic plans or incorporated HIV/AIDS into their broader strategic plans. All plans have at least some policy content: Health - NCHADS: Strategic Plan for HIV/AIDS Prevention and Care, 2004-07 - CENAT: National Health Policies and Strategies for Tuberculosis Control, 2006-10 - NRHP: National Strategy for Reproductive and Sexual Health, 2006-10 Interior - NACD: Drug Control Master Plan 2005-10 National Defence - HIVAIDS Strategic Plan 2002-06, with revised Plan for 2007-10 under development Rural Development - HIV/AIDS Strategic Plan 2002-06 Social Affairs, Veterans and Youth Rehabilitation - HIV/AIDS Strategic Plan 2002-06, with revised Plan for 2007-10 under development Education, Youth and Sports - HIV/AIDS Strategic Plan 2002-06, with revised Plan for 2007-10 under development Sector specific snapshot of legal provisions, policies and guidelines The areas covered by sector specific provisions in the HIV/AIDS Law and the 26 policies and guidelines (with policy content), by Ministry, is set out in Table 3. The purpose of this table is to give a sector specific snapshot of the areas covered by the Law and policies/guidelines. More details of the legal provisions and policies are in the HIV/AIDS Policy Inventory. Table 3 does not include legal provisions that are not sector specific. See table 4 in section 5 for a complete overview of the HIV/AIDS Law. Ministries with no HIV/AIDS strategy or policies Ministry s without HIV/AIDS strategies and/or policies are: - Agriculture, Forestry and Fisheries - Commerce - Culture and Fine Arts - Foreign Affairs - Information - Economy and Finance - Environment - Industry, Mines and Energy - Justice - Planning - Tourism 10

Table 3: Snapshot of the range of areas covered by the HIV/AIDS Law and policies/guidelines, by Ministry Ministry Legal provision Policy or guidelines 3 Cults and Religions Religious response policy Education and Youth HIV/AIDS education and prevention programs in schools School health policy Youth Policy (draft) Life Skills Education Policy (draft) Health Safety of the blood supply Safety of the blood supply (under review) Counselling and HIV testing Counselling and HIV testing HIV education and information provision through health service delivery 100% Condom Use Program Targeted outreach for sex entertainment services Outreach and peer education in the community STD prevention and control STI services implementation Health and support services to PLWHAs Continuum of care Antiretroviral therapy selection Antiretroviral therapy use in adults Antiretroviral therapy paediatric use Opportunistic infection prophylaxis Universal infection control Universal infection control Management of occupational exposure to HIV Research ethics National Authority for Combating Drugs Labour and Vocational Training Public Works and Transport Social Affairs, Veterans and Youth Rehabilitation Women s Affairs Monitoring trends in the epidemic and sexual behaviours Law on the control of drugs Workplace HIV/AIDS education, prevention and control plans Pre-departure education of Cambodians working overseas IEC information for tourists and travellers at international entry and exit points Surveillance of HIV/AIDS, STIs and related behaviours HIV/AIDS and TB joint statement PMTCT (under review) Drug Control Master Plan Needle and Syringe Exchange Program (draft) Methadone maintenance (under development) Drug treatment and rehabilitation (draft) Residential drug treatment and rehabilitation centres (draft) Access by drug users to HIV VCCT in closed settings (under development) Workplace HIV/AIDS committees and education programs HIV/AIDS Safe Migration and Labour Rights for Cambodian Workers Abroad HIV/AIDS and Prevention in Public Works and Transport Sectors Alternate care for children National framework for orphans and vulnerable children (under development) Women and girls and STIs/HIV/AIDS 3 Policies shown in italics are currently under development. 11

While some of these Ministries could make a useful contribution to the Cambodian multisectoral response (eg Justice in relation to implementation and enforcement of the HIV/AIDS Law), none would be regarded as central to the response nor more important to involve compared to Ministries that already have HIV/AIDS policies. Previous efforts have been made to expand the number of Ministries involved in HIV/AIDS. A first step has often been the development of strategic plans. The degree to which these plans have been operationalised, costed and implemented varies widely. A decision on whether a broader range of Ministries should be engaged in the HIV/AIDS response should be based on an overall assessment of priorities and available resources and the likely outcomes to be achieved through broader involvement. This should include an assessment of whether development of strategies and policies is likely to result in implementation or not. documents. 12

4. Nine key thematic findings This section sets out the key thematic findings from the policy assessment and audit. Findings in relation to particular policies are set out in section 5, Areas for law reform, policy development and improved implementation. 1. Formal policy development followed program development The rapid and effective Cambodian response to HIV/AIDS in the 1990s in developing programs for most at risk populations, occurred in the absence of an explicitly stated policy framework. While some policy was contained in early national HIV/AIDS plans developed in the 1990s, almost all HIV policy and guidelines documents, including in the health sector, have been developed since 2000. The HIV/AIDS Law, which enshrines key policy directions, came into force in 2002. A conventional good governance approach emphasises the importance of policy development preceding, or at least accompanying, program development. 4 While there was an absence of policy documents to guide HIV/AIDS program development and implementation, program design involved at least some implicit policy decisions. That is, while programs developed without explicit policies, some key policy decisions were made as part of program development. When policy and guidelines were formulated in the years since 2000, the experience of programs informed policy development. Program approaches were also enhanced through the informal debates and discussions that accompanied subsequent policy development. 5 2. Policies are consistent with international best practice Cambodian HIV/AIDS laws, policies and related documents are largely consistent with international best practice. A notable exception to this is the current PMTCT policy which provides for opt-in testing, compared to the standard international approach of opt-out. A decision has been made to change the Cambodian policy to opt-out, although as of December 2006 the policy had not been updated to reflect this. The other main variation from international best practice is that the HIV/AIDS Law provides no penalties for HIV/AIDS-related discrimination in employment, although there are penalties for discriminatory practices in other areas such as education and service provision. The development of programs and interventions in the 1990s was significantly influenced by international technical assistance agencies and donors. Their contributions to program design were largely influenced by international best practice. This may have influenced the very high degree of Cambodian compliance with international best practice. While policies are consistent with international best practice, implementation has had to be adapted to the Cambodian setting and its resource constraints. 3. Strategies and guidelines contain a lot of policy content Clear distinctions have not been used in how the terms strategies, policies and guidelines are applied. This has resulted in some strategies and guidelines containing a good deal of policy content. In some guidelines, the policy content is clearly stated, while in others it is implied or has to be inferred. 4 See section 6 for a discussion on why policy matters. 5 Buhler, M Turning the Tide. Cambodia s Response to HIV/AIDS 1991-2005. August 2006. p. 7. 13

4. Policies are consistent with the HIV/AIDS Law All HIV/AIDS policies and related documents are consistent with the HIV/AIDS Law. 5. A significant amount of new policy development and policy revision is taking place Six new policies were adopted in 2006. They were the: - School Health Policy (MoEYS) - Alternate Care for Children Policy (MoSVY) - Guidelines for the Management of Occupational Exposure to HIV (MoH - NCHADS) - HIV/AIDS workplace committees and managing HIV/AIDS in the workplace (Prakas) (MoLVT) - Education of HIV/AIDS, Safe Migration, and Labour Rights for Cambodians Working Abroad (Prakas) (MoLVT) - Public Works and Transport Policy on HIV/AIDS Prevention (MoPWT) Most of the new policies were in non-health sectors. This refects the fact that the health sector is the most advanced in terms of HIV/AIDS policy development, with over half of all existing policies. Reflecting this greater level of policy maturity, NCHADS has been concentrating on the development of standard operating procedures (SOPs). While SOPs do not usually contain policy, they are important instruments in facilitating policy implementation. Table 3 indicates that 8 new policies are currently being developed. In addition, the policies on safety of the blood supply, PMTCT and HIV counselling and testing are currently under review. The Ministry of National Defence may also consider developing new policies, in the context of its newly developed HIV/AIDS Strategic Plan. The 2005 Situation and Response Analysis concluded that one of the three main achievements of the national HIV/AIDS response was in the area of policy development. 6 Given the extent of recent and ongoing policy development, it is fair to conclude that Cambodia has a dynamic HIV/AIDS policy environment. This raises the question of what is driving policy development. A number of factors appear to be at work: - Implementation of the HIV/AIDS Law: three of the policies developed in 2006 directly relate to specific provisions in the HIV/AIDS Law. These policies are MoLVT s policies on HIV/AIDS and safe migration and HIV/AIDS in the workplace, and the MoEYS School Health Policy. - Implementation of NSP II: The review of NSP I identified a number of gaps which were addressed in the development of NSP II. For example, the area of impact mitigation was identified as a gap and this has resulted in the work to develop a national OVC framework. - Universal access targets: Policies are being developed to support programs to achieve these targets. For example, development of policies in relation to injecting drug use. - A maturing national HIV/AIDS program: In the 1990 s programs were developed in the absence of a policy framework. The national response has matured considerably and there has been time for policy to catch-up with program development. - Policy is increasingly driving program development rather than the other way around. This is partly because approval for policy is needed in sensitive areas such as needle and syringe exchange 6 National AIDS Authority, A Situation and Response Analysis of the HIV/AIDS Epidemic in Cambodia. 2005 Update. p 6. The other two main achievements were targeted interventions and access to treatment. 14