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National Population Size Estimation, HIV Related Risk Behaviors and HIV Prevalence Among People Who Use Drugs in Cambodia in 2012

Authors:
  • National Instittue of Public Health, Cambodia
Implemented by Prepared by
Chhea Chhorvann, MD., MPH., PhD
Heng Sopheab, MD., MPH., PhD
Tuot Sovannary, MA
March 2014
National Population Size Estimation,
HIV Related Risk Behaviors and HIV Prevalence
among People Who Use Drugs in Cambodia in
2012
KINGDOM OF CAMBODIA
Nation Religion King
TABLE OF CONTENTS
Abbreviation ................................................................................................................................ IV
List of Tables ................................................................................................................................ V
List of Figures .............................................................................................................................. VI
Preface ....................................................................................................................................... VII
Acknowledgements ...................................................................................................................... 1
Background .................................................................................................................................. 2
Study objectives ........................................................................................................................... 4
Methodology ................................................................................................................................ 5
Methods for PWUD population size estimation .................................................................... 5
Working denition .......................................................................................................... 5
Introduction to methodologies used for PWUD size estimation .................................... 5
Capture-recapture methodology ............................................................................ 5
Multiplier method .................................................................................................... 6
Existing Reports and Mapping of PWUD ................................................................ 6
Primary data collection ................................................................................................. 7
Field Assessment Stage ......................................................................................... 7
Capture stage ........................................................................................................ 7
Recapture stage ...................................................................................................... 8
Sampling ........................................................................................................................ 8
Study sites .................................................................................................................... 8
Sample size ................................................................................................................... 9
Data collection ............................................................................................................. 10
Recruitment process ............................................................................................. 10
Methodology for assessing related risk behaviors and HIV prevalence ............................. 10
Collection of data on HIV-related risk behaviors ................................................. 10
Collection of blood specimens ............................................................................. 11
Monitoring and supervision .................................................................................. 11
HIV testing and quality control procedures ........................................................... 11
Ethical considerations ......................................................................................................... 11
Findings ...................................................................................................................................... 13
Recruitment of study participants ....................................................................................... 13
Estimation of the size of the PWUD population .................................................................. 15
Capture-Recapture Method ......................................................................................... 15
Multiplier Methods ....................................................................................................... 17
Estimating PWUD population size using KHANA Program Reports ..................... 17
Estimating PWUD population size using the Preap Samorphum Report ............. 19
Estimating PWUD population size using Rehabilitation Reports .......................... 20
Extrapolation of PWUD population size ....................................................................... 21
Limitations of the estimation methods ................................................................................ 22
Triangulation of data on the population of PWUD in Cambodia ......................................... 23
III
TABLE OF CONTENTS
Abbreviation ................................................................................................................................ IV
List of Tables ................................................................................................................................ V
List of Figures .............................................................................................................................. VI
Preface ....................................................................................................................................... VII
Acknowledgements ...................................................................................................................... 1
Background .................................................................................................................................. 2
Study objectives ........................................................................................................................... 4
Methodology ................................................................................................................................ 5
Methods for PWUD population size estimation .................................................................... 5
Working denition .......................................................................................................... 5
Introduction to methodologies used for PWUD size estimation .................................... 5
Capture-recapture methodology ............................................................................ 5
Multiplier method .................................................................................................... 6
Existing Reports and Mapping of PWUD ................................................................ 6
Primary data collection ................................................................................................. 7
Field Assessment Stage ......................................................................................... 7
Capture stage ........................................................................................................ 7
Recapture stage ...................................................................................................... 8
Sampling ........................................................................................................................ 8
Study sites .................................................................................................................... 8
Sample size ................................................................................................................... 9
Data collection ............................................................................................................. 10
Recruitment process ............................................................................................. 10
Methodology for assessing related risk behaviors and HIV prevalence ............................. 10
Collection of data on HIV-related risk behaviors ................................................. 10
Collection of blood specimens ............................................................................. 11
Monitoring and supervision .................................................................................. 11
HIV testing and quality control procedures ........................................................... 11
Ethical considerations ......................................................................................................... 11
Findings ...................................................................................................................................... 13
Recruitment of study participants ....................................................................................... 13
Estimation of the size of the PWUD population .................................................................. 15
Capture-Recapture Method ......................................................................................... 15
Multiplier Methods ....................................................................................................... 17
Estimating PWUD population size using KHANA Program Reports ..................... 17
Estimating PWUD population size using the Preap Samorphum Report ............. 19
Estimating PWUD population size using Rehabilitation Reports .......................... 20
Extrapolation of PWUD population size ....................................................................... 21
Limitations of the estimation methods ................................................................................ 22
Triangulation of data on the population of PWUD in Cambodia ......................................... 23
III
LIST OF TABLES
Table 1: Sample size for PWUD and PWID ................................................................................. 9
Table 2: Actual number of study participants included in the study .........................................13
Table 3: Networks of People Who Use Drugs ...........................................................................13
Table 4: Coupon Distribution ..................................................................................................... 14
Table 5: Calculation of PWUD population in 9 provinces using Capture Recapture method ...15
Table 6: Estimating total number of PWUD based on number of PWUD in 9 provinces ..........16
Table 7: Estimation of the proportion of non-hidden PWUD by province ................................. 18
Table 8: Reported Number of non-hidden PWUD from different reports .................................. 18
Table 9: Estimated PWUD population based on KHANA Program Reports ............................. 19
Table 10: Estimated Number of PWUD across 9 provinces, based on
Preap Samorphum report 2011 ................................................................................. 20
Table 11: Estimated number of PWUD using Preap Samorphum report 2012 .........................20
Table 12: Estimated number of PWUD based on reports from Rehabilitation Centers in
Cambodia ..................................................................................................................21
Table 13: Extrapolation of the total number of PWUD based on estimated PWUD
in Phnom Penh ...........................................................................................................21
Table 14: Extrapolation of total PWUD using PWUD in Banteay Meanchey province .............. 22
Table 15: Estimated number of PWUD in Phnom Penh ............................................................24
Table 16: Estimated number of female PWUD .......................................................................... 24
Table 17: Calculation of the number of PWID in Phnom Penh and other provinces ................. 25
Table 18: Calculation of the number of regular PWID and non-injecting PWID ........................26
Table 19: Calculation of regular PWID and non-injecting PWID in Phnom Penh ......................27
Integrated Bio-Behavior Survey .......................................................................................... 27
Demographic Characteristics ...................................................................................... 27
Rehabilitation and Other Drug-related Services .......................................................... 29
History of Drug Use ...................................................................................................... 30
Patterns of Drug Use ................................................................................................... 30
Drug use behavior among PWID .................................................................................. 32
Mental Health ...................................................................................................................... 35
Sexual behavior among female PWUD ............................................................................... 36
Sexual Behavior among male PWUD .................................................................................. 37
Access to Condoms ............................................................................................................ 39
STI symptoms and Health Seeking Behavior ...................................................................... 39
Sources of HIV/AIDS and Drug use information ................................................................. 40
HIV Prevalence among PWUD ............................................................................................ 41
Conclusions ................................................................................................................................ 43
References ................................................................................................................................. 44
Annex: Questionaire ................................................................................................................... 45
IV
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 20: Demographic Characteristics of PWUD included in the survey ................................ 28
Table 21: Living place and mobility ...........................................................................................28
Table 22: Usage of Drop-in centers and temporary rehabilitation centers ................................ 29
Table 23: Patterns of Drug use .................................................................................................. 30
Table 24: Reported types of illicit drug use & frequency of drug use........................................ 31
Table 25: Characteristics of PWID ............................................................................................. 33
Table 26: Access to Needles and Syringes for PWID ................................................................ 34
Table 27: Mental Health among PWUD ..................................................................................... 35
Table 28: Mental Health of Occasional and Regular Drug users ............................................... 36
Table 29: Sexual Behavior among female PWUD ..................................................................... 36
Table 30: Sexual behaviors among male PWUD .......................................................................37
Table 31: Condom use with not-commercial sexual partners ................................................... 38
Table 32: Access to condoms among PWUD ...........................................................................39
LIST OF FIGURES
Figure 1: Impact of injection status on the recruitment of participants .....................................14
Figure 2: Impact of HIV status on the recruitment of participants ............................................ 15
Figure 3: Proportion of PWUD in 9 provinces compared to total PWUD population ................ 16
Figure 4: Summary of the population size of PWUD, by different estimation methods ............ 23
Figure 5: Estimated number and range of PWUD, by location ................................................ 24
Figure 6: Estimated number of female PWUD in Cambodia ................................................... 25
Figure 7: Estimated number of PWID, by location .................................................................... 25
Figure 8: Estimated number of PWID, by frequency of drug use ..............................................26
Figure 9: Estimation of regular PWID and non-injecting PWUD in Phnom Penh ...................... 27
Figure 10: Proportion of PWUD using different Drug-Related Services ....................................29
Figure 11: History of Drug Use ................................................................................................. 30
Figure 12: Occasional and Regular Drug users .........................................................................32
Figure 13: Sharing needles and syringes among PWID ............................................................ 33
Figure 14: Practices of cleaning needles and syringes ............................................................. 35
Figure 15: Condom use among male PWUD ............................................................................37
Figure 16: Places where male PWUD nd their paid sexual partners ....................................... 38
Figure 17: Reported Symptoms of Sexually Transmitted Infection ........................................... 40
Figure 18: Health seeking behaviors the last time you experienced an STI symptom ............40
Figure 19: Sources of HIV/AIDS and drugs information ........................................................... 41
Figure 21: HIV Prevalence among PWID, by gender .................................................................41
Figure 20: HIV Prevalence among PWUD ................................................................................. 41
Figure 22: HIV Prevalence among non-injecting PWUD, by gender ......................................... 41
Figure 23: HIV Prevalence among PWUD in Phnom Penh and other provinces .......................42
Figure 24: HIV Prevalence, by duration of using drugs ............................................................. 42
Figure 25: HIV Prevalence among PWUD, by age group .......................................................... 42
V
ABBREVIATION
AIDS : Acquired Immunodeciency Syndrome
ART : Antiretroviral Treatment
AusAID : Australian Agency for International Development
ATS : Amphetamine Type Stimulants
DIC : Drop-In Center
FHI 360 : FHI 360
GFATM : Global Fund to Fight AIDS
HIV : Human Immunodeciency Virus
KHANA : KHANA
MARP : Most at Risk Population
MoEYS : Ministry of Education, Youth and Sport
MoSVY : Ministry of Social Affair, Veterans and Youth Rehabilitation
NACD : National Authority for Combating Drugs
NCHADS : National Center for HIV/AIDS Dermatology and STD
NGO : Non-Government Organization
NPMH : National Program for Mental Health
NSP : Needle and Syringe Program
RDS : Respondent Driven Sampling
PSI : Population Service International
PWID : People Who Inject drug
PWUD : People Who Use Drug
STI : Sexual Transmitted Infection
UNICEF : United Nations International Children's Emergency Fund
UNAID : Joint United Nations Team on HIV and AIDS
UNODC : United Nations Ofce on Drugs and Crime
USAID : United States Agency for International
VCCT : Voluntary Condential Counseling and Testing
WHO : World Health Organization
VI
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
GFATM, AusAID/HAARP និងUSAID
VII
1
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
ACKNOWLEDGEMENTS
2
BACKGROUND
Over the past two decades, tremendous progress has been made in the ght against HIV and
AIDS in Cambodia, and the HIV prevalence has fallen by more than half, to a rate of 0.9% in
2006. Among the general population, the estimated prevalence rate among those aged 15 – 49
years old was 0.7% in 20101. However, high HIV prevalence rates are still observed among most
at risk populations (MARP) such as female sex workers (14.7%) (data from 2005) and men who
have sex with men (5.1%) and men who have sex with men and women (2.2% in 2010)2.
Over the past few years, evidence has accumulated that both the number of people who use
drugs (PWUD) and the availability of drugs in Cambodia have been increasing considerably.
Today Cambodia is affected by an emerging drug abuse problem, the main component of which
is amphetamine use. Notable increases in drug use among young people and sex workers,
particularly of methamphetamines and other Amphetamine Type Stimulants (ATS), have been
observed. A MoEYS study of most at risk young people in 2010 found that 3.5% of female and
15% of male respondents (aged between 10-24 years old) reported ever having using drugs3.
PWUD, and particularly people who inject drugs (PWID), share syringes and needles with multiple
partners, or have unprotected sex, contribute signicantly to a higher HIV prevalence in Cambodia
and are at higher risk of contracting hepatitis B and hepatitis C. Non-injecting drug users are at
higher risk of experiencing health problems more generally, and of becoming injecting drug users
in the future. A study among drug users in 4 cities/provinces (Phnom Penh, Siem Reap,
Battambang and Banteay Meanchey) in 2007 found that overall HIV prevalence among PWID
was 24.4% and 1.1% among non-injecting PWUD4. These groups should therefore be a high
priority for the national HIV prevention and control program.
However, data on the drug user population size varies as different data collection methods have
been used in previous efforts to quantify this. For example, an annual report compiled by NACD,
there were 5,797 PWUD in 20075 and 6,500 PWUD in 2008 in the whole of the country. However,
a population size estimate carried out by NCHADS in 2007 using the multiplier method found
that there were between 9,000 and 20,000 PWUD in Cambodia, of whom about 2,000 were
PWID6. An estimate by UNAIDS using the Delphi method suggested that there were about 46,300
illicit drug users in Cambodia, of whom 23,150 (50%) were using ATS and some 2,900 (6.3%)
were using heroin, including 2,025 who injected drugs (range: 1,250-7,500) (ibid). In addition to
these challenges, the denition of ‘drug user’ in Cambodia has until now not been clearly dened.
Given the dynamic and growing pattern of drug use in Cambodia, and the current inconclusive
data on the population size of PWID/PWUD, a consistent and scientic approach was needed to
gather up-to-date data to inform the national HIV response. Although it is understood that each
method used for size estimation has its limitations, establishing a joint effort and approach is
critically important for better advocacy, resource mobilization, program planning, management
of effective targeted health programming and better HIV projections. A joint study to estimate the
size of the drug user population is therefore an essential component of Cambodia’s national HIV
response, allowing a better understanding of the knowledge, attitudes and practices as well as
the risk behaviors and HIV prevalence of PWUD and PWID.
Overall objective: to estimate the national drug user population size, including injecting drug users,
1 NCHADS: Report of a consensus workshop: HIV estimates and projection for Cambodia 2006- 2012. Phnom Penh: Ministry of Health; 2007.
2 Bros Khmer 2010: Behavioral Risks On-Site Serosurvey among At Risk Urban Men in Cambodia.
3 Ministry of Education Youth and Sport, 2010, Most At Risk Young People Survey Cambodia 2010.
4 Chhea C, Seguy N: HIV prevalence among drug users in Cambodia 2007. NCHADS & NACD; 2010.
5 Report on illicit Drug Data and Routine Surveillance Systems in Cambodia 2006.
6 Ibid
3
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
and the HIV prevalence in this population in Cambodia.
Specic objectives:
1. To estimate the size of the PWUD population and to disaggregate
by type of drug use, sex and age (i.e. including non-injecting PWUD
and PWID, regular and occasional users).
2. To estimate the prevalence of HIV infection across different groups
of drug users (PWID and non-injecting PWUD).
3. To investigate knowledge, attitudes and practices of drug users
regarding drug use behaviors, HIV infection, STI treatment,
Voluntary Counseling and Testing and use of other health services.
4. To make recommendations for relevant stakeholders to contribute
to better program design, program planning, resource allocation
and advocacy.
STUDY OBJECTIVES
4
METHODOLOGY
The study combined primary and secondary data collection, and detailed descriptions of the
methodology used are outlined below. Please note that the methods used for the PWUD population
estimation are nested within the main study, which was originally designed as a study of HIV
prevalence and related risk behaviors.
METHODS FOR PWUD POPULATION SIZE ESTIMATION
Working denition
The denition of a ‘drug user’ varies between countries, and until now there has been no clear and
widely accepted denition used in Cambodia. The proposed working denition outlined below was
agreed through discussions at the rst consultative meeting on the methodology of the population
size estimation, chaired by NACD.
Proposed working denition for People Who Use Drugs (PWUD)
A person who has used illicit drugs, as dened by the Cambodian Drug Control Law, by any route
of administration in the past 12 months;
An occasional PWUD refers to a person who has used drugs twice per week or less in the past
month (Neak rongka paspol);
A regular PWUD refers to a person who has used drugs more than twice per week in the past
month (Neak krom itthipol).
Proposwed working denition for People Who Inject Drugs (PWID)
A person who has injected illicit drugs, as dened by the Cambodian Drug Control Law, in the
past 12 months;
An occasional PWID refers to a person who has injected drugs twice per week or less in the past
month;
A regular PWID is dened as a person who has injected drugs more than twice per week in
the past month. Please note that drug users who both inject drugs and use other routes of
administration will be classied as regular PWID if they have used drugs (not necessarily by
injecting) more than 3 times in the past week.
Introduction to methodologies used for PWUD size estimation
The types of methodology used to develop an estimation of the population size of PWUD included
capture-recapture, multiplier methods, and the review of existing reports and mapping for use in the
extrapolation of PWUD population size data. The estimates derived from these different methods were
then triangulated to generate one gure that best represents the total PWUD population in Cambodia.
5
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Capture-recapture methodology
This requires primary data collection which is described in more detail in the section below. Specically,
capture and recapture methodology requires the steps outlined below:
Mapping of the sites where PWUD/PWID can be found;
Visiting these sites and ‘tagging’ all or some specied number of the population at the site
(through giving them a card, a token, or a memorable gift);
Counting the number of persons tagged;
Returning to the sites 3-4 weeks later and carrying out the same exercise;
In the second visit, counting:
PWUD/PWID who were counted in the rst sample (conrmed by the fact they received a tag
from the research team)
New PWUD/PWID who are being counted for the rst time in the second sample (i.e. were not
met in the rst round).
Multiplier method
The multiplier method, which is based on the use of existing benchmarks, was also used to estimate
the size of the PWUD/PWID population in Cambodia. Generally, this method requires two gures:
a benchmark and its corresponding multiplier, and it is therefore highly dependent on the quality of
existing data7. The benchmark being used needs to be carefully reviewed before it can be used to
produce the estimate. The main sources of data in the multiplier method should be program data
focusing on the population whose size is being estimated, for example the number of PWUD/PWID
visiting drop-in centers or participating in needle and syringe programs (NSP).
Existing Reports and Mapping of PWUD
The research team made use of the existing data collection system developed by NACD in the Drug
Use Competitive Plan (Preap Samorphoum) program to contribute to an estimated gure for the
PWUD population in Cambodia. Another source of data was mapping exercises on the number of
PWUD in selected provinces, performed by NGOs working in the community and coordinated by
NCHADS. Existing grassroots-level NGOs assisted the team in the mapping exercise by identifying
places where PWUD in their communities gather, or hotspots where PWUD could be seen in public.
This mapping exercise happened on the same date in all locations in all selected provinces. The
results from these mapping exercises were used as the sampling frame for data collection in the
capture-recapture method.
7 UNAIDS: Guidelines on estimating the size of the populations most at risk to HIV; UNAIDS/WHO working group on global HIV/AIDS and STI
surveillance. 2010
6
Primary data collection
A cross-sectional survey was conducted among drug users, with the aim of collecting information for
both the PWUD/PWID population size estimation as well as data/information on HIV risk behaviors
and HIV prevalence among these populations (see later sections for more detail on the behavioral/
prevalence components). The primary data collection comprised three stages: a eld assessment, a
capture stage and a recapture stage. These are outlined below.
Field Assessment Stage
Two eld assessments were conducted before the capture-recapture stage began: a feasibility
assessment and a eldwork assessment.
Results from the feasibility assessment conducted in September 2011 in Phnom Penh, Banteay
Meanchey and Svay Rieng showed that implementation of a drug user survey would be feasible.
There had been concerns that the village and commune safety policy might affect implementation of
the survey, which requires intensive involvement of PWUD. However, meetings with law enforcement
ofcials, police and the local authority gave the team the ‘green light’ for this survey to take place.
A eldwork assessment was also carried out prior to the survey, with the following objectives: 1)
to create a sampling frame for the PWUD survey; 2) to count the number of PWUD in the selected
provinces; and 3) to identify potential locations and seeds for the Respondent Driven Sampling (RDS)
method (see sampling section below).
The eldwork assessment was conducted across all nine selected study provinces. Data
collection was divided into 2 phases:
First, exhaustive mapping was performed by local NGOs, existing PWUD networks and
communities under KHANA and FHI 360, in collaboration with NACD to establish the sampling
frames. In each city/province, the local teams mapped and counted the number of PWUD present
at each survey site using a time-location approach (counting the number of PWUD present in a
specic location at a specic time).
The second phase of the eldwork assessment was undertaken by data collectors from the
central level (e.g. NCHADS, KHANA and FHI 360). These teams visited each pre-identied site to
count the number of drug users in each location.
Capture stage
The main objectives of this component of the survey were:
To collect information on multipliers to be used in the multiplier method
To tag study participants
To collect information on different types of drug users
To collect information on drug use as well as HIV related risk behaviors for the HIV behavior
component of the survey
To collect blood specimens for HIV testing for the HIV prevalence component of the survey.
7
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Sample groups of PWUD were recruited at each site using the RDS method, a network referral
process (see sampling section below for details on RDS methodology). After receiving consent, the
research team interviewed and ‘tagged’ study participants and asked for a blood sample. All study
participants were ‘tagged’ by giving them a token which would help the participant to remember their
meeting with the research team. A set of questionnaires were then used to interview participants in
order to collect information on multipliers and related risk behaviors (thereby also contributing to the
HIV related behavior component of the study).
Recapture stage
This stage was conducted 3-4 weeks after the capture stage. The research team used the same
recruitment method, RDS, to recruit PWUD from the same geographic locations. At this stage
participants were asked whether they had previously been interviewed and tagged in the rst
(capture) stage.
Sampling
Respondent Driven Sampling (RDS), a network referral process, was used in this survey to ensure
that researchers could reach a representative sample of hard-to-reach populations. In order to
represent the PWUD population in the selected provinces, four ‘seeds’ were selected for each
province. Seeds were selected based on a matrix of two variables: gender (male/female) and type
of drug use (injecting/non-injecting). Seeds were determined during the mapping exercise with
inputs from the local NGOs. The details of the recruitment process for the seeds is described in the
‘Recruitment Process’ section below. Each seed was asked to recruit two study participants, and
the research aimed to have at least 4 or 5 waves of recruitment. Consequently, each province would
have a sample of at least 170 drug users (250 for Phnom Penh).
Another round of data collection using RDS was implemented at the re-capture stage, during which
all study participants were asked whether they had received a token in the past month or had
participated in research on drug use. The total size of the drug user population for the whole country
was estimated based on the sum of the number of PWUD in each province using the capture-
recapture technique.
Study sites
At the rst consultative meeting and launch of the PWUD population estimation exercise, 13
provinces were proposed for inclusion in the study. However, due to feasibility issues and limited
nancial resources, the data collection was conducted in just 9 provinces. The selection of these
provinces was based on the assumptions that they have the largest populations of PWUD and
the highest level of drug use activities. According to the monitoring report of the HIV and drug use
program at KHANA, the numbers of PWUD in these 9 provinces could represent an estimated 85%
of the national PWUD population.
8
The nine cities/provinces selected for the HIV related behaviors and prevalence component
of the study were:
1. Phnom Penh (PNP)
2. Battambang (BTB)
3. Banteay Meanchey (BMC)
4. Kampong Cham (KCM)
5. Kampong Speu (KSP)
6. Siem Reap (SRP)
7. Svay Rieng (SVG)
8. Prey Veng (PVG)
9. Sihanouk Ville (SHV)
Sample size
A 6.5-9% margin of error8 and 95% condence interval were taken into account when estimating
the required sample size for each province/city. Various indicators were used for the calculation,
for example the proportion of drug users sharing needles and syringes in the past year (13%)9,
consistent condom use among drug users with paid sexual partners (70%), those tested for HIV
at VCCT centers in the past year (45%)10, the HIV prevalence among PWUD in 2007 (24.4%) and
the HIV prevalence among PWID in 2007 (1.1%). The sample sizes were calculated using Open Epi
software.
The design effect for this sample size calculation was 1.5, based on the assumption of a PWUD
population in each province of 5,000 and 30,000 in Phnom Penh, and a PWID population in each
province of 500 and 3,000 in Phnom Penh.
Table 1: Sample size for PWUD and PWID
Expected
%
Precision
%
Type of
drug use
Sample
needed in
province
Sample
needed in
Phnom Penh
Sharing syringes and needles 13 6.5 PWID 152 154
Always used condom past year 70 8.5 PWUD 164 167
Access to information through
NGO 35 9 PWUD 158 162
VCCT test in the past year 44 9 PWUD 170 175
HIV prevalence among PWUD 25 7 PWID 170 243
Total sample size per site 170 250
8 The margin of error was calculated according to the inclusion criteria of HIV prevalence, HIV test and condom use, and varies according to province/
city.
9 Sopheab H, Chhea C, Tuot S: Baseline survey on HIV/AIDS knowledge, attitudes, practices and related risk behaviors among MARP. Phnom Penh,
Cambodia: KHANA; 2010.
10 Chhea C, Seguy N: HIV prevalence among drug users in Cambodia 2007. NCHADS & NACD; 2010.
9
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Based on the above sample size estimation, 170 PWUD needed to be recruited from each province
and 250 PWUD from Phnom Penh. The total sample size for the entire study would therefore be
1,610.
Data collection
Potential participants in this study are PWUD who reported using any illicit drug through any mode
of administration in the past year.
To be eligible for the survey, participants:
Must be at least 15 years of age
Must have a valid study coupon
Must not have participated in this survey in another site
Must meet criteria according to the denition of a drug user
Must know at least 3 other active drug users
Must be able to speak Khmer and have enough conscience for oral communication.
Recruitment process
The recruitment centers used for the survey were selected locally as sites which are known to and
easily accessible for PWUD. The study sites needed to be able to provide a private space to ensure
participants’ condentiality and to limit distractions. They also needed to be spacious enough so that
blood specimens could be collected and stored, and so that completed questionnaires could be
stored out of the sight of other participants and non-survey staff members.
Study participants received an incentive for participating in the survey (primary incentive) and another
incentive (secondary incentive) for recruiting their peers into the study. The primary incentive was a
gift worth $1 for completing the questionnaire and giving about 5ml of blood. The secondary incentive
was a gift worth another $1 for successfully recruiting one participant into the study.
METHODOLOGY FOR ASSESSING RELATED RISK
BEHAVIORS AND HIV PREVALENCE
A cross-sectional survey identifying HIV risk behaviors and collection of biological specimens was
incorporated into the primary data collection methods as described above, thereby combining the
size estimation and risk behavior/HIV prevalence components of the study into one piece of research.
Collection of data on HIV-related risk behaviors
A questionnaire was used to collect multipliers and risk behaviors relating to drug use and HIV. A
face-to-face, gender-matched interview was performed with each participant by trained interviewers
in a private setting. The questionnaire was developed based on the HIV prevalence survey among
11 Chhea C, Seguy N: HIV prevalence among drug users in Cambodia 2007. NCHADS & NACD; 2010.
10
Anonymity was ensured as personal identiers were not recorded; condentiality was guaranteed by
ensuring that no unauthorized person had access to the information given by study participants. The
survey protocol was reviewed and approved by the National Ethics Committee for Health Research
prior to the start of data collection.
12
drug users in Cambodia (2007)11, and was designed not to take longer than 20 minutes.
Collection of blood specimens
When study participants had given their consent to providing a blood sample, they were asked
whether they wanted their blood to be drawn before or after the interview. After drawing blood, the
anonymous specimen was kept in a tube with an anti-coagulant substance to prevent the blood
from clotting. At the end of each day, the blood samples were sent to a lab at a selected VCCT site
near the study recruitment center. At the VCCT, an HIV test was performed and sera were sent to the
NCHADS laboratory for quality control and storage. The testing algorithm for the HIV testing and
quality control was exactly the same as the one used in the national HIV Sentinel Surveillance (HSS)
conducted by NCHADS.
Monitoring and supervision
Interviewers and supervisors were staff from NACD, NCHADS and KHANA who have experience of
working with drug users. Interviewers had been trained on the recruitment process, informed consent
procedures and questionnaire administration. Supervisors were responsible for ensuring that
sampling had been performed according to the protocol and that the questionnaires were
appropriately lled.
HIV testing and quality control procedures
HIV testing was performed using two rapid tests. Firstly, all blood samples were tested with HIV
Determine. Specimens found to be positive in the rst test were retested using Stat Pak. This serial
testing algorithm has been used by NCHADS for all sentinel groups that have an HIV prevalence
greater than 10%.
All HIV positive specimens and 10% of all negative specimens were randomly selected for the HIV
test quality control, performed by the NCHADS laboratory. The quality control process uses a series
testing based on two Elisa tests (Vironostika and Murex). Vironostika was used rst, and if the result
was non-reactive, the test was considered HIV negative. However, if the blood specimen was reactive
with Vironostika, a second test would be carried out using Murex. The nal result in this case would
therefore depend on the result of the second test.
ETHICAL CONSIDERATIONS
Risks to participants through taking part in this study were low. Participation was voluntary,
anonymous and based on oral informed consent (the consent was oral to prevent any possible link
between identier information, the blood specimen and the behavioral data of the study participant).
Study participants could refuse to participate in any part of the data collection or to be excluded from
the whole study with no repercussions. Condentiality and anonymity were strictly ensured. The
opportunities for study participants being arrested or harassed by police were minimized through
close collaboration with NACD during the data collection period.
11
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Anonymity was ensured as personal identiers were not recorded; condentiality was guaranteed by
ensuring that no unauthorized person had access to the information given by study participants. The
survey protocol was reviewed and approved by the National Ethics Committee for Health Research
prior to the start of data collection.
12
Table 4: Coupon Distribution
Variables PWID Non-injecting
PWUD Total
n=119 % n=1,507 %
n=1,626
%
Person to be given study coupon
Friend 111 95.7 1,346 91.1 1,457 91.4
Wife/husband 2 1.7 9 0.6 11 0.7
Relative 4 3.5 43 2.9 47 3
Other 3 2.6 88 6 91 5.7
Participant received study coupon from:
Friend 101 86.3 1,274 85.2 1,375 85.2
Seed 9 7.7 103 6.9 112 6.9
Boyfriend/spouse 1 0.9 0 0 1 0.06
Relative 2 1.7 51 3.4 53 3.3
Other 4 3.4 68 4.6 72 4.5
As table 4 (above) shows, most study participants were planning to give the recruitment coupons to
their friends (91.4%), and in total 85.2% of all study participants were in fact referred by their friends.
Figure 1 shows that among the
study participants referred to
the study by PWID recruiters,
32% were PWID, while non-
injecting PWUD recruiters
mostly recruited participants
who did not inject drugs
(95%). Again, this indicates
low levels of mixing of non-
injecting PWUD with PWID.
The gure 2 shows the
distribution by HIV status of
study participants disaggre-
gated by group of recruiter.
Among study participants recruited by HIV positive male recruiters, 9% were HIV positive females,
2% were HIV positive males and 89% were HIV negative. In contrast, just 1% of participants recruited
by HIV negative males were HIV positive females. Unsurprisingly, female recruiters (both HIV positive
and negative) were far more likely to recruit female participants than were male recruiters.
100
32.1
67.9
95.1
4.9
90
80
70
60
50
30
20
10
0
40
%
PWID recruiter Non-injecting PWUD recruiter
PWID recruit Non-injecting PWUD recruit
Figure 1: Impact of injection status on the
recruitment of participants
14
FINDINGS
RECRUITMENT OF STUDY PARTICIPANTS
In each province, four seeds (2 men and 2 women) were selected at the start of data collection to
start the process of identication of study participants. As result, a total of 1,626 peer-recruited
PWUD were interviewed (290 female) across 9 selected cities/provinces.
Table 2: Actual number of study participants included in the study
Provinces PNP BTB BMC KCM KSP SRP SVG PVG SHV Total
Male 190 100 119 154 158 151 163 156 145 1,336
Female 66 71 53 16 12 21 12 14 25 290
Total 256 171 172 170 170 172 175 170 170 1,626
On average, each PWUD knew 28 other drug users. However, each PWID knew approximately 45
other drug users, among whom an average of 22 were also PWID. Interestingly, each non-injecting
drug user knew an average of just 1 injecting drug user, suggesting low interaction between injecting
and non-injecting groups.
Table 3: Networks of People Who Use Drugs
Variables
PWID Non-injecting PWUD Total
n=119 n=1,507 N=1,626
Mean number of PWUD known by each
participant (median) 45 (30) 27 (10) 28.5 (10)
Mean number of PWID known by each
participant (median) 22 (10) 1 (0) 2.8 (0)
Mean number of PWUD met by each
participant in the past month (median) 27 (10) 11 (5) 12 (5)
Mean number of PWID met by each
participant in the past month (median) 12 (6) 1 (0) 1.6 (0)
13
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 4: Coupon Distribution
Variables PWID Non-injecting
PWUD Total
n=119 % n=1,507 %
n=1,626
%
Person to be given study coupon
Friend 111 95.7 1,346 91.1 1,457 91.4
Wife/husband 2 1.7 9 0.6 11 0.7
Relative 4 3.5 43 2.9 47 3
Other 3 2.6 88 6 91 5.7
Participant received study coupon from:
Friend 101 86.3 1,274 85.2 1,375 85.2
Seed 9 7.7 103 6.9 112 6.9
Boyfriend/spouse 1 0.9 0 0 1 0.06
Relative 2 1.7 51 3.4 53 3.3
Other 4 3.4 68 4.6 72 4.5
As table 4 (above) shows, most study participants were planning to give the recruitment coupons to
their friends (91.4%), and in total 85.2% of all study participants were in fact referred by their friends.
Figure 1 shows that among the
study participants referred to
the study by PWID recruiters,
32% were PWID, while non-
injecting PWUD recruiters
mostly recruited participants
who did not inject drugs
(95%). Again, this indicates
low levels of mixing of non-
injecting PWUD with PWID.
The gure 2 shows the
distribution by HIV status of
study participants disaggre-
gated by group of recruiter.
Among study participants recruited by HIV positive male recruiters, 9% were HIV positive females,
2% were HIV positive males and 89% were HIV negative. In contrast, just 1% of participants recruited
by HIV negative males were HIV positive females. Unsurprisingly, female recruiters (both HIV positive
and negative) were far more likely to recruit female participants than were male recruiters.
100
32.1
67.9
95.1
4.9
90
80
70
60
50
30
20
10
0
40
%
PWID recruiter Non-injecting PWUD recruiter
PWID recruit Non-injecting PWUD recruit
Figure 1: Impact of injection status on the
recruitment of participants
14
SRP 172 135 21 0.1555556 1,106
SVG 175 119 32 0.2689076 651
PVG 170 133 43 0.3233083 526
SHV 170 129 46 0.3565891 477
Total 1,626 1,248 314 0.2516026 9,221
As previously stated, it is believed that the
estimated number of PWUD in these 9
provinces could represent a large
proportion of the whole PWUD population
in Cambodia. However, the remaining
portion needs to be investigated more
carefully if we want to ensure an accurate
national estimate (figure 3).
It was therefore informative to use data
from the Preap Samorphum report
2011/2012 to estimate to what extent the
proportion of PWUD in these 9 selected
study provinces represents the PWUD
population as a whole. Using this approach, it was found that on average the number of PWUD in
these 9 provinces could only represent 75% of the total number of PWUD in the whole country.
Table 6: Estimating total number of PWUD based on number of PWUD in 9
provinces
Parameters Values
Proportion of PWUD from 9 provinces contributing to the total PWUD in
Cambodia 75%
Average number of PWUD in 9 provinces 9,221
High Estimate* 9,777
Low Estimate* 8,666
Average number of PWUD in the whole country 12,296
High Estimate 13,037
Low Estimate 11,555
Note: * The low and high estimates were calculated using 95% CI formula from the Capture-Recapture method
(Guidelines on Estimating the Size of Populations Most at Risk to HIV).
Number of PWUD in 9 provinces
From Capture-Recapture = 9,221
Total PWUD in Cambodia
(24 cities/provinces)
Figure 3: Proportion of PWUD in 9 provinces
compared to total PWUD population
16
Figure 2: Impact of HIV status on the recruitment of participants
100
90
80
70
60
50
40
30
20
10
0
66
9
2
23
77
52
35
31
88
9
2
8
48
42
HIV+ male recruiter HIV+ female recruiter HIV- male recruiter HIV- female recruiter
HIV+ male HIV- maleHIV+ female HIV- female
%
ESTIMATION OF THE SIZE OF THE PWUD POPULATION
Capture-Recapture Method
A total of 1,626 PWUD were ‘tagged’ at the capture stage. At the recapture stage, 314 of the
previously tagged PWUD were recaptured. The calculation of the number of PWUD in each province
was the product of the number of PWUD met in the capture stage divided by the % of tagged PWUD
who were re-contacted at the recapture stage. By applying this formula to all provinces, the estimated
size of the PWUD population across 9 provinces could be 9,221.
Table 5: Calculation of PWUD population in 9 provinces using Capture Recapture
method
Province/organization
No.
reached
at capture
stage
No.
reached at
recapture
stage
Number
of tagged
PWUD
% tagged
Est. PWUD
population
(used drugs in
the past year)
Friends International (PNP) 86 68 2 0.0294118 2,924
Korsang (PNP) 85 65 24 0.3692308 230
KHANA (PNP) 85 62 24 0.3870968 220
BTB 171 130 23 0.1769231 967
BMC 172 143 37 0.2587413 665
KCM 170 127 33 0.2598425 654
KSP 170 137 29 0.2116788 803
15
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
SRP 172 135 21 0.1555556 1,106
SVG 175 119 32 0.2689076 651
PVG 170 133 43 0.3233083 526
SHV 170 129 46 0.3565891 477
Total 1,626 1,248 314 0.2516026 9,221
As previously stated, it is believed that the
estimated number of PWUD in these 9
provinces could represent a large
proportion of the whole PWUD population
in Cambodia. However, the remaining
portion needs to be investigated more
carefully if we want to ensure an accurate
national estimate (figure 3).
It was therefore informative to use data
from the Preap Samorphum report
2011/2012 to estimate to what extent the
proportion of PWUD in these 9 selected
study provinces represents the PWUD
population as a whole. Using this approach, it was found that on average the number of PWUD in
these 9 provinces could only represent 75% of the total number of PWUD in the whole country.
Table 6: Estimating total number of PWUD based on number of PWUD in 9
provinces
Parameters Values
Proportion of PWUD from 9 provinces contributing to the total PWUD in
Cambodia 75%
Average number of PWUD in 9 provinces 9,221
High Estimate* 9,777
Low Estimate* 8,666
Average number of PWUD in the whole country 12,296
High Estimate 13,037
Low Estimate 11,555
Note: * The low and high estimates were calculated using 95% CI formula from the Capture-Recapture method
(Guidelines on Estimating the Size of Populations Most at Risk to HIV).
Number of PWUD in 9 provinces
From Capture-Recapture = 9,221
Total PWUD in Cambodia
(24 cities/provinces)
Figure 3: Proportion of PWUD in 9 provinces
compared to total PWUD population
16
Based on the above calculation, the estimated total number of PWUD in Cambodia in 2012 could be 12,296,
with a range of 11,555 to 13,037.
These gures are based on the following assumptions:
PWUD in each province had an equal chance of being enrolled into the study.
The data collection during the capture stage was independent from the data collection during the recapture
stage.
The number of new PWUD arriving in an area, number of PWUD who died or quit using drugs and the
number of PWUD migrating between provinces was negligible and there was no duplication of numbers of
tagged PWUD found in the recapture period. This assumption was made based on a duration of 3-4 weeks
between the capture and the recapture stages of the study.
Multiplier Methods
Multiplier methods were used in addition to the capture-recapture method to estimate PWUD population size.
The main purpose of applying these additional methods was to investigate the consistency and accuracy of
the estimate derived from solely using the capture-recapture method. Consistency is however not always an
indication of a valid estimate, and using an additional method allows us to explore possible variations of the
number of PWUD in Cambodia.
In general, the multiplier method requires one benchmark and its correspondent multiplier. The estimation of
PWUD in Cambodia carried out in 2012 was performed using three sets of benchmarks and multipliers.
Estimating PWUD population size using KHANA Program Reports
PWUD can be classied into two groups: hidden and non-hidden. PWUD who have been reached through the
mapping exercise or have been reached by any health programs/interventions are likely to be those who do not
want to completely hide their drug use status, and this group is often known as ‘non-hidden’. In other words,
non-hidden PWUD are those who can be seen or contacted, while hidden PWUD are out of reach of any health
programs/interventions and are generally out of sight.
An estimation of the total number of PWUD in Cambodia could be done based on the total number of PWUD
reached by intervention programs (the non-hidden group) and the proportion of this non-hidden population
as part of the PWUD population as a whole. Data on the number of PWUD reached by KHANA in 2011 and
2012 was readily available, however the proportion of non-hidden PWUD out of the total PWUD population can
only be estimated. This was calculated by comparing the number of PWUD met during the mapping in 2012
(the non-hidden PWUD) with the number of PWUD estimated through the capture-recapture method in each
selected province, with the exception of Banteay Meanchey province. In Banteay Meanchey province (Table 7),
the number of PWUD estimated through the capture-recapture method was less than the number of PWUD
identied in the mapping exercise, as the latter was based entirely on the provincial ofcial gures collected by
the provincial health department and police.
The estimated proportion of the non-hidden population of PWUD across 9 provinces ranged from 14.6% to
73.4%. The median of the proportion of non-hidden PWUD was 35.6% (IQR: 28.8%, 60%).
17
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 7: Estimation of the proportion of non-hidden PWUD by province
Province Est. PWUD Population
(capture-recapture)
Data from Mapping
2012 (non-hidden) % non-hidden PWUD
PNP 3,374 2,026 0.601
BTB 967 709 0.734
BMC 665 1,762 2.650
KCM 654 328 0.501
KSP 803 231 0.288
SRP 1,106 206 0.186
SVG 651 95 0.146
PVG 526 187 0.356
SHV 477 154 0.323
Total 9,222 5,698
The proportion of non-hidden PWUD out of the PWUD population as a whole was also estimated
using Delphi Methodology. This was conducted under the coordination and facilitation of KHANA
and with the participation of fieldwork experts working in 9 provinces to get their views about the
percentage of hidden PWUD in Cambodia. The median of the expert responses was selected to
represent the percentage of non-hidden PWUD in Cambodia, which was 60% (IQR: 45%, 72%).
The percentage mean of non-hidden PWUD as a proportion of the whole PWUD population, derived
from the two methods outlined above, was 47.8% (ranging from 36.9% to 66.3%). This multiplier
was used to estimate the total number of PWUD in 9 provinces, based on the number of PWUD
reached by KHANA in 2011 and 2012 (see Table 8).
Table 8: Reported Number of non-hidden PWUD from different reports
Province Data from Mapping
2012 (non hidden)
KHANA report 2011 KHANA report 2012
PNP 2,026 2,507 1,894
BTB 709 347 498
BMC 1,762 467 450
KCM 328 201 151
KSP 231 253 253
SRP 206 741 569
SVG 95 205 200
PVG 187 198 198
SHV 154 131 131
Total 5,698 5,050 4,344
18
Table 10: Estimated Number of PWUD across 9 provinces, based on Preap
Samorphum report 2011
Provinces Reported number of
PWUD by province
% ever listed as
PWUD by Police (from
survey component)*
Est. PWUD
by province
PNP 413 0.2824 1,462
BTB 386 0.1796 2,149
BMC 1,330 0.1813 (1,713)
KCM 228 0.1353 1,685
KSP 129 0.213 606
SRP 61 0.1221 500
SVG 10 0.2312 43
PVG 69 0.0941 733
SHV 50 0.2647 189
Total PWUD in 9 provinces 9,080
Note: * This gure was taken from the 2012 survey of drug users
Based on the number of 9,080 PWUD in 9 provinces captured from the Preap Samorphum program
in 2011 (Table 9), the total estimate of PWUD across the country could be 12,108. If we use the
number of PWUD reported under the Preap Samorphum program in 2012, this corresponds to an
estimated total of PWUD in Cambodia of about 13,051 (table 11 below).
Table 11: Estimated number of PWUD using Preap Samorphum report 2012
Provinces Reported number of
PWUD by province
% ever listed as
PWUD by Police*
Est. PWUD per
province
PNP 393 0.2824 1,391
BTB 366 0.1796 2,037
BMC 1,713 0.1813 (1,713)
KCM 277 0.1353 2,047
KSP 136 0.213 638
SRP 61 0.1221 499
SVG 29 0.2312 125
PVG 101 0.0941 1,073
SHV 69 0.2647 260
Total PWUD in 9
provinces
4,313 9,787
Estimated PWUD in 24 provinces 13,051
Note: * This gure was taken from 2012 drug user survey
Estimating PWUD population size using Rehabilitation Reports
Data from all temporary rehabilitation centers across Cambodia (15 centers in total) was also used
in this PWUD population size estimation. The benchmark and multipliers used were the number of
PWUD in all rehabilitation centers, and the percentage of PWUD who had been sent to rehabilitation
in the past year, respectively (the multiplier was based on data from the 2012 drug use survey). The
details of the calculation are presented in the table below.
20
The KHANA reports show that the number of PWUD reached by KHANA programs in the 9 selected provinces in
2011 and 2102 was 5,050 and 4,344 respectively. These gures were then divided by the estimated proportion
of non-hidden PWUD (47.8%) to get the total number of PWUD in the 9 study provinces; and then divided
by 75% (the proportion of PWUD in the 9 provinces out of the total national population of PWUD) to get the
estimated total number of PWUD in the country.
Table 9: Estimated PWUD population based on KHANA Program Reports
Program Reports Est. PWUD by
KHANA Report
Estimated number of PWUD in 9 provinces, based
on KHANA data 2011
Average 10,569
High Estimate 13,693
Low Estimate 7,623
Estimated total number of PWUD nationally based on
KHANA 2011 report
Average 13,714
High Estimate 17,767
Low Estimate 9,891
Estimated number of PWUD in 9 provinces, based on
KHANA data 2012
Average 9,092
High Estimate 11,779
Low Estimate 6,557
Estimated total number of PWUD nationally based on
KHANA 2012 report
Average 12,123
High Estimate 15,706
Low Estimate 8,743
The total estimated number of PWUD in Cambodia, based on KHANA reports from 2011 and 2012, was
therefore 13,714 and 12,123 respectively. These gures are similar to the estimates calculated using the
capture-recapture method.
Estimating PWUD population size using the Preap Samorphum Report
Preap Samorphum is a program that has been implemented by the Ministry of the Interior since 2006. The aim
of the program is to monitor and control drug use in each administrative village, commune, district and province.
Police usually have the role of monitoring drug use activities in their communities, and consequently have the
duty under this program to register all PWUD who reside in their communities.
Based on informal communication with police ofcers working in the Preap Samorphum program, only PWUD
who have been recognized by the head of the village or village police are recorded in the annual report sent to
the Ministry of Interior. The number of PWUD stated in the Preap Samorphum reports is therefore believed to be
lower than the actual number of PWUD living in communities.
However, in Banteay Meanchey province, the total number of PWUD reported by the Preap Samorphum
program was entirely based on the consensus between police working in the program and in other provincial
institutions (health departments and NGOs) that also work with drug users in the province. Its data could
therefore not be compared to the data generated by other provinces.
19
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 10: Estimated Number of PWUD across 9 provinces, based on Preap
Samorphum report 2011
Provinces Reported number of
PWUD by province
% ever listed as
PWUD by Police (from
survey component)*
Est. PWUD
by province
PNP 413 0.2824 1,462
BTB 386 0.1796 2,149
BMC 1,330 0.1813 (1,713)
KCM 228 0.1353 1,685
KSP 129 0.213 606
SRP 61 0.1221 500
SVG 10 0.2312 43
PVG 69 0.0941 733
SHV 50 0.2647 189
Total PWUD in 9 provinces 9,080
Note: * This gure was taken from the 2012 survey of drug users
Based on the number of 9,080 PWUD in 9 provinces captured from the Preap Samorphum program
in 2011 (Table 9), the total estimate of PWUD across the country could be 12,108. If we use the
number of PWUD reported under the Preap Samorphum program in 2012, this corresponds to an
estimated total of PWUD in Cambodia of about 13,051 (table 11 below).
Table 11: Estimated number of PWUD using Preap Samorphum report 2012
Provinces Reported number of
PWUD by province
% ever listed as
PWUD by Police*
Est. PWUD per
province
PNP 393 0.2824 1,391
BTB 366 0.1796 2,037
BMC 1,713 0.1813 (1,713)
KCM 277 0.1353 2,047
KSP 136 0.213 638
SRP 61 0.1221 499
SVG 29 0.2312 125
PVG 101 0.0941 1,073
SHV 69 0.2647 260
Total PWUD in 9
provinces
4,313 9,787
Estimated PWUD in 24 provinces 13,051
Note: * This gure was taken from 2012 drug user survey
Estimating PWUD population size using Rehabilitation Reports
Data from all temporary rehabilitation centers across Cambodia (15 centers in total) was also used
in this PWUD population size estimation. The benchmark and multipliers used were the number of
PWUD in all rehabilitation centers, and the percentage of PWUD who had been sent to rehabilitation
in the past year, respectively (the multiplier was based on data from the 2012 drug use survey). The
details of the calculation are presented in the table below.
20
Table 12: Estimated number of PWUD based on reports from Rehabilitation
Centers in Cambodia
2010 2011 2012
Total number of PWUD in rehab centers 2,786 2,246 4,796
Adjust for duplication of 30%* (% of PWUD sent to rehab at
least twice in the past year)
1,950 1,572 3,357
Percentage of PWUD sent to rehab in the past year (from survey component)*
Average 0.0738 0.0738 0.0738
Low estimate 0.061 0.061 0.061
High estimate 0.0865 0.0865 0.0865
Estimated total PWUD in the country
Average 26,425 21,304 45,491
High estimate 31,970 25,774 55,036
Low estimate 22,546 18,176 38,812
Average of PWUD population size 2010/11 and 2011/12 23,864 33,397
High estimate 28,872 40,405
Low estimate 20,361 28,494
Note: * These gures were taken from 2012 drug use survey
Extrapolation of PWUD population size
The population size estimation process also included an extrapolation of the estimated number of PWUD in
Phnom Penh, to give the total number of PWUD nationwide. The number of PWUD using drop-in centers (DIC)
in Phnom Penh was used as the benchmark and the percentage of PWUD in Phnom Penh who reported using
services at these DICs in the past 12 months was the multiplier. The estimated number of PWUD in Phnom
Penh was calculated to be 4,976. The team then used data from the drug user survey 2007 to form the
assumption that PWUD in Phnom Penh represented about 24% of the total PWUD population in Cambodia.
This gave a total PWUD estimated population of 20,749 (see table 13 below).
Table 13: Extrapolation of the total number of PWUD based on estimated PWUD
in Phnom Penh
Location
of Drop
In Center
Reported
PWUD/
PWID
% PWUD
used at least
two DIC in
the past 12
months*
Reported
PWUD after
reducing the
duplication
% PWUD
from
province
using DIC
in PNP*
Estimated
number of
PWUD in
PNP used
DIC
% of PWUD in
PNP reported
using service at
these DIC in the
past 12 months*
Est.
PWUD
in PNP
Friends/
FI
515 0.355 332.175 0.53 330 0.1602 2,063
Korsang
DIC
411 0.355 265.095 2.12 259 0.4063 639
KHANA
drop in
centers
515 0.355 332.175 1.06 329 0.1445 2,274
Total 4,976
% of PWUD in Phnom Penh compared to total PWUD (based on PWUD survey data 2007) 23.98%
Total number of PWUD in Cambodia based on number of PWUD in Phnom Penh 20,749
Note: * These values were derived from the 2012 drug user survey
21
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Another extrapolation was made specically for Banteay Meanchey province, where a technical
working group was formed to estimate the number of PWUD. The group estimated that there were
1,713 PWUD in the province in 2012. If we assume that this gure is an accurate estimate, the
estimate derived through the capture-recapture method would represent just 38.8% of the total
PWUD in the province. If this proportion was applied to the other 8 selected provinces, the total
estimate of the number of PWUD in all 9 provinces would be 23,763. The estimated number of
PWUD nationwide would be 31,686.
Table 14: Extrapolation of total PWUD using PWUD in Banteay Meanchey
province
Provinces Estimate Number
of PWUD*
Working group
consensus
% estimated vs
group consensus
Extrapolation
using BMC
Friends International
(PNP)
2,924 7,535
Korsang (PNP) 230 593
KHANA (PNP) 220 566
BTB 967 2,491
BMC 665 1,713 0.388065824 1,713
KCM 654 1,686
KSP 803 2,070
SRP 1,106 2,849
SVG 651 1,677
PVG 526 1,355
SHV 477 1,229
Total of 9 provinces 9,221 23,763
Total PWUD in
Cambodia
31,686
Note: * This gure was taken from capture-recapture method
LIMITATIONS OF THE ESTIMATION METHODS
Each method used for estimating the size of the PWUD population in this study has its own limitations.
The capture-recapture method was only conducted in the major urban areas of selected provinces/
cities, and might therefore underestimate the true size of the PWUD population. However, a clear
denition of drug users was agreed and used when conducting the capture-recapture method,
which at a minimum ensures consistency within this methodology.
However, estimates based on program reports from KHANA, rehabilitation centers and drop-
in centers did not use the same agreed denition of drug users, which may have resulted in an
overestimation of the population size, and the issue of duplication cannot be ruled out in the reports
from all sources. The estimation based on KHANA program reports, which had also been used to
estimate the total number of PWUD nationwide, might also produce an underestimate as the KHANA
project does not cover PWUD in the whole province. As the Preab Samorphum reports are usually
based on a urine test and require an exact PWUD home address, it is likely that estimates based on
this information under-report the number of PWUD in each province.
22
Finally, the estimation of the proportion of non-hidden PWUD as part of the PWUD population as a
whole was based solely on information collected from mapping and consensus among eld experts.
TRIANGULATION OF DATA ON THE POPULATION OF PWUD
IN CAMBODIA
The capture-recapture method
remains relatively robust
compared to the other methods
of population size estimation
as it is based on primary data
collection with a clear timeframe
and denition of terms. However,
data derived from this method
might be underestimated due
to the focus on urban areas, as
described above. The variations
in the different estimation methods
are shown in gure 4 below.
Estimates based on the reports from Preab Samorphom may also be underestimated, reecting the
fact that Preab Samorphom is likely to only record PWUD who stay in communities, those who have
the potential to cause harm to communities or those that have a positive urine test.
In contrast, the estimation method based on program data from rehabilitation centers and Drop-In
centers, and the extrapolation based on the number of PWUD in Banteay Meanchey, appear to
overestimate the size of the PWUD population. This is mainly due to a lack of a clear denition on
what constitutes a ‘drug user’, and also issues of duplication of records which could not be adjusted.
Given the limitations of each method outlined above, it appears that the capture-recapture method
might produce the least biased estimate. The research team has therefore concluded that the number
of PWUD who reported using drugs in the past 12 months in Cambodia in 2012 is estimated at
13,000, rounding up to take into account the fact that the capture-recapture method might produce
an underestimated gure, and also to be more within the range of other estimates. The variation of
the population size estimate is assumed to be within the range produced by the different multiplier
methods, from the lowest estimate of 12,000 to the highest of 28,000.
The number of PWUD living in Phnom Penh was reported based on the estimate that 24% of PWUD
nationally live in Phnom Penh (proportion from the drug user survey 2007). The detailed calculations
for the PWUD and PWID in Phnom Penh is presented in the table below.
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
13,037
17,767
12,296
11,555 9,891
13,714 15,706
8,743
12,123 12,108 13,051
20,361
23,864
28,494
33,397
40,405
31,686
20,749
28,872
CRC* KHANA 2011 KHANA 2012 Preap.S 2011Preap.S 2012 Rehab 2011 Rehab 2012 Extrapotate
from BMC
Extrapotate
from PNP
Figure 4: Summary of the population size of PWUD,
by different estimation methods
Note: * CRC = Capture-Recapture
23
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 15: Estimated number of PWUD in Phnom Penh
Est. PWUD % PWUD in Phnom
Penh out of the total* PWUD in PNP
High estimate 28,000 24 6,720
Low estimate 12,000 24 2,880
Average 13,000 24 3120
Note: * These gures were derived from the drug use survey 2007
Out of a total estimate of 13,000
PWUD nationally, it is estimated
that about 3,120 are living in
Phnom Penh while 9,880 are
living other provinces (see gure 5,
below).
The capture-recapture method
reported far fewer female than
male PWUD. The 2012 drug user
survey estimated that 14% of
PWID were female and 18% of
non-injecting PWUD were female.
These estimates were used with
the population size estimates from this study to estimate total female PWUD population size,
disaggregated by type of drug use (see table 16 below).
Table 16: Estimated number of female PWUD
Est.
PWUD
Est.
total
PWID
%
Female
PWID*
% female
non-injecting
PWUD*
Est. non-
injecting
PWUD
Female
PWID
Female
non-
injecting
PWUD
Total
female
PWUD
High
estimate 28,000 2,807 14 18 25,193 379 4,585 4,964
Low
estimate 12,000 1,203 14 18 10,797 162 1,965 2,127
Average 13,000 1,303 14 18 11,697 176 2,129 2,305
Note: * These gures were taken from the 2012 survey
The estimate shows that there were approximately 2,305 female PWUD in Cambodia in 2012,
among whom 176 were injecting drugs. The ranges in these estimates are shown in Figure 6 below.
Est. total PWUD PWUD in PNP PWUD in province
30,000
25,000
20,000
15,000
10,000
5,000
0
28,000
13,000
12,000
2,880
9,880 9,120
21,280
6,720
3,120
Figure 5: Estimated number and range of PWUD,
by location
24
The population size estimates developed in this study were also used to calculate numbers of PWID
by type and regularity of drug use. Based on data from the 2012 drug use study (that 42% of PWID
were regular drug users, and 20% of non-injecting PWUD were regular drug users), we found that
547 out of 1,303 PWID are regular users who have injected drugs more than twice in the past week.
The variations in these estimates are shown in gure 8.
Table 18: Calculation of the number of regular PWID and non-injecting PWUD
Est. total
PWID
Est. total
non-injecting
PWUD
% of regular
PWID*
% of regular
non-injecting
PWUD*
Est. total
regular
PWID
Est. regular
non-injecting
PWUD
High
estimate 2,807 25,193 0.42 0.20 1,179 4,913
Low
estimate 1,203 10,797 0.42 0.20 505 2,105
Average 1,303 11,697 0.42 0.20 547 2,281
Note: * These gures were taken from this 2012 drug use survey
Figure 8: Estimated number of PWID, by frequency of drug use
6,000
5,000
4,000
3,000
2,000
1,000
0
547
1,179
505
2,281
2,105
4,913
Est. total regular PWID Est. regular non injecting PWUD
The data collated in this study was also used to calculate number of PWUD living in Phnom Penh,
by type and regularity of drug use. Based on the population size estimates from this study as well
as data from the 2012 drug user survey, there were found to be 524 regular PWID and 281 regular
non-injecting PWUD in Phnom Penh (the latter are those who have used but not injected drugs at
least three times in the past week). The variations in these estimates are shown in Figure 9 below.
26
PWID are a subset of the total
PWUD population, and based on
the estimation methods used in
this survey and data on proportions
of PWID from the 2012 drug
use survey (i.e. 35% of PWUD in
Phnom Penh are PWID, and 2% of
PWUD in the provinces are PWID),
there were an estimated 1,300
PWID in Cambodia in 2012 (see
table 17 below). Figure 7 shows
the variations in the estimates of
number of PWID by location.
Table 17: Calculation of the number of PWID in Phnom Penh and other provinces
Est.
PWUD
PWUD
in PNP
PWUD in
provinces
% PWID
in
Phnom
Penh*
% PWID
in other
prov*
Est.
PWID
in PNP
Est.
PWID
in other
prov
Est.
total
PWID
Est. non
injecting
PWUD
High estimate 28,000 6,720 21,280 35 2 2,339 468 2,807 25,193
Low estimate 12,000 2,880 9,120 35 2 1,002 201 1,203 10,797
Average 13,000 3,120 9,880 35 2 1,086 217 1,303 11,697
Note: * these gures were taken from 2012 drug use survey
Figure 7: Estimated number of PWID, by location
6,000
5,000
4,000
3,000
2,000
1,000
0176 379
162
2,129 1,965
4,585
4,964
2,127
2,305
Female PWID Female non-injecting
PWUD
Total female PWUD
Figure 6: Estimated number of female PWUD in
Cambodia
3,000
2,500
2,000
1,500
1,000
500
0
2,339
1,002
1,086
217
468
201
1,303 1,203
2,807
Est. PWID in PNP Est. PWID in other provs Est. total PWID
25
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
The population size estimates developed in this study were also used to calculate numbers of PWID
by type and regularity of drug use. Based on data from the 2012 drug use study (that 42% of PWID
were regular drug users, and 20% of non-injecting PWUD were regular drug users), we found that
547 out of 1,303 PWID are regular users who have injected drugs more than twice in the past week.
The variations in these estimates are shown in gure 8.
Table 18: Calculation of the number of regular PWID and non-injecting PWUD
Est. total
PWID
Est. total
non-injecting
PWUD
% of regular
PWID*
% of regular
non-injecting
PWUD*
Est. total
regular
PWID
Est. regular
non-injecting
PWUD
High
estimate 2,807 25,193 0.42 0.20 1,179 4,913
Low
estimate 1,203 10,797 0.42 0.20 505 2,105
Average 1,303 11,697 0.42 0.20 547 2,281
Note: * These gures were taken from this 2012 drug use survey
Figure 8: Estimated number of PWID, by frequency of drug use
6,000
5,000
4,000
3,000
2,000
1,000
0
547
1,179
505
2,281
2,105
4,913
Est. total regular PWID Est. regular non injecting PWUD
The data collated in this study was also used to calculate number of PWUD living in Phnom Penh,
by type and regularity of drug use. Based on the population size estimates from this study as well
as data from the 2012 drug user survey, there were found to be 524 regular PWID and 281 regular
non-injecting PWUD in Phnom Penh (the latter are those who have used but not injected drugs at
least three times in the past week). The variations in these estimates are shown in Figure 9 below.
26
1,200
1,130
524
484
605
281
259
1,000
800
600
400
200
0
Regular PWID in PNP Regular non-injecting PWUD in PNP
Table 19: Calculation of regular PWID and non-injecting PWUD in Phnom Penh
Total PWUD in
PNP
Total PWID
in PNP
% regular
PWID in
PNP*
% regular non
injecting
PWUD in
PNP*
Regular
PWID in
PNP
Regular non
injecting
PWUD in PNP
High
estimate 6,720 2,339 48 14 1,130 605
Low
estimate 2,880 1,002 48 14 484 259
Average 3,120 1,086 48 14 524 281
Note: * These gures were taken from the behavioral component of 2012 survey
Figure 9: Estimation of regular PWID and non-injecting PWUD in Phnom Penh
INTEGRATED BIO-BEHAVIOR SURVEY
Demographic Characteristics
The mean age of the study participants was 25 years old. PWID tended to be slightly older than non-
injecting PWUD. There was an interesting crossover between PWUD and transgender, with 13.5%
of male PWID participants and 18.2% of non-injecting PWUD considering themselves as female.
Approximately 52% were single with no partner at the time of survey. 31.5% were married and living
with their spouse. Non-injecting PWUD were very slightly more likely to be married and living with
their spouse than PWID, although PWID were more likely to be married and living alone (17% vs.
10.3%). The percentage of PWUD with no formal schooling was 12.3% for PWID and 8% for non-
injecting PWUD. Only a small number of female PWUD were recruited into the study (17.8%, or 290
out of 1,626).
27
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Table 20: Demographic Characteristics of PWUD included in the survey
Variables PWID Non-injecting
PWUD Total
n=119 % n=1,507 % n=1,626 %
Male 103 86.6 1,232 81.8 1,335 82.2
Consider themselves as
Male 102 85.7 1,228 81.6 1,330 81.9
Female 16 13.5 274 18.2 290 17.9
Male and female 1 0.8 3 0.2 4 0.2
Mean age (Median) in years 28.4(29) 28.4(29) 25.2 (24)
Marital status
Married & living together 32 27.2 477 31.9 509 31.5
Married & living with other 2 1.7 15 1.0 17 1.1
Partner
Married & living alone 20 17.0 154 10.3 174 10.8
Single & living with partner 10 8.5 67 4.5 77 4.8
Single with no partner 54 45.8 783 52.3 837 51.9
% with no formal education 14 12.3 115 8.0 129 8.3
Mean years of schooling
(Median) 6.4 (7) 7.5 (8) 7.4 (7)
Approximately 50% of PWUD reported currently living with their parents, followed by their wife/
husband (21.8%). PWID were less likely to live with their parents than were non-injecting PWUD,
but were more likely to live with friends (15.3% vs. 7.8%). 2.7% of participants reporting living on
the street, with PWID more likely to be living on the street than non-injecting PWUD. Nearly 80% of
participants reported never having been away to another province for more than 1 month in the last
6 months. For those who had been away for more than 1 month, the median number of provinces
they had stayed in was 1, which implies there is not a huge amount of movement of PWUD around
Cambodia.
Table 21: Living place and mobility
Variables PWID Non-injecting PWUD Total
n=119 % n=1,507 % n=1,626 %
Current living place
Street 5 4.2 38 2.5 43 2.7
Parent 36 30.5 763 51.0 799 49.5
Wife/husband 19 16.0 332 22.2 351 21.8
Friend 18 15.3 117 7.8 135 8.4
Other 40 33.9 245 16.4 285 17.7
% who had not stayed for
>1 monthin other provinces
in the past 6 months
99 83.9 1,193 79.5 1,292 79.8
Mean number of provinces
stayed in for >1 month in
the past 6 months
2.3 (2) 1.4 (1) 1.4 (1)
28
Rehabilitation and Other Drug-related Services
In the past 12 months, 80% of
survey participants reported never
having used an NGO drop-in
center. Among those who reported
having used a drop-in center,
35% of PWID had used at least
2 different drop-in centers in the
past 12 months, while 14% of non-
injecting PWUD had done so.
Similarly, a higher proportion of
PWID than non-injecting PWUD
reported ever having been called
by the police to talk about drug use
(49.2% vs. 17.1%). A much higher
proportion of PWID had also been sent to temporary rehabilitation centers (47.1% vs. just 6.4% of
PWUD). The majority of PWID who had been sent to a rehabilitation center had been sent in the past
year (35.3%).
8.6% of PWUD had ever been sent to prison. The main reason for being sent to prison was use
of drugs and committing crime (33.6%), followed by committing other crimes while not on drugs
(30.7%). PWID were much more likely to have been sent to prison than non-injecting PWUD (29.7%
compared to 6.9%).
Table 22: Usage of Drop-in centers and temporary rehabilitation centers
Variables PWID Non-injecting PWUD Total
n=119 % n=1,507 % n = 1,626 %
% never used NGO drop-in
center in the past 12 months
56 47.1 1,244 82.7 1,300 80.1
Mean duration of stay when
being sent to temporary
rehabilitation (months)
3.5 (3) 3.8 (3) 3.7 (3)
Ever been sent to prison 35 29.7 104 6.9 139 8.58
Reasons for being in prison for the last prison stay
Use of drugs and committing a
crime
13 36.0 34 32.7 47 33.6
Selling drugs 1 2.8 5 4.8 6 4.3
Distributing drugs 2 5.6 7 6.7 9 6.4
Other crime 12 33.3 31 29.8 43 30.7
Others 8 22.0 27 26.0 35 25.0
60
50
40
30%
20
10
0
Used at least 2 dierent
drop in center in the
past 12 months
Ever been called by
police to talk/register
about using drug
Ever been sent to
temporary
rehabilatation center
Ever been sent to
temporary
rehabilatation center
in the past year
PWID non-injecting PWUD Total
35.3
14.1 15.7
49.2
17.1 19.4
47.1
6.4 9.4
35.3
5.2 7.4
Figure 10: Proportion of PWUD using different
Drug-Related Services
29
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
History of Drug Use
It was found that some study participants had started using drugs as early as the late 1980s.
However, the majority of PWID in the sample started using drugs in 2000, while a high proportion of
non-injecting PWUD participants reported having started using drugs during the period 2010-2011.
Patterns of Drug Use
Only 18.6% of PWID rst started using drugs by injection, and about 74% initially started with
smoking drugs. 91% of all PWUD reported starting using drugs with friends. About 35% of PWUD
in Phnom Penh injected drugs, while just 2% of PWUD in the provinces reported injecting drugs.
The most common people who rst introduced the study participants to using drugs were their
friends (85.9%), followed by self (6.7%) and relatives (2.4%).
Table 23: Patterns of Drug use
Variables
PWID Non-injecting PWUD Total
n=119 % n=1,507 % n=1,626 %
First time you used drugs, what method you use
Inject 22 18.6 6 0.4 28 1.7
Smoke 87 73.7 1,440 96.1 1,527 94.5
Sniff 9 7.6 34 2.3 43 2.7
Drink 0 0 18 1.2 18 1.1
First time you used drugs, whom you use with
Alone 4 3.4 43 2.9 47 2.9
Friend 103 87.3 1,370 91.3 1,473 91.0
Sweetheart 3 2.5 25 1.7 28 1.7
Husband/wife 2 1.7 17 1.1 19 1.2
Relatives 5 4.2 31 2.1 36 2.2
Being forced 0 0 3 0.2 3 0.2
Other 1 0.9 12 0.8 13 0.8
18
16
14
12
10
%8
6
4
2
0
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
PWID Non-injecting PWUD Total
Figure 11: History of Drug Use
30
Who was the rst one to introduce you to using drugs
Self 10 8.5 99 6.6 109 6.7
Friend 98 83 1,292 86.1 1,390 85.9
Sweetheart 4 3.4 25 1.7 29 1.8
Husband/wife 1 0.9 17 1.1 18 1.1
Relatives 5 4.2 34 2.3 39 2.4
Being forced 0 0 19 1.3 19 1.2
Other 0 0 15 1.0 15 0.9
Regarding the type of drug used in the last 12 months, 81% of all PWUD reported using Ice/
metamphetamine with 46% using Yama. Among PWID, 78% reported using Ice/metamphetamine
followed by heroin (61.9%) and Yama (31.4%). 95.2% of non-injecting PWUD had never used heroin,
while 13.6% of PWID used it three times a week or more.
Table 24: Reported types of illicit drug use & frequency of drug use
Variables
PWID Non-injecting
PWUD Total
n=119 % n=1,507 % n=1,626 %
Types of illicit drug used in the past 12 months
Heroin 73 61.9 42 2.8 115 7.1
Yama 37 31.4 710 47.1 747 46.0
Ecstasy 7 5.9 80 5.3 87 5.4
Ice/metamphetamine 92 78 1,228 81.5 1,320 81.3
Inhalant 10 8.5 57 3.8 67 4.1
Marijuana 17 14.4 153 10.2 170 10.5
Cocaine 5 4.2 9 0.6 14 0.9
Other 4 3.4 13 0.9 17 1.1
Used heroin in the past month
Two times or less per week 22 18.6 24 1.6 46 2.8
Three times or more 16 13.6 48 3.2 64 3.9
Never 80 67.8 1,433 95.2 1,513 93.2
Used Yama in the past month
Two times or less per week 17 14.4 374 24.8 391 24.1
Three times or more 18 15.3 236 15.7 254 15.6
Never 83 70.3 896 59.5 979 60.3
Used ecstasy in the past month
Two times or less per week 3 2.5 55 3.6 58 3.6
Three times or more 3 2.5 80 5.3 83 5.1
Never 112 94.9 1,370 91.0 1,482 91.3
31
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
Used Ice/metamphetamine in the past month
Two times or less per week 43 36.4 747 49.6 790 48.7
Three times or more 44 37.3 365 24.2 409 25.2
Never 31 26.3 394 26.2 425 26.2
Used glue/inhalants in the past month
Two times or less per week 0 0 18 1.2 18 1.1
Three times or more 3 2.5 52 3.5 55 3.4
Never 115 97.5 1,435 95.4 1,550 95.5
Used marijuana in the past month
Two times or less per week 4 3.4 58 3.9 62 3.8
Three times or more 3 2.5 61 3.9 64 3.9
Never 111 94.1 1,386 92.1 1,497 92.2
Used cocaine in the past month
Two times or less per week 0 0 11 0.7 11 0.7
Three times or more 3 2.5 41 2.7 44 2.7
Never 115 97.5 1,453 96.5 1,568 96.6
Survey participants were also
asked about the frequency of their
drug use and were then classied
into two groups: occasional and
regular drug users, based on the
working denitions set by the
technical working group. 42%
of PWID in the study were found
to be regular users, while about
20% of non-injecting PWUD were
regular users. Note that regular
PWID included those who injected
2 times or more per week and those who injected less than 2 times, but used other drugs more than
2 times per week.
Drug use behavior among PWID
The survey ndings show that regular PWID have on average been injecting drugs for 24 months,
while occasional PWID have been injecting drugs for 9 months on average. Both regular and
occasional users were most likely to have been introduced to injecting drugs by friends.
80
90
70
60
50
40
30
20
10
0
%
76.5
42
80.5
19.5
PWID non-injecting PWUD
Occational drug user Regular drug user
Figure 12: Occasional and Regular Drug users
32
Table 25: Characteristics of PWID
Variables Occasional PWID Regular PWID Total
n=69 % n=50 % n=119 %
Median duration (months) of
injecting drugs (IQR) 9 (57) 24 (55) 20 (57)
Who rst introduced you to injecting drugs
Self 5 7.3 9 18 14 11.8
Friends 52 75.4 38 76 90 75.6
Sweetheart 5 7.3 2 4 7 5.9
Husband/wife 3 4.4 0 0 3 2.5
Relatives 2 2.9 0 1 2 2.5
Others 2 2.9 0 0 2 1.7
Used/Injected heroin in the past month
Less than 2 times/week 20 29 9 18 29 24.4
Two times or more per week 4 5.8 31 62 35 29.4
Never 45 65.2 10 20 55 46.2
Used/Injected Yama in the past month
Less than 2 times/week 5 7.3 2 4 7 5.9
Two times or more per week 3 4.4 2 4 5 4.2
Never 61 88.4 46 92 107 89.9
Used/Injected ecstasy in the past month
Less than 2 times/week 0 0 0 0 0 0
Two times or more per week 1 1.5 1 2 2 1.7
Never 68 98.6 49 98 117 98.3
Used/Injected Ice/Metamphetamine in the past month
Less than 2 times/week 16 23.2 7 14 23 19.3
Two times or more per week 2 2.9 0 0 2 1.7
Never 51 73.9 43 86 94 79.0
Sharing of needles and syringes
by PWID is of course a major risk
in terms of HIV transmission. 63%
of PWID reported never having
shared needles and syringes with
other drug users in the past month.
Furthermore, 68.5% did not share
injecting materials and 86.8%
reported never injecting drugs
mixed with their own blood or with
blood of other drug users. Regular
PWID were less likely to have
shared needles or other materials
than occasional PWID.
100
90
80
70
60
50
40
30
20
10
0
%
16.2 12.9 14.7
60.6
66.7 63.3 58.6
80
68.5
79.6
95.2
86.8
Always clean used
needdle/syringes before
using it again
Never share
needles/syringes in the
past month
Never share other
materials with other PWID
the past month
Never inject drug with
blood or mixing with
blood from other PWID
Occasional Regular Total PWID
Figure 13: Sharing needles and syringes among
PWID
33
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
However, the survey ndings show that 31.9% of PWID had reused syringes/needles last time they
injected drugs, and 14.4% reported not having received new needles/syringes in the past 12 months.
Among those who had used new needles/syringes, 70% received them from NGO staff, with regular
PWID more likely to have received new needles from NGO staff or to have bought them themselves.
Interestingly, regular PWID were less likely to have re-used syringes/needles than occasional users,
implying that regular PWID are more aware of the risk in this. Regular PWID also showed more
awareness of NSP and NGO drop-in centers as providers of clean needles.
Table 26: Access to Needles and Syringes for PWID
Variables
Occasional PWID Regular PWID Total
n=69 % n=50 % n=119 %
Last time you injected drugs, re-used
syringes/needles 27 39.1 11 22.0 38 31.9
Frequency of re-using syringes/needles in the past month
Always 7 11.5 1 2.2 8 7.5
Frequent 2 3.3 3 6.5 5 4.7
Sometime 15 24.6 7 15.2 22 20.6
Never 36 59.0 35 76.1 71 66.4
Never received new needles/syringes
in the past 12 months 13 18.8 4 8.2 17 14.4
Sources of receiving new needles/syringes in the past 12 months
Buy themselves 20 35.7 24 53.3 44 43.6
Outreach team 4 7.1 5 11.1 9 8.9
NGOs staff 34 60.0 37 82.2 71 70.3
Drop in center 4 7.1 8 17.8 12 11.9
Friends 11 19.6 2 4.4 13 12.9
Other 2 3.6 2 4.4 4 4.0
Use only new needles/syringes in the
past month 21 36.2 14 31.1 35 34.0
Clean used needle/syringes before using it again
Always 6 16.2 4 12.9 10 14.7
Frequent 4 10.8 4 12.9 8 11.8
Sometimes 3 8.1 4 12.9 7 10.3
Never 22 59.5 18 58.1 40 58.8
Don’t know 2 5.4 1 3.2 3 4.4
Do you know where clean needles/syringes can be found
Health facilities 11 26.8 9 18.1 20 27.4
Family 2 4.9 2 6.3 4 5.5
Sexual partner 1 2.4 1 3.1 2 2.7
Friends 12 29.3 3 9.4 15 20.5
Other drug user 4 9.8 4 12.5 8 11.0
Drug sellers 5 12.2 7 21.9 12 16.4
Needle/syringe exchange program 13 31.7 16 50.0 29 39.7
NGO drop in Center 13 31.7 18 56.3 31 42.5
34
Among the PWID who reported cleaning used syringes/needles before re-use, about 52% used cold
water, followed by hot water (20.7%) and alcohol (17.2%). Regular PWID were more likely to use
alcohol or soap to clean the syringe/needle than occasional PWID.
Figure 14: Practices of cleaning needles and syringes
60
50
40
30
20
10
0
%
50
53.3 51.7
21.4 20 20.7
14.3 13.313.8
7.1
13
10.3 7.1
26.7
17.2
Cold water Hot water Boiling it Using soap Using alcohol
Occasional Regular Total PWID
MENTAL HEALTH
The mental health status of PWUD was also measured as part of this study through the use of K10
questionnaires (Kessler Psychological distress scale), developed by Kessler and others in 1992. The
scores ranges from 1 (no problems) to 5 (experiencing a major problem). The average mental health
score for PWUD participants was 2.06. PWID were more likely to report frequent or constant mental
health issues than non-injecting PWUD.
Table 27: Mental Health among PWUD
Variables PWID Non-injecting
PWUD Total
n=119 % n=1507 %
n=1626
%
Mean score of mental issues in the
past month (1: no problem, 5: always) 2.2 (2.2)2.1 (2.0) 2.1(2.0)
Frequency of having mental issues
Never had any problem 25 21.6 313 21.3 338 21.3
Rarely 21 18.1 388 23.0 359 22.6
Sometimes 14 12.1 310 21.1 324 20.4
Frequent 26 22.4 257 17.5 283 17.8
Always 30 25.9 255 17.3 285 17.9
When examining the mental health scores of occasional and regular PWUD, it was found that a higher
proportion of regular PWID (30.6%) reported always having mental problems than did occasional
35
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
PWID (22.4%). A similar pattern was reported among non-injecting PWUD (see table 28). While this
is not surprising, it is important to take into account when reaching regular PWID and PWUD with
health interventions.
Table 28: Mental Health of Occasional and Regular Drug users
Variables Occasional Regular Total
n % n % n %
Frequency of having mental issues among PWID
Never had any problem 17 25.4 8 16.3 25 21.6
Rarely 12 17.9 9 18.4 21 18.1
Sometimes 6 9.0 8 16.3 14 12.1
Frequent 17 25.4 9 18.4 26 22.4
Always 15 22.4 15 30.6 30 25.9
Frequency of having mental issues among non-injecting PWUD
Never had any problem 263 22.2 51 17.6 314 21.3
Rarely 280 23.7 58 20.0 338 22.9
Sometimes 248 21.0 62 21.4 310 21.0
Frequent 212 17.9 45 15.5 257 17.4
Always 181 15.3 74 25.5 255 17.3
SEXUAL BEHAVIOR AMONG FEMALE PWUD
Sexual behavior was analyzed separately for female and male PWUD. Among female PWUD, 94.4%
reported ever having had sex, and the mean age at rst sex was 18.2 years old. Condom use during
the last episode of sex in exchange for money was high at 91.2% (slightly lower among PWID).
Female PWUD found paying sexual partners (partners who bought sex) at guest houses (57%)
and karaoke clubs (26%). Non-injecting PWUD had a higher mean number of sexual partners in
exchange for money/drugs than PWID (5.4 in the last month compared to 2.3).
Table 29: Sexual Behavior among female PWUD
Variables PWID Non-injecting PWUD Total
n=16 % n=272 % n=288 %
Ever had sex 16 100 256 94.1 272 94.4
Mean age at rst sex (median) 18.1 (18) 18.2 (18) 18.2 (18)
Ever had sex in the past month 7 43.8 206 80.2 213 78.0
Used condom during the last sex in
exchange for money 6 85.7 128 91.4 134 91.2
Places of nding partners for sex in exchange for money
Garden 0 0 14 10.1 14 9.6
Beer garden 1 14.3 8 5.8 9 6.2
Karaoke club 2 28.6 36 25.9 38 26.0
Guesthouse 4 57.1 79 56.8 83 56.9
Other 0 0 11 7.9 11 7.5
Mean number of sex partners in
exchange for money or drugs in the
past month (median)
2.3 (2) 5.4 (3) 5.2 (3)
36
SEXUAL BEHAVIOR AMONG MALE PWUD
Among male PWUD, 88.7% reported being sexually active. Their mean age at rst sex was 18.8
years old with no major difference between PWID and non-injecting PWUD observed. 66.5% of male
PWUD reported having had sex in the past month.
Table 30: Sexual behaviors among male PWUD
Variables PWID Non-injecting PWUD Total
n=103 % n=1,232 % n=1,335 %
Ever had sex 98 95.2 1,083 88.0 1,181 88.7
Mean age at rst sex (median) 17.8 (18) 18.9 (18) 18.8 (18)
Ever had sex in the past month 55 57.3 724 67.3 779 66.5
Mean number of male paying
sexual partners in the past month 0 (0) 0.2 (0) 0.2 (0)
Mean number of female paying
sexual partners in the past month 2.1 (1) 1.6 (1) 1.6 (1)
Number of female partners you
have had in exchange for money or
drugs in the past month (among
those who had sex in the past
month)
2.7 (3) 2.2 (2) 2.2 (2)
7.6% of male participants
reported having had sex
with men in the past
12 months and 57.4%
reported having sex
immediately after using
drugs in the past 12
months (Figure 15).
Consistent condom use
was not high among
male PWUD. 53.7% of
men reported consistent
condom use with female
paid sex partners (female
commercial sex workers) in the past 12 months and just one third reported using condoms with paid
male sex partners (male commercial sex workers).
Always used condom when having sex with paid
female partners in the past 12 month
Condom use last time they had sex right after
using drug
Ever had sex with men in the past 12 month
Having sex right after using drug in the past 12
month
Always used condom when having sex with paid
male partners in the past 12 month (n=37)
53.7
53 59
29.7
29.4
33.3
73.4
74.1
65.2
57.4
58.5
44.7
7.6
7.8
6.3
0 20 40 60 80
%
Total non-Injecting PWUD PWID
Figure 15: Condom use among male PWUD
37
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
In general, male PWUD most commonly found their commercial female sexual partners in karaoke
clubs (44.6%) or guest houses (33.4%). On the other hand, public gardens were the most common
place where male PWUD recruited their paying male sexual partners. These differences and varied
locations need to be taken into account in targeted HIV prevention interventions.
Non-commercial sexual partners include regular partners (sweethearts or spouses) and non-regular
partners (casual partners). The study showed that only 22.4% of PWUD had no regular partner
(sweethearts or spouse). Among those with regular partners, the rate of condom last time they had
sex with their regular partner was 49.5%.
For those who reported ever having had casual partners, 88% reported using a condom with a
non-regular partner last time they had sex, while only 64.4% reported always using a condom with
a non-regular partner in the past 12 months.
Table 31: Condom use with not-commercial sexual partners
Variables PWID Non-injecting PWUD Total
n=113 % n=1,335 % n=1,448 %
Used condom with non regular
unpaid partner
35 31.0 289 21.7 324 22.4
Used condom last time had sex
with regular partner
39 50.0 517 49.4 556 49.5
Always used condom with regular
partner in the past 12 months
23 32.4 230 23.5 253 24.1
Used condom with non-regular/
casual partner
45 40.2 405 30.4 450 31.2
Used condom last time had sex
with casual partner
59 88.1 815 88.1 874 88.0
Always used condom with casual
partner in the past 12 months
44 68.8 577 64.0 621 64.4
Female partner
Male partner
Female partner
Female partner
Male partner
Male partner
Total
non-injecting PWUD
PWID
14.4 33.4 44.6
15.7 19.3
7.1
6.1 8.1
6.1 14.1
14.3 32.7 45.4
15.4 18.9
5.4
6.5
7.5
5.4 14
16.7 41.7
33.3
20 25
33.3
16.7
0
16.7
16.7
010 20 30 40 50
Other Guest houses Karaoke club Beer garden Garden
%
Figure 16: Places where male PWUD nd their paid sexual partners
38
ACCESS TO CONDOMS
The main source of free condoms accessible by PWUD were outreach/NGO staff (85.6%), followed
by peer educators (26.9%). However, up to 38.4% of participants reported never having received
free condoms in the past year. Non-injecting PWUD were much more likely never to have received
free condoms, and were much less likely to mention NGO staff as a route to accessing condoms.
PWUD reported seeking condoms at pharmacies (78%), bar/guesthouse/hotels (33.4%), with NGO
staff (29.2%) and from health facilities (23.7%).
Table 32: Access to condoms among PWUD
Variables PWID Non-injecting PWUD Total
n=119 % n=1,507 % n=1,626 %
Sources of free condoms received in the past 12 months
Never received free condoms 18 15.3 599 40.2 617 38.4
Outreach/NGO staff 93 93.0 754 84.7 847 85.6
Peer educator 31 31.0 235 26.4 266 26.9
Drop in center 23 23.0 66 7.4 89 9.0
STI clinics 7 7.0 83 9.3 90 9.1
Others 9 9.0 72 8.1 81 8.2
Places to access condoms
Pharmacy 82 70.1 1,166 78.6 1,248 78.0
Health facilities 38 32.5 342 23.1 380 23.7
Bar/guesthouse/hotel 45 38.5 489 33.0 534 33.4
NGO staff 73 62.4 394 26.6 467 29.2
Friends 19 16.2 149 10.0 168 10.5
Don’t know 3 2.6 81 5.5 84 5.3
Others 3 2.6 63 4.3 66 4.1
STI SYMPTOMS AND HEALTH SEEKING BEHAVIOR
Genital discharge was common among PWUD with 13.8% reporting it in the past year. The prevalence
of any self-reported STI symptoms in the past year was 16.1%. Non-injecting PWUD were slightly
more likely to experience STI symptoms than PWID.
10.8% of PWUD who reported having STI symptoms did not seek treatment. For those who did seek
treatment the most common place attended was STI public clinic (38.5%), followed by NGO clinics
(23.7%). PWID were more likely to access NGO clinics than non-injecting PWUD.
39
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
PWID Non-injecting PWUD Total
18
16
14
12
10
8
6
4
2
0
12.7
13.9 13.8
2.5 3.4 3.5
1.7 1.2 1.2
14.5
16.2 16.1
Genital discharge Genital sore/ulcer Genital warts Any of the STI
symploms
%
Figure 17: Reported Symptoms of Sexually Transmitted Infection
45
40
35
30
25
20
15
10
5
0
%
26.3 25.5
15.8 15.8
9.710.1
26.3
39.4 38.5
31.6
23.223.7
21.1
56.1
15.8
10.4 10.8 10.5
2.7 3.2
Phamacies Private clinics STI
clinics/public
clinics
NGO clinics Traditional
healers
Not seeking
treatment
Others
PWID Non-injecting PWUD Total
Figure 18: Health seeking behaviors the last time you experienced an STI
symptom
SOURCES OF HIV/AIDS AND DRUG USE INFORMATION
HIV/AIDS and drug information has been widely available for PWUD. Only about 5% of PWUD had
not received any information related to HIV/AIDS and drugs in the past 3 months. The main sources
of information for participants were TV/radio (70.4%), followed by NGO staff (66.6%) and family
members (22.9%). PWID were more likely to know where they could access VCT, and were also
more likely to cite NGO staff as a source of information.
The majority of PWUD (72.9%) knew that public health facilities in their province provided antiretroviral
treatment (ART) and believed that they could receive the treatment from public facilities if necessary
(73.1%).
40
HIV PREVALENCE AMONG PWUD
HIV prevalence for PWID and non-
injecting PWID was analyzed using
RDSAT-version 7.1.38. This analysis
helped the researchers to estimate
the high and low boundaries of HIV
prevalence. It was found that the
HIV prevalence among non-injecting
PWID participating in the study was
4% (95% CI: 2.7%- 5.5%) and the HIV
prevalence among PWID was 24.8%
(95% CI: 7.3%- 39.9%).
The HIV prevalence among regular PWID was higher (28.6%) than among that of occasional PWID
(23.9%). However, the HIV prevalence among male occasional and regular PWID were not vastly
different. On the other hand, the HIV prevalence among female regular PWID was 50% but 16.7%
among occasional female PWID. However, there were only 16 female PWID included in the study.
60
50
40
30
20
10
0
24.5
%
16.7
23.9 23.1
50
28.6
Occasional
Male Female Total
Regular
Figure 21: HIV Prevalence among
PWID, by gender
25
20
15
10
5
0
1.6
8.8
%
2.7 1.4
21.5
6.9
Occasional
Male Female Total
Regular
Figure 22: HIV Prevalence among non-
injecting PWUD, by gender
5.5
39.9
%
7.3
2.7 4
24.8
45
40
35
30
25
20
15
10
5
0
High bound Low bound Average
PWID Non-injecting PWUD
Figure 20: HIV Prevalence among PWUD
Belief they could received ART from public facilities
if they need
Total Non-injecting PWID PWID
NGO sta
TV/Radio
Sta in Rehab center
Family members
Never received any information
Knowing place for voluntary HIV testing
Knowing public facilities in their province/city oer
antiretroviral therapy
%
72.9
72.677.3
73.1
72.877.3
74.7
74 84
4.7
4.8
3.4
22.9
22.4 29.4
2.3
1.5 13.5
70.4
70.5
69.8
66.6
65.2 84
0 10 20 30 40 50 60 70 80 90
Figure 19: Sources of HIV/AIDS and drugs information
41
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
When comparing survey ndings disaggregated
by subgroup, the HIV prevalence among non-
injecting PWID was heterogeneous in terms of
the occasional/regular drug use split. However,
when disaggregated by gender much larger
differences were observed. The HIV prevalence
among regular female and occasional female
non-injecting PWUD was very different (21.5%
vs. 8.8%), while this difference was not observed
among male non-injecting PWUD. However,
these gures are based on a relatively small female
study group (just 272 female non-injecting PWUD
participated in the study). On average, the HIV prevalence among regular non-injecting PWUD was
higher than among occasional non-injecting PWUD (6.9% vs. 2.7%).
A very high concentration of HIV positive PWID were found in Phnom Penh with a prevalence of
33.7% compared to just 3.3% in other provinces. Interestingly, the HIV prevalence rates among
PWID and non-injecting PWUD were not different in the provinces.
HIV prevalence among PWID who had been
injecting drugs for more than 1 year was more
than two times higher than among those who
had recently started injecting drugs (Figure
25). However, for non-injecting PWUD the HIV
prevalence in those who had recently started
using drugs was not vastly different from the
prevalence in those who had used drugs for more
than 1 year (2.3% vs. 3.7%).
Among both PWID and non-injecting PWUD, the
HIV prevalence among those aged 20 years old
or less remained very low. The ndings indicate
that the older PWUD are, the higher the HIV
prevalence.
40
35
30
25
20
15
10
5
0
%
6
3.3
33.7
3.2
Phnom Penh Other provinces
PWID Non-injecting PWUD
Figure 23: HIV Prevalence among
PWUD in Phnom Penh and other
provinces
One year or less More than 1 year
PWID Non-injecting PWUD
11.1
30
25
20
15
10
5
0
2.3
26.6
3.7
%
Figure 24: HIV Prevalence, by duration
of using drugs
PWID Non-injecting PWUD
20 years old or less 21-29 years old 30 + or missing age
0
20
38
0.3 2.2
10.2
40
35
30
25
20
15
10
5
0
%
Figure 25: HIV Prevalence among
PWUD, by age group
42
REFERENCES
1 Bros Khmer 2010: Behavioral Risks On-Site Serosurvey among At Risk Urban Men in
Cambodia.
2. Chhea C, Seguy N: HIV prevalence among drug users in Cambodia 2007. NCHADS &
NACD; 2010.
3 Ministry of Education Youth and Sport, 2010, Most At Risk Young People Survey
Cambodia 2010.
4. NCHADS: Report of a concensus workshop: HIV estimates and projection for Cambodia
2006- 2012. Phnom Penh: Ministry of Health; 2007.
5. Sopheab H, Chhea C, Tuot S: Baseline survey on HIV/AIDS knowledge, attitudes,
practices and related risk behaviors among MARP. Phnom Penh, Cambodia: KHANA;
2010.
6. UNAIDS: Guidelines on estimating the size of the populations most at risk to HIV;
UNAIDS/WHO working group on global HIV/AIDS and STI surveillance. 2010.
44
CONCLUSIONS
There is currently no widely accepted single method to estimate the size of PWUD populations. In
this population size estimation, multiple methods were therefore used, followed by triangulation of
the results (capture recapture, multiplier methods and extrapolation to ensure the reliability of the
estimates).
Based on the nature of the data collected, the research team and population size estimation working
group have agreed that the size of the population derived through the capture-recapture method
might produce the least biased estimate. The ndings from this study therefore conclude that the
number of PWUD who reported using drugs in the past 12 months in Cambodia in 2012 is 13,000,
with a low estimate of 12,000 and a high estimate of 28,000.
Non-injecting drug use is the most common type of drug use method found in Cambodia. It is
estimated that there are 1,300 PWID in the whole country (ranging from 1,200 to 2,800), the majority
of whom reside in Phnom Penh (1,086).
The ndings of this size estimation do not differ greatly to those produced by NCHADS in 2007.
However, it is estimated that about 50% of PWUD remain hidden, which results in difculties in
increasing the coverage of health intervention programs designed for PWUD, and particularly
PWID. A detailed understanding of the dynamics and behaviors of drug users is therefore needed in
order to help program implementers and policy makers to launch effective health interventions and
appropriate health policies.
The HIV prevalence among PWID was found to be around 25% and the HIV prevalence among non-
injecting PWUD was 4%. Female PWUD appear to be among the most vulnerable sub-group, and
special interventions should be designed to reach this group.
Unsafe practices such as low consistent condom use when having sex correlate strongly with high
reported symptoms of STIs in the past year. Needle and syringe sharing among PWID also persists,
and is more common among occasional PWID. More targeted interventions for PWID should
therefore be developed and implemented to ensure access to adequate supplies of clean needles
and syringes. Programs need to ensure they are reaching both occasional and regular PWID.
In summary, PWUD remain one of the most at risk groups in Cambodia in terms of HIV infection,
and therefore warrant a greater focus in HIV and AIDS prevention and care programs. This is of
particular importance in the face of ndings on overlapping areas of risk such as sex work (male and
female PWUD) and sex between men. Innovative strategies will be needed to reach the different sub-
groups of PWUD (PWID/non-injecting PWUD, male/female, occasional/regular). An increase in HIV
prevalence is likely, especially among non-injecting PWUD and female PWUD, and it is hoped that
the ndings of this survey can contribute to preventing this.
43
Section 11. Venereal disease
Q70 In the last 12 months, have you ever experienced
the following symptoms?
Genital discharge/leucorhee
Genital ulcer/sore
Genital wart
Yes No Don’t know
1 2 8
1 2 8
1 2 8
Q71 Where did you go for treatment the last time you had
one of the above symptoms?
(Multiple answers possible)
No symptom: 0
Pharmacies/drug seller: 1
Private clinic: 2
STI clinic/Health facility: 3
NGOs clinic: 4
Traditional healer: 5
No treatment: 6
Other (specify)...........................: 7
Section 11. HIV Knowledge
Q72 Can the Risk of HIV transmission
be reduced by having sex with
only one uninfected partner who
has no other partners?
Yes: 1
No: 2
Don’t Know: 8
Q73 Can HIV transmitted through
faithful partner?
Yes: 1
No: 2
Don’t Know: 8
Q74 Can healthy looking person have
HIV?
Yes: 1
No: 2
Don’t Know: 8
Q75 Can eating with HIV/AIDS infected
person transmit HIV/AIDS
infection?
Yes: 1
No: 2
Don’t Know: 8
Q76 Can a person get HIV by injecting
with a needle and syringe that has
already been used by someone
else?
Yes: 1
No: 2
Don’t Know: 8
Q77 Have you received HIV/AIDS
education and/or information
about HIV?AIDS and drug use?
(Multiple answers possible)
NGO staff: 1
TV/radio: 2
Rehab center: 3
Family: 4
Never received: 5
Other (specify)……………….: 6
Don’t know: 8
Q78 Do you know VCCT? Yes: 1
No: 2
Don’t Know: 8
Q79 ARV services available in your
province for HIV/AIDS infected
people?
Yes: 1
No: 2
55
REFERENCES
1 Bros Khmer 2010: Behavioral Risks On-Site Serosurvey among At Risk Urban Men in
Cambodia.
2. Chhea C, Seguy N: HIV prevalence among drug users in Cambodia 2007. NCHADS &
NACD; 2010.
3 Ministry of Education Youth and Sport, 2010, Most At Risk Young People Survey
Cambodia 2010.
4. NCHADS: Report of a concensus workshop: HIV estimates and projection for Cambodia
2006- 2012. Phnom Penh: Ministry of Health; 2007.
5. Sopheab H, Chhea C, Tuot S: Baseline survey on HIV/AIDS knowledge, attitudes,
practices and related risk behaviors among MARP. Phnom Penh, Cambodia: KHANA;
2010.
6. UNAIDS: Guidelines on estimating the size of the populations most at risk to HIV;
UNAIDS/WHO working group on global HIV/AIDS and STI surveillance. 2010.
44
ANNEX: QUESTIONAIRE
Questionnaire Code:…………………
City/Province: 1. Phnom Penh 2. Battambang 3. Banteay Meanchey 4. Kampong Cham
5. Kampong Speu 6. Siem Reap 7. Svay Reang 8. Prey Veng 9. Sihanouk Ville
District/Khan: ………………………….. Interview Location: …………………………..........................
Introduction: “My name is………………………….. from NCHADS in collaboration with KHANA
and NACD. We are studying some issues related to drug users, their rates of HIV prevalence. I’m
going to ask you some very personal questions that some people nd difcult to answer. Your
answers are completely condential. Your name will not be written on this form, and will never be
used in connection with any of the information you tell me. You do not have to answer any questions
that you do not want to answer, and you may end this interview at any time you want to. However,
your honest answers to these questions will help us better understand what people think, say and do