Sam Samrithea shook his head as Thai Bunthorn laid out the plan for his next money-making scheme.
“No, pig raising is too hard. Pigs are more money. They get infected. You have so much potential with your chickens. It’s a risky investment,” Mr. Samrithea said.
Mr. Bunthorn then floated the idea of starting a fish farm, which Mr. Samrithea again shook his head at before calmly refocusing the conversation on his chicken farm.
“It would be better if you stuck with chickens,” Mr. Samrithea said.
Mr. Samrithea – formerly the social enterprise manager for Khana, the largest NGO providing HIV prevention, care and support services in Cambodia – walked over to Mr. Bunthorn’s chicken cages and started giving tips on how to expand them.
Mr. Bunthorn, 39, has been living with HIV since 1999. His brother died from AIDS in the early ’90s when the country was still trying to get a handle on the epidemic after its 1991 arrival in Cambodia.
In 1995 alone, there were an estimated 23,000 new infections and Mr. Bunthorn said there were no drugs available for his brother at the time.
“I’m lucky that I have survived this long,” he said while sitting next to his wife – who is also HIV positive – his mother and his young son.
He was born in Poneras village in Kampong Chhnang province and moved between working as a motodop and a laborer before his diagnosis.
With the help of Mr. Samrithea and Khana, he is transitioning into farming and is slowly learning the ins and outs of chicken raising, eagerly picking up on the sort of minutia that separate successful chicken farmers from the rest.
Mr. Samrithea and Mr. Bunthorn met through Khana’s Livelihood Program, a somewhat revolutionary approach in Cambodia to addressing the social stigmas, poverty and health issues that people with HIV struggle to overcome on a daily basis.
Sam Samrithea (right) discusses Thai Bunthorn’s chicken farm. (Photo: Jonathan Greig)
To commemorate World AIDS Day on December 1, US Ambassador William Heidt and UNAIDS country director Marie-Odile Emond urged Cambodia to “continue efforts to protect human rights, to ensure respect for all, to combat discrimination and to enable legal and policy environments,” for people infected with HIV.
But how do you combat discrimination? How do you ensure respect for all?
Despite the herculean efforts of both Cambodian medical officials and international organizations to successfully fight the epidemic’s spread in the kingdom, the next step in the process has largely been ignored.
The estimated number of new HIV infections fell from its peak of 20,978 in 1995 to 1,003 in 2014 and people living with HIV among adults aged 15 and over decreased from its peak of 102,440 in 2000 to an estimated 72,159 in 2014.
However, the lives of these 72,159 people living with HIV have rarely been explored. Outside of providing medical care and vital antiretroviral therapy (ART), few have asked them how they were coping with the virus, ignoring studies that show strong links between depression and poor adherence to ART, a more rapid progression of HIV and a lower quality of life.
Sadly, the situation is dire for many infected with HIV, even those now receiving regular treatment for the virus.
Khana’s researchers found that Cambodians with HIV were 3.5 times more likely to be diagnosed with depression than those who were not infected.
“There is a vicious cycle between HIV infection and poverty, wherein HIV-affected households are more likely to develop economic problems, which in turn worsen individuals’ symptoms,” they wrote in a study last year.
“Using only medical approaches is insufficient for supporting people living with HIV who are dealing with these multifaceted problems.”
Due to the physical toll of the treatment, many people with HIV have to search for new, less physically intensive professions, which can be difficult in small towns and villages where social stigmas around the virus outweigh all other factors.
This is where Khana stepped in.
Im Srey Mom and her family on their farm in Kampong Chhnang province. (Photo: Jonathan Greig)
Mr. Samrithea has worked on a variety of local economic programs for Khana since August 2007 and said the Livelihood Program started in April 2010.
Khana’s executive director Choub Sok Chamreun, one of the founding members of the program, said the idea for the initiative sprouted from the beneficiaries themselves, who told of ceaseless financial troubles and outright discrimination by local community members.
One of the goals of the Livelihood Program was to help people with HIV learn how to properly save their money and integrate them into more formal lending practices that can spare them the aggressive interest rates of private loan sharks.
For some infected with HIV, treatment can be a costly burden on already tight budgets. In a survey of 510 people with HIV involved in their programs, Khana found their average monthly income to be just less than $88.
“We help people save money and promote saving behavior for our beneficiaries. We have learned from our studies that the poor don’t know what they should save for,” Mr. Samrithea said.
“They keep their money in the wall so it’s too accessible. They use it and lose it.”
Mr. Samrithea explained that Khana, along with their implementing partners at local NGOs, created village savings and loan (VSL) associations comprised of anywhere between 10 and 30 people.
These groups were initially meant to stimulate the local economy and increase the savings of people with HIV in the community.
“Once they form the group, the first thing we tell them is that there will be three benefits from doing this,” Mr. Samrithea said.
“Their own savings, loans to group members at reasonable interest rates and emergency loans in case something happens.”
The VSL group creates a set of rules and regulations on a variety of things – interest rates, time limits on reimbursement, punishments for late payments, the group’s meeting schedule – before signing on the dotted line.
Each person can buy any number of shares, usually for between 5,000 and 10,000 riel, and the group puts the total sum in a local bank. After 10 to 12 months of accruing interest, people can cash out or put their money in again for the next year.
In each successive year, Khana takes less and less of a role in the group in the hope that participants will continue it on their own. But they do continue their support in other ways.
“Once people know how to save, give loans and pay loans, then the Khana staff works with them to see how they want to use the money. How are they going to use their new savings?” he said.
“Some people want to open small businesses, some people want to raise cows or chickens.”
The groups, he said, morphed into brainstorming sessions, with people contributing their own knowledge of certain fields or tasks to help others start businesses and try new things with their savings.
Once the beneficiaries figure out their plan of action, Khana provides them with free skills training sessions to help them along.
“This is a unique program in Khana. We are providing capacity building in technical skills through trainers with years of experience. They get theoretical skills and practical skills from watching,” Mr. Samrithea said.
All of the skills training sessions are held at Khana’s Livelihood Learning Center in Kampong Chhnang province. Beneficiaries are invited to come for free and allowed to stay at the center for the duration of the training. More than 2,000 people have come to the center for classes.
Sim Nhep has worked at the center since it was created in 2012 and said local government officials were helpful in providing Khana with land for the facility.
For him, participation in the classes at the center was personal. His cousin has HIV and that has propelled him into helping more people with the virus.
“They are poor, but they can still get help for these activities. The support, both financial and medical, from Khana brings hope to infected people,” Mr. Nhep said.
“We want to make them feel important. We want to let them know that they matter.”
Mr. Nhep is an experienced teacher at this point, and Mr. Samrithea said the trainings are a mix of classroom sessions on theory and hands-on lessons.
“We are not teaching them from step one. We are only picking up on the areas that are hardest for them,” Mr. Samrithea said.
“For chicken raising, we focus on chick selection, vaccination and medicine because many farmers have to deal with deaths. It’s the number one failing in the business.”
They also allow people in the group to give tips from their own experience, and this part of the program ended up blossoming into something greater than expected.
“We adopt storytelling because we feel that by using stories they can learn a lot from their peers. This is very practical. It’s easy for them to understand and they enjoy an environment where they are comfortable and learning,” he said.
The collaborative – as well as lucrative – nature of the groups fostered an unexpected closeness between the participants, turning the VSL associations into something more akin to support groups.
Members share their daily struggles with HIV equally as often as they share recipes and business tips.
“People with HIV and AIDS need not only medicine, not only prevention, but a livelihood to sustain themselves. By creating the VSL group, they have a platform and mechanism where they can meet, talk about their problems, share their experiences and support each other,” Mr. Samrithea said.
“It’s become about more than savings.”
The groups have been so successful in some communities that people who are not infected with HIV are eager to join, bringing a new fold into the initiative’s efforts to address the problems of people with HIV more holistically.
Siyan Yi, the founding director of the Center for Population Health Research at Khana, said interaction and exposure are integral for people with HIV.
“When you live alone, you just don’t know a better way. In the Livelihood Program and VSL, we did not restrict it to only PHIV [people with HIV]. The group only needs to be led by someone with HIV.
“When people in the community join, it may help reduce the gap. They work together and speak together and indirectly reduce discrimination.
“People still feel it, the shame of the disease,” he said.
“But the goal of the program is to reduce the stigma and discrimination in the community, so we provide an opportunity to improve their socio-economic conditions while at the same time connecting them to those who do not have HIV.”
Mr. Bunthorn, who has been involved in the Livelihood Program since 2011, said his VSL group finished its fifth year in December and their 30 members, both people with and without HIV, plan to sign up for another year.
“I’m proud to be a member of this group. I’m proud to have their support for my ideas and I’m proud to have such good relations with all of the VSL members,” Mr. Bunthorn said.
Mr. Yi was adamant that the program needed to be kept going, as Khana’s own research found that it was immensely helpful to almost everyone involved and gave the NGO an opportunity to conduct a variety of groundbreaking surveys on the HIV population in Cambodia.
“As you can see, people living with HIV can live normal lives for a long time. So it’s not just about the disease. It’s about the living conditions, the quality of life. Their overall well-being,” he said.
“If we only provide medical care and prevention, it will not solve the problem. We have to provide other support to improve their quality of life.”
Im Srey Mom agreed wholeheartedly.
The 44-year-old mother of four discovered she was HIV positive in 2011, months after her husband, 52-year-old Proeung Sinat, tested positive for the virus.
She started participating in Khana’s programs in 2012, joining a VSL group in her home village of Andong Rovieng in Kampong Chhnang province and subsequently receiving business training from the NGO. Her husband, who moved to the area from Battambang province, attended a poultry farming course and has been running his farm for a year now.
Their VSL group, she said, was made up entirely of people with HIV and is set to begin its fourth year after a short hiatus.
“We have access to loans for medicine and for our business and, at the meetings, we talk about health issues and each person goes around and talks about themselves,” she said.
“We feel happy, friendly and open to speak about any issues. By joining this program we can get skills training and have access to ideas about what kind of things we can do with ourselves, both from the group and from the program.
“No matter what, we want to continue this, even without the NGO.”
In Tek Hout commune, Kampong Chhnang province, Sun Thom’s VSL group helped her expand from chicken farming into making furniture out of coconut shells. Ms. Thom, 43, and her husband, Pov Sovann, moved to the area eight years ago from Kandal province and soon after realized they were both HIV positive.
Ms. Thom was forced to sell all of her land in Kandal province and spend everything they had on their treatment and children.
They both joined Khana’s programs in 2011, with Ms. Thom taking part in a food processing training session and Mr. Sovann learning chicken farming at the Livelihood Center.
They now have 200 chickens and are expanding into other small businesses with their savings from the VSL group, which finished its fifth year in December and has grown from five members to 30.
Many of those involved in the group are not HIV positive and plans are underway to split it into two groups to accommodate the deluge of new members for the next year.
The VSL group is depositing almost 10 million riel (about $2,500) in their local bank this year, more than they ever have before.
“This is what happens when both [HIV and non-HIV] work together. We settle issues easily and motivate each other,” she said.
Despite the overwhelming success of the program and the wealth of information gained on Cambodia’s HIV population, funding for the program ended in 2015. Mr. Samrithea said the donors, one of which is USAID’s PEPFAR program, wants more of a focus on health as well as medical treatment and asked them to move on from the Livelihood Program.
Cambodia’s success in fighting HIV and AIDS has become a problem for those living with the virus as international donors – who provide the lion’s share of monetary support for HIV and AIDS programs in Cambodia – move funding to other more at-risk nations and populations.
“Cambodia’s showing of success in response to HIV and AIDS has led to the funding from donors to decline since late 2015. About $20 million has been cut since then and this funding is going to get less and less in the near future,” Khana executive director Mr. Chamreun said.
He added that Khana is now looking into grants from the US as well as from UK Aid Direct and is already preparing proposals that will include some form of the Livelihood Program.
UNAIDS chief Ms. Emond said that while funding for HIV/AIDS programs was secured through 2017, subsequent years are shrouded in uncertainty.
“The funding for national AIDS response remains highly dependent on external resources, mainly the Global Fund to Fight AIDS, TB and Malaria and the US government, whose contribution has been declining for a few years,” she said.
“Though there has been some additional national funding allocated for the AIDS response, this does not totally compensate for the external resources’ decline.
“Cambodia is on the right track to be among the first countries to achieve its national goals of the elimination of new HIV infections and ending AIDS as a public health threat by 2025 [even before the global goal] but sufficient and well prioritized investment in the coming years will be decisive to make this a reality.”
She went on to lament the decline in the number of livelihood programs and said it was key in helping at-risk populations cope with their ailment and advance in society.
“Increasingly, people living with HIV who are on HIV treatment are doing much better in terms of health but indeed still need livelihood opportunities and want a job as any other Cambodian as they do not want to be dependent on aid. With external funding declining, there has clearly been a decline of livelihood programs specific for HIV-affected communities,” she said.
Even though funding for the programs is largely nonexistent now, both local and international groups have tried to help people with HIV integrate into broader social protection programs that are not specifically tailored to people with the virus.
The problem that they face, she said, is discrimination, both in the community and in the distribution of services and resources.
“Some key population groups such as sex workers, men who have sex with men, transgender people or people who inject/use drugs who are at higher risk for HIV also face additional livelihood hardship and difficulties to find jobs because of stigmatization and discrimination or other reasons,” she said.
“This can be a vicious circle leading some to a poverty trap which further increases their vulnerability to HIV and other health and social issues.”
The government, she said, has pledged to “not let successful programs collapse because of a lack of funding,” but the meager amount of subsidies they are now trying to provide will not offset the loss of international donations and cannot sustain efforts like Khana’s Livelihood Program.
In spite of the tenuous future of funding for HIV programs in Cambodia, the VSL groups Khana started continue to grow and expand with some freelance help from the local NGOs they worked with in the community. Mr. Chamreun said more than 4,000 people with HIV in 12 provinces participated in the program throughout its run.
Mr. Samrithea left Khana last September and took a job at the Mine Action Authority. But he was strident in his beliefs about the effect of Khana’s work and how worthwhile their mission was – while they had it.
“The key change is behavior. They know they can save and are willing to save. This is the biggest change. The change is in the confidence in knowing that they can do things like this. They are proud to participate in this social activity.
“Before, when there was an invitation to join any social activity, they were scared. But with the change in their livelihood, they seem to want to show themselves to the community. Some even talk about their HIV status without being asked,” he said.
“They are now like everyone else in the village.”
When asked if he was worried about what would happen to the program’s beneficiaries if there was no one to nurture the Livelihood Program and expand it, much less continue it officially, Mr. Samrithea turned and waved his hand at me as if I’d suggested pig farming.
“We were just watering these seeds,” Mr. Samrithea said. “The potential was always there and will be.”