The exchange of sex for money remains a major driver of the spread of HIV/AIDS throughout Southeast Asia, but the karaoke bars, massage parlors, beer gardens, and other settings where these transactions are brokered remain some of the most viable employment venues for vulnerable women.

In Cambodia—where more than 10 percent of female entertainment workers are infected with HIV, and more than 25 percent of these women and girls report having no education—USAID programming supported by the U.S. President's Emergency Plan for HIV/AIDS Relief (PEPFAR) is implementing a new approach to reducing HIV risk by focusing on the central principle of the Global Health Initiative: that the health and well-being of women is key to the health of all.

Instead of exclusively focusing on distributing condoms and conducting risk-reduction education for high-risk women, the SmartGirl program aims to improve the sexual and reproductive health of its beneficiaries more broadly through linkages to personal counseling, voluntary family planning services, clinical care, savings schemes, and legal services.

Late last year, the program received a PEPFAR Heroes award from the Office of the U.S. Global AIDS Coordinator for its efforts to reduce the risks associated with entertainment work, while also supporting women in the pursuit of other employment.

"We're committed to having women in the driver's seat," said Michael Cassell, the coordinator of the PEPFAR initiative in Cambodia. "SmartGirl is largely designed and run by entertainment workers to address their own felt needs. And the skills they acquire in the process help many of them to consider and pursue other careers, including ones in HIV and reproductive health service delivery."

Avoiding "Message Fatigue"

Previous HIV/AIDS programs have focused on raising awareness of HIV, and educating people about how to avoid getting infected. But by demonstrating that staying healthy is key to the pursuit of education, wealth, happiness, and other personal objectives, SmartGirl strives to engage beneficiaries while sidestepping some of the "message fatigue" and monotony associated with more didactic approaches. Education sessions are run by peers, cover a broad range of topics that are updated regularly, and offer referrals to free HIV testing, family planning, and other services.

During a recent visit to a SmartGirl club in Phnom Penh, U.S. Rep. Laura Richardson (D-Calif.) was inspired to join program beneficiaries in a rousing karaoke rendition of Gloria Gaynor's "I Will Survive," noting her appreciation for the leadership of club members in providing health education and referrals to health care, vocational training, and legal services to other entertainment workers.

"I am so proud of you," Richardson told the club members.

The SmartGirl program, which is implemented by USAID-partner Family Health International, currently provides services to 12,600 of the estimated 35,000 women working in clubs and night spots in Cambodia. The program is funded by PEPFAR but is consistent with the overarching objectives of the Global Health Initiative, the U.S. government's six-year, $63 billion commitment to help partner countries strengthen their health systems, with a particular focus on improving the health of women, newborns, and children.

"Almost 30 percent of entertainment workers in Cambodia report having an abortion in the past year, suggesting inconsistent condom use and unmet needs for family planning," said Cassell. "By linking these women to sexual and reproductive health services, we stand to prevent new HIV infections while also reducing maternal mortality—the latter arguably being Cambodia's biggest public health challenge."

A Model Approach

Cambodia is home to one of the most renowned national success stories in the fight against HIV/AIDS. Late last year, the country received international recognition in the form of a Millennium Development Goals country award for cutting adult HIV prevalence in half, from 2 percent to 0.9 percent between 1998 and 2006, while extending HIV-related care to more than 70 percent of HIV-infected adults, and HIV treatment to more than 90 percent of eligible individuals.

The estimated proportion of sex workers infected with HIV is down to around 10 percent from over 21 percent in 2003, according to the 2006 HIV Sentinel Surveillance (HSS). However, the maternal mortality ratio in Cambodia remains the second highest in East Asia.

"We're particularly excited about the potential of this program to serve as a model for the scale up of higher quality and more holistic approaches to address the needs of populations at high risk for HIV infection," said Cassell. "Many of the service delivery and referral protocols pioneered through SmartGirl are now being implemented as part of Cambodia's national program with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria."

In the past decade, the U.S. government has invested more than $150 million in HIV/AIDS programs in the Southeast Asian nation, providing almost 40 percent of the resources available to the national response.