The CHC initiated its work in 1994 with a pilot project in Svay Rieng, a rural province bordering Vietnam that has one of the highest TB rates in the country and the world (approximately 700 cases of TB per 100,000 people). Subsistence agriculture is the primary source of income for most of Svay Rieng's residents. Because of the poor soil quality and decades of war, Svay Rieng was and remains one of Cambodia's poorest provinces. The CHC TB program pioneered a community-based, patient-centered approach to the treatment of TB. The Svay Rieng project, based in local district hospitals, combined directly observed therapy (DOT) with CHC innovations such as the use of patient supporters, treatment contracts, and  nutritional support. Some patients received home delivery of medicines from mobile teams of health workers. Poverty reduction strategies were an integral pat of the program, which linked microcredit and village bank programs to TB education and treatment.

In 1997, CHC expanded its program to the province of Kompot, a former stronghold of the Khmer Rouge. The CHC’s efforts began just a few months after the Khmer Rouge put down its guns in its long-standing civil war with the Cambodian government. CHC rapidly scaled up care for TB using its signature approaches of community health workers, patient supporters, food, treatment contracts, and training. At the same time, the organization began to build a village network with village bank and HIV prevention activities.

From this initial pilot project in three district hospitals of Svay Rieng Province in 1994, CHC has progressively scaled up comprehensive TB care to include more and more Cambodians. Currently, CHC TB treatment and TB/HIV screening programs cover Svay Rieng, Kompot and the whole of Kandal province, which surrounds the capital city of Phnom Penh. The total area of activity embraces a population of 1,242,507, which includes 90 health centers and 1083 villages.

Starting in 1997, the CHC provided HIV/AIDS education and prevention programs in Svay Rieng ad Kompot, and later established an AIDS clinic at the Svay Rieng Provincial Hospital.  In 2005, the CHC began the first district-level AIDS treatment program in rural Cambodia, with the delivery of AIDS medicines from in the Kompong Trach district of Kompot. Today, the CHC oversees rural AIDS programs in both Kompot and Svay Rieng, providing 3,000 people with desperately needed AIDS care.

CHC activities in rural Cambodia have strengthened the capacity of the National Tuberculosis Program and the National AIDS Program, and have built strong community and organizational links to educate, prevent and treat both diseases. The CHC has also sought to incorporate basic research into its efforts, in partnership with labs at Harvard University Medical School, which offer the most sophisticated molecular and immunological approaches available to study disease. With its approach of linking community-based care to the best in scientific discovery and treating patients as partners, the CHC strives to learn lessons that will lead to future treatments, vaccines and cures.

The CHC believes that its success in joining TB and AIDS discovery and care with access to drugs and poverty reduction programs,  provides a powerful example of a practical approach that could be used by other organizations and governments worldwide who are grappling with TB and AIDS.

From its inception, the CHC has worked closely with the Cambodian National TB Program to set up clinics and DOTS programs all over Cambodia. Many of the CHC’s pioneering strategies have been incorporated into national program, CHC clinics have become training sites for national program staff, as well as Cambodian and international non-government organizations interested in TB and AIDS care.

Today, the clinic-based activities of the CHC and Cambodian national TB program provide care to thousands of people who otherwise would have gone without. However, these efforts only address the needs of part of the population. For many rural TB patients, traveling to the clinic to collect medicine is difficult. Poor road conditions, the cost of travel, and the need to take time away from work and family responsibilities all present barriers to seeking medical help. This is particularly true for people who live on less than a dollar a day, and depend on the wages of that day’s work to feed their families. Because of these factors, some people with TB get no treatment, others are not diagnosed until their disease is very severe, causing irreversible lung damage and rendering them pulmonary cripples.

To address these issues, the CHC created a TB Home Care DOTS program, which began in 1999 and has benefited over 3000 patients to date. This pioneering program provides patients with daily home delivery of drugs by CHC mobile health teams during the week and uses patient supporters to ensure medication is taken on the weekend during the initial two-month intensive phase of TB therapy. At the same time, the mobile teams screen clusters of villages, going house-to-house to find people who may be suffering from TB. By doing this, TB can be diagnosed and treated earlier, before the infection has had an irreversible impact on patients’ lungs and health. In Home Care DOTS areas where this active case finding has been instituted, more than 90 percent of new cases are detected. This leads to improved health outcomes for people when their disease is discovered  and can be treated relatively early. At the same time, efficient detection helps limit the spread of TB, which occurs when people with untreated lung infections cough, sneeze or even talk.  

In an effort to increase accessibility for vulnerable rural populations, in 2002 the CHC developed a Community DOTS program in Cambodia, which trains community volunteers, sometimes former TB patients, to assist with distribution of TB medications. This program expands the reach of treatment beyond the area of mobile health teams, by training community members to help patients adhere to their medication regimen during the entire course of treatment. The CHC mobile staff provides guidance to the patient and their supporter, during all phases of treatment. The CHC Community DOTS initiative has been able to further increase detection, education and cure rates as well as engaging the community in controlling the spread of TB.  The program, which covers all of Svay Rieng Province has become a training site for staff from a variety of non-governmental health organizations and the National TB Program. Planning is in progress to scale up the Community DOTS program to cover the entire country.

CHC is leading the Community DOTS efforts in Cambodia and has been a training site for staff from a variety of NGOs and the TB National Program. If patients live within 1km of a health center, they receive TB DOT at the health center.  If they live outside of this area, they receive DOT from a trained community member, who is a volunteer and a former TB patient or TB patient family member in the patient's village, and who is rotated approximately every 6 months.  Currently in Kompot and Svay Rieng provinces, CHC covers a catchment area of approximately 998,452 people.  In 2008 we anticipate expanding our direct activities in Community DOTS and TB/HIV screening to the whole of Kandal province (where Phnom Penh is located) to covered a population of 1,242,507, which includes 90 health centers and 1083 villages.

The CHC is the only local non-governmental organization in Cambodia that is providing treatment for AIDS in rural areas. Building upon a small HIV treatment project that started in 2004, the CHC is now engaged in the scaling up of a comprehensive community based program of prevention, treatment and awareness for HIV/AIDS. CHC is providing treatment for over three thousand HIV/AIDS patients, with over 98% treatment adherence, in its provincial ART clinics, as well as supporting dozens of community based HIV/AIDS support groups.

CHC began its rural HIV treatment program in Svay Rieng at a time when no AIDS treatment was available anywhere in rural Cambodia. In January of 2004, the CHC purchased some medicines with a private donation and began a pioneering home delivery DOT program of AIDS drugs to 36 villagers who were close to death. Four years later, most of the initial patients are living productive and healthy lives with undetectable viral load in their blood.

From this beginning, the CHC demonstrated its firm commitment to rural care as a key to successfully fighting HIV in Cambodia. Treating patients in their home province maintains the strong social connections and support networks that are destroyed when patients seek care in urban centers. Community-based treatment programs prevent the homelessness and family separations that occur when parents must leave home to get medical attention.  AIDS is a family disease and often attacks both parents and children. Community care allows our multidisciplinary team to focus on all members of the family who may need not only medical but social support.

Beyond medical care, the CHC is also committed to increasing community involvement in providing education, access to drugs, care and prevention for HIV/AIDS. In Kompot Province, the CHC has helped establish more than 22 support groups for persons living with HIV/AIDS. These groups are trained in human rights issues, psychological services, care and treatment, counseling, program planning and monitoring and evaluation. Community support groups are an important mechanism for reaching all HIV patients and linking them to existing clinics for care, medication and treatment.  Support group members make home visits in the community to increase knowledge and awareness of HIV/AIDS, thus reducing stigma and discrimination. These activities are linked with poverty reduction strategies such as providing shelters, school uniforms and materials, and loans for income generation activities. The CHC believes that only by empowering the community can we prevent the spread of the disease, and expand access to HIV/AIDS drugs. 

In Cambodia, as in the rest of the world, the burden of diseases like TB and AIDS falls disproportionately on those who can least afford it. Poverty and disease are perilously intertwined, and each makes the other worse. People with limited resources are less likely to be able to afford the food they need to keep their immune systems strong to fight off disease. They are less able to afford travel costs to visit a clinic, so usually their disease has become very serious by the time it is diagnosed. Even with diagnosis and treatment, illness can be a significant drain on already inadequate resources. With the cost of medicine and time away from work, illness is the major reason for rural debt.  

From 1994 until 2005, the TB treatment program was linked to a network of village banks. The poorest residents of the villages were invited to join these banks, which made small, low-interest loans to groups of women who agreed to collectively provide collateral to one another. The loans were invested in income-generating ventures such as small businesses and agricultural projects. Examples of businesses created by village bank members include noodle shops, pig-raising projects and handicrafts businesses. Income generated from interest on the loans funded the training of dozens of village health workers, who provided community education on TB, and AIDS and other sexually transmitted infections, and referred suspected TB cases to the CHC.

Participating in a village bank improved patient compliance with TB treatment: among village bank participants who had TB or had a family member with TB, TB cure rates exceeded 99 percent. Similarly, loan repayment among TB-affected families has been higher than in the program overall.

By working to eliminate poverty, village banks address one of the underlying causes of disease in Cambodia. The village bank program, which was operational in both Svay Rieng and Kompot provinces, became an independent Cambodian Microfinance Institution, CHC-Limited, in 2005.