The Linked Response: Lessons Emerging from Integration of HIV and Reproductive Health Services in Cambodia

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission. 1. Introduction Over the last decade, the importance of linking sexual and reproductive health and HIV policies, systems, and services has been increasingly recognized. Several studies have shown how such linkages might be beneficial for both HIV and reproductive health (RH) programmes [1, 2]. More specifically, efforts have been deployed to integrate HIV testing, care, and, more recently, treatment within antenatal and delivery care services as a strategy to prevent mother-to-child transmission of HIV (PMTCT; [3]). A systematic review concluded that limited, nongeneralizable evidence supports the effectiveness of integrated PMTCT programmes versus non- or partially integrated services [4]. Limited evidence also suggests that PMTCT integration may improve the overall quality of antenatal (ANC) and delivery care services and female attendance at ANC services [4–9], although causal relationships are hard to ascribe [10]. Conversely, however, some commentators have noted that the integration of PMTCT might decrease quality of care and have potential negative