Cambodia: clients find everything they need in one place.

The year was 1996. HIV incidence was clearly rising in Cambodia, but in Phnom Penh only one group--the Pasteur Institute--provided voluntary counseling and testing (VCT) for HIV. Incidence of HIV was mainly rising among people at high risk of infection. Yet, ominously, between 30 percent and 40 percent of clients (mainly married women) served at that time by the two-year-old Reproductive Health Association of Cambodia (RHAC) had reproductive tract infections (RTIs) or sexually transmitted infections (STIs). Such infections are, in themselves, risk factors for HIV infection. Furthermore, the same sexual behaviors that put people at risk for RTIs and STIs also put them at risk for HIV.

RHAC, an International Planned Parenthood Federation affiliate primarily supported by the U.S. Agency for International Development (USAID), was quick to act. That year, it sent staff to Thailand to learn to do HIV/AIDS counseling. It also began drawing blood samples for clients wanting to know their HIV status and sending samples to the Pasteur Institute for testing.

The following year, RHAC conducted a study of the feasibility of performing HIV testing at its own clinics. Staff reactions were mixed. "One-third of staff expressed doubts, but their professional expertise told them that the chances of serving AIDS patients would keep rising," recalls Dr. Var Chivorn, associate executive director of RHAC. Client reactions were more favorable: Most welcomed the introduction of HIV services into a package of existing services that included family planning, diagnosis and treatment of RTIs/STIs, pregnancy care, and counseling about and treatment of minor gynecological problems.

Overall, the study suggested that RHAC clinics should provide HIV testing. But the cost per test--at that time limited to the ELISA technique--was simply too high for RHAC. Then, in 2002, a breakthrough occurred: Rapid test methods, suitable for clinics where the volume of testing was too low to efficiently use the ELISA machine, became available. RHAC then moved forward to introduce HIV counseling and testing services, supported by the United Nations Children's Fund (UNICEF), into its six USAID-funded clinics.

VCT service guidelines for use by clinic staff and counselors were established. Informational materials were developed for staff use and for display in waiting rooms. HIV educational services via media and hot lines were created. More staff were added to busy clinics. Counselors were hired and trained. Nurses and midwives were trained to provide information about AIDS. Issues of HIV acquisition risks and post-exposure prophylaxis were addressed to reassure staff that they ran little risk of being infected. Alert systems in clinic rooms addressed provider fears that they might be in danger if clients became violent in reaction to a positive test. To better serve clients testing HIV-positive, links with home-based care teams, locations offering antiretroviral drug therapy, and the national tuberculosis center were established.

The next year, RHAC clinics provided VCT services to 13 percent (14,208) of their clients, of whom about 7 percent (some 995) were found to be HIV-infected. More than 100 infected clients needing additional services were referred either to home-based care teams or to tuberculosis centers.

Early concerns about the cost of providing HIV testing are no longer an issue. While a testing fee of U.S. $1 can be waived if a client cannot pay, the RHAC has found that "most clients are happy and able to pay this fee," says Dr. Chivorn. "RHAC has proved that, regardless of the fee, clients come for testing because the service is of good quality."

Similarly, fears that offering VCT services would be stigmatizing and scare away family planning and other clients were laid to rest. "We do not see any decline in family planning or other clients. In fact, clients in the clinics are increasing," says Dr. Chivorn. About 13 percent of clients now are men, most of whom come for STI services. RHAC has also trained staff to serve adolescents.

"Overall, clients have been happy to find everything they need in one place," says Dr. Chivorn. "This has strengthened RHAC's resolve to further integrate services, which now also include early detection of cervical cancer, premarital counseling, and support to rape victims. And, this year, child health services are being added."