Impact of integrated family planning and HIV care services on contraceptive use and pregnancy outcomes: a retrospective cohort study. The feasibility, demand, and effect of integrating primary care services with HIV voluntary counseling and testing: evaluation of a 15-year experience in Haiti, 1985-2000. Does the delivery of integrated family planning and HIV/AIDS services influence community-based workers' client loads in Ethiopia? Impact and process evaluation of integrated community and clinic-based HIV-1 control: a cluster-randomised trial in eastern Zimbabwe. Effective/efficient mental health programs for school-age children: a synthesis of reviews. Improving services for disadvantaged childbearing women. STD services for women at truck stop in Tanzania: evaluation of acceptable approaches. The use of routine monitoring and evaluation systems to assess a referral model of family planning and HIV service integration in Nigeria. The impact of scaling-up prevention of mother-to-child transmission (PMTCT) of HIV infection on the human resource requirement: the need to go beyond numbers. Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews. The impact of an integrated treatment on HIV risk behavior among homeless youth: a randomized controlled trial. A randomized controlled trial to promote long-term contraceptive use among HIV-serodiscordant and concordant positive couples in Zambia. Do targeted HIV programs improve overall care for pregnant women?: Antenatal syphilis management in Zambia before and after implementation of prevention of mother-to-child HIV transmission programs. HIV voluntary counseling and testing among injection drug users in south China: a study of a non-government organization based program. Feasibility and effectiveness of integrating provider-initiated testing and counselling within family planning services in Kenya. Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period. Integrating family planning into Ethiopian voluntary testing and counselling programmes. Adding consumer-providers to intensive case management: does it improve outcome? Changes in contraceptive use following integration of family planning into ART Services in Cross River State, Nigeria. Special features of health services and register based trials - experiences from a randomized trial of childbirth classes.
To determine the impact of routine care (RC) and integrated family planning (IFP) and HIV care service on family planning (FP) uptake and pregnancy outcomes.
                Retrospective cohort study conducted between October 10, 2005, and February 28, 2009.
                United States Agency for International Development-Academic Model Providing Access To Healthcare (USAID-AMPATH) in western Kenya.
                Records of adult HIV-infected women.
                Integration of FP into one of the care teams. PRIMARY OUTCOMES MEASURES: Incidence of FP methods and pregnancy.
                Four thousand thirty-one women (1453 IFP; 2578 RC) were eligible. Among the IFP group, there was a 16.7% increase (P < 0.001) [95% confidence interval (CI): 13.2% to 20.2%] in incidence of condom use, 12.9% increase (P < 0.001) (95% CI: 9.4% to 16.4%) in incidence of FP use including condoms, 3.8% reduction (P < 0.001) (95% CI: 1.9% to 5.6%) in incidence of FP use excluding condoms, and 0.1% increase (P = 0.9) (95% CI: -1.9% to 2.1%) in incidence of pregnancies. The attributable risk of the incidence rate per 100 person-years of IFP and RC for new condom use was 16.4 (95% CI: 11.9 to 21.0), new FP use including condoms was 13.5 (95% CI: 8.7 to 18.3), new FP use excluding condoms was -3.0 (95% CI: -4.6 to -1.4) and new cases of pregnancies was 1.2 (95% CI: -0.6 to 3.0).
                Integrating FP services into HIV care significantly increased the use of modern FP methods but no impact on pregnancy incidence. HIV programs need to consider integrating FP into their program structure. HIV voluntary counseling and testing (VCT) may be an effective strategy to prevent transmission of HIV in developing countries. Hypothesizing that primary care services and HIV VCT have synergistic benefits, we examine the feasibility, the demand, and the effect of integrating on-site primary care services into VCT at a stand-alone VCT center in Port au Prince, Haiti.
                Through a retrospective review of patient records, we describe the integration of primary care services at the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) VCT center between1985 and 2000.
                Between 1985 and 1999, services for HIV care, tuberculosis care, treatment of sexually transmitted diseases, and reproductive health were sequentially integrated into HIV VCT at GHESKIO. The number of new people seeking voluntary counseling and testing at GHESKIO increased from 142 in 1985 to 8175 in 1999, with an increasing percentage of women, adolescents, symptom-free clients, and self-referred clients. Of new adults seeking VCT in 1999, the center was able to provide AIDS care to 17%, tuberculosis treatment to 6%, sexually transmitted infection management to 18%, and family planning to 19%. HIV transmission between discordant couples was 0 infections/100 follow-up years (95% CI, 0-3.2); vertical transmission from mother to child was 11 infections/100 live births (95% CI, 4.6-21.9); These rates are significantly lower than expected rates of transmission in Haiti.
                This report demonstrates the feasibility, demand, and effective synergy of integrating on-site primary care services into HIV VCT in Haiti. VCT is a good entry point for people in need of services for communicable diseases and reproductive health, and, reciprocally, services attract more people to VCT, including populations that are at high risk for HIV infection. This program is being duplicated elsewhere in Haiti and can serve as a model for other countries. Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents' demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents' capacity to provide integrated services than demographic characteristics, while agents' gender and work-related characteristics are significantly associated with increased likelihood of serving more clients. HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.
                We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92-1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24-0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28-0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21-5.12).
                Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups. The prevalence of mental health problems, some of which seem to be occurring among younger cohorts, leads researchers and policy-makers to search for practical solutions to reduce the burden of suffering on children and their families, and the costs to society both immediate and long term. Numerous programs are in place to reduce or alleviate problem behaviour or disorders and/or assist positive youth development. Evaluated results are dispersed throughout the literature. To assess findings and determine common elements of effective children's services, a literature search was undertaken for evidence-based evaluations of non-clinical programs for school-age children. Prescriptive comments aim to inform service-providers, policy-makers and families about best practices for effective services such as: early, long-term intervention including reinforcement, follow-up and an ecological focus with family and community sector involvement; consistent adult staffing; and interactive, non-didactic programming adapted to gender, age and cultural needs. Gaps are identified in our understanding of efficiencies that result from effective programs. Policy implications include the need to develop strategies for intersectoral interventions, including: new financing arrangements to encourage (not penalize) interagency cooperation and, to ensure services reach appropriate segments of the population; replication of best practices; and publicizing information about benefits and cost savings. In many jurisdictions legislative changes could create incentives for services to collaborate on service delivery. Joint decision-making would require intersectoral governance, pooling of some funding, and policy changes to retain savings at the local level. Savings could finance expansion of services for additional youth. Tackling health inequalities is high on the political agenda of the Labour government. The government wants to reduce inequalities through policies based on evidence, the health of childbearing women and their babies being priority areas for action. National Service Frameworks (NSFs) are being set up to ensure high quality services for all groups. The External Working Group looking into maternity services for the Children's NSF seeks evidence upon which to plan strategies for all women, while focusing attention on the most disadvantaged. Wide differentials are noted between high- and low-income groups in the outcomes of pregnancy and the health of babies. The worst outcomes appear to be concentrated in small subgroups of disadvantaged women.
                To report on a review of studies of interventions improving perinatal outcomes for disadvantaged women, to inform policy and practice around the organization and delivery of statutory services in the UK.
                We searched six relevant databases for reviews, intervention studies, audits and descriptions of services reporting outcomes for disadvantaged groups of women, published between 1990 and 2003. Synthesis was performed around what works and what does not work. Gaps in the evidence base were identified.
                We found limited evidence of effective and promising interventions for childbearing women from minority ethnic groups, women experiencing domestic violence, women with mental health illness and HIV infected women. Few studies were well-designed or powered to detect effectiveness. There were no studies of interventions for women prisoners, homeless women and travellers.
                Searching for intervention studies primarily by participant subgroup has brought in evidence from few well-designed studies on which to plan policy. Combining this approach with searching for intervention studies addressing behaviour like smoking, and needs like social support, may provide further evidence to tackle inequalities in the perinatal period. AIDS continues to be the commonest cause of death in Tanzania among those aged between 15 and 45 years. Both ulcerative and non-ulcerative sexually transmitted diseases have been identified as major co-factors in HIV transmission. Certain groups including long distance truck drivers and their sexual partners have been reported as having a disporportionate effect on the transmission dynamics of STD including HIV, in a population. In 1993 African Medical and Research Foundation decided to add an STD component to their HIV/AIDS prevention programme along the Tanzania-Zambia highway which had been targeting truck drivers and their sexual partners through peer education and condom distribution since 1989. A study to evaluate the acceptability and feasibility of four different approaches of delivering STD services, was conducted over a period of one year. The approaches for delivering STD services were: special STD services offered twice a week at a site and at hours of the women's choice, special outreach services once every three months, or STD services integrated into the nearest Primary Health Clinic. Drugs were provided at three of the four interventions. 1,330 women at seven truckstops, participated in the evaluation study. The women were generally satisfied with all approaches that included the provision of drugs. The most expensive and ineffective way of treating STD was by not providing drugs. These findings confirm the fact that it is feasible to provide STD services to women at high risk in HIV high transmission areas. These women would utilise STD services provided in a manner that suits them if mobilised and encouraged by their peer educators. To measure changes in service utilization of a model integrating family planning with HIV counselling and testing (HCT), antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in the Nigerian public health facilities.
                It is a retrospective survey of attendance and family planning commodity uptake in 71 health facilities in Nigeria that analyzes the preintegration and postintegration periods between March 2007 and January 2009.
                A prepost retrospective comparison of mean attendance at family planning clinics and couple-years of protection (CYP) compared 6 months preintegration with 9 months postintegration period. An analysis of service ratios was conducted, relating completed referrals at family planning clinics to service utilization at the referring HIV clinics.
                Mean attendance at family planning clinics increased significantly from 67.6 in preintegration to 87.0 in postintegration. The mean CYP increased significantly from 32.3 preintegration to 38.2 postintegration. Service ratio of referrals from each of the HIV clinics was low but increased in the postintegration period by 4, 34 and 42 per 1000 clients from HCT, ART and PMTCT clinics, respectively. Service ratios were higher in primary healthcare settings than in secondary or tertiary hospitals. Attendance by men at family planning clinics was significantly higher among clients referred from HIV clinics.
                Family planning-HIV integration using the referral model improved family planning service utilization by clients accessing HIV services, but further improvement is possible. Male utilization of family planning services also improved. The government of Nigeria should review the family planning user fee policy and scale up the integration in primary healthcare facilities. Although the mother-to-child transmission (MTCT) contributes only 5% of transmission of HIV infection, its impact has reversed the decline in infant and child mortality rates. With antenatal service coverage of over 90%, the integration of prevention of MTCT (PMTCT) of HIV infection into the Reproductive and Child Health (RCH) services in Tanzania, this is likely to overstretch the staff capacity and undermine the already compromised quality of health care services. A retrospective study was conducted to assess the impact of integrating and scaling-up PMTCT of HIV infection into routine RCH services, on the magnitude of staff workload in RCH clinics. The study was conducted in 60 health facilities identified from five regions that had participated in the pilot phase of PMTCT implementation in the Mainland Tanzania. The average staff workload was calculated from staff-load obtained from attendance records and activity-time obtained by direct observation; and staff-time from records that were kept at the clinic. The average staff workload was found to be 50.5% (8-147%) for facilities providing PMTCT of HIV infection and 37.8% (11-82%) for facilities without PMTCT services. The average staff workload was computed on the assumption that all clients attending various antenatal clinics received PMTCT services from trained staff only and the result revealed staff workload of 87.2%. This study concludes that services for PMTCT of HIV infection can easily be scaled-up and integrated into RCH services using the already existing staff. In the wake of the human resource crisis in the health sector in developing countries, strategies to address the problem will need to go beyond numbers to address issues of staff productivity and their distribution.
                Copyright 2008 John Wiley & Sons, Ltd. Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care and achieving the vision of the Alma-Ata Declaration. Effective governance, financial and delivery arrangements within health systems, and effective implementation strategies are needed urgently in low-income and middle-income countries. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to primary health care in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades. While many studies provide useful information on the risk behaviors in which homeless youth engage, few prior studies evaluate Human Immunodeficiency Virus (HIV) risk related reduction strategies. In this study, homeless youth (n = 180) were recruited from a drop-in center and randomly assigned to one of two conditions, either an integrated individual cognitive-behavioral treatment and HIV prevention intervention that focused on skills building and education or to treatment as usual. All youth were assessed at entry into the program and at 3 and 6 month follow-up points. Findings showed an interaction between treatment condition, age and time. In the interaction, youth assigned to the integrated treatment reported greater condom usage than youth assigned to treatment as usual, with younger youth assigned to treatment as usual showing no change in condom use. The number of sexual partners reported by youth in both treatment conditions was also reduced over time. However, youth in both conditions continued to engage in other high-risk behaviors. The integrated treatment findings are promising and suggest that interventions which target both HIV risk behavior in addition to other life areas (substance use, mental health and housing) among homeless youth may be necessary in order to significantly impact high-risk behaviors among this unique group. Countries facing high HIV prevalence often also experience high levels of fertility and low contraceptive use, suggesting high levels of unmet need for contraceptive services. In particular, the unique needs of couples with one or both partners HIV positive are largely missing from many current family planning efforts, which focus on the prevention of pregnancies in the absence of reduction of the risk of HIV and other sexually transmitted infections (STIs).
                This article presents an examination of contraceptive method uptake among a cohort of HIV serodiscordant and concordant positive study participants in Zambia.
                Baseline contraceptive use was low; however, exposure to a video-based intervention that provided information on contraceptive methods and modeled desirable future planning behaviors dramatically increased the uptake of modern contraceptive methods.
                Including information on family planning in voluntary counseling and testing (VCT) services in addition to tailoring the delivery of family planning information to meet the needs and concerns of HIV-positive women or those with HIV-positive partners is an essential step in the delivery of services and prevention efforts to reduce the transmission of HIV. Family planning and HIV prevention programs should integrate counseling on dual method use, combining condoms for HIV/STI prevention with a long-acting contraceptive for added protection against unplanned pregnancy. The implementation of disease-specific research or service programs may have an ancillary beneficial or harmful impact on routine clinical services.
                We reviewed the records of 5801 first visits to 22 antenatal clinics from 1997 to 2004 in Lusaka, Zambia and examined documented syphilis rapid plasma reagin (RPR) screening and syphilis treatment before and after implementation of research and/or service programs in prevention of mother-to-child (PMTCT) HIV transmission.
                Compared with before PMTCT program implementation, the prevalence odds ratios (PORs) and 95% confidence intervals (CIs) for documented RPR screening were 0.9 (0.7 to 1.1) after implementation of research, 0.7 (0.6 to 0.8) after service, and 2.5 (2.1 to 3.0) after research and service programs.
                Documented RPR screening was improved after implementation of PMTCT research and service were operating simultaneously and not with research or service alone. Health policy makers and researchers should plan explicitly for how the targeted HIV programs, service, and/or research can have a broader primary care impact. HIV voluntary counseling and testing (VCT) programs are usually delivered by government health agencies in China. This study examined the feasibility of using a Chinese non-government organization (NGO) to deliver a VCT program to injection drug users (IDUs) in a southern Chinese city. The process data indicated the program successfully recruited and served 226 male and female IDUs in 4 months. The HIV prevalence rate of the study population was 57.5% by rapid HIV testing with a secondary rapid test to confirm. Quantitative and qualitative evaluations indicated that the VCT program was implemented appropriately and participants' HIV knowledge and safe drug and sex practices were significantly improved after participation in the VCT program. This study demonstrates the feasibility of a Chinese NGO to provide VCT for IDUs and documents the processes and outcomes of the program. There remains a great need to find additional sources to provide VCT and other HIV prevention services to IDUs and other high-risk populations in China. Chinese NGOs have the potential to fill this need. To assess an intervention for increasing access to and use of HIV testing among family planning clients through provider-initiated testing and counselling for HIV.
                Two versions of the intervention were prospectively compared using a prepost intervention only design. Health facilities were purposively selected and family planning consultations randomly selected.
                Twenty-three public-sector hospitals, health centres and dispensaries in two districts of Central Province, Kenya.
                One group of 28 family planning providers were trained in the integrated family planning-HIV counselling intervention and in providing HIV testing and counselling to family planning clients requesting a test during the consultation and another group of 47 family planning providers were trained in the intervention and in referring clients interested in an HIV test. Samples of family planning clients willing to be observed and interviewed were randomly selected (538 preintervention, 520 postintervention) and their informed consent obtained to observe their consultation.
                All family planning providers were trained in an algorithm that integrates HIV/sexually transmitted infection prevention counselling, including offering HIV testing and counselling, with family planning counselling. Clients choosing to be tested were either referred or tested during the consultation by a trained family planning provider.
                The proportion of family planning clients with whom HIV testing was discussed; the proportion offered HIV testing; and the proportion choosing to have a test.
                The proportion of consultations in which HIV prevention counselling was provided and HIV testing offered increased significantly. The proportion of clients requesting an HIV test increased from 1 to 26%; approximately one third of these had never been tested previously.
                Provider-initiated testing and counselling is feasible and acceptable in family planning services, does not adversely affect the quality of the family planning consultation and increases access to and use of HIV testing in a population who would benefit from knowing their status. Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities. Governments and donors encourage the integration of family planning into voluntary testing and counselling (VCT) services. We aimed to determine if clients of VCT services have a need for and will accept quality family planning services.
                'Voluntary HIV counselling and testing integrated with contraceptive services' is a proof-of-concept study that interviewed 4019 VCT clients before the addition of family planning services and 4027 different clients after family planning services were introduced. Clients attended eight public VCT facilities in the Oromia region, Ethiopia. The intervention had four components: development of family planning counselling messages for VCT clients, VCT provider training, contraceptive supply provision and monitoring.
                Ethiopia's population of 80 million is increasing rapidly at an annual rate of 2.5%. Contraceptive prevalence is only 15%. The estimated adult HIV prevalence rate is 2.1%, with more than 1.1 million people infected. The number of VCT facilities increased from 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled from 1.7 million tests in 2007 to 3.5 million in 2008.
                Clients interviewed after the introduction of family planning services received significantly more family planning counselling and accepted significantly more contraceptives than those clients served before the intervention. However, three-quarters of the clients were not sexually active. Of those clients who were sexually active, 70% were using contraceptives.
                The study demonstrated that family planning can be integrated into VCT clinics. However, policy-makers and programme managers should carefully consider the characteristics and reproductive health needs of target populations when making decisions about service integration. Over the past decade, there has been increasing interest in the employment of mental health consumers in various roles as providers of services. Although integration of consumers into case management services has been studied, the roles of consumers have been poorly defined and the benefits have not been established. The goal of this study was to evaluate whether consumers enhance case management outcome through the provision of social support.
                This study compared consumer-assisted and non-consumer-assisted case management with standard clinic-based care. The consumer role focused on the development of social support by using peer staff who matched the profile of participants. A total of 203 clients with severe and persistent mental illness were randomly assigned to one of the three conditions and followed for 12 months.
                All three programs yielded the same general pattern of improvement over time for symptoms, health care satisfaction, and quality of life. Clients in the three programs also showed similar but small changes in measures of social network behavior. Consumer-assisted case management was unique in its use of peer-organized activities. Non-consumer-assisted case management made greater use of individual contacts with professional staff. Standard clinic-based care relied more on group and on individual therapy. Despite these variations in the pattern of services over a 12-month period, no one program emerged as categorically superior to the others.
                Although more research is needed to determine optimal roles for consumers in mental health service delivery, a randomized trial found no evidence that the presence of consumers enhances case management outcome. One strategy for meeting the contraceptive needs of HIV-positive women is to integrate family planning into HIV services. In 2008 in Cross River State, Nigeria,family planning was integrated into antiretroviral (ART) services in five local government areas. A basic family planning/HIV integration model was implemented in three of these areas, and an enhanced model in the other two. We conducted baseline interviews in 2008 and follow-up interviews 12-14 months later with 274 female ART clients aged 18-45 in 2009 across the five areas. Unmet need for contraception was high at baseline (28-35 percent). We found that modern contraceptive use rose in the enhanced and basic groups; most of the increase was in consistent condom use. Despite an increase in family planning counseling by ART providers, referrals to family planning services for noncondom methods were low. We conclude by presenting alternative strategies for family planning/HIV integration in settings where large families and low contraceptive use are normative. Evaluating complex interventions in health services faces various difficulties, such as making practice changes and costs. Ways to increase research capacity and decrease costs include making research an integral part of health services and using routine data to judge outcomes. The purpose of this article is to report the feasibility of a pilot trial relying solely on routinely collected register data and being based on ordinary health services.
                The example intervention was education to public health nurses (PHN) (childbirth classes) to reduce caesarean section rates via pre-delivery considerations of pregnant women. 20 maternity health centers (MHC) were paired and of each 10 pairs, one MHC was randomly allocated to an intervention group and the other to a control; 8 pairs with successful intervention were used in the analyses (1601 mothers). The women visiting to the study maternity centers were identified from the Customer Register of Helsinki City. A list of the study women was made using the mother's personal identification number, visit date, the maternity center code, birth date and gestation length. The mode of delivery and health outcomes were retrieved from the Finnish Medical Birth Register (MBR). Process data of the intervention are based on observations, written feedback and questionnaires from PHNs, and project correspondence.
                It took almost two years to establish how to obtain permissions and to actually obtain it for the trial. Obtaining permissions for the customer and outcome data and register linkages was unproblematic and the cluster randomization provided comparable groups. The intervention did not succeed well. Had the main aim of the trial been to cause a change in PHNs behavior, we would have very likely intensified the intervention during the trial.
                Our experiences encourage the use of trials that obtain their outcomes from registers. Changing the behavior of ordinary health service providers is a challenging intervention.
                not registered (see Results).
This systematic review's findings show that integrated HIV/AIDS and MNCHN-FP services are feasible to implement and show promise towards improving a variety of health and behavioral outcomes. However, significant evidence gaps remain. Rigorous research comparing outcomes of integrated with non-integrated services, including cost, cost-effectiveness, and health outcomes such as HIV and STI incidence, morbidity and mortality are greatly needed to inform programs and policy.