Structure and quality of outpatient care for people living with an HIV infection

Figures & data

Figure 1. Countries in which the identified studies were based (n = 28).

Table 1. Summary of assessed structural characteristics (n = 28).

Structural characteristics	Sources (Author, year, countries)
Health facility characteristics
Facility volume (number of patients in care).	Anaya et al. (2004), Backus et al. (2010), Boyer et al. (2011), Fatti et al. (2011), Nemes et al. (2009), Solomon et al. (2005), Wilson, Landon, Ding et al. (2005) (Brazil, Cameroon, South Africa, the USA)
Facility specialization (exclusively treating HIV patients).	Nemes et al. (2009), Wilson Landon, Ding et al. (2005) (Brazil, the USA)
Health facility setting: including private vs. public funding, level of care, community-based vs. hospital care, and urban vs. rural setting.	Anaya et al. (2004), Assefa et al. (2012), Balcha and Jeppsson (2010), Boyer et al. (2011, 2011), Chan et al. (2011), Ekouevi et al. (2012), Fatti et al. (2010), McGuire et al. (2012), Odafe, Idoko, et al. (2012), Odafe, Torpey, et al. (2012), Reidy et al. (2014), Shet et al. (2011) (Cameroon, Ethiopia, India, Kenya, Malawi, South Africa, other countries in SSA)
HIV care team composition.	Horberg et al. (2007), Rodriguez et al. (2008) (the USA)
Care provider characteristics
Health-care provider expertise: specialization/training.	Assefa et al. (2012), Kerr et al. (2012), Landon et al. (2005), Rodriguez et al. (2008), Sherr et al. (2010), Wilson, Landon, Ding et al. (2005), Wilson, Landon, Hirschhorn et al. (2005) (Ethiopia, Mozambique, the USA)
Health-care provider expertise: HIV experience/ caseload.	Kitahata et al. (2003), Landon et al. (2005), Sangsari et al. (2012), Wilson, Landon, Ding et al. (2005), Wilson, Landon, Hirschhorn et al. (2005) (the USA, Canada)
Other characteristics (self-reported cultural competence).	Saha et al. (2013) (the USA)

Notes: SSA, sub-Saharan Africa.

Table 2. Summary of assessed quality of care measures (n = 28).

Quality of care measures	Operationalization and definitions	Sources (Author, year, countries)
	Clinical outcomes
Virologic success	Predominantly one HIV-RNA measurement, with or without a specified period of time after cART initiation. Thresholds ranging from 50 to 500 copies/ml.	Backus et al. (2010), Chu et al. (2010), Fatti et al. (2010, 2011), Horberg et al. (2007), Landon et al. (2005), McGuire et al. (2012), Saha et al. (2013), Sangsari et al. (2012), Shet et al. (2011), Wilson, Landon, Hirschhorn et al. (2005) (Canada, India, Malawi, South Africa, the USA)
Mortality	Mortality after 12 or 24 months of follow-up, death during study period.	Assefa et al. (2012), Balcha and Jeppsson (2010), Chan et al. (2011), Fatti et al. (2010, 2011), Kitahata et al. (2003), McGuire et al. (2012), Odafe, Idoko, et al. (2012), Reidy et al. (2014) (Ethiopia, Kenya, Malawi, Nigeria, South Africa, the USA)
Immunologic success	Mean CD4 cell change (gains of 100 cells/µL with periods ranging from 12 to 24 months after starting cART), average monthly CD4 cell gain.	Assefa et al. (2012), Boyer et al. (2010), Chu et al. (2010), Horberg et al. (2007); Kerr et al. (2012), McGuire et al. (2012) (Cameroon, Ethiopia, Malawi, the USA)
Other clinical outcomes	Side effects, number of drug-resistant mutations.	Chan et al. (2011), Shet et al. (2011) (India, Malawi)
	Process measures
cART exposure	Rates of cART exposure among eligible population, time on cART.	Backus et al. (2010), Ekouevi et al. (2012), Kerr et al. (2012), Landon et al. (2005), Reidy et al. (2014), Rodriguez et al. (2008), Solomon et al. (2005), Wilson, Landon, Ding et al. (2005), Wilson, Landon, Hirschhorn et al. (2005) (Kenya, other countries in SSA, the USA)
PCP prophylaxis	Rates of appropriate prophylaxis.	Backus et al. (2010), Kerr et al. (2012), Landon et al. (2005), Rodriguez et al. (2008), Solomon et al. (2005), Wilson, Landon, Hirschhorn, et al. (2005) (the USA)
TB, hepatitis B, hepatitis C, cervical cancer screening	Rates of screening (among eligible population).	Backus et al. (2010), Kerr et al. (2012), Landon et al. (2005), Rodriguez (2008), Solomon et al. (2005), Wilson, Landon, Hirschhorn et al. (2005) (the USA)
CD4 cell count	Rates and frequency, depending on followed guidelines.	Backus et al. (2010), Kerr et al. (2012), Sherr et al. (2010), Solomon et al. (2005) (Mozambique, the USA)
Influenza vaccination	Rates of vaccination.	Landon et al. (2005), Wilson, Landon, Hirschhorn et al. (2005) (the USA)
HBV vaccination	Rates of vaccination.	Backus et al. (2010), Solomon et al. (2005) (the USA)
Other process measures	Laboratory measurements (complete blood cell count, creatinine, ALT or AST, cholesterol, glucose), syphilis screening; MAC prophylaxis; measurement of HIV-RNA; quality improvement interventions; service levels (composite score).	Anaya et al. (2004), Backus et al. (2010), Kerr et al. (2012), Nemes (2009), Solomon et al. (2005) (Brazil, the USA)
	Patient reported outcome measures (PROMS)
Patient satisfaction with care	Rating based on one question.	Rodriguez et al. (2008) (the USA)
Other PROMS	Problem Index score, number of unmet needs, perceived access to care, “7 items patient trust,” “interpersonal quality of care,” willingness to recommend care.	Rodriguez et al. (2008) (the USA)
	Other outcome measures
Loss to follow-up (retention in care)	Predominantly: absence from outpatient clinic for at least 3 months after the last missed appointment date.	Assefa et al. (2012), Balcha and Jeppsson (2010), Chan et al. (2011), Fatti et al. (2010, 2011), Odafe, Idoko, et al. (2012) Odafe, Torpey, et al. (2012), Reidy et al. (2014), Sherr et al. (2010) (Ethiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa)
Care utilization	Primary care, specialty care and emergency room visits, hospitalization, home health visit, outpatient visits in 3 or 4 quarters.	Kitahata et al. (2003), Landon et al. (2005), Rodriguez et al. (2008), Sherr et al. (2010), Wilson, Landon, Hirschhorn et al. (2005) (Mozambique, the USA)
Adherence	Pharmacy refill compliance data, self-reported adherence (VAS), “mean adherence rate.”	Boyer et al. (2011, 2011), Saha et al. (2013), Sherr et al. (2010) (Cameroon, Mozambique, the USA)

Notes: ALT, alanine aminotransferase; AST, aspartate aminotransferase; cART, combination antiretroviral therapy; MAC, Mycobacterium avium complex; PCP, Pneumocystis jiroveci pneumonia; SSA, sub-Saharan Africa; TB, Tuberculosis; VAS, Visual analogue scale.

Table 3. Summary of fully reviewed studies (n = 11).

Source (Author, year)	Study design, population	Investigated factors	Outcome HIV-RNA (copies/ml)	Results
Backus et al. (2010)	RCS; 73 sites; 21,564 veterans; the USA	Facility volume: <25; 25–99; 100–299 or >300 patients in care.	<400	Patients from care sites with smaller numbers of HIV-infected patients in care (< 300) were less likely to have HIV-RNA control.
Chu et al. (2010)	RCS; 423 patients; the USA	Health facility setting: hospital-based specialty center vs. community-based primary care network.	“Undetectable”	No significant differences in the likelihoods of achieving viral suppression (16–32 weeks after starting cART) between patients from community-based vs. hospital care sites.
Fatti et al. (2010)	RCS; 59 sites; 29,203 cART naïve patients; South Africa	Health facility setting: primary health-care facilities, district hospitals or regional hospitals.	<400	Patients from district and regional hospitals were less likely to have viral suppression than patients in care at primary health-care facilities.
Fatti et al. (2011)	RCS; 54 sites; 40,861 cART naïve patients; South Africa	Facility volume: <950 or >950 patients in care.	<400	Patients from care sites with smaller numbers of HIV-infected patients in care were more likely to achieve viral suppression within 12 months of starting cART. No significant differences in the proportion of patients achieving viral suppression at all time points.
Horberg et al. (2007)	CSS; 14 sites; 1571 patients; the USA	Team composition: HIV clinical pharmacists.	<500	Patients exposed to an HIV clinical pharmacist were more likely to achieve viral suppression at 12 months.
Landon et al. (2005)	RCS; 64 sites; 5247 patients; the USA	Health-care provider expertise: Infectious disease specialists, expert generalist or non-expert generalist; and current caseload: low (0–19), medium (20–299), or high (>300 patients).	<400	Patients treated by Infectious disease specialists were most likely to have a controlled viral load, followed by those treated by expert generalists and non-expert generalists. No significant differences in viral suppression between patients with physicians with low, medium or high caseloads.
McGuire et al. (2012)	CSS; 1 hospital vs. 10 rural health sites; 702 patients; Malawi	Health facility setting: centralized vs. decentralized.	<50	No significant differences in viral suppression (one year after starting cART) between patients followed at centralized vs. decentralized facilities.
Saha et al. (2013)	CSS; 4 sites; 45 providers; 437 patients; the USA	Other health-care provider characteristics: self-rated cultural competence.	≤75	Greater racial disparity in viral suppression among patients with providers with a low cultural competence.
Sangsari et al. (2012)	PCS; 267 drug users; Canada	Health-care provider expertise - current caseload: number of patients enrolled in HIV registry.	<500	Patients treated by physicians with greater HIV experience were more likely to have viral suppression.
Shet et al. (2011)	CSS; 471 patients; India	Health facility setting: public, private or public–private.	<100	Patients visiting public and public–private health facilities were more likely to have viral suppression compared to those in private settings.
Wilson, Landon, Hirschhorn et al. (2005)	CSS; 68 sites; 6651 patients; the USA	Health-care provider expertise: physician vs. nurse practitioner/physician assistant.	<400	Patients treated by nurse practitioners and physician assistants were more likely to have viral suppression than those treated by non-expert generalists. Rates of viral suppression among patients treated by these non-physician clinicians were similar to that of those treated by infectious disease-trained physicians and expert generalists.

Notes: cART, combination antiretroviral therapy; ID, Infectious diseases; CSS, Cross-sectional study; PCS or RCS, Prospective or retrospective cohort study

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