Organization of care for persons with HIV-infection: a systematic review

ABSTRACT

The objective of this systematic review was to examine the effectiveness of the organization of care: case management, multidisciplinary care, multi-faceted treatment, hours of service, outreach programs and health information systems on medical, immunological, virological, psychosocial and economic outcomes for persons living with HIV/AIDS. We searched PubMed (MEDLINE) and 10 other electronic databases from 1 January 1980 to April, 2012 for both experimental and controlled observational studies. Thirty-three studies met the inclusion criteria. Eleven studies were randomized controlled trials (RCTs), three of which were conducted in low–middle income settings. Patient characteristics, study design, organization measures and outcomes data were abstracted independently by two reviewers from all studies. A risk of bias tool was applied to RCTs and a separate tool was used to assess the quality of observational studies. This review concludes that case management interventions were most consistently associated with improvements in immunological outcomes but case management demonstrates no clear association with other outcome measures. The same mixed results were also identified for multidisciplinary and multi-faceted care interventions. Eight studies with an outreach intervention were identified and demonstrated improvements or non-inferiority with respect to mortality, receipt of antiretroviral medications, immunological outcomes, improvements in healthcare utilization and lower reported healthcare costs when compared to usual care. Of the interventions examined in this review, sustained in-person case management and outreach interventions were most consistently associated with improved medical and economic outcomes, in particular antiretroviral prescribing, immunological outcomes and healthcare utilization. No firm conclusions can be reached about the impact of any one intervention on patient mortality.

KEYWORDS:

• HIV
• organization of care
• case management
• outreach
• multi-disciplinary care
• multifaceted treatment
• systematic review

Acknowledgements

The authors would like to thank Carolyn Ziegler, MLS for revising and conducting the later strategy and advice; Julia Miranda Rackal, MD, who provided expertise in the earlier phase of the manuscript; Hacsi Horvath, MSc, University of California, San Francisco for on-going advice; Angela Eady, MLS and Sheila Iacono for their contributions to the earlier stages of this review.

The following students also assisted tremendously with the review process: Alisha Olsthoorn, B.Sc, MD; Jacqueline Glazier, BSc, MA (candidate); Kamyab Ghatan, MD; Lauren Watson, BA; David Watson, BA; Nancy (Yang) Kou, MSc; Rebecca Jeffery BSc, MSc, MD (candidate). We gratefully acknowledge the support of the Ontario Ministry of Health and Long-Term Care and the Centre for Urban Health Solutions, St. Michael’s Hospital. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred.

Disclosure statement

No potential conflict of interest was reported by the authors.