Clinical outcomes of HIV care delivery models in the US: a systematic review

ABSTRACT

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

KEYWORDS:

• HIV/AIDS
• healthcare delivery
• specialty care
• primary care
• primary care redesign
• nursing
• telemedicine
• systematic review

Acknowledgements

Preliminary results for this manuscript were presented in part at the AcademyHealth Annual Research Meeting [abstract 4089], 14–16 June 2015, Minneapolis, USA, and the 8th International Conference on HIV Pathogenesis, Treatment & Prevention [abstract MOPED693], 19–22 July 2015, Vancouver, Canada.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This research was supported in part by the National Institutes of Health [CTSA award number KL2TR000057 from the National Center for Advancing Translational Sciences and R01 AI42006 from the National Institute of Allergy and Infectious Diseases and Health Resources and Services Administration [H97HA27534]. The funding sources played no role in the study, including study design; collection, analysis, and/or interpretation of data; the writing of the manuscript; and the decision to submit the manuscript for publication.