Adherence Strategies

Study finds benefits to providing case management to homeless HIV patients

ART adherence and CD4 cell counts were improved

San Francisco investigators have found that case management as part of HIV medical treatment is associated with better adherence to antiretroviral therapy (ART) among people who are homeless or marginally housed.

"Case management also was associated with greater improvement in CD4 cell count, and it was associated with improved health outcomes among HIV positive people," says Grant Colfax, MD, co-director of the HIV/AIDS statistics, epidemiology, and intervention research section of the San Francisco Department of Public Health in San Francisco, CA.

"It's not a causal relationship, and we can't say it's causal because this was not a randomized study," Colfax notes. "We looked at homeless people and compared those who were marginally housed or homeless, and we looked at whether they had a case manager or not."

Investigators defined case manager loosely, including those with professional degrees and those with training, but less formal education.

"We didn't distinguish in our study between nurse case managers or peer counselors or other types," says Margo Kushel, MD, an assistant professor of medicine at the University of California, San Francisco and San Francisco General Hospital.

"We included case managers who offered some services themselves, including counseling, and we included others who operated more in a brokerage model in which they made sure the client got to the proper services," Kushel explains.

When a participant indicated receiving case management services, investigators confirmed this by interviewing the case manager, Kushel says.

The case management programs were operated by a variety of different organizations, Colfax notes.

"We looked at what was the impact of case management as it is currently in the community on these outcomes, and we looked at whether people reported having a case manager or not and then compared the outcomes to those who didn't," he says. "We didn't do anything to the case management programs."

Case management services were divided according to the frequency of use: people who saw a case manager in less than 25 percent of the study's five quarters were grouped with people who reported receiving no case management services. About 41 percent of study participants fell into this category, she says.

Clients who saw a case manager between 25 percent and 75 percent of the quarters were grouped together as receiving moderate case management, Kushel adds.

About 24 percent of clients reported receiving moderate case management services, she says.

The category of consistent case management included people who had received case management in 75 to 100 percent of the five quarters, and 35 percent of participants were in this group, Kushel says.

"We saw that in terms of adherence there was very little difference between moderate and consistent case management," Kushel says. "With the CD4 cell count it did look like people with consistent case management did better than those with moderate case management and those with none, but for virological outcomes, it was pretty much the same thing."

Investigators accounted for a number of factors, including gender, race, ethnicity, age, drug use, etc., Colfax says.

"We still found that case management was associated with a better outcome," Colfax adds. "It's hard to do a study where you randomize to case management or not, so it's an important outcome that people in our system who had case management had better outcomes than those who didn't."

There appeared to be no difference in consistent primary care services or emergency room visits between the groups of clients who received moderate or consistent case management and those who received little or none, Kushel says.

"Everyone had high rates of regular primary care, so it was hard to improve on that," Kushel says.

Adherence was measured according to both missed pills and CD4 cell count, she notes.

Those who had good adherence also were more likely to have an undetectable viral load of less than 400, Kushel says.

Case management was not independently associated with improved viral load, however, she adds.

Nonetheless, the results are encouraging, Kushel says.

"This was exciting to us because it hasn't been shown before that having a case manager helped with adherence," Kushel says. "Although, it certainly makes a lot of sense because this population is poor, homeless, has substance abuse problems, and perhaps case managers were helping people get to doctor appointments, take their medications, help with side effects, and help with medications refilled."

What the research doesn't show is whether one type of case management provides more benefits than another type, Kushel notes.

"It's possible some worked better than others," she adds. "If one form of case management is better than others, then we should base our resources on it."

The agencies included in the study were promised anonymity, but Kushel found that the case management programs were generally impressive.

"We were impressed with the dedication and resourcefulness of the case managers we met in the systems, but I wouldn't say that one model stood out over another one," Kushel says.

"The bottom line is this study supports the need for case management in this marginalized and homeless population because it showed improvements in health outcomes," Colfax says. "We had hoped that was the case, but now we've looked at it here, and we've found strong evidence that this was the case."