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Case management may improve adherence to antiviral therapy as well as outcomes of HIV-infected homeless persons

Case management (CM) may be one way to improve adherence to antiretroviral therapy and clinical outcomes among HIV-infected homeless and marginally housed adults, according to a new study. Most HIV case management is funded through the Ryan White CARE Act of 1990, which provides grants to States and cities to promote access to health care for impoverished HIV-infected persons. Case managers of HIV-infected patients manage complex medication regimens, coordinate primary medical care, and assist with referrals to housing, mental health, and substance abuse services, explains Margot B. Kushel, M.D., of the University of California, San Francisco.

Dr. Kushel and coinvestigators prospectively studied a sample of HIV-infected homeless and marginally housed adults in San Francisco. They examined their receipt of primary care, emergency department (ED) visits and hospitalizations, and adherence to antiretroviral therapy, as well as CD4 cell count and HIV load (indicators of disease progression) in association with the degree of CM they received over a 5-quarter study period. This ranged from none or rare (any CM in less than 25 percent of quarters in the study) to moderate (more than 25 percent but 75 percent or less) or consistent (more than 75 percent).

CM was not associated with increased use of primary care, ED use, or hospitalizations. However, patients who received moderate CM compared with no or rare CM were more likely to comply with their antiretroviral medication regimen. Patients who received consistent and moderate CM were 10.7 and 6.5 times, respectively more likely to have 50 percent or greater improvement in CD4 cell count (signaling improved immune system functioning).

CM was not significantly associated with HIV load less than 400 copies/mL (undetectable viral load), when antiretroviral therapy adherence was considered. The benefits of CM are likely due to case managers' encouragement to adhere to medication, their assistance in communicating side effects to primary care providers, and their regular checking on clients to make sure medications are prescribed and refilled, note the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS11415).

See "Case management is associated with improved antiretroviral adherence and CD4 cell counts in homeless and marginally housed individuals with HIV infection," by Dr. Kushel, Grant Colfax, M.D., Kathleen Ragland, Ph.D., and others, in the July 15, 2006, HIV/AIDS 43, pp. 234-242.

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