title: Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection.
abstract: BACKGROUND
  Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection.
  
  
  METHODS
  We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in <or=25% of quarters in the study), moderate (>25% but <or=75%), or consistent (>75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of <or=400 copies/mL).
  
  
  RESULTS
  In multivariate models, CM was not associated with increased primary care, emergency department use, or hospitalization. Moderate CM, compared with no or rare CM, was associated with an adjusted beta coefficient of 0.13 (95% confidence interval [CI], 0.02-0.25) for improved antiretroviral adherence. Consistent CM (adjusted odds ratio [AOR], 10.7; 95% CI, 2.3-49.6) and moderate CM (AOR, 6.5; 95% CI, 1.3-33.0) were both associated with >or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization.
  
  
  CONCLUSIONS
  CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.
authors.affiliation: Division of General Internal Medicine, San Francisco General Hospital Medical Center, University of California, San Francisco 94143-1372, USA.
authors.forename: M B
authors.initials: MB
authors.lastname: Kushel
authors.forename: G
authors.initials: G
authors.lastname: Colfax
authors.forename: K
authors.initials: K
authors.lastname: Ragland
authors.forename: A
authors.initials: A
authors.lastname: Heineman
authors.forename: H
authors.initials: H
authors.lastname: Palacio
authors.forename: D R
authors.initials: DR
authors.lastname: Bangsberg
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D019090:Case Management; D003695:Delivery of Health Care; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology* / Q000628:therapy*; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D010349:Patient Compliance; D011446:Prospective Studies; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents