title: Availability of volunteer-led home-based care system and baseline factors as predictors of clinical outcomes in HIV-infected patients in rural Zambia.
abstract: BACKGROUND
  We assessed the impact of home-based care (HBC) for HIV+ patients, comparing outcomes between two groups of Zambians receiving antiretroviral therapy (ART) who lived in villages with and without HBC teams.
  
  
  METHODS
  We conducted a retrospective cohort study using medical charts from Macha Mission Hospital, a hospital providing HIV care in Zambia's rural Southern Province. Date of birth, date of ART initiation, place of residence, sex, body mass index (BMI), CD4+ cell count, and hemoglobin (Hgb) were abstracted. Logistic regression was used to test our hypothesis that HBC was associated with treatment outcomes.
  
  
  RESULTS
  Of 655 patients, 523 (80%) were eligible and included in the study. There were 428 patients (82%) with favorable outcomes (alive and on ART) and 95 patients (18%) with unfavorable outcomes (died, lost to follow-up, or stopped treatment). A minority of the 523 eligible patients (n = 84, 16%) lived in villages with HBC available. Living in a village with HBC was not significantly associated with treatment outcomes; 80% of patients in a village with HBC had favorable outcomes, compared to 82% of patients in a village without HBC (P = 0.6 by χ(2)). In bivariable analysis, lower BMI (P<0.001), low CD4+ cell count (P = 0.02), low Hgb concentration (P = 0.02), and older age at ART initiation (P = 0.047) were associated with unfavorable outcomes. In multivariable analysis, low BMI remained associated with unfavorable outcomes (P<0.001).
  
  
  CONCLUSIONS
  We did not find that living in a village with HBC available was associated with improved treatment outcomes. We speculate that the ART clinic's rigorous treatment preparation before ART initiation and continuous adherence counseling during ART create a motivated group of patients whose outcomes did not improve with additional HBC support. An alternative explanation is that the quality of the HBC program is suboptimal.
authors.affiliation: Vanderbilt University School of Medicine, Nashville, Tennessee, USA. chris.estopinal@vanderbilt.edu
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Estopinal
authors.forename: Janneke H
authors.initials: JH
authors.lastname: van Dijk
authors.forename: Stanley
authors.initials: S
authors.lastname: Sitali
authors.forename: Hannah
authors.initials: H
authors.lastname: Stewart
authors.forename: Mario A
authors.initials: MA
authors.lastname: Davidson
authors.forename: John
authors.initials: J
authors.lastname: Spurrier
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D017028:Caregivers; D003695:Delivery of Health Care; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006699:Home Care Services; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012424:Rural Population; D016896:Treatment Outcome; D014838:Volunteers; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents