title: Adoption of the chronic care model to improve HIV care: in a marginalized, largely aboriginal population.
abstract: OBJECTIVE
  To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes.
  
  
  METHODS
  Multisite, prospective, interventional cohort study.
  
  
  METHODS
  Two urban community health centres in Vancouver and Prince George, BC.
  
  
  METHODS
  Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites.
  
  
  METHODS
  Systematic implementation of the CCM during an 18-month period.
  
  
  METHODS
  Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period.
  
  
  RESULTS
  Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up.
  
  
  CONCLUSIONS
  Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an "infectious disease" approach to a "chronic disease management" approach to HIV care for marginalized populations is strongly recommended.
authors.affiliation: Vancouver Native Health Society, 449 Hastings St E, Vancouver, BC V6A 1P5, Canada. davidtu9@gmail.com
authors.forename: David
authors.initials: D
authors.lastname: Tu
authors.forename: Patricia
authors.initials: P
authors.lastname: Belda
authors.forename: Doreen
authors.initials: D
authors.lastname: Littlejohn
authors.forename: Jeanette Somlak
authors.initials: JS
authors.lastname: Pedersen
authors.forename: Juan
authors.initials: J
authors.lastname: Valle-Rivera
authors.forename: Mark
authors.initials: M
authors.lastname: Tyndall
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D002170:Canada; D002908:Chronic Disease / Q000628:therapy; D003151:Community Health Centers; D005260:Female; D006679:HIV Seropositivity / Q000208:ethnology / Q000628:therapy*; D006801:Humans; D007198:Indians, North American; D008297:Male; D055118:Medication Adherence / Q000208:ethnology; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team; D022242:Pneumococcal Vaccines; D011018:Pneumonia, Pneumococcal / Q000517:prevention & control; D019984:Quality Indicators, Health Care; D062487:Social Marginalization; D013587:Syphilis / Q000175:diagnosis; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis; D019037:Urban Health Services; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents; D022242:Pneumococcal Vaccines