title: Implementation and Operational Research: Impact of Nurse-Targeted Care on HIV Outcomes Among Immunocompromised Persons: A Before-After Study in Uganda.
abstract: Improving HIV outcomes among severely immunocompromised HIV-infected persons who have increased morbidity and mortality remains an important issue in sub-Saharan Africa. We sought to evaluate the impact of targeted clinic-based nurse care on antiretroviral therapy (ART) initiation and retention among severely immunocompromised HIV-infected persons.
  
  
  
  The study included ART-naive patients with CD4 counts <100 cells per microliter registered in seven urban clinics in Kampala, Uganda. Data were retrospectively collected on patients enrolled from July to December 2011 (routine care cohort). Between July 2012 and September 2013, 1 additional nurse per clinic was hired (nurse counselor cohort) to identify new patients, expedite ART initiation, and trace those who were lost to follow-up. We compared time to ART initiation and 6-month retention in care between cohorts and used a generalized linear model to estimate the relative risk of retention.
  
  
  
  The study included 258 patients in the routine care cohort and 593 in the nurse counselor cohort. The proportion of patients who initiated ART increased from 190 (73.6%) in the routine care cohort to 506 (85.3%) in the nurse counselor cohort (P < 0.001). At 6 months, 62% of the routine care cohort were retained in care versus 76% in the nurse counselor cohort (P = 0.001). A 21% increase in the likelihood of retention in the nurse counselor cohort (relative risk: 1.21, 95% CI: 1.09 to 1.34) compared with the routine care cohort was observed.
  
  
  
  Implementation of targeted nurse-led care of severely immunocompromised HIV-infected patients in public outpatient health care facilities resulted in decreased time to ART initiation and increased retention.
authors.affiliation: *Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; †Division of Infectious Disease and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN; ‡Division of Global HIV/AIDS (DGHA), Center for Global Health (CGH), Centers for Disease Control and Prevention, Atlanta, GA; §Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; and ‖Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Agnes N
authors.initials: AN
authors.lastname: Kiragga
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Nalintya
authors.forename: Bozena M
authors.initials: BM
authors.lastname: Morawski
authors.forename: Joanita
authors.initials: J
authors.lastname: Kigozi
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Park
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Kaplan
authors.forename: David R
authors.initials: DR
authors.lastname: Boulware
authors.forename: David B
authors.initials: DB
authors.lastname: Meya
authors.forename: Yukari C
authors.initials: YC
authors.lastname: Manabe
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D065187:Controlled Before-After Studies; D003695:Delivery of Health Care / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000451:nursing*; D006296:Health Services; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016867:Immunocompromised Host; D008297:Male; D009874:Operations Research; D057184:Practice Patterns, Nurses'; D015397:Program Evaluation; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014454:Uganda / Q000453:epidemiology; D014505:Urban Population; D000078329:Workforce; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents