HIV Case Management Associated With Fewer Unmet Needs, Increased Medication Adherence Among Patients, Study Says
HIV-positive individuals who have a case manager have fewer unmet needs and utilize HIV medications more often than other people with the disease, according to a study in today's issue of the Annals of Internal Medicine. In 1996 and 1997, Dr. Mitchell Katz, director of the San Francisco Department of Public Health, and colleagues with the HIV Cost and Services Utilization Study interviewed twice 2,437 HIV-positive individuals at 52 urban and rural sites -- once to assess their needs at baseline and six months later to determine whether those needs were being met. The researchers assessed the following needs at the time of the baseline interview:
- Need for income assistance -- defined as being unemployed and receiving no public assistance aside from general welfare;
- Need for health insurance -- defined as having no insurance;
- Need for housing -- defined as having "unstable" housing such as living in a shelter, hotel, residential care facility, nursing home, hospital or with a relative or friend;
- Need for home health care -- self-reported need for paid or volunteer home medical care;
- Need for emotional counseling -- self-reported need for counseling in the six months prior to the baseline interview.
At baseline, 56.5% of participants had a case manager. Seventy-one percent of women and 69% of minorities had someone assisting in the coordination of their needs, compared to 52.2% of men and 43.7% of whites. Six months after baseline, those with case managers met their needs for income assistance (OR 0.57), health insurance (OR 0.54), home health care (OR 0.29) and emotional counseling (OR 0.62) at a higher rate than those without case managers. The assistance of a case manager was not significantly associated with the utilization of medical services such as ambulatory visits, emergency room visits and hospitalization, but was associated with increased use of two-drug (OR 1.58) and three-drug (OR 1.34) antiretroviral therapy and the use of either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor (OR 1.29). In the primary analysis, data was unclear whether participants were more likely to be on medication because they saw a case manager or if being on medication led them to use a case manager. The researchers completed a second analysis using a sample limited to those who were not receiving medication at baseline and found that sustained case management was significantly associated with use of AIDS medications (OR 1.99 for two-drug therapy, OR 2.32 for three-drug therapy and OR 1.68 for protease inhibitor/NNRTI). This finding may be "surprising" because case managers cannot prescribe medication. However, they can help clients "overcome fears" about treatment, assist them with adherence to treatment regimens and attendance to medical visits and advocate treatment with the client's physician, the authors note. "Because an increasing proportion of HIV-infected persons are living in poverty, needing both supportive services and medical treatment, case managers may be particularly useful allies to clinicians and their patients," the authors conclude, noting that additional studies are needed to ascertain the "most beneficial models of case management and to calculate the cost-effectiveness of this intervention" (Katz et al., Annals of Internal Medicine, 10/16).
More Funding of Programs Needed
Several AIDS advocates and public health officials have called for increased funding for support services including case managers. In an accompanying editorial, Kevin Conare, executive director of Action AIDS, and Dr. William Holmes of the University of Pennsylvania School of Medicine note that the majority of funding for case management programs comes from the Ryan White CARE Act. President Bush's proposed budget for FY 2002 held funding steady at $1.8 billion, however, $300 million in additional funding is needed to fund such programs, according to Holmes. "HIV is also a public health problem. Case managers help guide financially needy HIV-infected people through our fragmented health system," he added. According to Conare, Action AIDS will have to scale back case management services unless funding is increased, cutting the number of people who have "access to stable medical care and appropriate drug treatment" and "add[ing] financial burden to both patients" and the health care system (Loviglio, Associated Press, 10/15).