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15 July 2006

Volume 43, Number 2
Clinical Infectious Diseases 2006;43:234–242
© 2006 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2006/4302-0017$15.00
DOI: 10.1086/505212
HIV/AIDS MAJOR ARTICLE

Case Management Is Associated with Improved Antiretroviral Adherence and CD4+ Cell Counts in Homeless and Marginally Housed Individuals with HIV Infection

M. B. Kushel,1

G. Colfax,4

K. Ragland,2

A. Heineman,2

H. Palacio,5 and

D. R. Bangsberg3

1Division of General Internal Medicine, 2Department of Epidemiology and Biostatistics, and 3Epidemiology and Prevention Interventions Center, Division of Infectious Diseases and The Positive Health Program, San Francisco General Hospital Medical Center, University of California, San Francisco, and 4Epidemiology and Intervention Research Section, AIDS Office, San Francisco Department of Public Health, San Francisco, California; and 5Harris Public Health and Environmental Services, Houston, Texas

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 25% of quarters in the study), moderate (>25% but 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 50% and geometric mean HIV load of 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 β 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 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.

Conclusion.CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV‐infected homeless and marginally housed adults.

Received 2 January 2006; accepted 4 April 2006; electronically published 8 June 2006.

Reprints or correspondence: Dr. David Bangsberg, Epidemiology and Prevention Interventions Center, San Francisco General Hospital, POB 1372 UCSF, San Francisco, CA 94143‐1372 ().

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