Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial. Evaluation of the transprofessional model of home health care for HIV/AIDS. Home visits to improve adherence to highly active antiretroviral therapy: a randomized controlled trial. Adherence to antiretroviral therapy in HIV-infected pediatric patients improves with home-based intensive nursing intervention. Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS Community Demonstration Projects. A palliative-care intervention and death at home: a cluster randomised trial. Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. Meta-analysis of home-care effects on mortality and nursing-home placement. Effectiveness of a home-based exercise intervention for HIV-infected adults: a randomized trial. Quality of life in nurse case management of persons with AIDS receiving home care.
Identification of new ways to increase access to antiretroviral therapy in Africa is an urgent priority. We assessed whether home-based HIV care was as effective as was facility-based care.
                We undertook a cluster-randomised equivalence trial in Jinja, Uganda. 44 geographical areas in nine strata, defined according to ratio of urban and rural participants and distance from the clinic, were randomised to home-based or facility-based care by drawing sealed cards from a box. The trial was integrated into normal service delivery. All patients with WHO stage IV or late stage III disease or CD4-cell counts fewer than 200 cells per microL who started antiretroviral therapy between Feb 15, 2005, and Dec 19, 2006, were eligible, apart from those living on islands. Follow-up continued until Jan 31, 2009. The primary endpoint was virological failure, defined as RNA more than 500 copies per mL after 6 months of treatment. The margin of equivalence was 9% (equivalence limits 0.69-1.45). Analyses were by intention to treat and adjusted for baseline CD4-cell count and study stratum. This trial is registered at http://isrctn.org, number ISRCTN 17184129.
                859 patients (22 clusters) were randomly assigned to home and 594 (22 clusters) to facility care. During the first year, 93 (11%) receiving home care and 66 (11%) receiving facility care died, 29 (3%) receiving home and 36 (6%) receiving facility care withdrew, and 8 (1%) receiving home and 9 (2%) receiving facility care were lost to follow-up. 117 of 729 (16%) in home care had virological failure versus 80 of 483 (17%) in facility care: rates per 100 person-years were 8.19 (95% CI 6.84-9.82) for home and 8.67 (6.96-10.79) for facility care (rate ratio [RR] 1.04, 0.78-1.40; equivalence shown). Two patients from each group were immediately lost to follow-up. Mortality rates were similar between groups (0.95 [0.71-1.28]). 97 of 857 (11%) patients in home and 75 of 592 (13%) in facility care were admitted at least once (0.91, 0.64-1.28).
                This home-based HIV-care strategy is as effective as is a clinic-based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care.
                Copyright 2009 Elsevier Ltd. All rights reserved. To determine if a Transprofessional care-management approach (experimental group) produces savings in service delivery dollars when compared to a Traditional treatment approach (control group). The care-management approach utilizes an interdisciplinary mix of allied health professionals who adhere to a service delivery protocol based on active, medical, surgical treatment (curative services) as well as on pain, symptoms, and emotional care (palliative services).
                Data were collected from 549 AIDS patients admitted for medical/surgical home-care services to the Visiting Nurse Association of Los Angeles (VNA-LA). Demographic and disease-specific data were collected from admitting records; service-utilization data were collected from the VNA-LA's computerized data system.
                Upon admission for home-care services, patients were randomly assigned to an experimental (Transprofessional) or control (Traditional) treatment group. Service levels were comparable.
                Post-test measures indicate an 8 percent reduction in labor delivery costs for an average experimental patient's entire episode of home-care versus for an average control patient's.
                An integrated model of service delivery, which is based on interdiscriplinary, care-management and blended modalities of service, provides a cost-effective method in the provision of home-care services for terminally ill AIDS patients. Few rigorously designed studies have documented the efficacy of interventions to improve medication adherence among patients prescribed highly active antiretroviral. Data are needed to justify the use of limited resources for these programs.
                A 2-arm, randomized, controlled trial evaluated the efficacy of a community-based, home-visit intervention to improve medication adherence. Participants were 171 HIV-infected adults prescribed a minimum of 3 antiretroviral agents. The majority had a past or current history of substance abuse. Subjects were randomly assigned to receive home visits for 1 year or usual care. Medication adherence was assessed with Medication Event Monitoring stem caps at 3-month intervals from randomization through 3 months after the conclusion of the intervention.
                A larger proportion of subjects in the intervention group demonstrated adherence greater than 90% compared with the control group at each time point after baseline. The difference over time was statistically significant (Extended Mantel-Haenszel test: 5.80, P = 0.02). A statistically significant intervention effect on HIV-RNA level or CD4 cell count was not seen, but there was a statistically significant association between greater than 90% adherence and an undetectable HIV-RNA over time (P < 0.03).
                Home visits from a nurse and a community worker were associated with medication adherence greater than 90% among a cohort of socially vulnerable people living with HIV/AIDS in northeastern United States. Adherence to combination antiretroviral therapy (ART) has been shown to be a determining factor in controlling viral replication, maintaining immunologic function and long-term survival in HIV-positive individuals. Little information is available on strategies to improve adherence in pediatric HIV-infected patients. We conducted a randomized, nonblinded, pilot study to determine if a home-based nursing intervention would improve medication adherence. The study was offered to all eligible HIV-positive patients receiving care at Connecticut Children's Medical Center's (CCMC) Pediatric and Youth HIV Program. Sixty-seven percent (37/55) of the patients and their caretakers participated. We randomized participants to either standard of care or the intervention trial. The intervention was designed to improve knowledge and understanding of HIV infection and HIV medications and to resolve or modify barriers to adherence. Both groups completed pre- and post-intervention questionnaires, assessing their knowledge and understanding of HIV, ART, and adherence. Adherence was estimated objectively from medication refill history and subjectively from a self-report score. We also inferred adherence from pre- to post-test plasma viral load and CD4+ T-cell percentages. The knowledge score (p = 0.02) and medication refill history (p = 0.002) improved significantly in the intervention group. The adherence self-report score improved, although not significantly (p = 0.07). We did not observe statistical differences in CD4+ T-cell counts or viral load between groups. We conclude that our home-based nursing intervention helped HIV-positive children and their families in better adhering to prescribed medication regimens. This study evaluated a theory-based community-level intervention to promote progress toward consistent condom and bleach use among selected populations at increased risk for HIV infection in 5 US cities.
                Role-model stories were distributed, along with condoms and bleach, by community members who encouraged behavior change among injection drug users, their female sex partners, sex workers, non-gay-identified men who have sex with men, high-risk youth, and residents in areas with high sexually transmitted disease rates. Over a 3-year period, cross-sectional interviews (n = 15,205) were conducted in 10 intervention and comparison community pairs. Outcomes were measured on a stage-of-change scale. Observed condom carrying and intervention exposure were also measured.
                At the community level, movement toward consistent condom use with main (P < .05) and nonmain (P < .05) partners, as well as increased condom carrying (P < .0001), was greater in intervention than in comparison communities. At the individual level, respondents recently exposed to the intervention were more likely to carry condoms and to have higher stage-of-change scores for condom and bleach use.
                The intervention led to significant communitywide progress toward consistent HIV risk reduction. The Palliative Medicine Unit at University Hospital of Trondheim, Norway, started an intervention programme that aims to enable patients to spend more time at home and die there if they prefer. Close cooperation was needed with the community health-care professionals, who acted as the principal formal caregivers, and a multidisciplinary consultant team coordinated the care. We did a cluster randomised trial to assess the intervention's effectiveness compared with conventional care
                Community health-care districts in and around Trondheim, Norway, were defined as the clusters to be randomised. We enrolled 434 patients (235 assigned intervention and 199 conventional care [controls]) in these districts who had incurable malignant disease and an expected survival of 2-9 months. Main outcomes were place of death and time spent in institutions in the last month of life.
                395 patients died. Of these, more intervention patients than controls died at home (54 [25%] vs 26 [15%], p<0.05). The time spent at home was not significantly increased, although intervention patients spent a smaller proportion of time in nursing homes in the last month of life than did controls (7.2 vs 14.6%, p<0.05). Hospital use was similar in the two groups.
                The palliative-care intervention enabled more patients to die at home. More resources for care in the home (palliative care training and staff) and an increased focus on use of nursing homes would be necessary, however, to increase time at home and reduce hospital admissions. To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care.
                Prospective cluster randomized controlled clinical trial.
                Villages surrounding 1 rural clinic in western Kenya.
                HIV-infected adults clinically stable on antiretroviral therapy (ART).
                The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits.
                Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits.
                After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001).
                Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments. This meta-analysis was designed to illustrate how the relatively new discipline of meta-analysis could be employed in health-services research. In pursuit of this goal, the results of 13 studies on the effect of home care on mortality and nursing-home placements were examined. The analysis demonstrated a small, beneficial effect of home care on mortality, which fell short of statistical significance. Study-to-study variation in the odds ratio was found that was not strongly associated with differences in the study samples, designs, or interventions as categorized here. The analysis produced stronger evidence of a reduction in nursing-home placements. In this case, differences in study design explained much of the heterogeneity in results, with the randomized controlled trials showing considerably weaker effects. The analysis also provides insight into the benefits and limitations of alternative meta-analytic methods. The "odd man out" method recently described by Walker et al. detected statistically significant heterogeneity of effects across studies for nursing-home placement, but not for mortality. Loglinear modeling made it easier to detect and explore study-to-study variation in home-care effects. The authors conducted a randomized controlled trial to assess the impact of a 15-week (20 minutes three times per week) home-based aerobic exercise intervention versus usual care on the physical endurance, immune status, and self-reported health status of 99 HIV-infected adults. In the exercise group, there was no improvement in physical endurance or health-related quality of life (HRQOL), except in the Medical Outcomes Study-HIV Health Survey Overall Health subscale (difference = 12.1, 95% confidence interval = 2.0-22.2, p = .02). Although physical endurance levels were maintained at baseline levels in the intervention group and declined in the control group, differences between the groups were small and not significant. There were also no significant changes in CD4+ T-lymphocyte counts. Exercise appears to be safe in HIV-infected patients. Improvements in physical endurance and HRQOL might result if the exercise protocol is longer or progressive. Further research is needed to establish guidelines for exercise in patients on highly active antiretroviral therapy. Effects of case management on quality of life were tested with 57 home care patients with AIDS, randomly assigning individuals to either usual care or case-managed care over the duration of home services (ranging from 5 days to over 2 years). Participants were primarily male (93%), white (79%), and never married (82%). Quality of life was measured monthly using the quality of Well-Being Index (QWB). Case-managed patients showed advantages over the usual care group in descriptive analyses of quality of life and survival. Large standard deviations in the QWB scores resulting from high fatality among subjects impeded statistical analyses of effects.
Studies were generally small and very few studies were done in developing countries. There was a lack of studies truly looking at the effect of home based care itself or looking at significant end points (death and progression to AIDS). However, the range of interventions and HBC models evaluated can assist in making evidence-based decisions about HIV care and support.