Background
Home-based care
Home-based care for HIV
Home-based care for other conditions
Task-shifting
Why is it important to do this review?
Methods
Criteria for considering studies for this review
Search methods for identification of studies
Search | Most recent queries |
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#1 | Search HIV Infections[MeSH] OR HIV[MeSH] OR hiv[tw] OR hiv-1*[tw] OR hiv-2*[tw] OR hiv1[tw] OR hiv2[tw] OR hiv infect*[tw] OR human immunodeficiency virus[tw] OR human immunedeficiency virus[tw] OR human 19rospe-deficiency virus[tw] OR human immune-deficiency virus[tw] OR ((human 19rospe*) AND (deficiency virus[tw])) OR acquired immunodeficiency syndrome[tw] OR acquired immunedeficiency syndrome[tw] OR acquired 19rospe-deficiency syndrome[tw] OR acquired immune-deficiency syndrome[tw] OR ((acquired 19rospe*) AND (deficiency syndrome[tw])) OR “Sexually Transmitted Diseases, Viral”[MeSH:NoExp] |
#2 | Search randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR random allocation [mh] OR double-blind method [mh] OR single-blind method [mh] OR clinical trial [pt] OR clinical trials [mh] OR (“clinical trial” [tw]) OR ((singl* [tw] OR doubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw])) OR (placebos [mh] OR placebo* [tw] OR random* [tw] OR research design [mh:noexp] OR comparative study [mh] OR evaluation studies [mh] OR follow-up studies [mh] OR prospective studies [mh] OR control* [tw] OR 19rospective* [tw] OR volunteer* [tw]) NOT (animals [mh] NOT human [mh]) |
#3 | Search Home-based care or homebased care or home based care |
#4 | Search Home care or homecare or home-care |
#5 | Search Home |
#6 | Search #3 OR #4 OR #5 |
#7 | Search #1 AND #2 AND #6 |
Selection of studies, data collection and analysis
Results
Description of studies
Reason for exclusion | Number of studies [references] |
---|---|
Not all participants are HIV positive | |
Intervention studied was not home-based care | |
Intervention was not provided by qualified nurses | |
Comparison of two models of home-based care | |
Study investigating home-based voluntary HIV counselling and testing | |
Not a randomised controlled trial | |
Trial terminated for non-compliance with human subject regulations | 1 study [83] |
Category | Type of intervention and comparison | Study ID | Participants | Follow-up duration | Study location | Outcomes |
---|---|---|---|---|---|---|
Adherence support | Home-based nursing vs. standard care | Berrien 2004 [23] | HIV-positive children. N = 37. | 12 months. | Connecticut, USA. | Adherence; Viral load; CD4 count. |
Wang 2010 [28] | HIV-positive adults; active or previous heroin addicts; on ART at least 1 month prior to starting study. N = 116. | 10 months. | Hunan, China. | Adherence. | ||
Williams 2006 [27] | HIV-positive adults on ART. N = 171. | 15 months. | Connecticut, USA. | Adherence; Viral load; CD4 count. | ||
Williams 2014 [29] | HIV-positive adults; on ART; self-reported < 90% adherence to pre-ART medications or to ART; willing to receive home visits. N = 110. | 12 months. | Hunan, China. | Adherence; Viral load; CD4 count. | ||
Improved psycho-social wellbeing | Home based nursing vs. standard care | Blank 2014 [25] | HIV-positive adults; understand spoken English; had a diagnosed serious mental illness; able to provide informed consent. N = 238. | 24 months. | Philadelphia, USA. | Health related quality of life; Viral load; CD4 count. |
Hanrahan 2011 [26] | HIV-positive adults; lived within the city limits of Philadelphia; had a diagnosed serious mental illness (SMI). N = 238. | 12 months. | Philadelphia, USA. | Psychiatric symptoms; Health related quality of life | ||
Miles 2003 [24] | African American women with HIV who were primary caregivers for at least one child under the age of 9 years. N = 109. | 6 months. | USA. | Emotional distress (depression, stigma, worry); Health related quality of life | ||
Wang 2010 [28] | HIV-positive adults; active or previous heroin addicts; on ART at least 1 month prior to starting study. N = 116. | 10 months. | Hunan, China. | Quality of life, Depression | ||
Williams 2014 [29] | HIV-positive adults; on ART; self-reported < 90% adherence to pre-ART medications or to ART; willing to receive home visits. N = 110. | 12 months. | Hunan, China. | Depressive symptoms; social support; HIV stigma scale. |
Risk of bias in included studies
Bias | Berrien 2004 [23] | Blank 2014 [25] | Hanrahan 2011 [26] | Miles 2003 [24] | Wang 2010 [28] | Williams 2006 [27] | Wiliams 2014 [29] |
---|---|---|---|---|---|---|---|
Random sequence generation | Small table of random digits. | Randomised on a 1:1 basis but method unclear. | Computer-generated algorithm | Table of random numbers. | Not reported. | Stratified randomisation, with block size of 10. | Stratified randomisation, with block size of 10. |
Allocation concealment | Randomisation list held by clinical coordinator of HIV program, kept in a locked file. | Not reported. | Person allocating different from the one assessing the inclusion. | Not reported. | Not reported. | Not reported. | Not reported. |
Incomplete outcome data | Lost to follow-up: 5% intervention; 11% control. | Lost to follow up not reported. | Lost to follow-up: 10% intervention; 5% control. | Lost to follow-up at 6 months: 51% intervention; 58% control. | Lost to follow-up: 14% intervention; 17% control. | Lost to follow-up at 12 months: 28% intervention; 25% control. | Lost to follow-up at 12 months: 5% intervention; 22% control. |
Selective reporting | All outcomes reported. | All outcomes reported. | All outcomes reported. | All outcomes reported. | All outcomes reported. | All outcomes reported. | Incomplete reporting of social support and stigma. |
Blinding of participants and personnel | None. | Participants not blinded. | None. | None. | Not reported. | All personnel were blinded except the home visit team. Participants not blinded. | None. |
Blinding of outcome assessment | None. | Research staff blinded. Participants disclosed information, unmasking experimental status. | Data collectors blinded. | Data collectors blinded. | Not reported. | All personnel including interviewers were blinded except the home visit team. | Not reported. |
Allocation (selection bias)
Blinding (performance bias and detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Effects of interventions
Outcomes | Summary | |
---|---|---|
Adherence support | Adherence | -Intervention increased ratio of the number of recorded Medication Event Monitoring Systems (MEMS) cap openings to the number of openings to be expected if the medication were taken as prescribed [27]. -Pharmacy drug refill increased significantly with intervention [23]. |
Viral load | ||
CD4 count | ||
Improved psycho-social wellbeing | Health-related quality of life | -SF-12 mental health subscale improved with intervention but not the SF-12 physical health subscale [25]. -No clear difference in health related quality of life outcomes (SF-12) [26]. -Improved WHO quality of life measures [28]. |
Psychiatric symptoms | No significant difference between groups in reduction in psychiatric symptoms (Colorado Symptom Index (CSI) score) [26]. | |
Emotional distress (depression, stigma, worry) | -Reduced symptoms of depression (PHQ-9 score) with intervention [26]. -Reduced HIV stigma, worry, physical functioning but no significant difference in depressive symptoms, mood, general health or overall functioning [24]. -Reduced symptoms of depression (Self-rating Depression Scale) [28]. -Reduced symptoms of depression (CESD scale) in intervention group. No significant difference in social support (SSRS) and stigma (HIV stigma scale) [29]. |
Adherence support
Psychiatric care
Counselling and emotional support
Discussion
Review | Date of search, number of included studies | Participants | Intervention | Comparison | Outcomes | Summary of key findings |
---|---|---|---|---|---|---|
Decroo 2013 [84] | Feb 2013. 18 studies: 2 cluster RCTs, 11 prospective/ retrospective cohort studies, 2 qualitative studies, 1 cost-effectiveness study, 1 activity report from an NGO, 1 abstract. | PLWHA | -Home-based ART delivery by CHWs. -Home-based ART delivery by volunteers. -Home-based ART by peer CHWs. -Patient-led community ART dispensing. | Facility based ART | -Attrition on ART. -Virological rebound on ART. -Cost –health service costs, patient costs. -Social. | -Increase adherence and accessibility to AR. -Cost effective -Positive social outcomes |
Kredo 2013 [5] | March 2013. 16 studies: 2 RCTs, 14 cohort. | HIV-infected patients at point of initiating treatment and patients already on treatment requiring maintenance and follow-up. | Any form of decentralised care delivery model for initiation or continuation of treatment, or both. | Care delivered at centralised site (usually a hospital or health facility) | -Attrition (composite of loss to follow up or death). -Loss to follow up at set time points after intervention. -Death. -Time to starting ART. -Patients diagnosed with TB after entry into HIV care. -Virologic response to ART (viral load). -Immunological response to ART (CD4+). -Occurrence of new AIDS-defining illness. -Patient satisfaction with care. -Cost to provider. -Cost to patient and family. -Any negative impact on other programme and health care delivery. | -Lower attrition in partial decentralisation models (ART started in hospital and continued at health centre). -No difference in attrition in full decentralisation models (ART started and continued at peripheral health centre) but fewer patients lost to care. -No difference in outcomes detected for ART provided at home by trained volunteers compared to facility-based care. |
Mwai 2013 [85] | December 2012. 21 studies: 5 qualitative, 7 cohort, 6 mixed method, 3 RCTs. | PLWH | CHWs in HIV | Facility based HIV care | Patient related: -Knowledge and literacy of HIV -Behaviour change -Uptake of HIV and other services. -Adherence to ART. -Retention in care. -Viral suppression. -Mortality. -Socio-economic status and quality of life. -Palliative care. Health system: -Service organisation and delivery -Data collection, surveillance and reporting -Service cost | CHWs perform a variety of roles in HIV including counselling, testing, home-based care, education, adherence support, livelihood support, screening, referral and surveillance activities, retention in care. No evidence that patient outcomes and quality of care are compromised. CHWs may also have positive impacts on HIV service organisation, delivery and cost. But to be sustainable, need to be better integrated into wider health systems. |
Nachega 2016 [86] | January 2016. 22 studies: 11 RCTs, 11 cohort. | HIV-infected individuals initiated on ART. | Community-based ART delivery. | Health-care facility (e.g. hospital or clinic) | -Proportion of PLWHA with optimal ART adherence levels (> 80%). -Proportion of PLWH with virologic suppression at 12 and/or 24 months after ART initiation. -Engagement (proportion of patients retained in care at 12 and/or 24 months post-ART initiation). -All-cause mortality. -Reported stigma. -Cost to patient and provider and cost effectiveness. | -No significant difference in optimal ART adherence, virological suppression, all-cause mortality and loss to follow-up between 2 groups when analysis was restricted to RCTs. -Pooled analysis from both RCTs and cohort studies showed higher rates of retention in care in community-based ART group than facility-based group. -Only 2 eligible studies reported on cost or cost-effectiveness outcomes. These suggest that community-based ART services may be more cost-effective in the long run but more research using economic outcomes is needed. |
Rachlis 2013 [87] | December 2011, updated February 2012. 21 CBC programs | Urban /rural populations including PLWHA, their family members, orphans, vulnerable children. | Community-based care (CBC) programmes | -Region -Vision -Characteristics of target population -Program scope (services provided) -Program operations -Funding models -Human resources -Sustainability -Monitoring and evaluation. | 9 key categories useful for describing and organising CBC HIV/AIDS programs in resource limited settings. Suggest can be used to inform potential logic models to enhance overall program performance and to develop evidence based tools for sustainable HIV/AIDS service delivery. | |
Wouters 2012 [9] | December 2011. 30 studies: 9 descriptive, 4 quasi-experiments, 5 retrospective/observational cohort studies, 2 qualitative, 6 (cluster/nested) RCTs. | PLWHA | 9 types community support providers: -CHWs (non-professional healthworkers who undertake short course training, work in own communities to support services provided by other health workers) -Peer health workers (CHWs who are HIV positive). -Field officers -Health extension workers -HIV/AIDS lay counsellors -DOT for ART -Adherence supporters -HBC volunteers | Health facility based care | ART programme outcomes: -Access and increasing coverage of ART programmes -Adherence -Virological/ immunological -Patient retention -Survival rates Contributory role of community program: -Integration of ART services into general health system. -Providing psychosocial care. -Empowered ART patients towards self-management. -Defaulter tracing. -Community as a resource. | Community support can positively impact ART programme delivery and outcomes in resource-limited settings. Potential strategy to address shortage of health workers/ broaden care to accommodate needs associated with chronic HIV/AIDS. More research needed to understand which tasks performed by community support initiatives contribute to long-lasting ART success and limits to which lay health workers can assume multiple roles. |