Adoption of the chronic care model to improve HIV care In a marginalized, largely aboriginal population

作者：Tu David^*; Belda Patricia; Littlejohn Doreen; Pedersen Jeanette Somlak; Valle Rivera Juan; Tyndall Mark

来源：Canadian Family Physician, 2013, 59(6): 650-657.

Objective To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes. %26lt;br%26gt;Design Multisite, prospective, interventional cohort study. %26lt;br%26gt;Setting Two urban community health centres in Vancouver and Prince George, BC. %26lt;br%26gt;Participants Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites. %26lt;br%26gt;Intervention Systematic implementation of the CCM during an 18-month period. %26lt;br%26gt;Main outcome measures Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period. %26lt;br%26gt;Results Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P%26lt;.001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up. %26lt;br%26gt;Conclusion Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an %26quot;infectious disease%26quot; approach to a %26quot;chronic disease management%26quot; approach to HIV care for marginalized populations is strongly recommended.

• 出版日期2013-6