Impact of the nurse-led case management program with retention in care on mortality among people with HIV-1 infection: A prospective cohort study

Background: Long-term retention of patients in care is emerging as an important factor for the mortality among persons with human immunodeficiency virus (HIV) infection. Objectives: The study was to determine the impact of the case management with retention in care on mortality among HIV infected patients. Design and settings: A longitudinal prospective cohort study was conducted at a tertiary referral HIV-designated hospital in Taiwan. Participants: Charts from 1040 patients who had made at least one visit for HIV care at the HIV Clinic in the study hospital in 2009 were abstracted. Methods: A computerized data collection form was used to retrospectively retrieve the electronic demographic and clinical data generated during each clinic visit. Follow-up ended at death or at the last clinic visit as of December 31, 2009. Results: Less than half (44.2%) of 961 HIV-infected patients were retained for follow-up from 2005 to 2009. Patients who received case management were 4.78 times more likely to remain consistently in care than those who did not receive case management, after controlling for other confounding variables. In the Cox proportional hazard analysis, higher hazards of death were independently associated with older age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.026-1.055), entering care before 2005 (HR: 1.73; 95% CI: 1.035-2.885), low baseline CD4 cell count (HR: 0.997; 95% CI: 0.995-0.998), without antiretroviral therapy (HR: 0.55; 95% CI: 0.334-0.909), irregular attendance of HIV care or loss to follow-up (HR: 0.058; 95% CI: 0.023-0.148), acquisition of HIV infection through sexual contact (HR: 2.95; 95% CI: 1.517-5.746), and irregular attendance or lost to follow-up and did not enrolled in the case management program (HR: 3.76; 95% CI: 1.015-14.777). Conclusion: Retention in care is independently predictive of survival, and case management is a mediator affecting retention on survival. Case managers need to identify high risk patients for irregular attendance and to retain them in HIV care in order to maximize their health outcomes.