Does Ryan White Funded Case Management Improve Retention in Care for HIV Positive Adults? a Review of Outcome Studies

Background and Purpose

Estimates show that one third of people living with HIV/AIDS (PLWHA) in the United States do not engage in adequate health care. When PLWHA don't connect to care the result is often delayed diagnosis of opportunistic infections, requiring more intensive medical intervention, and creating a higher financial strain on the health care system. As such, Federal initiatives have been set to engage PLWHA into early care, maintain those in care, and locate and reengage those who drop out of care. The most notable of these initiatives is the Ryan White Treatment Modernization Act of 2006 (Ryan White). Multidisciplinary models of HIV care have long recognized the structural, financial, personal, cultural, and medical barriers to care and have employed case managers in an attempt to ameliorate their affects. Despite the intentions set forth by Ryan White, a systematic review has not yet been conducted to determine if receipt of case management services funded by Ryan White money actually does improve retention in HIV care.

Methods

The purpose of this review was to locate and analyze publications addressing the following questions. First, have any systematic reviews or meta-analyses been conducted on this area to date? Secondly, if the intention of Ryan White funding is improve access to care, have any evaluations empirically examined the effect of Ryan White case management on retention in care? Multiple literature searches were conducted using two search engines. Each search was comprised of varying combinations of search terms. Results were limited to English language only, peer-reviewed journals, and published between 1989 and 2007.

Results

A review of the seven studies produced reveals that there have been no systematic reviews or meta-analyses conducted on this subject to date. Furthermore, there have been no randomized controlled trials (RCT) evaluating the effectiveness of case management on retention in care for PLWHA. Of the seven studies located, five were pre-experimental retrospective analyses of data garnered from review of medical records. One study employed a quasi-experimental design of self-reported data from a cohort of patients followed over time. One study examined the effects of two interventions using a quasi-experimental non-randomized, nonequivalent control groups design.

Conclusions and Implications

The internal validity of the studies reviewed here was compromised by no controls on various rival explanations, such as maturation, social desirability influences, or concurrent history. Most disconcerting about the studies reviewed here is that the researchers did not conduct any analyses on attrition of participants, especially given that one of the priorities of Ryan White funding is to improve retention in medical care for those most at risk for attrition. Future research in this area should employ the more rigorous randomized control trial with a control group who does not receive case management and a test group that receives an intervention that entails the identification and location those patients who have already dropped out of care through enrollment of case management services.