Setting and organization of care for persons living with HIV/AIDS

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Abstract
Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi‐disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood. Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS. Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages. Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS. Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta‐analysis. Twenty‐eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV‐positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi‐faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed. Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area. 照護人類免疫缺乏病毒/人類免疫缺乏病毒感染者(HIV/AIDS)之的安置與組織 全世界的HIV/AIDS病患人數已多達4300萬人，治療已成為國際性的任務，在組織上所遭遇的挑戰也是史無先例的。關鍵的議題在於集中性的或是分散性的照護，所需的健康照護者之類型及團隊組合，以及干預、組織的計畫，何者為佳。專門的醫學中心，個案管理方式，及多重學科的照護已被證實有利於部分慢性疾病的治療。這樣的發現是否適用於HIV/AIDS，則尚未了解。 我們的目標是評估照護人類免疫缺乏病毒感染者/後天性免疫不全症候群病患(HIV/AIDS)之安置及組織與病患預後間的關聯。 運用電腦搜尋自西元1980年1月1日至西元2002年12月31日止，在MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts上發表的研究、相關的會議摘要、以及有關的期刊、參考書目中，符合收案條件的研究。搜尋的範圍包含以英語及非英語發表的文章。 符合收案條件的文章，可以是觀察型或實驗型研究，針對HIV/AIDS的成人及/或兒童，同時比較不同的照護安置及/或組織，對死亡率、伺機性感染、高效能抗反轉病毒治療(highly active antiretroviral therapy; HAART、1995年問世，俗稱雞尾酒療法)藥物的使用與預防、生活品質、健康照護資源的使用及費用支出的影響。 由兩位作者對照收案條件對全文版本獨立地檢閱評估摘要的關聯性，並由這兩位作者共同擷取研究的結論。最後有28篇文章符合收案條件，然而其研究的族群、處置方式及結果是大相逕庭以致於無法進行多項性之研究綜合分析(metaanalysis)。 28篇收入統計的研究總共有39,776 位受試者。研究結果顯示，個案管理策略及專門針對人類免疫缺乏症病毒陽性的醫學中心/病房，有利於降低死亡率。個案管理方式也可以增加抗反轉病毒治療的接受度。關於結合多重學科的團隊或多面向的治療方式，則沒有一致性的結果。沒有任何一篇文章探討到對生活品質、免疫方面或病毒方面的影響。各個研究對健康照護運用的結果則是不一致的。 某些特定的照護安置方式(例如將人類免疫缺乏病毒感染者大量集中照護)及照護模式(如個案管理方式)可以降低病患死亡率及改善預後。對於在開發中國家的運用，我們需要針對照護模式更詳細的說明，與更一致的名詞定義及創新模式的研究。到目前為止,在這個領域中，尚未有足夠的證據來引導臨床照護上的策略。