This study, which examined the relationship between use of support services and use of HIV medical services offered in a unique collaborative program serving marginalized HIV-infected individuals, found that case management and support groups were positively associated with subsequent quarterly medical visits and outreach was positively associated with subsequent medical visits in a traditional health care setting.
Several studies have reported similar findings regarding the relationship between case management and increased use of HIV ambulatory care.7–9,11–13,22
Of the two randomized trials of case management, one found that individuals randomized to a case manager after recently testing positive for HIV were more likely to have ambulatory HIV medical visits over 6 and 12 months than those randomized to the control arm who received standard of care.22
The other study that randomized HIV-infected substance users to a case manager versus brief contact found no differences in service utilization between groups.23
Consistent with many studies, our study strengthens the notion that the use of case management services is an important element in the care of HIV-infected individuals.
In addition to case management, we found that support groups and outreach were also associated with medical visits. We are aware of only one other study that specifically examined the association between use of support groups and use of HIV health care services. Kang and colleagues found that attending HIV support groups was associated with taking antiretroviral medications among Hispanic drug users.17
Although support groups are nearly routinely offered in programs serving marginalized populations, it is surprising that the effect of such groups on HIV care has not been explored in more detail. Clearly, additional research is needed.
While outreach has been one strategy to address HIV infection and prevention for many years, few studies have examined the association between outreach and utilization of medical care. One multi-site study of HIV outreach programs revealed that having nine or more outreach contacts over a 3-month period was associated with fewer gaps in medical care.14
In addition, an evaluation of the addition of physicians to an outreach program targeting HIV-infected individuals demonstrated that after medical outreach was established, more individuals reported having a regular health care provider.24
One outreach program that focused on youth who were HIV-infected or at risk for HIV infection also found that outreach was associated with retention in care.16
Finally, another outreach/case management program that focused on recently released HIV-infected prisoners found that after 12 months, 98% of ex-offenders in their program remained in medical care.25
Our findings are consistent with these studies.
We were surprised that use of mental health services was not associated with use of medical services. Mental illness is common among HIV-infected individuals,26–28
and several studies have demonstrated that mental health services utilization is associated with improved HIV ambulatory health care utilization.8,10–12
However, one study examining co-location of mental health services and HIV services found that co-location was not associated with higher utilization rates.29
This last study differed from others in that patients were identified via mental health facilities, rather than HIV medical facilities. It is possible that with severely mentally ill HIV-infected patients simple co-location of services may not suffice. In our study, we did not collect data to measure mental illness severity. It is possible that individuals entering our medical program have severe mental illness and require more intensive services to improve their HIV health care utilization pattern.
Our study is unique in several ways. First, it evaluates a program that was designed to provide care for an exceptionally marginalized population that would not access the traditional health care system without intervention. Thus, support services are even more important for this population than other marginalized groups. Second, our study demonstrates that use of support services is associated with subsequent use of ambulatory medical services, indicating that the availability and use of support services may lead to better HIV care for this population. Although there are limitations to reliance on program and health services databases, it is noteworthy that our findings are generally consistent with patterns reported from interview data and health services databases from other studies, strengthening their validity.
We acknowledge that our study has limitations. It is possible that patients in this study received services from other providers or community-based organizations. If so, this information would not be included in our databases, and therefore would not be measured in this study. In addition, we had limited data on individual-level factors that may have confounded observed associations. Although we adjusted for sociodemographic factors in our analyses, we did not include measures of drug use or illness severity in our analyses, which could have affected our findings. Finally, our non-randomized design does not account for the possibility of unmeasured confounding variables, and does not allow one to determine causality. Despite these limitations, however, findings from this study are important, and may inform further HIV policy and program development for effective engagement and retention in care.
In summary, this study examining the association between support services and HIV ambulatory health services found that case management, support groups, and outreach were associated with subsequent medical visits. Ongoing research exploring how the integration of support services into health care programs for disadvantaged and underserved populations can improve HIV health care delivery and patient outcomes is crucial for both health policy and program development.