Research Article

iMedPub Journals 2018

www.imedpub.com Journal of Psychology and Brain Studies Vol.2 No.1:4

Effects of the Hypnosis in Jose Ramon Ponce

Patients Infected by the HIV University of Humanistic Psychoanalysis,
Brazil

Abstract *Corresponding author: Jose Ramon Ponce

A pilot study carried out under quantitative strategy with clinical experimental
character. Testing evaluation pretest-retest in order to measure the effect of  joseramon333@hotmail.com
relaxation by means of the hypnosis. The sample consisted of 22 subjects in a
group control and an experimental group, standardized in male subjects between University of Humanistic Psychoanalysis,
20 and 50 years old, HIV carriers without any acute or chronic disorders that Brazil.
might interfere the relaxation treatment, with a basic level of under-standing and
expressed willingness to the fulfilment of the regularity of the meetings of the Tel: 7863021275
treatment. Aims: adjustment of variables, monitoring of the behaviour of the
experimental variable on the immune system, on the affective-emotional
changes and the setting up of new experimental models.
Citation: Ponce JR (2018) Effects of the
Keywords: HIV; Hypnosis; Relaxation; Immune system Hypnosis in Patients Infected by the HIV. J
Psychol Brain Stud. Vol.2 No.1:4

Received: February 04, 2018; Accepted: February 08, 2018; Published:

February 18, 2018

Introduction
One of the diseases indirectly related to the stress, that is,
where it only works as an aggravating factor, is the HIV/AIDS.
Since the first case of Pneumocystis Carinii was reported in June,
1981 and, at the same time, several cases of Sarcoma de
Karposi, some scientific circles all around the world started the
study and definition of the disease called Acquired Immune
Deficiency Syndrome (AIDS), due to the virus which caused it.
This illness has become a global pandemia initially provoked by
the HIV type 1, which suffered a mutation until becoming the
HIV type 2. The HIV was found in West Africa [1] and they are
former retrovirus that were kept in the remains of the DNA of
ancient animals such as the Bonobos and the Red Colobus [2]
which at the end were fixed to the human genome [3], and were
brought up to the present days.
The virus surface is covered by glycoproteins neutralizing
monoclonal antibodies, which will make easier the deterioration
and destruction of the T-lymphocites (T-cells), even more the
CD4 ones. Therefore, one of the difficulties in the treatment of
the HIV is its ability to penetrate into the internal part of the
immune cells and its quick replication. It is carried out to an
extent that exceeds the participation of the CD4 [4], taking
under consideration that these immune cells are the principal
biomarkers of the HIV/AIDS [5].
So, even though the virus life cycle is short, where at least ten
thousand millions are produced and destroyed everyday inside
the patient’s body, with an average life of just a few hours, its
quick replication can lead to the shown clinical symptoms. The
deterioration is shown in different ways, but essentially by the
immune system [6].
Even though nowadays this disorder is no more considered for
the patients as a lost beyond hope of recovery, it continues to
cause physical and mental helplessness on the patients, hence, a
severe emotional stress. Its most common causes are the
following ones:
- Being a carrier, -with a high probability of falling ill and
with no potential cure, at least at this moment-, to feel
the nearness of death [7,8].
- His social support system turning into pieces [9-11].
- To be discriminated in its social, work, family and sexual
environment [12,13] even by the health care specialists
[14]. Patients sometimes avoid treatment for fear of
being rejected.
- He feels himself limited in his sexual satisfaction, so his
self-esteem is diminished [15].
- He suffers symptoms which increase his dissatisfaction,
such as anxiety, depression, fatigue and irritability [8,16].
© Under License of Creative Commons Attribution 3.0 License | This article is available in:
http://www.imedpub.com/psychology-and-brain-studies/ 1
 Journal of Psychology and Brain Studies
Todd [17] has mentioned psyco-social factors in the rapidly
spreading of this pandemia, such as: the disability of the
patients to face the disease, the loose of the social support due
to the grief or separation, depression caused by the end of hope,
and repressed anger due to the frustration.
A study on over 65 HIV patients [18], shows how the infested
one is susceptible to the psychiatric disease since the very
moment of being aware about his health condition.
Besides, it has been found a relationship between depression
and not adherence to the treatment [19]. So the social support
is a very important factor in the treatment of HIV patients, and
its lost diminishes the effect of the anti-retroviral drugs [20].
López y Calles [21] has studied through specific scales, the stress
produced by the knowledge of being a HIV carrier, and specially the
feeling of the nearness of the death. He used the instrument Death
Anxiety Scale (DAS), put it into practice in the Spanish version in a
clinical area with a sample of 109 men and 39 women. That report
concludes the validity of measuring on these patients through the
scale, the anxiety produced. Other instruments have been used in
order to measure the global stress level. [22,23].
In the application of therapeutic techniques in HIV positive patients,
it can be noticed the effect of the relaxation techniques [24], of the
Group Therapy [25], relaxation mixed with acupuncture
[26] and multivariate programs of psychological intervention
[27]. It has been highlighted the role of the Manstram in the
achievement of deep mental focus.
To similar conclusions arrived Beswass [28] in another study.
Cruess et al. [29] made a further study about the application of
relaxation techniques in 30 VIH positive patients during ten
weeks and in them they found a significant reduction of the
anxiety and the depression, as far as the normalization of the
adrenocorticotropic hormone (ACTH) and, hence, the cortisol,
increasing in fact the capacity for action of the CD4 ones.
In order to complete some studies about the relaxation, the
effect of the hypnotic induction on infested VIH patients have
been carried out. Shrier Rucklidge & Saunders [30,31], referring
to the pain related to their disorder [32] and in the functioning
of the immune system [33].
Marcus [34] has created a model of hypnotic induction for VIH
positive patients, where he established two populations for the
validity of this model. One included some persons recently
diagnosed as infested, and some others with longstanding
infections. Both samples were chosen and within them, it could
be proved the positive effect of the diminishing of the stress and
the possibility of a better control of their treatment.
The cognitive behavioural therapy mixed with the Tai Chi has
also been applied on HIV McCain et al. [35] carried out a study
about the application of this technique for ten weeks, in groups
of spiritual growth. The sample chosen included 252 subjects,
divided into a Control Group and an Experimental Group. An
increase of the lymphocites (T-cells) was noticed.
Taylor [36] has examined the effect of a handling of the stress
2 This article is available in: http://www.imedpub.com/psychology-and-brain-studies
2018
Vol.2 No.1:4
program through Progressive Relaxation, Bio-feedback,
Meditation and hypnosis, aimed to the lowering of anxiety, an
improvement of the state of mind and the raise of the self-
esteem. Vieille [37] carried out the study of a therapeutic
system formed by the hypnosis, the self-hypnosis and the
visualization, whose aim was to know if any physical, psychical
or psyco-social changes were taking place in the sample of HIV
infected patients. The amount of CD4 was measured within it
before and after applying the experimental variable, and an
improvement in psychological aspects was found even though
there were no reported changes in the CD4 ones.
Antoni [38] presents a psyconeuroimmunological training model
in the management of the stress for HIV infected patients along
ten weeks. It included the cognitive managing of the stress,
complemented with relaxation techniques and support therapy.
In the study, changes on cortisol and norepinephrine were
reported, therefore, the depression and the anxiety were
reduced and positive changes in CD4 and CD8 were achieved.
Method
The pathogenic mechanisms of the stress on the immune
system and the revision of the VIH/AIDS literature, led us to a
pilot study about the effects of the hypnosis with relaxing
purposes in VIH positive patients. This study took place under a
quantitative strategy with an experimental clinical character.
It was taken a random sample of 22 VIH positive patients
undergoing medical treatment and medication through the NGO
“Amigos de la Vida” in Caracas. It was randomly distributed into
the experimental group and the control group, standardized in
men between 20-50 years old, HIV carriers, without acute or
chronic disorders which could interfere the induction, having, at
least, a basic understanding level and who would show their
willingness to join it.
It was based on the criteria obtained from the literature that
reducing the stress by means of the inhibition of the nervous
central system, by the induction of the hypnosis it could be
achieved the raising of the defensive capability of the immune
system, and, hence, a lowering of the set of symptoms.
The aims were to create a baseline for further investigations
about the effect of the relaxing hypnosis in VIH positive patients;
specifically, the adjustment of variables, effect and behaviour of
the experimental variable and symptomatic changes of the
patient.
The null hypothesis formulated is that there was no Mean
Difference between the stress indices measured in the sample
neither before nor after the application of the independent
variable. The research hypothesis issued is that there was a Mean
Difference between the stress indices measured in the sample
before and after the application of the independent variable.
The strategy followed was: measurement pretest-retest and
comparison of the Control Group with the Experimental Group.
The variable control revolved around the biochemical
examination of viral load, Beck’s Depression Inventory and
 Journal of Psychology and Brain Studies
Beck’s Inventory of Anxiety (Aaron Beck), the physical exam and
the medical interview, the consumption of medicinal products
control and a survey.
The experimental variable consisted on the induction of relaxing
hypnosis, put into practice under group conditions, through daily
sessions for three months and with a duration of fifteen minutes
each, resulting in an average of four weekly sessions per patient.
Procedure
At first, some tests were put into practice for the selection of the
sample; once it was defined, it was subdivided into the control
group and the experimental group.
Later, a lecture about the stress was given to the experimental
group: its adverse consequences, its effect on the immune
system and its harm on VIH infected persons. It was also
included an explanation about the relaxation and the hypnosis;
its function in the individual and the immunological effects that
from this condition are derived. They were even told about the
state we pretended to achieve and the procedure to follow.
On the next day, the application of the independent variable
started as a group. It took place in a room with stretchers of low
height so that the evolution of the patient could be observed.
The environment was quiet and absolutely silent, in the
darkness, with a very low light, with a properly temperature and
breezy, but no drafty, and with the only presence of the inductor
and the subjects of the experimental sample, who were wearing
comfortable clothes, without any kind of pressure or discomfort
in them, but under those conditions it did not seem to matter
their type, colour or form
During that first session, the subjects were told that:
- They would feel a state very much like feeling sleepy, as
being asleep outside and awaken inside.
- They would feel a deep calm, which could continue for
some time.
- They did not have to do or think in nothing else, not to try to
put their minds to go blank, whatever should appear it
would disappear by itself while the process deepens.
- They only need to adopt a passive attitude and “let it do”.
- The passive attitude to adopt excludes homing
procedures, purpose or observation of the process.
- They should not have outstanding matters, urges, insects
nearby, a cough, rhinitis, nor any other trouble
(discomfort).
In the first step, it was carried out the exercise of contraction
and straining of muscles, in order to help reduce anxiety and its
interference in mental concentration.
Afterwards, the breathing exercise was indicated, applied with
deep breath, natural and spontaneous, while the body and the
muscles got relaxed. Once felt the proper rest and the passivity
the relaxing hypnosis was inducted by the inductor’s voice.
© Under License of Creative Commons Attribution 3.0 License
2018
Vol.2 No.1:4
Before starting the session, the subjects adopted the supine
position, lying one meter away from each other, and then the
preliminary exercises began. Their purpose was to increase the
performance of induction through the muscular tension; and, as
a matter of facat, to decrease the initial anxiety, and they are
inspired on Jacobson’s theory and practice [39].
Its usefulness lies in removing temporarily, emotional
interferences to the relaxation that proceeds to the hypnosis,
mostly anxiety, strain (tension) and depression.
In this exercises the body is contracted for some seconds and it
was left to fall down distended. The legs were put together and
slightly raised, pointing their toes, hands opened or closed but
contracted, the backs were arched upward in a convex way, the
sphincters contracted, also the neck, the jaws (without pressing
the teeth in order to avoid any damage), the eyelids were tightly
shut. They were kept this way for two or three seconds, until
suddenly the body was released, allowing it to collapse for its
own weight, and without exerting any kind of control or
restriction on it. This exercise was to be repeated three times.
After the mentioned exercise, they would inhale deeply, the
would exhale and gave in to rest. This breathing was completely
passive, not controlled nor dosed. Leaving mouth and lips to
their own weight, in a proper rest position without being
deliberately opened or closed; it’s to say, leaving the jaws hang
by themselves. Allowing the air to flow in and out pleasantly
through the mouth and the nose, filling up the lungs without
forcing its entry or its exit in no way. Just looking for distension
and stillness. There cannot be a pre-established position in the
way of breathing in the mouth nor the body, neither improvised
procedures of taking in the air through the nose and exhaling it
by the mouth, or holding some air and allow it to go out little by
little, turning out to be these schemes self-defeating [40].
There are no exact formulae in the hypnotic messages to convey,
and in this study the emphasis was placed in transmitting rest,
to feel the tranquillity transmitted by the inductor, the showing
up of a soft and deep sleep impossible to avoid and the invasion
of a very peaceful calm. Thirty minutes after the hypnotic
induction, the subjects were awakened and the final interview
took place [40].
Results and Discussion
The viral load test turned out to be from 173 201 copies before
to 42 467 copies after, as well as 65 822 in the control group
compared with 42 468 in the experimental one, both measured
at the end of the treatment, three months later, for 9 cases. In
general, the viral load lowered in five cases under medical
treatment with medicines and in one of the ones that did not
take them, and it remained stable in two that were taking them
and in one that did not take them.
The body weight resulted in an average increase of 67 to 69
kilograms for the 11 cases. The depression diminished in an average
of 16 to 11 at the end of the treatment for 10 cases. Meanwhile,
the anxiety decreased from 14 to 12, for equal quantity of cases.
The physical vigour had a significant improvement in a
3
 Journal of Psychology and Brain Studies
9%, a clear improvement in an 82% and no variance (variation) in a
9%, for 11 cases. The quality (of) sleep turned into a significant
improvement in an 18%, a clear improvement in a 64% and no
variation in the 9%, for the same quantity of cases. The state of
mind turned into a significant improvement in a 36% and a clear
improvement in a 64%, for equal quantity of cases.
Some symptoms submitted in those cases who were suffering
them: the peripheral neuropathy symptoms (2 cases), dizziness
(5 cases), and muscle aches (3 cases), nauseas (9 of 10 cases),
diarrhea (5 from 7 cases) and headache (9 from 10 cases).
In the experimental group, according to the pretest-retest
evaluation it was observed an increase in case 8, but not a
significant one, while it turned out in 751 copies during the period
what is taken biochemically, as stable, as well as also it was the one
that proved with the least possibility of mental concentration due to
several factors as scepticism and a consequence of toxoplasmosis
which prevented an optimal muscle strain. The cases 9 and 10
caught opportunistic diseases before and at the beginning of the
period, which affected their attendance, their state of mind and
their disposal for the treatment.
Some doubts arose about the increase of the viral load in case 5.
However, in this case, and in those in which no decrease was
References
1 Maueia C, Costa C, Meggi B, Ismael N, Walle C, et al. (2011)
Frequency of human immunodeficiency virus type-2 in HIV infected
patients in Maputo City, Mozambique. Virol J 8: 408.
2 Ahuka-Mundeke S, Ayouba A, Mbala-Kingebeni P, Liegeois F, Esteban A,
et al. (2011) Novel multiplexed HIV/simian immunodeficiency virus
antibody detection assay. Emerg Infect Dis 17: 2277–2286.
3 Jones RB, Garrison KE, Mujib S, Mihajlovic V, Aidarus N (2012)
HERV-K–specific T cells eliminate diverse HIV-1/2 and SIV primary
isolates. J Clin Invest 122: 4473-89.
4 Todd PB (2008) The psychoneuroimmunological database for
psychological interventions in HIV infection. Gay & Lesbian Issues &
Psychology Review 4: 141–147.
5 O’Connell-Edwards C, Jones DJ, Forehand R, Larkin K (2008) CD4
count and physical symptoms among urban african american
mothers with HIV: An examination of the role of optimism and
depressive symptoms. J Clin Psychol Med Settings 15: 322-330.
6 Dwight LE, Leserman J & Perkins DO (1995) Stress-associated
reductions of cytotoxic T lymphocytes and natural killer cells in
asymptomatic HIV infection. Am J Psychiatry 152: 543-550.
7 Kemppainen JK, Eller LS, Bunch E, Hamilton MJ, Dole P (2006)
Strategies for self-management of HIV- related anxiety. AIDS Care
18: 597-607.
8 Hand GA, Phillips KD, Dudgeon WD (2006) Perceived stress in HIV-
infected individuals: Physiological and psychological correlates.
AIDS Care, 18: 1011-1017.
9 Kadushin G (1999) Barriers to social support and support received
from their families of origin among gay men with HIV/AIDS. Health
Soc Work 24: 198-210.
4 This article is available in: http://www.imedpub.com/psychology-and-brain-studies
2018
Vol.2 No.1:4
produced as well, there were observed the worst conditions for
their stress management for one reason or another.
The decrease body weight and the asthenia conditions,
pathognomics of this Acquired Immunodeficiency Syndrome,
give a high importance to this variation. The average in weight
gain that was consistently produced in the experimental group is
an additional indicative of the effects of the applied treatment.
In the two cases in which it was not specifically achieved, it was
due to a diarrheal disease caused by the consumption of some
drugs. It must be highlighted that even three of the four cases in
which there was no lowering of their viral load, they gained
some weight in spite of everything; even one of them had to be
put on diet.
Conclusion
The satisfaction level was obvious in all cases to a greater or
lesser extent, five of the subjects who were incapable of
working, started to do it or to look for a job, even that who was
reported as unchanged, under the Vigour category. All of them
improved their state of mind. An improvement of their sleep
condition was produced, except for one case, due to the
consumed drugs; the rest slept better. An important decrease or
remission of the adverse consequences of the medicines was
found, as it could be observed.
10 Li L, Zunyou W, Sheng J, Manhong LE, Lu Y (2008) Impacts of HIV/
AIDS stigma on family identity and Interactions in China. Fam Syst
Health 26: 431-442.
11 Li L, Li-Jung L, Chunqing L, Zunyou W, Yi W (2009) Individual
attitudes and perceived social norms: Reports on HIV/AIDS-related
stigma among service providers in China. Int J Psychol 44: 443-450.
12 Trezza GR (1994) HIV knowledge and stigmatization of persons with
AIDS: Implications for the development of HIV education for young
adults. Prof Psychol Res Pr 25: 141-148.
13 Swendeman D, Rotheram-Borus MJ, Comulada S, Weiss R, Ramos
ME (2006) Predictors of HIV-related stigma among young people
living with HIV. Health Psychol 25: 501-509.
14 Massiah E, Roach T, St. John A, Blackwood Ch, Jacobs C, Inniss, V. &
Walcott, J. (2004) Stigma, discrimination, and HIV/AIDS knowledge
among physicians in Barbados. Rev Panam Salud Publica, 16: 395-401.
15 Edo MT, Ballester R (2006) Emotional state and illness behavior in
patients with HIV/AIDS and cancer patients. Journal of
Psychopathology and Clinical Psychology 11: 79-90.
16 Teva I, Bermudez M, Hernandez-Quero J, Buela-Casal G (2005)
Assessment of depression, anxiety and anger in patients with HIV/
AIDS. Mental Health 28: 40-49.
17 Zanatta M, Saracco A, Gervith RS, Collado A, Ruiz C (2005)
Psychiatric disorders in patients with HIV/AIDS at the HIV/AIDS
clinic, 220 regional general hospital. Mexican Social Security
Institute. Psychiatry 21: 12-18.
18 Piña JA, Dávila M, Sánchez-Sosa J, Togawa C, Cazares O (2008)
Association between stress and depression levels and treatment
adherence among HIV-positive individuals in Hermosillo, México.
Rev Panam Salud Publica 23: 377-383.
 Journal of Psychology and Brain Studies
19 Littrell J (2008) The mind-body connection: Not just a theory
anymore. Soc Work Health Care 46: 17–37.
20 López A , Calles I (2008 ) Psychometric characteristics of the Death
Anxiety Scale (DAS) in HIV/AIDS patients. Psicothema 20: 958-963.
21 Pakenham KI, Rinaldis M (2002) Development of the HIV/AIDS stress
scale. Psychol Health 17: 2.
22 Remor EA, Carrobles JA, Arranz P, Martínez-Donate A, Ulla S (2001)
Anxiety and perception of control in HIV infection and AIDS. Int J
Clin Health Psychol 9: 323-336.
23 Bormann J E, Gifford AL, Shively M, Smith TL, Redwine L (2006)
Effects of spiritual mantram repetition on HIV outcomes: A
randomized controlled trial. J Behav Med 29: 359-376.
24 Qingling C, Zengquan Z (2002) Group therapy of those with
HIV/AIDS. Chin Ment Health J 16: 663-666.
25 Bei-Hung CH, Boehmer U, Yue Zh, Sommers E (2007) The combined effect of
relaxation response and acupuncture on quality of life in patients with HIV:
A pilot study. J Altern Complement Med 13: 807–815.
26 Baratas D, Monteserín F, Parejo M, Peña C, Polo A (1996)
Framework program of psychological intervention with affected by
HIV/AIDS. Ansiedad y Estrés 2: 69-82.
27 Biswas UN (2007) Promoting health and well-being in lives of
people living with HIV and AIDS. Psychol Dev Soc J 19: 215-247.
28 Cruess DG, Antoni MH, Kumar M, SchneidermanN (2000) Reductions in
salivary cortisol are associated with mood improvement during
relaxation training among HIV-seropositive men. J Behav Med 23: 2.
29 Shrier LS (1993) The effect of hypnosis on the immune systems of
aids and HIV-infected patients. Dissertation Abstracts International
53: 4999.
30 Rucklidge JJ, Saunders D (2002) The efficacy of hypnosis in the
2018
Vol.2 No.1:4
treatment of pruritus in people with HIV/AIDS: A time-series analysis.
Int J Clin Exp Hypn 50: 149-169.
31 Langenfeld M CH (2000) The effects of hypnosis on pain-control with
people living with HIV-AIDS. Dissertation Abstracts International:
Section B: The Sciences and Engineering, 60: 5780-81.
32 Laidlaw TM, Kerstein R, Bennett BM, NaitoA, Dwivedi P, et al. (2004)
Hypnotizability and immunological response to psychological
intervention in HIV. Contemp Hypn 21: 126-135.
33 Marcus JD (2002) The use of hypnosis with HIV/AIDS spectrum
illnesses: A model of treatment. Dissertation Abstracts
International: Section B. The Sciences and Engineering, 63: 2593.
34 McCain NL, Gray DP, Elswick RK, Robins J, Tuck I (2008) A randomized
clinical trial of alternative stress management interventions in persons
with hiv infection. J Consult Clin Psychol 76: 431–441.
35 Taylor DN (1995) Effects of a behavioral stress-management
program on anxiety, mood, self-esteem, and t-cell count in HIV-
positive men. Psychol Rep 76: 451-457.
36 Vieille RC (1998) The use of hypnosis, self-hypnosis, mental imagery
and naturalistic trance to enhance immunity and health in gay men
with HIV. A contextualistic perspective. Dissertation Abstracts
International: Section B: The Sciences and Engineering, 58: 5692.
37 Antoni M H, Baggett L, Ironson G, LaPerriere A, August SH, et al. (1991)
Cognitive-behavioral stress management intervention buffers distress
responses and immunologic changes following notification of hiv-1
seropositivity. J Consult Clin Psychol, 59: 906-15.
38 Jacobson E (1938) Progressive Relaxation. Chicago: University of
Chicago Press
39 Ponce JR (2013) Hypnosis and emotional relaxation. Editorial PAX:
México
5
Wood et al. BMC Health Services Research (2018) 18:219 https://doi.org/10.1186/s12913-018-3002-4

RESEARCHARTICLE Open Access

Nurse led home-based care

for people with HIV/AIDS
1* 2 3 2,3
Elizabeth M. Wood , Babalwa Zani , Tonya M. Esterhuizen and Taryn Young

Abstract
Background: Home-based care is used in many countries to increase quality of life and limit hospital
stay, particularly where public health services are overburdened. Home-based care objectives for
HIV/AIDS can include medical care, delivery of antiretroviral treatment and psychosocial support. This
review assesses the effects of home-based nursing on morbidity in people infected with HIV/AIDS.
Methods: The trials studied are in HIV positive adults and children, regardless of sex or setting and all
randomised controlled. Home-based care provided by qualified nurses was compared with hospital or health-
facility based treatment. The following electronic databases were searched from January 1980 to March 2015:
AIDSearch, CINAHL, Cochrane Register of Controlled Trials, EMBASE, MEDLINE and PsycINFO/LIT, with an
updated search in November 2016. Two authors independently screened titles and abstracts from the
electronic search based on the study design, interventions and types of participant. For all selected abstracts,
full text articles were obtained. The final study selection was determined with use of an eligibility form. Data
extraction was performed independently from assessment of risk of bias. The results were analysed by
narrative synthesis, in order to be able to obtain relevant effect measures plus 95% confidence intervals.
Results: Seven studies met the inclusion criteria. The trial size varied from 37 to 238 participants. Only
one trial was conducted in children. Five studies were conducted in the USA and two in China. Four
studies looked at home-based adherence support and the rest at providing home-based psychosocial
support. Reported adherence to antiretroviral drugs improved with nurse-led home-based care but did
not affect viral load. Psychiatric nurse support in those with existing mental health conditions improved
mental health and depressive symptoms. Home-based psychological support impacted on HIV stigma,
worry and physical functioning and in certain cases depressive symptoms.
Conclusions: Nurse-led home-based interventions could help adherence to antiretroviral therapy and improve
mental health. Further larger scale studies are needed, looking in more detail at improving medical care for HIV,
especially related to screening and management of opportunistic infections and co-morbidities.
Keywords: HIV/AIDS, Home-based care, Nurse-led care, Adherence to antiretroviral drugs, Psychosocial support

Background people became newly infected with HIV/AIDS while 1.1

HIV/AIDS is a significant cause of morbidity and mor-
tality in low and middle-income countries (LMICs),
where health services already contend with poor infra-
structure and limited resources including staff, drugs and
equipment. Approximately 36.7 million people are living
with HIV and around 52% of these are in Sub-Saharan
Africa [1]. In 2015, an estimated 2.1 million
* Correspondence: elizabethwood3@nhs.net
1
Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool,
UK Full list of author information is available at the end of the article
million of those with HIV/AIDS died [1].
The 2016 World Health Organisation (WHO) guide-
lines broaden the number of people eligible to start life-
saving antiretroviral therapy (ART) [2]. Although these
changes can improve clinical outcomes and reduce the
incidence of HIV, they pose a challenge for public health
services already overburdened with limited human and
financial resources. Global coverage of antiretroviral
therapy increased to 46% at the end of 2015 but dispar-
ities remain between high and low income countries [1].

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
Wood et al. BMC Health Services Research (2018) 18:219
Barriers to accessing and retaining care include amongst
others transport costs, long waiting times and a shortage
of healthcare staff [3]. Decentralising HIV treat-ment to
community or home based settings and task-shifting using
non-physician health workers for the initiation and
maintenance of ART may help to over-come some of
these problems, and these measures are being adopted as
key management strategies [4–6].
Home-based care
The WHO defines home-based care (HBC) as any form of
care given to ill people in their homes, including physical,
psychosocial, palliative and spiritual activities [7]. There
are various types of HBC including integrated HBC
where all service providers are involved, single ser-vice
HBC involving one organisation, and informal HBC with
no formal support structure [8]. HBC can be car-ried out
by a variety of people including qualified health-care
practitioners, nurses, trained lay community health
workers, peer health workers and HBC volunteers [9].
Providing care in the home can overcome some of the
barriers to care, such as transport costs and waiting times,
and help to reduce the burden on health facilities [10]. Other
benefits of HBC include lower costs at both individ-ual and
country level, personalised care and being in famil-iar
surroundings. It can also reduce demand on hospital beds and
increase effective time use in hospitals [10].
Fig. 1 Home-based care as a management strategy for people with HIV
Page 2 of 13
Home-based care for HIV
HBC has been defined by the Committee on a Na-tional
Strategy for AIDS (CNSA) for the USA as care at the
patient’s residence to supplement or replace hospital care
including medical management, palliative care and social
support [8]. HBC objectives for HIV/ AIDS can include
improved medical care, delivery of ART and improved
psychosocial well-being (Fig. 1 Home-based care as a
management strategy for people with HIV). It could have
positive social out-comes by helping to reduce the stigma
surrounding HIV, thereby improving support, access and
adherence to ART and uptake of testing [10, 11]. An
integrated approach using HBC to provide co-ordinated
care for a number of conditions has been suggested, for
in-stance combining HIV and tuberculosis management
[12, 13].
Recent expansion of ART programmes has led to a
growing emphasis on the decentralisation of HIV treat-
ment in LMICs. Kredo assessed the effects of decentra-
lised HIV care in relation to both initiation and
maintenance of ART [5]. Wringe reviewed whether the
conditions are in place to effectively scale up HBC pro-
grammes for increased ART, in terms of available human
resources, health systems and funding mechanisms. They
concluded that sustainable funding needs to be en-sured,
and policies to encourage staff retention and ser-vice
integration are needed [10].
Wood et al. BMC Health Services Research (2018) 18:219
Home-based care for other conditions
A number of reviews have examined the effects of home
care for a variety of conditions. Okwundu found that
home or community-based programmes for treating
malaria could increase the number of people who receive
appropriate anti-malarial treatment and may re-duce all-
cause mortality [14]. For cardiovascular disease, Clark
found that home-based secondary prevention pro-
grammes conducted by health professionals are as
effective as hospital based cardiac rehabilitation, and
considerably lower in cost [15]. A study looking at end of
life care at home for terminal patients supported the use of
home care programmes for increasing the num-bers of
patients who will die at home [16]. In contrast, Smeenk
concluded that the effectiveness of home care
programmes for patients with terminal cancer remains
unclear [17].
Task-shifting
Task shifting from medical doctors to nurses is a poten-
tially effective strategy to overcome the medical work-
force shortage and to address the needs associated with
chronic HIV/AIDS [13]. The increasing use of lay health
workers to fill gaps in the work force raises the issues of
training required and the quality of care provided. A re-
view examining the use of lay health workers in the
management of infectious diseases found them to be ef-
fective for improving tuberculosis outcomes but there was
insufficient evidence to make a conclusion regarding
adherence support in HIV/AIDS [18].
Kredo found that there is probably no reduction in the
quality of care when trained nurses or community health
workers initiate and maintain ART. When nurses initiate
and maintain ART, there may also be lower loss to follow-
up compared with doctors [6]. More research is needed
into the level of training required and the ability of these
workers to perform effectively whilst taking on multiple
roles [9, 19].
Why is it important to do this review?
In addition to the delivery of ART, other current key is-
sues in the multidimensional care of HIV/AIDS include
counselling and home-based testing, pre-ART care (such
as repeating eligibility assessment), delivery of preventa- teria. Full text articles were obtained of all selected
tive interventions, distribution of prophylaxis, treatment
of opportunistic infections and supportive psychosocial
activities.
Young found a range of HBC models and interven- independently by two authors using a standardised data tions for
HIV but these were generally from small stud- extraction form.
ies and the majority were based in developed countries
[20]. Since this review was published, there has been a
change in the evidence with more focus on HBC in
LMICs. Home-based HIV voluntary counselling and
testing has been found to have the potential to increase
Page 3 of 13
uptake in developing countries [21]. Nurses are an im-
portant element of HBC for HIV but have not been cov-
ered in depth in Young or any other recent review. This
review assesses the effects of home-based nursing to re-
duce morbidity in people infected with HIV/AIDS.
Methods
Criteria for considering studies for this review
We included all randomised controlled trials (RCTs)
conducted amongst HIV/AIDS positive individuals, adults
and children, comparing home-based care, includ-ing all
forms of treatment, care and support offered in the
HIV/AIDS positive person’s home by qualified nurses
who have received a formal professional certifi-cate or
tertiary education degree, compared to hospital or health-
facility based treatment. Home-based HIV vol-untary
counselling and testing was excluded as it is cov-ered in
Bateganya [21]. Initiation and delivery of ART was
excluded as it is covered in Kredo [5]. We consid-
ered various outcomes including progression to AIDS,
death, psychosocial outcomes (mood scores, stigma, pa-
tient and carer preferences), quality of care, quality of
life, inpatient days, and number and type of opportunis-
tic infections.
Search methods for identification of studies
The following electronic databases were searched from
1980 to March 2015: Cochrane Register of Controlled
Trials, MEDLINE, EMBASE, AIDSearch, CINAHL,
PsycINFO/LIT, with an updated search in MEDLINE in
November 2016. Detailed search strategies were com-
piled for each database searched (Table 1 details the
MEDLINE search strategy). Clinicaltrials.gov and the
WHO International Clinical Trials Registry Platform were
searched in March 2015 to identify on-going trials. The
strategy was iterative, in that references of included
studies were searched for additional references. All lan-
guages were included.
Selection of studies, data collection and analysis
Titles, abstracts and descriptor terms of the electronic
search results were screened independently by two au-
thors for relevance based on predefined eligibility cri-
abstracts and final eligibility assessed. Data including ad-
ministrative details, study design, details of the interven-
tion and control, and outcomes were extracted
The risk of bias of included studies was also evaluated
independently by two authors using the Cochrane risk of
bias tool. We assessed and summarised the following
main items in the ‘Risk of Bias’ table: sequence gener-
ation, allocation concealment, blinding of participant
Wood et al. BMC Health Services Research (2018) 18:219 Page 4 of 13

Table 1 MEDLINE search strategy

Search Most recent queries
#1 Search HIV Infections[MeSH] OR HIV[MeSH] OR hiv[tw] OR hiv-1*[tw] OR hiv-2*[tw] OR hiv1[tw] OR hiv2[tw] OR hiv infect*[tw] OR
human immunodeficiency virus[tw] OR human immunedeficiency virus[tw] OR human 19rospe-deficiency virus[tw] OR human
immune-deficiency virus[tw] OR ((human 19rospe*) AND (deficiency virus[tw])) OR acquired immunodeficiency syndrome[tw] OR
acquired immunedeficiency syndrome[tw] OR acquired 19rospe-deficiency syndrome[tw] OR acquired immune-deficiency
syndrome[tw] OR ((acquired 19rospe*) AND (deficiency syndrome[tw])) OR “Sexually Transmitted Diseases, Viral”[MeSH:NoExp]
#2 Search randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR random allocation [mh] OR double-
blind method [mh] OR single-blind method [mh] OR clinical trial [pt] OR clinical trials [mh] OR (“clinical trial” [tw]) OR ((singl* [tw] OR doubl* [tw] OR
trebl* [tw] OR tripl* [tw]) AND (mask* [tw] OR blind* [tw])) OR (placebos [mh] OR placebo* [tw] OR random* [tw] OR research design [mh:noexp]
OR comparative study [mh] OR evaluation studies [mh] OR follow-up studies [mh] OR prospective studies [mh]
OR control* [tw] OR 19rospective* [tw] OR volunteer* [tw]) NOT (animals [mh] NOT human [mh])
#3 Search Home-based care or homebased care or home based care
#4 Search Home care or homecare or home-care
#5 Search Home
#6 Search #3 OR #4 OR #5
#7 Search #1 AND #2 AND #6

and personnel, blinding of outcome assessment, whether
incomplete outcome data were adequately addressed, se-
lective reporting and any other bias.
Missing or inadequate data were addressed by contact-
ing authors. We resolved disagreements by discussion.
Relevant effect measures and the 95% confidence in-
tervals (CI) were reported. We planned to assess sources
of clinical and methodological heterogeneity by looking
at characteristics of studies, evaluating similarity be-
tween type of participants, intervention used and out-
comes. However, due to the varied outcomes used in the
included studies no meta-analysis could be conducted.
Results
Description of studies
Seven studies met the inclusion criteria (Fig. 2 Flow dia-
gram of study selection). In addition, we identified one
on-going trial currently being conducted in Kenya inves-
tigating home-based directly observed ART [22]. Fifty
studies were excluded. Reasons for exclusion are detailed
in Table 2.
Individuals were randomised in each of these seven
studies. Trial sizes varied from n = 37 to n = 238. Only
one trial was conducted in children [23] whilst the rest
were conducted in adults (≥18 years). One trial focused
on female adults [24] and the others included males and
females. Five studies were conducted in the USA [23–27]
and two in China [28, 29].
The interventions studied and outcomes measured var-
ied between studies (Table 3). Four studies could be
classi-fied under home-based adherence support [23, 27–
29]. Five studies investigated providing home-based
psycho-social support [24–26, 28, 29].
Detailed information on the participants, interven-tions,
controls and outcomes can be found in Table 3.

Risk of bias in included studies

The risk of bias assessment is summarised in Table 4.
Table 2 Table of excluded studies
Reason for exclusion Number of studies [references]
Not all participants are HIV positive 3 studies [34–36]
Intervention studied was not 5 studies [37–41]
home-based care
Intervention was not provided 15 studies [42–56]
by qualified nurses
Comparison of two models of 2 studies [57, 58]
home-based care
Study investigating home-based 12 studies [59–70]
voluntary HIV counselling and testing
Not a randomised controlled trial 12 studies [71–82]
Trial terminated for non-compliance 1 study [83]
Fig. 2 Flow diagram of study selection with human subject regulations
Wood et al. BMC Health Services Research (2018) 18:219 Page 5 of 13

Table 3 Description of included studies

Category Type of intervention Study ID Participants Follow-up Study Outcomes
and comparison duration location
Adherence Home-based Berrien HIV-positive children. N = 37. 12 months. Connecticut, Adherence;
support nursing vs. 2004 [23] USA. Viral load; CD4 count.
standard care
Wang HIV-positive adults; active or previous heroin 10 months. Hunan, Adherence.
2010 [28] addicts; on ART at least 1 month prior to China.
starting study. N = 116.
Williams HIV-positive adults on ART. N = 171. 15 months. Connecticut, Adherence;
2006 [27] USA. Viral load; CD4 count.
Williams HIV-positive adults; on ART; self-reported 12 months. Hunan, Adherence;
2014 [29] < 90% adherence to pre-ART medications China. Viral load; CD4 count.
or to ART; willing to receive home visits.
N = 110.
Improved Home based Blank HIV-positive adults; understand spoken 24 months. Philadelphia, Health related quality
psycho-social nursing vs. 2014 [25] English; had a diagnosed serious mental USA. of life; Viral load;
wellbeing standard care illness; able to provide informed consent. CD4 count.
N = 238.
Hanrahan HIV-positive adults; lived within the city 12 months. Philadelphia, Psychiatric symptoms;
2011 [26] limits of Philadelphia; had a diagnosed USA. Health related quality
serious mental illness (SMI). N = 238. of life
Miles African American women with HIV who 6 months. USA. Emotional distress
2003 [24] were primary caregivers for at least one (depression, stigma,
child under the age of 9 years. N = 109. worry); Health related
quality of life
Wang HIV-positive adults; active or previous 10 months. Hunan, Quality of life,
2010 [28] heroin addicts; on ART at least 1 month China. Depression
prior to starting study. N = 116.
Williams HIV-positive adults; on ART; self-reported 12 months. Hunan, Depressive symptoms;
2014 [29] < 90% adherence to pre-ART medications China. social support; HIV
or to ART; willing to receive home visits. N = 110. stigma scale.

Allocation (selection bias) Incomplete outcome data (attrition bias)

All trials stated that participants were randomised. Five
trials used adequate methods for generating the alloca-
tion sequence. Of these five trials, two used random
number tables [23, 24], one used a computer generated
algorithm [26] and two used a stratified randomisation
procedure [27, 29]. Allocation concealment was ad-equate
in two trials [23, 26] and not reported in the remaining
trials.
Three trials reported a loss to follow up of less than 20%
and two reported a loss to follow up of less than 30% [23,
26, 28]. Miles had a high loss to follow up of 51% in the
intervention group and 58% in the control group [24].
One study did not report loss to follow up [25].
Selective reporting (reporting bias)
All outcomes stated were reported.

Blinding (performance bias and detection bias) Effects of interventions

In Williams 2006 all personnel (except the home
intervention team) and the interviewers were blind
throughout the course of the study whereas in Hanrahan
and Miles, only the data collectors were blinded [24, 26,
27]. Blank was designed to be single blind for the
research staff but participants sometimes disclosed
information, which made it possible to iden-tify their
experimental status [25].
In Williams 2014 there was no blinding of the partici-
pants but it was unclear whether the outcome assessors
were blinded [29]. Berrien used no blinding and Wang did
not report blinding [23, 28].
The effects of the various interventions are summarised in
Table 5.
Adherence support
Four studies, one in children [23] and three in adults [27–
29] examined the effects of an intensive home based
nursing programme compared to standard care on
adherence to ART. Berrien, Williams 2006 and Williams
2014 also reported viral load and CD4 counts [23, 27, 29].
However, due to differences in the way these three
outcomes were measured and reported we could not do a
meta-analysis.
Wood et al. BMC Health Services Research (2018) 18:219 Page 6 of 13

Table 4 Risk of bias of included studies

Bias Berrien 2004 [23] Blank 2014 [25] Hanrahan 2011 [26] Miles 2003 [24] Wang 2010 [28] Williams 2006 [27] Wiliams 2014 [29]
Random Small table of Randomised on Computer- Table of Not reported. Stratified Stratified
sequence random digits. a 1:1 basis but generated random randomisation, randomisation,
generation method unclear. algorithm numbers. with block size with block size
of 10. of 10.
Allocation Randomisation list Not reported. Person allocating Not reported. Not reported. Not reported. Not reported.
concealment held by clinical different from the
coordinator of HIV one assessing the
program, kept in a inclusion.
locked file.
Incomplete Lost to follow-up: Lost to follow up Lost to follow-up: Lost to Lost to Lost to follow-up Lost to follow-up
outcome 5% intervention; not reported. 10% intervention; follow-up at follow-up: 14% at 12 months: at 12 months:
data 11% control. 5% control. 6 months: 51% intervention; 28% intervention; 5% intervention;
intervention; 17% control. 25% control. 22% control.
58% control.
Selective All outcomes All outcomes All outcomes All outcomes All outcomes All outcomes Incomplete
reporting reported. reported. reported. reported. reported. reported. reporting of
social support
and stigma.
Blinding of None. Participants None. None. Not reported. All personnel None.
participants not blinded. were blinded
and except the home
personnel visit team.
Participants
not blinded.
Blinding of None. Research staff Data collectors Data collectors Not reported. All personnel Not reported.
outcome blinded. blinded. blinded. including
assessment Participants interviewers were
disclosed blinded except
information, the home visit
unmasking team.
experimental
status.

Table 5 Summary of results

Outcomes Summary
Adherence Adherence -Self-reported adherence improved with intervention [23, 28, 29].
support -Intervention increased ratio of the number of recorded Medication Event Monitoring Systems
(MEMS) cap openings to the number of openings to be expected if the medication
were taken as prescribed [27].
-Pharmacy drug refill increased significantly with intervention [23].
Viral load No significant change [23, 27, 29].
CD4 count No significant change [23, 27, 29].
Improved Health-related -SF-12 mental health subscale improved with intervention but not the SF-12 physical
psycho-social quality of life health subscale [25].
wellbeing -No clear difference in health related quality of life outcomes (SF-12) [26].
-Improved WHO quality of life measures [28].
Psychiatric symptoms No significant difference between groups in reduction in psychiatric symptoms
(Colorado Symptom Index (CSI) score) [26].
Emotional distress -Reduced symptoms of depression (PHQ-9 score) with intervention [26].
(depression, stigma, worry) -Reduced HIV stigma, worry, physical functioning but no significant
difference in depressive symptoms, mood, general health or overall functioning [24].
-Reduced symptoms of depression (Self-rating Depression Scale) [28].
-Reduced symptoms of depression (CESD scale) in intervention group.
No significant difference in social support (SSRS) and stigma (HIV stigma scale) [29].
Wood et al. BMC Health Services Research (2018) 18:219
In Berrien’s study (n = 37) a home care registered nurse
made eight pre-planned home visits over three months,
aiming to increase patient understanding of HIV infection
and ARVs and prevent issues with adher-ence [23].
Standard care in a clinic included the doctor, nurse, and
social worker providing customary medica-tion adherence
education. Medication adherence mea-sured by pharmacy
drug refill was significantly better (mean refill score 2.7
in the intervention group and 1.7 in control group, p =
0.002). The intervention group also showed improvement
in their knowledge score com-pared to the control group
(p = 0.02) and in their re-ported adherence although this
difference was not statistically significant (p = 0.07).
There were no significant differences in the change in
CD4 counts or viral loads either immediately or 6–11
months later. 45% of participants in the intervention
group maintained or achieved a viral load, < 2.6
log10copies/ml (<400copies/ml) compared to 24% in the
control group. CD4 figures were not reported [23]. This
study had a low risk of selection and attrition bias but the
small sample size of the study reduces the quality of these
results.
Wang (n = 116) provided nurse-delivered home visits
combined with telephone calls to HIV-infected heroin
users to the intervention group, whilst the control group
received routine care involving a monthly clinic visit [28].
Assessment of selection, performance and detection bias
was not possible due to lack of reporting of these
methodological aspects. There was a low risk of attrition
bias and at the end of the eight months, participants in the
experimental group were more likely to report taking
100% of pills (Mantel-Haensel 1.57, 95% CI 1.19 to 2.07,
reported p = 0.0001) and taking pills on time (Mantel-
Haensel 2.50, 95% CI 1.51 to 4.13, reported p = 0.0001)
than those in the control group.
Williams 2006 (n = 171) assessed an adherence tool
which followed a structured educational model facili-tated
by a nurse and community support worker con-ducting
home visits, compared to standard care [27]. Adherence
was recorded as the ratio of the number of Medication
Event Monitoring Systems cap (MEMS cap) openings to
number of openings expected if the medica-tion was taken
as prescribed. There was a low risk of detection bias, loss
to follow-up of 28% and 25% respect-ively, and
allocation concealment was not reported. The median
CD4 counts were 345 and 341 for the interven-tion and
control arms respectively. Comparing the proportion of
participants with greater than 90% adher-ence, there was a
statistically significant difference be-tween the two arms
at 15 months, favouring the intervention group (reported
extended Mantel-Hansel test 5.80, p = 0.02). There were
no significant changes at 12 and 15 months in proportion
of people with CD4
Page 7 of 13
count greater than 200 or undetectable viral loads (actual
figures not reported).
Williams 2014 (n = 110) investigated the effects of an
adherence intervention, which included home-based so-
cial and educational components provided by a nurse and
peer educator, compared to standard care adherence clinic
support services [29]. A visual analogue scale was used to
evaluate adherence to ART over the previous 30 days.
There is a risk of attrition bias with differential loss to
follow-up of 5% and 22% at 12 months. At base-line all
subjects reported taking 90% or less of prescribed
medication (pre-ART or ART). In reported bivariate
analyses, there was a significant difference in adherence
between the two groups at 6 and 12 months (p = 0.003
and p = 0.005). In reported multivariate analyses, con-
trolling for baseline factors, the experimental group had a
significantly higher proportion of people who were ad-
herent (p = 0.009). The proportion of those with an un-
detectable viral load increased in both groups at 6 months
(44% in control group, 57% in intervention group) and at
12 months (59% control group, 72% inter-vention group).
But in multivariate analyses controlling for baseline
factors, there was no difference between groups (p =
0.18). In reported multivariate analyses CD4 count did not
differ by group (p = 0.65) but an overall in-crease in CD4
count category was seen in all subjects between baseline
and 12 months (p = 0.003).
Psychosocial support
Five studies investigated the effects of a home-based
programme provided by nurses on psychological well-
being [24–26, 28, 29].
Psychiatric care
Blank (n = 238) examined a home-based advanced prac-
tice psychiatric nurse intervention in individuals with
serious mental illness and HIV [25]. The nurse provided
in-home consultations and co-ordinated medical and
mental health services. Growth curve analysis estimating
the treatment effects on viral load (log 10copies/ml) and
Medical Outcomes Study 12-Item Short-Form Health
Survey (SF-12) mental health scores, showed that the
intervention reduced the rate of change over time in viral
load and increased the rate of change over time in SF-12
mental health outcomes. They also compared CD4
percentage and the SF-12 mental health score, showing
only significant treatment effect for SF-12 men-tal health
score. A model comparing viral load and SF-12 physical
health scores showed a significant decline in viral load
but no change in perceptions of physical health status. A
model comparing CD4 and SF12 phys-ical health showed
no significant change. Therefore, re-sults show significant
improvement in health-related quality of life for a mental
health subscale but not for a
Wood et al. BMC Health Services Research (2018) 18:219
physical health subscale. However, there was a risk of
both detection and performance bias.
Hanrahan (n = 238) evaluated a home-based advanced
practice psychiatric nurse intervention in individuals with
serious mental illness and HIV [26]. The nurse pro-vided
in-home consultations and co-ordinated medical and
mental health services. Both groups had a reduction in
psychiatric symptoms (Colorado Symptom Index (CSI)
score) from baseline to 12 months, but the rela-tive
difference in these improvements was not signifi-cant
(reported effect (d) = − 4.03, 95% CI -15.99 to 7.83, p =
0.51). However, during the same period symptoms of
depression (PHQ-9 score) significantly decreased in the
experimental group compared to the control group, with
an average treatment effect of an increased PHQ-9 score
of 4.40 (95% CI -2.66 to 11.46, p = 0.2). There was no
clear difference in changes in health-related quality of life
outcomes (SF-12) over time between groups. In repeated
measured random regression models, Group x Time
interactions were all non-significant (reported p > 0.05).
Allocation conceal-ment was adequate and data collectors
were blinded.
Counselling and emotional support
Miles (n = 109) assessed the psychosocial impact of home
visits carried out by three registered nurses in the homes of
African American women with HIV who were the prin-cipal
caregivers for one or more children under the age of nine
[24]. At six months, there was a statistically signifi-cant
difference in scores for physical functioning (Medical
Outcomes Survey-HIV (MOS-HIV)) (WMD 1.45, 95% CI
0.01 to 2.89), HIV stigma (Demo HIV stigma scale) (WMD
-0.25, 95% CI -0.49 to − 0.01) and HIV worry (HIV worry
scale) (WMD -0.46, 95% CI -0.89 to − 0.03). For depressive
symptoms (Centre for Epidemiological Studies Depression
(CESD) scale), mood (Profile of Mood States (POMS)),
general health, and overall functioning (MOS-HIV), no
statistically significant difference was found. This study
however had a high loss to follow up which weakens the
quality of results.
Wang (n = 116) examined the effects of nurse-delivered
home visits combined with telephone calls on the quality
of life of HIV-infected heroin users [28]. The intervention
had a significant effect in reducing the symptoms of
depression (assessed using Chinese version of Self-rating
Depression Scale (SDS)) (MD -11.53, 95% CI -17.74 to −
5.92). Quality of life measures (measured by the Chinese
version of WHO Quality of Life) also im-proved
including physical (MD 2.97, 95% CI 1.75 to 4.19),
psychological (MD 2.72, 95% CI 1.61 to 3.83), so-cial
(MD 2.10, 95% CI 0.78 to 3.42) and environmental (MD
2.40, 95% CI 1.23 to 3.57) domains.
Williams 2014 (n = 110) investigated the effects of
nurse-delivered home visits on symptoms of depression
Page 8 of 13
(CESD scale), social support (Social Support Rating Scale
(SSRS)) and stigma (HIV stigma scale) [29]. At baseline,
reported multivariate analyses adjusting for baseline so-
cial support, stigma and raw CESD score, showed a sig-
nificant difference in overall depression scores between
the two groups (p = 0.001), with the control group hav-
ing a higher percentage of people with CESD score ≥ 16.
When baseline CESD scores were compared to 12-month
CESD scores, they reported a significant decrease in
depressive symptoms in the intervention group com-pared
to the control group (p = 0.03). There was also a
significant change between the six-month CESD scores
and 12-month CESD scores, with an increase in depres-
sive symptoms in control subjects and decrease in inter-
vention subjects (p = 0.05). Baseline raw CESD and
baseline stigma were significant predictors of CESD
scores (p < 0.001 and p = 0.003 respectively) but not
baseline social support.
Discussion
Over the past five years various reviews have assessed
community-based care for HIV (Table 6). Interventions
have looked at decentralised treatment and use of lay
health workers and volunteers. The WHO recommends
that nurse-led teams can deliver most interventions
including initiating and monitoring ART, managing
uncomplicated opportunistic infections and providing
primary mental health and neurological care [30]. Our
review adds to what is known by focussing on assessing
the effects of home-based nursing on morbidity in people
with HIV/AIDS.
To minimise publication and indexing bias, we used two
authors working independently to select studies, perform
data extraction and risk of bias assessments. The review
included seven studies, conducted in the USA and China.
Included studies were small, conducted mainly in adults.
Five trials used adequate methods for generating the
allocation sequence [23, 24, 26, 27, 29] and allocation
concealment was adequate in two trials [23, 26]. Only one
trial reported high losses to follow up [24]. This type of
intervention is difficult to blind and only one trial blinded
personnel and data collectors [27]. Another limitation is
that grey literature was not searched.
Reported adherence to ART improved with nurse-led
home-based care. Self-reported adherence measures could
be liable to a social desirability bias in which par-ticipants
felt obliged to report that their adherence was better at the
end of the trial because they were aware that this is what
the intervention is aiming to achieve. However more
objective measures to adherence such as the pharmacy
drug refill did also support this. Despite improved
adherence to ART, the interventions did not appear to
affect biological parameters. Interestingly a
Table 6 Summary of systematic reviews on community-based care for HIV

Wood et
Review Date of search, number of Participants Intervention Comparison Outcomes Summary of key findings
included studies
Decroo Feb 2013. PLWHA -Home-based ART delivery Facility -Attrition on ART. -Increase adherence and

. BMC Health Services Research (2018) 18:219

2013 [84] 18 studies: 2 cluster RCTs, 11 by CHWs. based ART -Virological accessibility to AR.
prospective/ retrospective cohort -Home-based ART delivery rebound on ART. -Cost effective
studies, 2 qualitative studies, by volunteers. -Cost –health service -Positive social outcomes
1 cost-effectiveness study, -Home-based ART by peer CHWs. costs, patient costs.
1 activity report from an NGO, -Patient-led community ART -Social.
1 abstract. dispensing.
Kredo March 2013. HIV-infected patients Any form of decentralised Care delivered -Attrition (composite -Lower attrition in partial decentralisation
2013 [5] 16 studies: 2 RCTs, at point of initiating care delivery model for at centralised of loss to follow up models (ART started in hospital and
14 cohort. treatment and patients initiation or continuation site (usually a or death). continued at health centre).
already on treatment of treatment, or both. hospital or -Loss to follow up at -No difference in attrition in full
requiring maintenance health facility) set time points after decentralisation models (ART started
and follow-up. intervention. and continued at peripheral health centre)
-Death. but fewer patients lost to care.
-Time to starting ART. -No difference in outcomes detected for
-Patients diagnosed ART provided at home by trained
with TB after entry into volunteers compared to facility-based care.
HIV care.
-Virologic response to ART
(viral load).
-Immunological response to
ART (CD4+).
-Occurrence of new
AIDS-defining illness.
-Patient satisfaction with care.
-Cost to provider.
-Cost to patient and family.
-Any negative impact on other
programme and health
care delivery.
Mwai December 2012. PLWH CHWs in HIV Facility based Patient related: CHWs perform a variety of roles in HIV
2013 [85] 21 studies: 5 qualitative, HIV care -Knowledge and literacy including counselling, testing, home-based
7 cohort, of HIV care, education, adherence support,
6 mixed method, -Behaviour change livelihood support, screening, referral and
3 RCTs. -Uptake of HIV and surveillance activities, retention in care.
other services. No evidence that patient outcomes and
-Adherence to ART. quality of care are compromised. CHWs
-Retention in care. may also have positive impacts on HIV
-Viral suppression. service organisation, delivery and cost.
-Mortality. But to be sustainable, need to be better
-Socio-economic integrated into wider health systems.
status and quality of life.
-Palliative care.
Health system:
-Service organisation

Page 9 of 13
and delivery
-Data collection, surveillance
and reporting
-Service cost
Table 6 Summary of systematic reviews on community-based care for HIV (Continued)
Review Date of search, number of
included studies
Nachega January 2016.
2016 [86] 22 studies: 11 RCTs,
11 cohort.
Rachlis December 2011,
2013 [87] updated February 2012.
21 CBC programs
Wouters December 2011.
2012 [9] 30 studies: 9 descriptive, 4 quasi-
experiments, 5 retrospective/ob-
servational cohort studies, 2
qualitative, 6 (cluster/nested)
RCTs.
Participants Intervention
HIV-infected individuals Community-based
initiated on ART. ART delivery.
Urban /rural Community-based
populations including care (CBC)
PLWHA, their family programmes
members, orphans,
vulnerable children.
PLWHA 9 types community support
providers:
-CHWs (non-professional
healthworkers who undertake short
course training, work in own
communities to support services
provided by other health workers)
-Peer health workers (CHWs who are
HIV positive).
-Field officers
-Health extension workers
-HIV/AIDS lay counsellors
-DOT for ART
-Adherence supporters
-HBC volunteers
Comparison Outcomes
Health-care -Proportion of PLWHA with
facility optimal ART adherence levels
(e.g. hospital (> 80%).
or clinic) -Proportion of PLWH with
virologic
suppression at 12 and/or
24 months
after ART initiation.
-Engagement (proportion of
patients retained in care at
12 and/or 24 months
post-ART initiation).
-All-cause mortality.
-Reported stigma.
-Cost to patient and provider
and cost effectiveness.
-Region
-Vision
-Characteristics of target
population
-Program scope (services
provided)
-Program operations
-Funding models
-Human resources
-Sustainability
-Monitoring and evaluation.
Health facility ART programme outcomes:
based care -Access and increasing coverage
of ART programmes
-Adherence
-Virological/ immunological
-Patient retention
-Survival rates
Contributory role of community
program:
-Integration of ART services into
general health system.
-Providing psychosocial care.
-Empowered ART patients
towards self-management.
-Defaulter tracing.
-Community as a resource.
Wood et al. BMC Health Services Research (2018) 18:219
Summary of key findings
-No significant difference in optimal ART
adherence, virological suppression,
all-cause mortality and loss to follow-up
between 2 groups when analysis was
restricted to RCTs.
-Pooled analysis from both RCTs
and cohort studies showed
higher rates of retention in care
in community-based ART group
than facility-based group.
-Only 2 eligible studies reported
on cost or cost-effectiveness
outcomes. These suggest that
community-based ART services
may be more cost-effective in
the long run but more research
using economic outcomes is
needed.
9 key categories useful for describing
and organising CBC HIV/AIDS programs
in resource limited settings. Suggest
can be used to inform potential logic
models to enhance overall program
performance and to develop evidence
based tools for sustainable HIV/AIDS
service delivery.
Community support can positively
impact ART programme delivery and
outcomes in resource-limited settings.
Potential strategy to address shortage
of health workers/ broaden care to
accommodate needs associated with
chronic HIV/AIDS.
More research needed to understand
which tasks performed by community
support initiatives contribute to
long-lasting ART success and limits
to which lay health workers can assume
multiple roles.
Page 10 of 13
Wood et al. BMC Health Services Research (2018) 18:219
review of direct observation in HIV therapy, mostly per-
formed in the community, also reported no effect on
virological suppression [31]. Possible reasons for a high
viral load despite adherence include drug resistance,
treatment failure or an adequate adherence irrespective of
the intervention [31]. Another systematic review
examining interventions for enhancing adherence to ART
also concluded that nurse-led home-based strat-egies are
effective [32].
In terms of psychological support, psychiatric nurse
home interventions improved depressive symptoms in
those with an existing mental health condition. Other
findings for home based psychological support were
mixed. Two studies found a reduction in symptoms of
depression, whilst another found no difference, but stigma
scales and physical functioning were improved. This
highlights the potential psychosocial benefits of home-
based care but with the self-reported scales, there could
also be an element of the social desirability bias
mentioned above, particularly as participants were not
blinded. Wouters 2012 also found that community-based
initiatives providing social support and counselling to
people living with HIV could effectively support and
improve medical care [9].
None of the included studies looked at improved med-
ical care (Fig. 1). With the current move to test and treat,
pre-ART care is now not so relevant but other medical
care such as screening for opportunistic infec-tions and
co-morbidities and related referral is import-ant. Oni et al.
found a high prevalence of multiple morbidities among
ART patients aged under 45 years [33]. With the increase
in diseases of lifestyle, such as diabetes and hypertension,
early identification and man-agement of co-morbidities is
also important [33].
Conclusions
The results indicate that nurse led home-based interven-
tions could help adherence to ART. Psychiatric nurse
support in those with existing mental health conditions
improved mental health and depressive symptoms. Home-
based psychological support impacted on HIV stigma,
worry and physical functioning and in certain cases
depressive symptoms.
However, studies were generally small and conducted in
limited geographic areas, limiting the quality of evi-
dence. Further larger scale studies are needed looking in
more detail at improving home-based medical care for
HIV, for example screening for opportunistic infections
and co-morbidities.
Abbreviations
AIDS: acquired immunodeficiency syndrome; ART: antiretroviral therapy; CD4
cell: T helper cell (type of white blood cell) that is a vital part of the human
immune system; CESD: Centre for Epidemiological Studies Depression Scale;
CHW: community health worker; CI: confidence interval; CNSA: Committee
Page 11 of 13
on a National Strategy for AIDS; DOT: directly observed treatment;
HBC: home-based care; HIV: human immunodeficiency virus; LMIC: low and
middle income country; MEMS: Medication Event Monitoring Systems;
MOS-HIV: Medical Outcomes Survey-HIV; PLWHA: People living with HIV/
AIDS; RCT: randomised controlled trial; SF-12: Medical Outcomes Study
12-Item Short-Form Health Survey; WHO: World Health Organisation;
WMD: weighted mean difference
Acknowledgements
Professor Paul Garner (Liverpool School of Tropical Medicine), for
guidance and assistance. Alfred Musekiwa (Centre for Evidence-
based Health Care), for advice on data analysis.
Availability of data and material
We included studies which are already in the public domain.
Funding
EMW, TY and TME are partially supported by the Effective Health Care
Research Consortium (www.evidence4health.org), which is funded by UK aid for
the UK Government for the benefit of developing countries (Grant: 5242). The
views expressed do not necessarily reflect UK government policy.
Authors’ contributions
EMW is corresponding author and guarantor of this manuscript. EMW
and TY reviewed the search results and selected potential studies for
inclusion. EMW and BZ independently carried out data extraction,
formal eligibility and risk of bias assessment. TME assisted with
statistical analysis. EMW drafted the manuscript, in conjunction with
BZ, TME and TY. All authors read and approved the final manuscript.
Ethics approval and consent to
participate Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Author details
1
Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
2
Cochrane South Africa, South African Medical Research Council, Cape Town,
3
South Africa. Centre for Evidence-based Health Care, Faculty of Medicine and
Health Sciences, Stellenbosch University, Cape Town, South Africa.
Received: 19 February 2017 Accepted: 14 March 2018
References
 UNAIDS: Global Aids update 2016. 2016.
 WHO CG: The use of antiretroviral drugs for treating and
preventing HIV infection. 2016.
 Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators
for linkage to antiretroviral therapy care. AIDS. 2012;26:2059–67.
 WHO: Consolidated guidelines on the use of antiretroviral drugs
for treating and preventing HIV infection. Recommendations for a
public health approach. 2013.
 Kredo T, Ford N, Adeniyi FB, Garner P. Decentralising HIV
treatment in lower- and middle-income countries. Cochrane
Database Syst Rev. 2013;6: CD009987.
 Kredo T, Adeniyi FB, Bateganya M, Pienaar ED. Task shifting from
doctors to non-doctors for initiation and maintenance of antiretroviral
therapy. Cochrane Database Syst Rev. 2014;7:CD007331.
 WHO: Community home-based care in resource-limiited
settings: a framework for action. 2002.

 Uys L. A model for home based care. In Home based HIV/AIDS Care.
Edited by Uys L, Cameron S. USA: Oxford University Press; 2003.
Wood et al. BMC Health Services Research (2018) 18:219
- Wouters E, Van Damme W, van Rensburg D, Masquillier C, Meulemans
H. Impact of community-based support services on antiretroviral
treatment programme delivery and outcomes in resource-limited
countries: a synthetic review. BMC Health Serv Res. 2012;12:194.
- Wringe A, Cataldo F, Stevenson N, Fakoya A. Delivering comprehensive home-
based care programmes for HIV: a review of lessons learned and challenges
ahead in the era of antiretroviral therapy. Health Policy Plan. 2010;25:352–62.
- Waterman H, Griffiths J, Gellard L, O’Keefe C, Olang G, Ayuyo J,
Obwanda E, Ogwethe V, Ondiege J. Power brokering, empowering, and
educating: the role of home-based care professionals in the reduction of
HIV-related stigma in Kenya. Qual Health Res. 2007;17:1028–39.
- Frasca K, Cohn J. Integration of HIV and tuberculosis in the
community. J Int Assoc Provid AIDS Care. 2014;13(6):534–8.
- WHO, PEPFAR, UNAIDS: Treat, train, retain. Task
shifting. Global recommendations and guidelines. 2008.
- Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based
programmes for treating malaria. Cochrane Database Syst Rev. 2013;
- Clark AM, Haykowsky M, Kryworuchko J, MacClure T, Scott J, DesMeules
M, Luo W, Liang Y. McAlister F a. A meta-analysis of randomized control
trials of home-based secondary prevention programs for coronary artery
disease. Eur J Cardiovasc Prev Rehabil. 2010;17:261–70.
- Shepperd S, Wee B, Straus SE. Hospital at home: home-based end of
life care. Cochrane Database Syst Rev. 2011;(7):CD009231.
- Smeenk FW, van Haastregt JC, de Witte LP, Crebolder HF. Effectiveness of home
care programmes for patients with incurable cancer on their quality of life and
time spent in hospital: systematic review. BMJ. 1998;316:1939–44.
- Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch
X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M,
Scheel IB. Lay health workers in primary and community health care for
maternal and child health and the management of infectious diseases.
Cochrane Database Syst Rev. 2010;(3):CD004015.
- Schneider H, Lehmann U. Lay health workers and HIV programmes:
implications for health systems. AIDS Care. 2010;22(Suppl 1):60–7.
- Young T, Busgeeth K. Home-based care for reducing
morbidity and mortality in people infected with HIV/AIDS.
Cochrane Database Syst Rev. 2010;(1):CD005417.
- Bateganya M, Abdulwadud OA, Kiene SM. Home-based HIV
voluntary counselling and testing (VCT) for improving uptake of
HIV testing. Cochrane Database Syst Rev. 2010;(7):CD006493.
- Modified Directly Observed Antiretroviral Therapy - Full Text View - ClinicalTrials. gov.
https://clinicaltrials.gov/show/nct01985269. Accessed Mar 2015.
- Berrien VM, Salazar JC, Reynolds E, McKay K. Adherence to antiretroviral
therapy in HIV-infected pediatric patients improves with home-based
intensive nursing intervention. AIDS Patient Care STDs. 2004;18:355–63.
- Miles MS, Holditch-Davis D, Eron J, Black BP, Pedersen C.
Harris D a. an HIV self-care symptom management intervention
for African American mothers. Nurs Res. 2003;52:350–60.
- Blank MB, Hennessy M, Eisenberg MM. Increasing quality of life and reducing
HIV burden: the PATH+ intervention. AIDS Behav. 2014;18:716–25.
- Hanrahan NP, Wu E, Kelly D, Aiken LH, Blank MB. Randomized
clinical trial of the effectiveness of a home-based advanced practice
psychiatric nurse intervention: outcomes for individuals with serious
mental illness and HIV. Nurs Res Pract. 2011;2011:1–10.
- Williams AB, Fennie KP. Bova C a, burgess JD, Danvers K a, Dieckhaus KD.
Home visits to improve adherence to highly active antiretroviral therapy: a
randomized controlled trial. J Acquir Immune Defic Syndr. 2006;42:314–21.
- Wang H, Zhou J, Huang L, Li X, Fennie KP, Williams AB. Effects
of nurse-delivered home visits combined with telephone calls on
medication adherence and quality of life in HIV-infected heroin
users in Hunan of China. J Clin Nurs. 2010;19:380–8.
- Williams AB, Wang H, Li X, Chen J, Li L, Fennie K: Efficacy of an evidence-
based ARV adherence intervention in China. AIDS Patient Care STDs 2014.
- WHO: Priority interventions: HIV/AIDS prevention, treatment and
care in the health sector. 2010.
- Ford N, Nachega JB, Engel ME, Mills EJ. Directly observed
antiretroviral therapy: a systematic review and meta-analysis of
randomised clinical trials. Lancet. 2009;374:2064–71.
- Mbuagbaw L, Sivaramalingam B, Navarro T, Hobson N, Keepanasseril A,
Wilczynski NJ, Haynes BR, Team the PAR. Interventions for enhancing
adherence to antiretroviral therapy (ART): a systematic review of high
quality studies. AIDS Patient Care STDs. 2015;29:248–66.
Page 12 of 13
[27] Oni T, Youngblood E, Boulle A, Mcgrath N, Wilkinson RJ. Disease
multi-morbidity in peri-urban South Africa- a cross sectional study
patterns of HIV, TB, and non-communicable disease multi-morbidity in
peri-urban South Africa- a cross sectional study; 2015. p. 1–8.
[28] le Roux IM, Tomlinson M, Harwood JM, O’Connor MJ, Worthman CM,
Mbewu N, Stewart J, Hartley M, Swendeman D, Comulada WS, Weiss
RE, Rotheram-Borus MJ. Outcomes of home visits for pregnant township
mothers and their infants in South Africa: a cluster randomised controlled
trial. AIDS. October 2012;2013:1461–71.
[29] Nsibande D, Doherty T, Ijumba P, Tomlinson M, Jackson D, Sanders D, Lawn
← Assessment of the uptake of neonatal and young infant referrals by
community health workers to public health facilities in an urban informal
settlement, KwaZulu-Natal, South Africa. BMC Health Serv Res. 2013;13:47.
[30] Tomlinson M, Doherty T, Ijumba P, Jackson D, Lawn J, Persson LÅ,
Lombard C, Sanders D, Daviaud E, Nkonki L, Goga A, Rohde S, Sitrin
D, Colvin M, Chopra M. Goodstart: a cluster randomised effectiveness
trial of an integrated, community-based package for maternal and
newborn care, with prevention of mother-to-child transmission of HIV
in a south African township. Trop Med Int Heal. 2014;19:256–66.
[31] Antoni MH, Cruess DG, Cruess S, Lutgendorf S, Kumar M, Ironson G,
Klimas N, Fletcher MA, Schneiderman N. Cognitive-behavioral stress
management intervention effects on anxiety, 24-hr urinary norepinephrine
output, and T-cytotoxic/suppressor cells over time among symptomatic
HIV-infected gay men. J Consult Clin Psychol. 2000;68:31–45.
[32] Iwuji CC, Orne-Gliemann J, Tanser F, Boyer S, Lessells RJ, Lert F, Imrie
J, Bärnighausen T, Rekacewicz C, Bazin B, Newell M-L, Dabis F.
Evaluation of the impact of immediate versus WHO recommendations-
guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249
TasP (treatment as prevention) trial in Hlabisa sub-district, KwaZulu-Natal
South Africa: study protocol for a clus. Trials. 2013;14:230.
[33] Maharaj SS, Chetty V. Rehabilitation program for the quality of life for
individuals on highly active antiretroviral therapy in KwaZulu-Natal, South
Africa: a short report. Int J Rehabil Res. 2011;34:360–5.
[34] Promoting Uptake and Retention of Option B+ in Malawi - Full Text View-
ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT02005835.
Accessed Mar 2017.
[35] Singer P, Levine R, Rothkopf M, Askanazi J. Home parenteral
lipids in AIDS: a three-month study. Nutrition. 1997;13:104–9.
[36] Baigis J, Korniewicz DM, Chase G, Butz A, Jacobson D, Wu AW.
Effectiveness of a home-based exercise intervention for HIV-infected
adults: a randomized trial. J Assoc Nurses AIDS Care. 2002;13:33–45.
[37] Chang LW, Kagaayi J, Nakigozi G, Ssempijja V, Packer AH, Serwadda D, Quinn TC,
Gray RH, Bollinger RC, Reynolds SJ. Effect of peer health workers on AIDS care in
Rakai, Uganda: a cluster-randomized trial. PLoS One. 2010;5:1–7.
[38] Colford JM, Saha SR, Wade TJ, Wright CC, Vu M, Charles S,
Jensen P, Hubbard A, Levy DA, Eisenberg JNS. A pilot randomized,
controlled trial of an in-home drinking water intervention among HIV
+ persons. J Water Health. 2005;3:173–84.
[39] Dolan SE, Frontera W, Librizzi J, Ljungquist K, Juan S, Dorman R, Cole ME,
Kanter JR, Grinspoon S. Effects of a supervised home-based aerobic and
progressive resistance training regimen in women infected with human
immunodeficiency virus: a randomized trial. Arch Intern Med. 2006;166:1225–31.
[40] Flatley-Brennan P. Computer network home care demonstration: a randomized
trial in persons living with AIDS. Comput Biol Med. 1998;28:489–508.
[41] Gustafson DH, Hawkins R, Boberg E, Pingree S, Serlin RE, Graziano F,
Chan CL. Impact of a patient-centered, computer-based health
information/ support system. Am J Prev Med. 1999;16:1–9.
[42] Jaffar S, Amuron B, Foster S, Birungi J, Levin J, Namara G, Nabiryo C,
Ndembi N, Kyomuhangi R, Opio A, Bunnell R, Tappero JW, Mermin J,
Coutinho A, Grosskurth H. Rates of virological failure in patients treated in a
home-based versus a facility-based HIV-care model in Jinja, Southeast
Uganda: a cluster-randomised equivalence trial. Lancet. 2009;374:2080–9.
[43] León A, Cáceres C, Fernández E, Chausa P, Martin M, Codina C,
Rousaud A, Blanch J, Mallolas J, Martinez E, Blanco JL, Laguno M,
Larrousse M, Milinkovic A, Zamora L, Canal N, Miró JM, Gatell JM,
Gómez EJ, García F. A new multidisciplinary home care telemedicine
system to monitor stable chronic human immunodeficiency virus-infected
patients: a randomized study. PLoS One. 2011;6(1):e14515.
[44] Lule JR, Mermin J, Ekwaru JP, Malamba S, Downing R, Ransom R, Nakanjako
D, Wafula W, Hughes P, Bunnell R, Kaharuza F, Coutinho A, Kigozi A, Quick
← Effect of home-based water chlorination and safe storage on diarrhea
Wood et al. BMC Health Services Research (2018) 18:219

among persons with human immunodeficiency virus in Uganda. Am J Trop Med Hyg. 2005;73:926–33.
- MacPherson P, Lalloo DG, Webb EL, Maheswaran H, Choko AT, Makombe SD, Butterworth AE, van Oosterhout JJ, Desmond N, Thindwa D, Squire SB, Hayes RJ, Corbett
EL. Effect of optional home initiation of HIV care following HIV self-testing on antiretroviral therapy initiation among adults in Malawi: a randomized clinical trial. JAMA.
2014;312(4):372–9.
- Melchior JC, Chastang C, Gelas P, Carbonnel F, Zazzo JF, Boulier A, Cosnes J, Boulétreau P, Messing B. Efficacy of 2-month total parenteral nutrition in AIDS
patients: a controlled randomized prospective trial. The French multicenter total parenteral nutrition cooperative group study. AIDS. 1996; 10:379–84.
- Muhamadi L, Tumwesigye NM, Kadobera D, Marrone G, Wabwire-Mangen F, Pariyo G, Peterson S, Ekström AM. A single-blind randomized controlled trial to evaluate the
effect of extended counseling on uptake of pre-antiretroviral care in eastern Uganda. Trials. 2011;12:184.
- Potterton J, Stewart A, Cooper P, Becker P. The effect of a basic home stimulation programme on the development of young children infected with HIV. Dev Med Child
Neurol. 2010;52:547–51.
- Roos R, Myezwa H, Van AH, Musenge E. Effects of an education and home-based pedometer walking program on ischemic heart disease risk factors in people infected
with HIV. A Randomized Trial. 2014;67:268–76.
- Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, Denski CD, Katschke AR, Wools-Kaloustian K. Task-shifting of antiretroviral
delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. J Acquir Immune Defic
Syndr. 2010;55: 483–90.
- Cherin DA, Huba GJ, Brief DE, Melchior LA. Evaluation of the Transprofessional model of home health care for HIV/AIDS. Home Health Care
Serv Q. 1998;17:55–72.
- Nickel JT, Salsberry PJ, Caswell RJ, Keller MD, Long T, O’Connell M. Quality of life in nurse case management of persons with AIDS receiving home care. Res
Nurs Health. 1996;19:91–9.
- Efficacy of promoting home-based HIV testing with online counseling on increasing HIV testing among men who have sex with men. ChiCTR-PRC-13003310. Chinese
Clinical Trial Register. http://www.chictr.org.cn/ showprojen.aspx?proj=6249. Accessed Mar 2015.
- DallaPiazza M, Aberg JA. HIV counseling and testing for household members of HIV-infected individuals in Africa: should prevention programs focus
on home-based rather than clinic-based outreach? Curr HIV/AIDS Rep. 2011;8:75–7.
- Doherty T, Tabana H, Jackson D, Naik R, Zembe W, Lombard C, Swanevelder S, Fox MP, Thorson A, Ekström AM, Chopra M. Effect of home based HIV
counselling and testing intervention in rural South Africa: cluster randomised trial. BMJ. 2013;346(June):f3481.
- Fylkesnes K, Sandøy IF, Jürgensen M, Chipimo PJ, Mwangala S, Michelo C. Strong effects of home-based voluntary HIV counselling and testing
on acceptance and equity: a cluster randomised trial in Zambia. Soc Sci Med. 2013;86:9–16.
- Jackson D, Naik R, Tabana H, Pillay M, Madurai S, Zembe W, Doherty T. Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South
Africa. J Int AIDS Soc. 2013;16:1–4.
- Jürgensen M, Sandøy IF, Michelo C, Fylkesnes K, Mwangala S, Blystad A. The seven Cs of the high acceptability of home-based VCT: results from a mixed methods
approach in Zambia. Soc Sci Med. 2013;97:210–9.
- Jürgensen M, Sandøy IF, Michelo C, Fylkesnes K. Effects of home-based voluntary counselling and testing on HIV-related stigma: findings from a cluster-randomized trial in Zambia.
Soc Sci Med. 2013;81:18–25.
- Labhardt ND, Motlomelo M, Cerutti B, Pfeiffer K, Kamele M, Hobbins MA, Ehmer J. Home-based versus mobile clinic HIV testing and counseling in rural Lesotho: a cluster-
randomized trial. PLoS Med. 2014;11:e1001768.
- Low C, Pop-Eleches C, Rono W, Plous E, Kirk A, Ndege S, Goldstein M, Thirumurthy H. The effects of home-based HIV counseling and testing on HIV/AIDS
stigma among individuals and community leaders in western Kenya: evidence from a cluster-randomized trial. AIDS Care. 2013; 25(Supplement 1):S97.
- Lugada E, Levin J, Abang B, Mermin J, Mugalanzi E, Namara G, Gupta S, Grosskurth H, Jaffar S, Coutinho A, Bunnell R. Comparison of home and clinic-based HIV
testing among household members of persons taking antiretroviral therapy in Uganda: results from a randomized trial. JAIDS J Acquir Immune Defic Syndr.
2010;55:245–52.
 Page 13 of 13

4 Home-based Partner Education and Testing (HOPE) Study - Full Text View - ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01784783. Accessed Mar
2015.
5 Osoti AO, John-Stewart G, Kiarie J, Richardson B, Kinuthia J, Krakowiak D, Farquhar C. Home visits during pregnancy enhance male partner
HIV counselling and testing in Kenya: a randomized clinical trial. AIDS. 2014; 28(July 2013):95–103.
6 Batamwita R. Assessment of antiretroviral therapy knowledge and willingness of persons with HIV to support its uptake in Uganda. Patient Prefer
Adherence. 2011;5:499.
7 Brennan PF, Ripich S. Use of a home-care computer network by persons with AIDS. Int J Technol Assess Health Care. 1994;10:258–72.
8 Byakika-Tusiime J, Crane J, Oyugi JH, Ragland K, Kawuma A, Musoke P, Bangsberg DR. Longitudinal antiretroviral adherence in HIV+ Ugandan parents and
their children initiating HAART in the MTCT-plus family treatment model: role of depression in declining adherence over time. AIDS Behav. 2009;13(Suppl
1):82–91.
9 Choy FN, Wilson DC, Willcox GS, Crocker KS. Experience with home aerosolized pentamidine treatment in patients with AIDS. DICP. 1990;24:592–4.
10 Di Sorbo PG, Chifamba DD, Mastrojohn J, Sisimayi CN, Williams SH. The Zimbabwe rural palliative care initiative: PCI-Z. J Pain Symptom
Manag. 2010;40:19–22.
11 Holzemer WL, Bakken Henry S, Portillo CJ, Miramontes H. The client adherence profiling-intervention tailoring (CAP-IT) intervention for enhancing
adherence to HIV/AIDS medications: a pilot study. J Assoc Nurses AIDS Care. 2000;11:36–44.
12 Kraak VI. Home-delivered meal programs for homebound people with HIV/ AIDS. J Am Diet Assoc. 1995;95:476–81.
13 Leibowitz A, Iberti T. Home TPN and AIDS patients. J Parenter Enter Nutr. 1992;16:496–7.
14 Ndekha MJ, Manary MJ, Ashorn P, Briend A. Home-based therapy with ready-to-use therapeutic food is of benefit to malnourished, HIV-infected Malawian
children. Acta Paediatr. 2005;94:222–5.
15 Morales JO, Von Behren L. Secondary bacterial infections in HIV-infected patients: an alternative ambulatory outpatient treatment utilizing intravenous
cefotaxime. Am J Med. 1994;97:9–13.
16 Sandige H, Ndekha MJ, Briend A, Ashorn P, Manary MJ. Home-based treatment of malnourished Malawian children with locally produced or imported ready-to-use food. J Pediatr
Gastroenterol Nutr. 2004;39:141–6.
17 Sjolander JC. Nursing management of the AIDS patient at home. J Enterostomal Ther. 1988;15(4):154–7.
18 Home-based AIDS Care Project - Full Text View - ClinicalTrials.gov. https:// clinicaltrials.gov/ct2/show/NCT00119093. Accessed Mar 2015.
19 Decroo T, Rasschaert F, Telfer B, Remartinez D, Laga M, Ford N. Community-based antiretroviral therapy programs can overcome barriers to retention of
patients and decongest health services in sub- saharan africa: a systematic review. Int Health. 2013;5:169–79.
20 Mw ai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic
review. J Int AIDS Soc. 2013;16:18586.
21 Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galárraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS,
Ford N, Mellins CA, Remien RH, Mills EJ. Community-based interventions to improve and sustain antiretroviral therapy adherence, retention in HIV care
and clinical outcomes in low- and middle-income countries for achieving the UNAIDS 90-90-90 targets. Curr HIV/AIDS Rep. 2016;13:241–55.
22 Rachlis B, Sodhi S, Burciul B, Orbinski J, Cheng AHY, Cole D. A taxonomy for community-based care programs focused on HIV/AIDS prevention,
treatment, and care in resource-poor settings. Glob Health Action. 2013;6:1–21.