Does multidisciplinary care improve health outcomes among people living with HIV and/or HCV? A review of the evidence

Prevention in Focus PiF 2015 Fall

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PiF Multidisciplinary care

People living with HIV and/or hepatitis C may benefit from multidisciplinary care models to help them achieve optimal health outcomes, and in the case of hepatitis C, a cure. Multidisciplinary care models use a team-based approach to care that consists of two or more professionals from different but complementary disciplines who have specific roles, perform interdependent tasks, and share a common goal.1

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Multidisciplinary care may reduce some of the barriers that people living with HIV and/or hepatitis C experience when accessing care.1 Across Canada, multidisciplinary care models are used to care for and treat people living with HIV and/or hepatitis C, but does the evidence support their increased use?

What are the findings of the evidence review?

The available scientific literature was reviewed to determine whether multidisciplinary care positively impacts health outcomes.

The evidence review demonstrated that in HIV:

  1. For clients in multidisciplinary care, those who access the services of an HIV multidisciplinary care team are better retained than those who do not access those services: Evidence suggests that clients who receive additional services (case management, mental health services, etc.) are 1.3 to 3 times more likely to be retained in HIV care than clients in care who need but do not access those services. Retention rates ranged from 27% to 91% in these studies (strength of the evidence is limited).
  2. For clients in multidisciplinary care, those who access the services of an HIV multidisciplinary care team initiate treatment at higher rates than those who do not access those services: Evidence suggests that clients in multidisciplinary care who use the team’s additional services initiate treatment at higher rates (1.8 times more likely to start on a protease inhibitor, an important part of many HIV treatment regimens) than clients who do not access these services (strength of the evidence is limited).
  3. Clients in HIV multidisciplinary care are more likely to remain in treatment compared to standard care: Evidence suggests that 55% of clients in multidisciplinary care maintain treatment for at least a year compared to only 43% of clients in standard care (strength of the evidence is limited).
  4. Clients in HIV multidisciplinary care are more likely to adhere to treatment than clients in standard care. Pharmacist inclusion in multidisciplinary care teams improves adherence: Evidence suggests that clients in various models of multidisciplinary care were 3.3% to 8.1% more adherent to medication than those in standard care. Evidence also suggests that the inclusion of pharmacist support in the care team significantly improves adherence (strength of the evidence is strong).
  5. Clients in HIV multidisciplinary care that includes a pharmacist and/or mental health services are more likely to have undetectable viral loads compared to a variety of comparison groups: Evidence suggests that clients in multidisciplinary care are more likely to have undetectable viral loads compared to various comparator groups (strength of the evidence is strong).
  6. CD4 counts increased when additional services were added to a person’s care: Evidence suggests that clients’ CD4 counts increase significantly when additional services are added to care such as a depression counsellor, dietitian, social worker and/or pharmacist. Increases were between 50 and 75 cells/mm3 (strength of the evidence is limited).
  7. Clients in HIV multidisciplinary care report improved mental health outcomes: Evidence suggests that clients in HIV multidisciplinary care report better mental health outcomes (strength of the evidence is limited).

The evidence review demonstrated that in hepatitis C:

  1. HCV clinic attendance is high among people who use drugs in multidisciplinary care: Evidence suggests that between 85% and 100% of people living with hepatitis who use drugs and are receiving multidisciplinary care attend their HCV clinic appointments (strength of the evidence is limited).
  2. Multidisciplinary care promotes treatment assessment among clients: Evidence suggests that treatment assessment rates range between 30% and 90% for clients in multidisciplinary care. Among clients with a mental health concern, the inclusion of a psychiatric nurse promotes hepatitis C treatment assessment. Evidence suggests that clients in multidisciplinary care who need psychiatric support and receive it from a psychiatric nurse are more likely to be assessed for treatment compared to standard care (strength of the evidence is limited).
  3. Clients in multidisciplinary care are more likely to initiate treatment than clients in HCV-specialist care alone: Evidence suggests that clients in multidisciplinary care have significantly higher rates of treatment initiation compared to clients in HCV-specialist only care. Rates of treatment initiation ranged from 23% to 73% (strength of the evidence is limited).
  4. Multidisciplinary care promotes hepatitis C treatment completion: Evidence suggests that between 64% and 86% of clients in multidisciplinary care complete treatment (strength of the evidence is strong).
  5. Clients in multidisciplinary care achieve cure: Evidence suggests that between 28% and 88% of clients who completed treatment within multidisciplinary care teams are cured of hepatitis C. Rates varied by treatment setting (strength of the evidence is strong).
  6. Multidisciplinary care that includes a psychiatrist reduces mental health concerns among clients during HCV treatment: Evidence suggests that multidisciplinary care that includes a psychiatrist reduces mental health concerns during hepatitis C treatment compared to standard care (strength of the evidence is moderate).
  7. Clients in HCV multidisciplinary care report reduced alcohol use: Evidence suggests that clients in HCV multidisciplinary care reduce their alcohol consumption (strength of the evidence is limited).
  8. Clients in HCV multidisciplinary care report positive lifestyle changes: Evidence suggests that enrolling in HCV multidisciplinary care helped clients make positive lifestyle changes (strength of the evidence is limited).

The evidence review also demonstrated that many client-reported outcomes were positive. Client-reported outcomes in HIV and/or hepatitis C multidisciplinary care show high levels of satisfaction with care; decreased substance use; positive lifestyle changes; and improved mental health (strength of the evidence is limited).

Organizations that currently offer multidisciplinary care in HIV and/or hepatitis C, and organizations considering developing multidisciplinary care models may want to learn from agencies that have already implemented these models. In Vancouver, the MAT Program, the Immunodeficiency Clinic, Towards Aboriginal Health and Healing and the STOP Outreach Team all provide multidisciplinary care to people living with HIV. In Ontario, hepatitis C teams have been established across the province to provide multidisciplinary hepatitis C services to people who use drugs, including in Thunder Bay, Guelph, and Ottawa.

What is multidisciplinary care?

Multidisciplinary care models use a team-based approach that consists of two or more professionals from different but complementary disciplines who have specific roles, perform interdependent tasks, and share a common goal.1

Multidisciplinary care can include a combination of disciplines and specialists within those disciplines. Depending on the needs of the program’s client population, teams may include:

  • physicians: general practitioners, infectious disease specialists, hepatologists, internal medicine specialists and/or psychiatrists
  • pharmacists
  • nurses, nurse-practitioners and nurse-clinicians
  • psychologists
  • social workers
  • social service workers: outreach workers, benefits coordinators and personal support workers
  • peers

As much as possible, multidisciplinary teams should be flexible and tailored to meet the needs of the local context, and the medical and/or social needs of the patient population. Over time, client needs may change and as such the team should evolve with them.

Multidisciplinary care can fall into two general categories: program collaboration and service integration.2 Program collaboration is a form of integrated multidisciplinary care where two or more programs develop “a mutually beneficial and well-defined relationship” to achieve common goals.2 It may be most useful in settings with limited resources, where community organizations develop strong linkages and navigation across the continuum of care to offer complimentary client-centred services.2 This type of multidisciplinary care may also be called care coordination,3 virtual integration4 or a managed care network.5

Service integration, the second type of multidisciplinary care, is a model that provides clients with seamless access to services through co-located services under one roof.2 This one-stop-shop approach aims to make it easier for clients to access services by providing a single point of entry.2 Including services such as case management, mental health and substance use treatment in HIV or hepatitis C outpatient clinics is an example of service integration. Combining HIV and/or hepatitis C services in community health centres and substance use treatment programs are also examples of service integration.6

Why is multidisciplinary care needed in HIV and hepatitis C?

HIV continuum of care

Among people living with HIV, we know that not everyone is successfully diagnosed, linked to and engaged in care. The HIV continuum of care (also known as the treatment cascade) is one of the tools increasingly being used to determine how well the system is doing to engage and keep clients in care. The continuum is based on the successive steps that are needed for a person living with HIV to achieve an undetectable viral load, which is an optimal clinical endpoint. Strong engagement in care and undetectable viral load improves quality of life for the person living with HIV7 and reduces the risk of transmitting HIV to others.8,9

Research on the HIV continuum of care from British Columbia and Ontario tells us we are not reaching the optimal clinical endpoint (an undetectable viral load) for the majority of people living with HIV. Although national data on the Canadian HIV continuum of care is not available, the estimates of the percentage of people living with HIV who are not undetectable from British Columbia (65%) and Ontario (60% to 73%) suggest most people living with HIV in Canada are not receiving optimal care as measured by an undetectable viral load.10,11 Although we are doing better than the United States (70%), many countries including Australia (38%), the United Kingdom (39%) and France (48%) are doing better than us.

Hepatitis C continuum of care

Among people living with hepatitis C, we know that not everyone is successfully diagnosed, linked to and engaged in care, despite the availability of a cure. New treatments, which can eliminate hepatitis C in as few as eight weeks, have the potential to reduce the harms associated with long-term hepatitis C infection and reduce the transmission of hepatitis C to others.

There is limited information about the hepatitis C continuum of care in Canada. However, in the United States, an estimated 50% of people living with hepatitis C are aware of their status, 43% have accessed care, 27% have an RNA-positive test result, 16% have been prescribed treatment and 9% have achieved a sustained virological response, or cure.12

The one piece of information we do have on the Canadian continuum of care is on status awareness. The Public Health Agency of Canada estimates that 56% of people living with chronic hepatitis C know they live with hepatitis C.13 This number is comparable to the United States, suggesting our hepatitis C cascade may also be similar to theirs.

Barriers to optimal care

People living with HIV and/or hepatitis C may not be optimally engaged in care because of the barriers many of them experience across the continuum of care. Barriers experienced by people living with HIV and/or hepatitis C who try to access care can be divided into four categories:

  • logistical barriers, such as transportation and elder and child care
  • coordination barriers, such as finding a healthcare provider, getting social assistance, and navigating the healthcare system
  • individual barriers, such as substance use, mental health concerns, trauma, HIV-related aging, and the presence of other co-morbidities
  • systemic barriers, such as poverty, stigma and access to adequate housing

Multidisciplinary care, whether it is program collaboration or service integration, may reduce barriers to care for clients. When services are co-located or when linkages to external services are explicit, clients may be less likely to be lost to care. The ability to seek services in one space or being offered navigation between services that are not co-located may mean less planning for clients and may reduce the burden healthcare has on the lives of people with complex needs.

Does multidisciplinary care work?

The available scientific literature from Canada and other jurisdictions with HIV and hepatitis C epidemics comparable to ours, including the United States and European countries, was reviewed. Details on the methodology we used can be found at the end of this article.

The available scientific evidence to support each outcome was assessed and assigned an evidence rating. Although the evidence rating is somewhat flexible, ratings were based on the following criteria:

  1. Strong Evidence: At least one systematic review or a large body of randomized-controlled trials and quasi-experimental studies (and observational research) supports the ability of the intervention to impact on the outcome.
  2. Moderate Evidence: Limited randomized-controlled trials and/or quasi-experimental studies (and observational research) support the ability of the intervention to impact the outcome.
  3. Limited Evidence: Observational research supports the ability of the intervention to impact the outcome.
  4. No Evidence: No published research exists to support the ability of the intervention to impact the outcome.

The strength of the evidence is based on the quantity and quality of the evidence and not the size of the outcome. Where we note that a result is significant, we are referring to the statistical significance and not the potential clinical significance of the outcome.

The evidence on HIV and hepatitis C care and treatment outcomes for clients in multidisciplinary care are reviewed separately. The care and treatment outcomes related to people living with HIV are reviewed first, followed by treatment outcomes of people living with hepatitis C. The literature on client-reported HIV and hepatitis C care outcomes is reviewed together.

All studies in this article were reviewed to ensure they fit the broad definition of multidisciplinary care. However, there is no one approach to multidisciplinary care so this review includes various approaches in different contexts and with different team compositions.

HIV outcomes

Care

Once a person is diagnosed with HIV, they should be linked to an HIV healthcare provider. Prompt linkage to care allows people living with HIV to benefit from the care and treatment necessary to achieve good health outcomes. Ideally people living with HIV enter into care as soon as possible after they are diagnosed,14 remain in continuous care and have regular HIV-specific check-ups with their HIV care provider.

Retention in HIV care

Once in care, people living with HIV should see their HIV physician every three to six months. Retention in care, sometimes called engagement in care, can be defined a number of ways but typically is determined by the number of viral load tests or HIV-specific healthcare visits in a given period of time (usually six months).

There is limited evidence from five observational studies3,15,16,17,18 that multidisciplinary care positively impacts retention in HIV care. The evidence from four of these studies15,16,17,18 suggests that clients who need additional services and who access those services are 1.3 to 3 times more likely to be retained in care than clients in multidisciplinary care who need those services but do not access them. Retention rates among these studies ranged from 27% to 91%.

The first observational study3 compared engagement in care among clients before and after they were enrolled in a program collaboration model of multidisciplinary care. The study found that rates of engagement in care among clients increased from 74% prior to enrollment in the program (they were receiving standard care) to 91% after enrollment.3 This study defined people who were engaged in care as having at least two viral load tests in each six-month period.

The second observational study15 found that the odds of being retained in care were two to three times more likely among clients in need of and who received medical case management, case management counselling, case management social services, housing, or drug use support groups compared to those who needed those services but did not receive them.

In the same study, the need and use of transportation services, therapeutic drug treatment, and mental health services increased the odds of being retained in care compared to those who expressed the need but who did not access these services; however, these comparisons were not significant. Retention in care was defined as seeing the same healthcare provider at the same organization in consecutive six-month periods.

The third observational study16 investigated retention in care within a variety of multidisciplinary care programs. The study compared the retention in care rates of clients with high need and high use of services to clients with high need but low use of the same services. The study found that 65% of high users – clients that used more than 11 services over a two-year period – were retained in care compared to 40% of low users. The odds of being retained in care were 1.3 times more likely among high users compared to low users – clients who used fewer than six services over a two-year period.16 This study defined retention in care as one or more medical visits in at least three consecutive six-month periods.

The fourth observational study17 found that female clients enrolled in multidisciplinary care who used more of the services of their team were more likely to be retained in care than women who used fewer services. The study showed that the odds of being retained in care were 2.8 times more likely among women who received four or more services a month compared to women who used three or fewer services a month. This study defined retention in care as at least one clinic visit every six months.

The fifth observational study18 found that clients who accessed the multidisciplinary team’s additional services – case management, transportation services and mental health supports – were significantly more likely to engage in care compared to clients who received no services. The study found that 35% of clients who had a need for case management and accessed the service were in regular care compared to 5% of clients who needed case management but did not access it. In addition, 30% of clients who needed transportation services and accessed them were in regular care compared to about 5% of clients who needed transportation services but did not access them. About 40% of clients who needed mental health supports were in regular care compared to 5% of clients who needed mental health supports but did not access them.

Treatment outcomes

There are significant benefits to starting, adhering to and remaining on HIV treatment including improved quality of life7 and reduced risk of transmitting HIV to others.9 A person living with HIV who starts treatment soon after their diagnosis and who takes treatment consistently and correctly can expect to live almost as long as the general population.7

Treatment initiation/maintenance

Starting treatment can be an important decision for people living with HIV. Decisions need to weigh both the benefits (quality of life, longevity) and potential challenges (side effects, adherence and the implications of other health problems) of treatment. Once on treatment, people living with HIV should remain on continuous treatment.

There is limited evidence from one observational study17 that clients who use more services within a multidisciplinary care clinic initiate treatment at higher rates than people who use fewer services. This study found that female clients enrolled in multidisciplinary care who used more services were more likely to start treatment than women who used fewer services.17 The study showed that women who received four or more services a month were 1.8 times more likely to start on a protease inhibitor (an important component of many HIV treatment regimens) than women who used three or fewer services in a month.

There is limited evidence from one observational study19 that clients receiving multidisciplinary care are significantly more likely to maintain treatment for at least a year compared to those in standard care. This study19 found that 55% of clients receiving multidisciplinary care stayed on treatment for at least a year, compared to 43% of clients from an historical comparator group that received standard care.

Treatment adherence

When clients are ready to start HIV treatment, medicines must be taken consistently and correctly to be effective. Levels of adherence below 95% have been associated with increased treatment resistance and failure, poorer health outcomes, reduced likelihood of achieving an undetectable viral load, and increased risk of passing HIV to others.20

There is strong evidence from one systematic review,21 one randomized-controlled trial,22 and two observational studies23,24 that multidisciplinary care teams that incorporate a pharmacist lead to better client adherence outcomes than care teams without a pharmacist.

The systematic review found that adherence rates were between 2% and 59% higher among clients in multidisciplinary care that included pharmacists compared to care models without a pharmacist.21 The randomized-controlled trial found that clients increased adherence significantly from 88% before adding a pharmacist to the team to 92% after adding pharmacist support to care.22

The first observational study24 found that 89% of clients who received support from a pharmacist were highly adherent to their medication (they took at least 95% of their pills).

The second observational study23 compared client adherence rates in a number of different HIV clinics. In HIV specialist care alone, adherence was only 74%. In comparison, clients who received multidisciplinary care were between 3.3% and 8.1% more adherent to their medications than clients who received specialist care alone.23 Team composition varied but all teams had a combination of professionals that included a pharmacist, nurse, social worker, coordinator, mental health provider and/or primary care provider. Compared to HIV specialist care alone, adherence rates were

  • 8.1% higher with a pharmacist, coordinator and primary care provider team
  • 7.5% higher with a nurse, social worker and primary care provider team
  • 6.5% higher with an HIV specialist and mental health care provider team
  • 5.7% higher with a pharmacist, social worker and primary care provider team
  • 3.3% higher with a pharmacist and primary care provider team

Outcomes related to clinical indicators

Effective treatment – where a person living with HIV takes their medications consistently and correctly – can lead to optimal treatment outcomes such as an undetectable viral load and an increased CD4 count.25

Undetectable viral load

Viral load is the measure of the amount of virus in a person’s bodily fluids. Low or undetectable viral load is associated with improved health outcomes and reduced risk of transmitting HIV to others.9

There is strong evidence from a systematic review21 and four observational studies3,19,26,27 that clients with HIV in multidisciplinary care achieve undetectable viral loads. The systematic review revealed that most studies found a positive association between decreased viral load and multidisciplinary care that included a pharmacist.21 The observational studies suggest that clients in multidisciplinary care are more likely to have an undetectable viral load compared to various comparator groups.3,19,26,27

The first observational study3 looked at the viral loads of clients in a program collaboration model of multidisciplinary care. The study found that rates of undetectability among clients increased from 32% before they were enrolled in the multidisciplinary care program (but receiving standard care) to 51% after one year’s engagement with the multidisciplinary care program.3

The second observational study26 found that clients who visited clinics that offered hepatitis, psychiatric, psychological and social services, as well as primary care and HIV specialist care were three times more likely to have an undetectable viral load compared to clinics offering only offering primary care and HIV specialty care.

The third observational study27 looked at the viral load among clients in a multidisciplinary team where mental health services for depression were co-located. It found that viral loads were significantly reduced from 14,100 copies/ml before depression counselling to 4,000 copies/ml after counselling.27

The fourth observational study19 found a statistically significant decrease in overall viral load (as measured by a log change) when comparing those in multidisciplinary care to the historical clinical comparator group. However, there was no difference in the percent of people with a suppressed viral load between those who met with a pharmacist, dietitian and a social worker (88%) before initiating treatment (multidisciplinary care) compared to an historical clinical comparator group who did not meet with these professionals ( 85%).         

CD4 count

CD4 count is an important measure of the health of the immune system. Successful treatment improves the CD4 count of a person living with HIV, keeping the immune system healthy.

There is limited evidence from two observational studies19,27 that CD4 counts of clients increased when additional services were added to a person’s care.

The first observational study27 found that integrating depression counselling into a multidisciplinary care team increased CD4 count significantly from 518 cells/mm3 at baseline to 592 cells/mm3 among clients who accessed depression counselling.

The second observational study19 found that over 12 months, CD4 counts increased significantly among people in multidisciplinary care who met with a pharmacist, dietitian and social worker before starting treatment compared to an historical comparator group that did not receive these services (100 cells/mm3 versus 50 cells/mm3).

Hepatitis C

Treatment outcomes

Once diagnosed, people with hepatitis C require access to healthcare providers to assess disease progression, discuss treatment options and monitor throughout the treatment process. The current Canadian guidelines recommend that people living with hepatitis C be linked to specialist care for assessment and the development of an effective treatment plan.28

When clinically appropriate, clients are prepared to initiate treatment. They must adhere to a treatment plan and attend clinics more regularly.  Clients are monitored to determine if treatment is having an effect on the virus. Treatment success is measured by an undetectable hepatitis C viral load or sustained virological response (SVR) six months after the end of treatment. At six months post-treatment if a person has an SVR, they are considered cured of hepatitis C. 

Clinic attendance

The current Canadian guidelines recommend that people diagnosed with hepatitis C should be linked to specialist care for assessment and to develop an effective treatment plan.28 Physicians specializing in hepatitis C care and treatment include infectious disease physicians, gastroenterologists, hepatologists and addiction medicine physicians with experience in hepatitis C care and treatment for their clients.                                                                                           

There is limited evidence from three observational studies29,30,31 that people living with hepatitis C who receive multidisciplinary care attend clinic appointments according to their treatment protocol. All three studies were conducted among people who use drugs.

The first observational study29 found that clients receiving multidisciplinary care in an opioid substitution therapy program attended clinic appointments 100% of the time.

The second31 and third observational studies30 found that clients who received multidisciplinary care in community health centres attended clinic appointments 85%31 and 99%30 of the time.

Treatment assessment

People diagnosed with hepatitis C must be assessed for treatment, including tests confirming acute or chronic infection, genotype (there are six common genotypes) and assessment of liver damage, also called fibrosis, which may have occurred as a result of hepatitis C infection. The psychosocial treatment readiness of people living with hepatitis C is also assessed, including mental health, substance use and housing stability. These treatment assessments determine whether treatment should be started as soon as possible or can be delayed while people are prepared 

There is limited evidence from six observational studies31,32,33,34,35,36 that clients in multidisciplinary care are assessed for treatment. Assessment rates ranged from 30% to 90%.

One observational study34 considered the impact of multidisciplinary care that included psychiatric support on treatment assessment rates. Clients with mental health concerns who received multidisciplinary care that included psychiatric support were more likely to complete treatment evaluation (90%) compared to those who received no additional care for their mental health concerns (59%) and those who received only routine mental health support (56%).34

Four observational studies31,33,34,35 conducted in a variety of settings where multidisciplinary care is offered did not compare their results to a comparator group.

Three of these observational studies31,32,35 were conducted in community health centres and found rates of treatment assessment between 30% and 54%.

The other observational study33 was conducted in substance use programs and found treatment assessment rates of 78%.

Treatment initiation

Once assessed for treatment and determined to be eligible, people living with hepatitis C can initiate a course of treatment to cure the virus. Without treatment, the long-term effects of hepatitis C infection can include cirrhosis, end-stage liver disease and liver cancer.

There is limited evidence from seven observational studies30,31,34,37,38,39,40 that clients receiving multidisciplinary care initiate treatment. Some evidence suggests that clients in multidisciplinary care are more likely to initiate treatment than clients in specialist care alone.34,37 Rates of treatment initiation across the seven studies ranged from 23% to 73%.

Two observational studies34,37 considered the impact of multidisciplinary care on treatment initiation rates compared to comparison groups. The first study, among veterans at an outpatient clinic, found that significantly more clients who received multidisciplinary care that included support from a psychiatric nurse started treatment compared to those who did not receive this added support despite their need (49% v. 14%).34 The second study, among people who use drugs, found that significantly more clients started treatment after the introduction of multidisciplinary care in an addictions centre compared to before multidisciplinary care was introduced (38% v. 2%).37

Five observational studies30,31,38,39,40 of multidisciplinary care did not have a comparison group. All five studies looked at multidisciplinary care among people who use drugs.

Among people who use drugs, hepatitis C treatment initiation rates were highest (73%) in an outpatient clinic,40 followed by community health centres (51% and 70%),30,31 and opioid substitution therapy programs (23% and 41%)38,39 that integrated hepatitis C care into their services.

Treatment completion

It is critical that people living with hepatitis C who are on treatment complete the full course of treatment, if medically indicated. Treatment completion optimizes the chance of a cure.

There is strong evidence from one meta-analysis,41 and eight observational studies5,36,42,43,44,45,46,47 that clients in multidisciplinary care complete treatment. Treatment completion rates among clients in multidisciplinary care ranged from 64% to 86%.

Of all these studies, only two observational studies5,47 compared treatment completion rates to a comparator group.

The first observational study,47 among people who use drugs, found that significantly more participants receiving multidisciplinary care completed treatment compared to participants in standard care (75% compared to 41%).The second observational study5 compared treatment completion rates before and after the introduction of a program collaboration model of multidisciplinary care. This study found that treatment completion increased from 66% to 74% after the implementation of a multidisciplinary care model. However, this finding was not statistically significant.

One meta-analysis,41 and six observational studies36,42,43,44,45,46 did not compare their treatment completion rates to a comparison group. The meta-analysis, which focused on studies that included drug users in multidisciplinary care, found a pooled treatment completion rate of 83%.41 Three observational studies36,43,46 conducted among clients of substance use treatment programs receiving multidisciplinary care found treatment completion rates between 64% and 85%. The fourth and fifth observational studies,42,45 among people who use drugs, found treatment completion rates of 78% and 86% among clients in outpatient clinics receiving multidisciplinary care. The final observational study44 conducted in a community health centre among people who use drugs receiving multidisciplinary care found a treatment completion rate of 76%.

Outcomes related to clinical indicators: Sustained virological response

Hepatitis C treatment outcomes are measured by sustained virological response (SVR), or cure. At six months post-treatment if a person has an SVR, they are considered cured of hepatitis C.

There is strong evidence from one meta-analysis,41 one randomized-controlled trial,48 three quasi-experimental studies,49,50,51 and 24 observational studies5,29,31,32,33,34,36,37,38,39,40,42,43,44,45,46,52,53,54,55,56,57,58,59 that clients in multidisciplinary care achieve high cure rates. Of the 24 observational studies, only five studies5,34,47,56,59 compared cure rates of clients in multidisciplinary care to a comparison group.

The first observational study,47 among people who use drugs, found 69% of clients engaged in multidisciplinary care who completed treatment were cured compared to 46% of clients who received standard care.47 This means that clients in multidisciplinary care were 2.6 times more likely to be cured than clients who received standard hepatitis C care.47

The second observational study,59 among people who use drugs, found that significantly more clients in multidisciplinary care (77%) were cured compared to those who received standard care ( 62%).

The third observational study34 found that 41% of clients with mental health needs who engaged in multidisciplinary care including a psychiatric nurse were cured compared to 33% of clients with mental health concerns who did not receive psychiatric support. However, this result was not statistically significant.

The fourth observational study56 found significantly higher cure rates for clients in multidisciplinary care (69%) compared to clients who received routine care (20%).

The final observational study5 looked at clients before and after the introduction of a program collaboration model of multidisciplinary care and found that only 51% of clients achieved an SVR before the program collaboration model was introduced compared to 61% afterward. This finding was not statistically significant.

The remaining studies – one meta-analysis,41 one randomized-controlled trial,48 three quasi-experimental studies,49,50,51 and 20 observational studies(29,31,32,33,36,37,38,39,40,42,43,44,45,46,52,53,54,55,57,58 – provided overall cure rates in a variety of settings offering multidisciplinary care for people who use drugs and alcohol but did not compare these results to a comparison group, or the comparison group was not relevant to this review.48

The meta-analysis found a pooled cure rate of 56% among people who inject drugs engaged in multidisciplinary care.41 The other studies found that:

  • in primary care, overall cure rates ranged from 57% to 71%50,51
  • in outpatient clinics, overall cure rates ranged from 44% to 88%40,42,45,48,52,53,57
  • in community health centres, overall cure rates ranged from 28% to 63%31,32,44,49,54,55,58
  • in substance use programs, including opioid substitution therapy programs, addictions centres and detox centres, overall cure rates ranged from 38% to 71%29,33,36,37,38,39,43,46

Mental health outcomes during treatment

There is moderate evidence from one randomized-controlled trial60 that multidisciplinary care significantly reduces mental health concerns among people living with hepatitis C who were on treatment compared to standard care. The study found that only 5% of clients who received care from a multidisciplinary team that included a psychiatrist experienced psychiatric problems related to treatment between the 24th and 36th week of treatment compared to 16% in a control group that received standard care.60

Client-reported outcomes in HIV and hepatitis C multidisciplinary care

For optimal outcomes, it is critical that clients are satisfied with the care they receive and that they report improved health and wellness while receiving multidisciplinary care.

Satisfaction

There is limited evidence from one observational study61 in HIV and one observational study35 in hepatitis C that clients receiving multidisciplinary care are satisfied with their care.

When asked if clients preferred their HIV clinic because of the clinic’s multidisciplinary approach, the first observational study found that clients, on average, rated their agreement with that statement as 3.79 on a 4-point scale.61 The mean satisfaction score reported in the second observational study among people living with hepatitis C who received multidisciplinary care was 13.7 on a 15-point scale, which was considered a score of “very satisfied.”35

Reported mental health outcomes

There is limited evidence from one quasi-experimental study in HIV62 and one observational study27 in HIV that clients in multidisciplinary care report improved mental health outcomes.

A quasi-experimental study among people living with HIV found that multidisciplinary care that included mental health support reduced reported experiences of distancing, blaming and discrimination associated with being HIV positive as measured by the HIV Stigma Scale.62 After receiving mental health supports, the mean distancing score, the mean blaming score, and the mean discrimination score decreased significantly.

One observational study27 of people living with HIV engaged with a multidisciplinary care team found a significant reduction in self-reported depression after initiation of depression counselling compared to before depression counselling.

Substance use outcomes

There is limited evidence from three observational studies35,54,63 in hepatitis C that clients in multidisciplinary care reduce risks associated with their substance use.

Two observational studies35,63 found that clients living with hepatitis C who received multidisciplinary care and who had alcohol use disorders reported reducing their alcohol consumption. The first observational study63 found a 51% reduction in alcohol severity score six months after starting alcohol use treatment.

The second observational study35 found that 70% of clients in multidisciplinary care who had alcohol use disorders reported reducing their alcohol consumption.

Lifestyle changes

There is limited evidence from two observational studies35,54 in hepatitis C that clients engaged in multidisciplinary care report making lifestyle changes. The first study35 found that 73% of clients reported having the confidence to make changes in their lives and 83% reported having the knowledge to maintain better health.

In addition to increased confidence and knowledge, some clients in multidisciplinary care also report using that confidence and knowledge to make changes in their lives. The same observational study reported that 48% of clients changed their diet.35 The second observational study reported that clients had better financial stability.54

Summary Table: Evidence to support multidisciplinary team care

 

Strong

Moderate

Limited

None

Ineffective

 Retention in HIV care

 

 

x

 

 

HIV treatment initiation

 

 

x

 

 

HIV treatment maintenance

 

 

x

 

 

HIV treatment adherence

x

 

 

 

 

HIV viral load

x

 

 

 

 

CD4 count

 

 

x

 

 

HCV clinic attendance

 

 

x

 

 

HCV treatment assessment

 

 

x

 

 

HCV treatment initiation

 

 

x

 

 

HCV treatment completion

x

 

 

 

 

SVR/cure

x

 

 

 

 

Mental health outcomes related to HCV treatment

 

x

 

 

 

Client-reported satisfaction

 

 

x

 

 

Client-reported mental health outcomes

 

 

x

 

 

Client-reported substance use outcomes

 

 

x

 

 

Client-reported lifestyle changes

 

 

x

 

 

What does this mean for HIV and hepatitis C services in Canada?

We know from the published care continua that people living with HIV and/or hepatitis C are not optimally engaged in care. One way to improve the engagement of people across the continuum of care is to engage them in multidisciplinary care to ensure they have access to the services they need to help them enter care, remain in care and start treatment (when ready).

Overall, there is evidence to suggest that multidisciplinary care in HIV and hepatitis C can improve engagement across the care continuum in both HIV and hepatitis C and improve health outcomes for clients.

In HIV, evidence suggests that clients in multidisciplinary care who engage with appropriate services as needed, such as case management and housing services are more likely to be retained in care. This appears to also affect treatment initiation; clients who access many care team services are more likely to initiate HIV treatment. There is evidence to suggest that retention in treatment is better among those in multidisciplinary care compared to those in standard care.

There is also evidence to suggest that multidisciplinary care teams that include pharmacists improve HIV treatment adherence rates. CD4 counts also increase when additional services are received through multidisciplinary care teams.

In hepatitis C, clinic attendance is high among clients in multidisciplinary care. Multidisciplinary care also promotes the completion of treatment assessments – with one study suggesting that the inclusion of psychiatric nurses is beneficial. There is evidence to suggest that people living with hepatitis C who receive multidisciplinary care are likely to complete treatment and to achieve a cure.

Like HIV multidisciplinary care, however, getting specific services, especially mental health supports, is crucial to client success in care. Clients with hepatitis C who receive psychiatric support as part of their care are more likely to be assessed for hepatitis C treatment and less likely to experience serious psychiatric distress during hepatitis C treatment than clients in multidisciplinary or standard care who do not receive this added support.

Wherever multidisciplinary care is established it must reflect local HIV and hepatitis C epidemics. Services should be client-centred and tailored to the specific needs of the local population. The evidence from both HIV and hepatitis C shows us that multidisciplinary care must offer the services clients need when they need them and ensure that clients have the support they need to access those services.

Jurisdictions across Canada are already using multidisciplinary care with people living with HIV, people living with hepatitis C and clients who are co-infected to improve their health. In Vancouver, the MAT Program, the Immunodeficiency Clinic, Towards Aboriginal Health and Healing and the STOP Outreach Team all provide multidisciplinary care to people living with HIV. In Ontario, hepatitis C teams have been established across the province to provide multidisciplinary hepatitis C services to people who use drugs, including in Thunder Bay, Guelph, and Ottawa.

Methodology

This review is based on a search that included the use of PubMed, Embase, and CINAHL. MeSH search terms included patient care team; patient care management; delivery of health care; community health services; HIV infections; and hepatitis C. EMBASE subject headings included health care delivery; patient care; and community care. CINAHL subject headings included multidisciplinary care team.

Keyword search terms included multidisciplinary; interdisciplinary; collabora*; coordinat*; integrat*; care; and service or services. The reference lists of relevant articles were also reviewed for additional citations. All searches focused on research relevant to health care delivery in Canada.

 

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About the author(s)

Logan Broeckaert holds a Master’s degree in History and is currently a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association.

Laurel Challacombe holds a Masters degree in Epidemiology and is currently Associate Director, Research/Evaluation and Prevention Science at CATIE. Laurel has worked in the field of HIV for more than 10 years and has held various positions in both provincial and regional organizations, working in research and knowledge transfer and exchange.