Establishing effective partnerships among case managers and clinicians to improve linkage to and engagement in HIV care: A scoping review

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Establishing effective partnerships among case managers and clinicians to improve linkage to and engagement in HIV care: A scoping review Piring’ar Mercy Niyang , Ibrahim Bola Gobir , Itunu Dave-Agboola , Joy Musa Shallangwa , Muhammad Zaharaddeen , Bashir Zubayr , Chika Obiora-Okafor , Terso Usha , Mabel Ikpeme , Onyeka Igboelina , Pamela Gado , Kolawole Olatunbosun , Dolapo Ogundehin doi: https://doi.org/10.1101/2025.05.10.25327371 Piring’ar Mercy Niyang 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: pmn35{at}georgetown.edu Ibrahim Bola Gobir 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Itunu Dave-Agboola 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Joy Musa Shallangwa 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Muhammad Zaharaddeen 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bashir Zubayr 1 Georgetown Global Health Nigeria Find this author on Google Scholar Find this author on PubMed Search for this author on this site Chika Obiora-Okafor 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Terso Usha 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Mabel Ikpeme 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Onyeka Igboelina 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Pamela Gado 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kolawole Olatunbosun 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Dolapo Ogundehin 2 United States Agency for International Development Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract HIV continues to pose significant health challenges globally, particularly in resource-limited settings such as Sub-Saharan Africa, which bears the brunt of the epidemic. The HIV care continuum, encompassing testing, linkage to care, retention, and antiretroviral treatment (ART) adherence, is critical in reducing morbidity and mortality while improving the quality of life for people living with HIV (PLHIV). Despite its potential, key HIV care continuum events such as linkage to treatment, retention in care and adherence remain substantial challenges due to barriers such as stigma, socio-economic inequalities, and systemic inefficiencies. This scoping review explores effective partnerships between clinicians and case managers to address these challenges. Using a Joanna Briggs Institute framework and population, concept and context (PCC) guidelines, 31 studies were analyzed, highlighting successful collaborative models, barriers, and facilitators in implementing effective HIV care. Results gotten from the review highlight the importance of role clarity, interdisciplinary approaches and collaborations, and patient-centered models integrating clinical and psychosocial support. Case managers, by addressing logistical challenges, complement clinicians’ medical expertise, resulting in improved ART adherence and retention. Effective interventions, such as holistic care models and community-based programs, were found to mitigate barriers like stigma and housing instability, and resource constraints. Recommendations call for enhanced training, clear role definitions, and policies fostering collaboration between case managers and clinicians to optimize care delivery. Strengthening these partnerships between clinicians and case managers is essential for the HIV care continuum and achieving better health outcomes for PLHIV. Background HIV infection continues to pose a critical health challenge worldwide, particularly in low-income developing nations ( Suleiman and Momo, 2016 ). According to the World Health Organization (WHO), over 85.6 million people have been infected with HIV, and more than 40.4 million HIV-related deaths have been recorded (World Health Organization, 2024). Notably, 71.0% of PLHIV reside in Sub-Saharan Africa, despite this region comprising just over 12% of the global population ( Suleiman and Momo, 2016 ). The HIV Continuum of Care (“care continuum”) encompasses HIV testing, linkage to care, retention and adherence to ART. This continuum has proven effective in reducing HIV transmission, morbidity, and mortality among those at risk or already infected and in improving treatment outcomes and quality of lives among PLHIV. Integrating HIV services with comprehensive primary healthcare has been recommended to improve health outcomes for individuals at higher risk of HIV exposure ( Rahman et al., 2021 ). Retention and adherence to ART remain significant challenges in managing HIV and care continuum. To address these issues, various strategies and interventions are being designed and implemented globally. HIV affects multiple facets of an individual’s life, including social, economic, physical, emotional, and spiritual well-being. PLHIV often face vulnerabilities such as poverty, stigma, discrimination, inequality, depression, guilt, prejudice, and anxiety, complicating efforts to maintain care retention and treatment adherence ( Rachlis et al., 2016 ; Comins et al., 2024 ). Multidisciplinary approaches are often necessary to address challenges associated with care continuum including adherence to ART and appointment-keeping, involving collaborations across nursing, pharmacy, social work, and case management. Clinicians in the context of this study refer to healthcare professionals such as physicians, nurse practitioners, and physician assistants, who provide direct medical care to individuals living with HIV ( Khalili and Landovitz 2020 ). Their responsibilities include diagnosing HIV, initiating and managing ART, monitoring patients’ health status, and adjusting treatments as necessary to achieve viral suppression ( Keene et al., 2023 ; Walker et al., 2023 ). They play a crucial role in helping patients understand the importance of adherence to the care continuum, identifying barriers to adherence, and addressing those within their capacity ( Walker et al., 2023 ). Linking patients to resources, including case managers, is essential to overcoming additional barriers. Similarly, a Case Manger is typically a non-clinical professional or peer support worker who coordinates care services to ensure that individuals engage with and remain in the HIV care continuum ( Besada et al., 2018 ). Case management support services are specialized services provided to HIV patients ( Øgård-Repål et al., 2023 ). These services involve establishing strong relationships and communication between HIV service providers and their clients, ensuring efficient coordination of medical care and social support services ( Besada et al., 2018 ; Keene et al., 2023 ). The ultimate goal of case management support services is to effectively engage and retain patients, ensuring good adherence to medication and overall treatment ( Sarfo et al., 2017 ). Effective partnership between the clinicians and case managers is essential for optimal HIV care continuum. Some factors may contribute to the prevention of this collaboration. E.g., unclear definitions of responsibilities between the two can lead to confusion and overlap, hindering teamwork, differences in communication styles and lack of standardized protocols can result in misinterpretations and fragmented care ( Rahman et al., 2021 ). Limited staffing, high caseloads, difference in remuneration, lack of trust and inadequate training can strain the capacity of both case managers and clinicians, reducing opportunities for collaboration. High employee turnover among providers further exacerbates these challenges ( Shamu et al., 2019 ; Fuller et al., 2024 ). Understanding the dynamics of these partnerships and identifying best practices will help improve the overall effectiveness of HIV care programs, thereby reducing transmission rates and improving health outcomes for PLHIV. Despite Sub-Saharan Africa being the epicenter of new HIV infections, there is limited attention to care and support services for individuals with HIV/AIDS beyond ART programs ( Mwai et al., 2013 ). This scoping review aims to explore best practices and successful models of collaboration between case managers and HIV clinicians, assess the impact of these partnerships on patient outcomes, particularly in terms of linkage to care and retention in HIV treatment, analyze the barriers and facilitators in forming effective partnerships between case managers and clinicians. Finally, the review will propose recommendations for policy and practice that can support the establishment and maintenance of these partnerships. Methodology This scoping review was conducted using the Joanna Briggs Institute (2020) scoping review framework as described by Santos et al., (2018) . Literature search approach was based on “Population, Concept and Context” (PCC) guide as described by Peters et al., (2015) . View this table: View inline View popup Download powerpoint Table 1: Literature search based on the PCC Download figure Open in new tab Download figure Open in new tab Figure 1. PRISMA Flow Diagram showing number of studies retrieved, screened and included in the review. Using the PCC guide a comprehensive search was conducted online to identify relevant studies, and reports with required information based on the guide. Screening and selection criteria were clearly defined based on these PCC elements, ensuring a focus on studies that provide data on keywords such as “HIV care,” linkage to care”, “retention to care”, “case management,” “clinician partnership,” “interprofessional collaboration”, “team-based care”, “patient engagement”, “community health services” and “treatment adherence.” Data extraction involved gathering detailed information on these keywords. Synthesis of the findings was used to map the existing evidence, identify gaps in knowledge, and provide recommendations for practice and future research. Inclusion Criteria Peer-reviewed studies and reports that provide data on collaboration between case managers and HIV clinicians, interventions aimed at improving care continuum, linkage, retention in HIV care, adherence to ART, and evaluations of collaborative models in diverse healthcare settings. Studies that focus on Sub-Saharan Africa or with clear policies that reflect or (and) could aid the Sub-Saharan African countries. Studies that were conducted within the last 10 years (from 2014 – 2024) and reflect current practices and outcomes. Exclusion Criteria Studies that do not focus on HIV care, those without clear provision on interprofessional partnerships that improve care continuum. Articles not available in English. Studies that were conducted more than 10 years ago. Study Selection The study selection was guided by the eligibility criteria that align with the aim and objectives of the scoping review. Typically, studies were selected based on their relevance to the research questions, research quality, and context-specific insights into the Nigerian healthcare setting. The selection process involved screening titles and abstracts followed by full-text review to ensure that the studies met the predefined inclusion criteria. Studies that did not meet the inclusion criteria or that did not provide clear data on the PCC elements were excluded to maintain the focus and quality of the review. Results Data Extraction Table on the Review Conducted on the Topic “Establishing effective partnerships among case managers and clinicians to improve linkage to and engagement in HIV care: A scoping review” A total of 31 studies were used for this scoping review based on the established inclusion and exclusion criteria with a major focus on high and low resource settings. The table below shows data extraction summary for ten of the studies that are most closely related to the research question and key themes. These papers provide a geographic and contextual representation of the review and also interventions and findings that can significantly contribute to HIV care continuum. Thematic Analysis of Result Findings The following themes were prominent in the reviewed studies: Collaboration and Role Clarity One of the predominant themes in improving linkage to and engagement in HIV care is the importance of collaboration and role clarity between case managers and clinicians. Studies emphasize that a lack of clear role definitions often leads to confusion and overlaps, undermining teamwork and the continuity of care ( Rahman et al., 2021 ). Sanchez et al. (2022) reported the importance of CHWs and Case Managers being integrated within clinical teams with clear role definitions and expectations to avoid overlap and ensure cohesive teamwork. The presence of fragmentation can impede the development of integrated care plans and result in missed opportunities to address patients’ comprehensive needs ( Shamu et al., 2019 ). Clinicians, including physicians, nurse practitioners, and physician assistants, provide direct medical care, including diagnosis and ART management. On the other hand, case managers (often non-clinical professionals) focus on coordinating care services to ensure patients remain engaged in the HIV care continuum ( Khalili & Landovitz, 2020 ; Besada et al., 2018 ). Effective partnerships hinge on defining these roles clearly while fostering mutual respect and understanding of each other’s contributions to patient care. Policy and Training Gaps The lack of standardized protocols and insufficient training are recurring themes in the studies reviewed. The need for ongoing professional development to equip both clinicians and case managers with the skills necessary for effective collaboration has been highlighted by several studies ( Besada et al., 2018 ; Wijesinghe & Alexander, 2020 ). Patient-provider relationships are strengthened through training programs that emphasize on interprofessional collaboration, communication, cultural competency, and support for case managers, thereby addressing gaps and enhancing care delivery ( Chinyandura et al., 2022 ). Patient-Centered Approach Collaborative partnerships have a demonstrable impact on patient outcomes, particularly in improving linkage to care, retention, and ART adherence. For instance, interventions that integrate case management with clinical care have shown significant improvements in retention rates, particularly among marginalized and mobile populations such as fisherfolk in Uganda ( Meya et al., 2022 ). As reported by Tolley et al., (2022) and Chinyandura et al., (2022), strong, supportive relationships between case managers and patients facilitated better communication and support for ART adherence. Holistic care models (incorporating social, psychological, and clinical support) have been effective in reducing stigma, improving disclosure rates, and enhancing ART adherence ( Masquillier et al., 2016 ; Chinyandura et al., 2022 ). This further highlight the value of multidisciplinary approaches in achieving better health outcomes and reducing HIV transmission rates. Leveraging Community Resources and Interdisciplinary Approaches Household context and dynamics are to be considered in designing community-based adherence support programs ( Masquillier et al., 2016 ). The adoption of interdisciplinary models is critical to addressing the multifaceted needs of PLHIV. Zablotska and O’Connor, (2017) encouraged fostering collaboration between case managers, clinicians, and community organizations to provide comprehensive care through joint training sessions and shared goals. Studies by Meya et al. (2022) and Williams et al. (2021) have highlighted the success of team-based care in Sub-Saharan Africa, where case managers work alongside clinicians and CHWs to improve ART adherence and retention rates. Addressing Barriers Numerous structural and systemic barriers inhibit effective collaboration between case managers and clinicians. High caseloads, inadequate staffing, and insufficient training are pervasive issues that limit the capacity of both groups to engage fully in collaborative care ( Rahman et al., 2021 ; Fuller et al., 2024 ). Differences in remuneration and status between case managers and clinicians also create tensions that can undermine teamwork ( Shamu et al., 2019 ). Stigma, social welfare and discrimination remain significant challenges in many healthcare settings, particularly in low- and middle-income countries. These factors discourage PLHIV from seeking care and reduce engagement in treatment programs ( Rachlis et al., 2016 ; Comins et al., 2024 ). Okeke et al., (2014) suggested adopting decentralization and task-shifting strategies in resource-poor settings to improve access and retention in care. It is optimal that efforts are increased to provide resources, foster cultural competency, ensure equitable treatment across care teams and disseminate accurate and actionable healthcare information through trusted sources. Addressing non-clinical barriers such as housing and transportation and leveraging high levels of trust in HIV clinicians to educate patients about healthcare policies, are shown to improve engagement in care ( Kaperak et al., 2020 ). DISCUSSION This study explored and identified effective strategies for establishing effective partnerships between case managers and clinicians in enhancing the HIV care continuum. These partnerships, which integrate medical and non-medical support services, address multifaceted challenges faced by PLHIV especially KP, including stigma, socioeconomic barriers, and psychological distress (Keane et al., 2016; Vorkoper et al., 2023 ). Well-coordinated, interdisciplinary approaches have consistently been shown to lead to improved retention, ART adherence, and overall health outcomes ( Chinyandura et al., 2022 ; Brennan-Ing et al., 2016 ). However, systemic barriers persist, such as resource limitations, medical hierarchy, unclear role definitions, and heavy workloads. Resource-constrained settings, in particular, report high caseloads and inadequate staffing, which limit the ability of care teams to provide tailored interventions ( Rahman et al., 2021 ; Fuller et al., 2024 ; Sanchez et al., 2022 ). These barriers are similar to those identified by Wijesinghe and Alexander, (2020) and Sousa et al., (2024), who reported that stigma, lack of resources, inadequate training of case managers, discrepancies in patient records and insufficient clinical training for community case managers were identified as key challenges in the United States and Mozambique respectively. Addressing these challenges requires significant investment in healthcare infrastructure, staffing, and training. Community engagement has emerged as a critical factor in bridging gaps between healthcare providers and patients, particularly in rural and underserved areas ( Masquillier et al., 2016 ; Williams et al., 2021 ). However, effective strategies vary across different geographic and socioeconomic settings as was reported by Meya et al. (2022) and Chinyandura et al., (2022), in resource-poor or socioeconomically disadvantaged settings, strategies such as decentralization of HIV care services, task-shifting and addressing barriers such as poverty and unemployment have proven effective in improving retention in care while in highly resourced settings, strength-based case management and peer navigation are more commonly implemented and have shown significant positive outcomes. Equally, studies such as Alderwick et al. (2021) challenge the assumption that inter-organizational collaboration inherently leads to better outcomes, emphasizing the importance of contextualized strategies that have shown inherent success rate. These submissions agree with those made by Agaba et al., (2018) who reported that different settings, including geographic and socio-economic contexts, significantly affect the effectiveness of these partnerships. Rural areas may face challenges related to accessibility and resource availability, whereas urban settings might deal with higher patient volumes and more complex social determinants of health. Patient-centered care models address both clinical and socioeconomic needs. Chinyandura et al. (2022) advocate for such models, which have shown to improve ART adherence and reduce stigma. However, Comins et al., 2024 argues that structural inequities, including housing instability and stigma, still remain significant barriers and integrating patient-centered approaches with structural interventions is essential for sustainable outcomes. Similarly, psychological support, individualized care, tailored to patients’ preferences and needs, correlates with higher CD4 counts and lower viral loads ( Sarfo et al., 2017 ; Eshiet & Njoku, 2023 ; Sousa et al., 2024 ). Okeke et al. (2014) however, caution that such interventions must account for resource constraints, as one-size-fits-all models may not be sustainable. There is ongoing debate about the relative effectiveness of micro-level (individual-focused) and macro-level (system-focused) strategies. Keane et al. (2016) argue for broader structural interventions, such as point-of-care testing and community-supported ART distribution models, while Brennan-Ing et al. (2016) emphasize the indispensability of comprehensive case management that encompasses psychosocial, medical, and logistical support. This suggest that integrating both approaches may yield optimal results. Fostering trust and mutual respect between case managers and clinicians is fundamental to building effective partnerships. Training programs should emphasize teamwork, communication, and the importance of interprofessional collaboration ( Besada et al., 2018 ; Shamu et al., 2019 ). Flexible, community-based case management models, as proposed by Williams et al. (2021) , have demonstrated high ART initiation and retention rates, further supporting the need for adaptable frameworks. Together, these perspectives reinforce the interconnectedness of social, structural, and clinical factors in effective HIV care. CONCLUSION All the studies reviewed emphasized the importance of effective partnerships between case managers and HIV clinicians which are vital for improving linkage to and retention in HIV care ( Rahman et al., 2021 ). The integration of various models, such as strength-based case management, peer navigation, and holistic, patient-centered approaches, has shown significant benefits in enhancing patient engagement and health outcomes ( Sanchez et al., 2022 ; Chinyandura et al., 2022 ; Brennan-Ing et al., 2016 ). Additionally, focusing on the dynamic nature of patient engagement and the importance of active self-management is crucial ( Agaba et al., 2018 ; Keene et al., 2023 ). RECOMMENDATION Based on the findings of this study, it is essential that hospitals or clinics employ a patient-centered approach, adopting holistic care models that integrate clinical, socioeconomic, and psychological support tailored to address the comprehensive needs of PLHIV. There is need for integration and role clarity and ensuring consistent and clear communication between all team members and the provision of comprehensive training and support to enhance the skills and confidence of these HIV clinicians and case managers. Implementing strategies to overcome barriers such as stigma, housing instability, and lack of access to technology is also found to be crucial in improving linkage and retention in HIV care. Develop policies to reduce stigma, improve access to technology, and provide financial support for housing and transportation. It is also important to leverage community resources by collaborating with community organizations and advocating for policies to improve healthcare access and reduce costs. Finally, it is paramount to regularly evaluate the effectiveness of implemented interventions and make necessary adaptations based on patient feedback and emerging best practices. 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Share Establishing effective partnerships among case managers and clinicians to improve linkage to and engagement in HIV care: A scoping review Piring’ar Mercy Niyang , Ibrahim Bola Gobir , Itunu Dave-Agboola , Joy Musa Shallangwa , Muhammad Zaharaddeen , Bashir Zubayr , Chika Obiora-Okafor , Terso Usha , Mabel Ikpeme , Onyeka Igboelina , Pamela Gado , Kolawole Olatunbosun , Dolapo Ogundehin medRxiv 2025.05.10.25327371; doi: https://doi.org/10.1101/2025.05.10.25327371 Share This Article: Copy Citation Tools Establishing effective partnerships among case managers and clinicians to improve linkage to and engagement in HIV care: A scoping review Piring’ar Mercy Niyang , Ibrahim Bola Gobir , Itunu Dave-Agboola , Joy Musa Shallangwa , Muhammad Zaharaddeen , Bashir Zubayr , Chika Obiora-Okafor , Terso Usha , Mabel Ikpeme , Onyeka Igboelina , Pamela Gado , Kolawole Olatunbosun , Dolapo Ogundehin medRxiv 2025.05.10.25327371; doi: https://doi.org/10.1101/2025.05.10.25327371 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area HIV/AIDS Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4440) Dentistry and Oral Medicine (444) Dermatology (383) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1510) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1126) Genetic and Genomic Medicine (6605) Geriatric Medicine (668) Health Economics (998) Health Informatics (4541) Health Policy (1369) Health Systems and Quality Improvement (1613) Hematology (543) HIV/AIDS (1265) Infectious Diseases (except HIV/AIDS) (15923) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (147) Nephrology (668) Neurology (6604) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1145) Occupational and Environmental Health (957) Oncology (3334) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (692) Primary Care Research (711) Psychiatry and Clinical Psychology (5448) Public and Global Health (9235) Radiology and Imaging (2199) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (594) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a01760c919bef047',t:'MTc3OTc0MTg2Ng=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();