Housing is HIV Prevention and Care

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Housing is HIV Prevention and Care

• Angela Aidala, PhD
• Department of Sociomedical Sciences
• Center for Homelessness Prevention Studies
• Mailman School of Public Health, Columbia
  University

HIV CENTER FOR CLINICAL AND BEHAVIORAL STUDIES
APRIL 10, 2008
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INTRODUCTION

• The goals of this presentation are to
• Examine the role of housing or lack of housing
  - for the continuing HIV epidemic and associated
  health disparities
• Review findings from NYC and national studies
  for evidence to support or challenge a number of
  causal models which have been proposed to
  explain observed relationships between housing
  and HIV/AIDS
• Discuss implications for housing as a structural
  intervention to reduce the spread of HIV as well
  as to increase the health and longevity of
  HIV-infected persons

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Housing as Structural Factor

• There is increasing awareness of the association
  between housing and HIV infection usually
  discussed in terms of the homeless as a
  special population
• Different focus homelessness/ housing
  instability is causally implicated in increased
  risk for of HIV disease and for the infected,
  causally implicated in their medical care and
  treatment outcomes
• Housing is a structural factor - an
  environmental or contextual influence that
  affects an individuals ability to avoid
  exposure to HIV, or for HIV positive individuals
  to avoid exposing others to infection

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NYC C.H.A.I.N. STUDY

• Community Health Advisory Information Network
• (CHAIN) Project
• Multi-stage probability sampling
• -- Stage 1 HIV health and social service
  agencies
• -- Stage 2 Random selection from lists or
  sequential enrollment
• Initial recruitment 1994-95, n700
• Refresher cohort 1998, n268
• Unconnected to care, n74
• New cohort 2002, n684 23 unconnected
• In-person comprehensive (2-3hr) interview every
  12 mos
• High retention rate 81 - 95 of eligible
  respondents at each wave
• Compares to surveillance data

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NATIONAL EVALUATION STUDY

• HRSA SPNS/ HUD HOPWA Multiple Diagnoses
  Initiative
• Interviews conducted with clients of
  demonstration projects providing health and
  social services to low income persons infected
  with HIV in 1996-2000
• Programs targeted hard to reach marginalized
  populations not often included in conventional
  clinical studies
• Sequential enrollment procedure
• Baseline information from 3191 clients from 24
  projects and follow-up data from 891 clients from
  16 projects
• Compares to clients in publicly funded services
  Ryan White, HOPWA, Medicaid

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HUD/HOPWA HRSA/SPNS Demonstration Projects
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MEASURING HOUSING STATUS

• HOMELESS
• -- homeless
• -- sleeping in the street, park, abandoned
  building
• -- in a public place (e.g. subway) not intended
  for sleeping
• -- in a shelter for homeless persons
• -- in a limited stay SRO or welfare hotel
• -- in jail with no other address
• UNSTABLY HOUSED
• -- in transitional housing, resident treatment,
  halfway house
• -- doubled up with other people
• STABLY HOUSED
• -- own, secure housing in regular apartment or
  house

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BACKGROUND HOUSING HIV EPI

• Co-occurrence of homelessness and HIV
  infection increasingly recognized
• -- The prevalence of HIV/ AIDS is 3 to 16
  times higher among persons who are homeless
  or unstably housed than among persons with
  stable, adequate housing depending upon
  population and geographic area studied
• -- Behaviors that put persons at risk for HIV
  are more prevalent among the homeless
  however among persons at highest risk due to
  IDU or high risk sex, those without a stable
  home are significantly more likely than others
  to become infected
• -- HIV infection risk factor for housing
  difficulties - 17 - 60 of all PLWHA report
  post diagnosis experience of homelessness/
  unstable housing

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HOUSING HIV EPI

• Housing need among NYC and national samples
• -- Approx 50 each NYC cohort were homeless or
  unstably housed during the year they were
  diagnosed with HIV
• -- Over 60 experienced unstable housing or
  homelessness at least once over the course of
  their illness
• -- In the national study over 40 of clients at
  general medical or social service agencies were
  homeless or unstably housed at program
  enrollment
• -- In NYC, at any point in time 25-35 of all
  PLWH are homeless or unstably housed even more
  report housing problems
• -- From a system perspective NYC rates of
  housing need remain fairly constant over time
  as some PLWH get housing needs met, others
  develop housing problems

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Aggregate Rates of Housing Need Remain High
Rate of Housing Service Need by Date of Interview
1994 thru 1996
Rate of Housing Service Need by Date of Interview
2001 thru 2003
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STUDY QUESTIONS HOUSING HIV RISK

• STUDY QUESTIONS
• What is the association between homelessness/
  unstable housing and HIV drug and sex risk
  behaviors among HIV positive people
• Does the effect of housing on HIV risk
  behaviors remain when controlling for the
  concurrent receipt of medical care and other
  treatments and services?

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ANALYSIS

• Logistical regression used to compare the odds
  of risk behavior associated with different
  housing situations
• Adjusted odds ratios show odds of risk
  behavior controlling for socio- demographics
  (age, race/ethnicity, gender) risk exposure group
  (sexual orientation, history of substance use)
  economic resources (education, income, primary
  language, incarceration experience), health
  status (CD4 count, mental illness) and receipt
  of health and supportive services (regular
  source of medical care, case management)
• National study presents cross-sectional
  relationships at program entry
• CHAIN study examines 1000- 4000 observation
  points -logistic regression equations used GEE
  procedures to adjust for dependency among
  multiple observations contributed by the same
  individual

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FINDINGS HOUSING AND RISK BEHAVIORS
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HOUSING RISK BEHAVIORS

• In both the NYC CHAIN sample and the national
  sample
• Significant differences in drug and sex risk
  behaviors are associated with current housing
  status
• The association of risk behaviors with housing
  status remains controlling for a wide range of
  client demographic, health, and service use
  variables
• There is an apparent dose-relationship with
  the homeless at greater risk than the unstably
  housed, and both of these groups at greater
  risk than the stably housed

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ODDS OF RECENT HARD DRUG USE
1Odds of drug use past 6 mos by current housing
status controlling for demographics economic
factors, health status, mental health, and
receipt of health and supportive services
Note All relationships statistically significant
plt .01
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ODDS OF RECENT NEEDLE USE
1Odds of needle use past 6 mos by current
housing status controlling for demographics econom
ic factors, health status, mental health, and
receipt of health and supportive services
Note All relationships statistically significant
plt .01
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ODDS OF RECENT NEEDLE SHARINGNATIONAL SAMPLE
1Odds of needle sharing past 6 mos by baseline
housing status controlling for demographics econom
ic factors, health status, mental health, receipt
of health and supportive services
All relationships statistically significant plt
.01
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ODDS OF UNPROTECTED SEX PAST 6-12 MOSNATIONAL
SAMPLE
1Odds of unprotected sex past 12 mos by baseline
housing status controlling for demographics
economic factors, health status, mental health,
receipt of health and supportive services
Note All relationships statistically significant
plt .05 except ( )ns
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ODDS OF UNPROTECTED SEX PAST 6 MOSCHAIN SAMPLE
Men
Women
1Odds of unprotected sex past 6 mos by baseline
housing status controlling for demographics
economic factors, health status, mental health,
receipt of health and supportive services
Note All relationships statistically significant
plt .05 except ( )ns
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ODDS OF RECENT SEX EXCHANGE
1Odds of needle use past 6 mos by current
housing status controlling for demographics econom
ic factors, health status, mental health, and
receipt of health and supportive services
Note All relationships statistically significant
plt .01 except plt .05
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HOUSING MEDICAL CARE
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HOUSING HIV MEDICAL CARE

• STUDY QUESTIONS
• What is the relationship between unstable
  housing and access and engagement with
  medical care and treatments?
• Does housing need predict receipt of medical
  care that meets good clinical practice
  standards?

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HOUSING MEDICAL CARE

• In both the CHAIN and the national samples
• Unstable housing leads to delayed entry into
  care and to discontinuous care - recent breaks
  in care, dropping in and out of care and/or
  changing providers often
• Homeless or unstably housed individuals are less
  likely than other PLWHS to be receiving
  medical care that meets minimum clinical
  practice guidelines
• Homelessness /unstable housing is one of the
  most important barriers limiting the use of
  antiretroviral combination therapy
• High viral load, recent opportunistic
  infection, and hospitalization for HIV related
  disease are associated with homelessness/
  unstable housing

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EXPLANATION OF FINDINGS?
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EXPLANATION OF FINDINGS

• Accumulating evidence documents the association
  between housing and risk behaviors and medical
  care outcomes mechanisms less often
  investigated
• Need to understand the causal direction and the
  mechanisms linking housing and behaviors that put
  people at risk for HIV infection and/or poor
  medical care outcomes
• Question Does housing status influence
  individual risk behaviors and medical care
  outcomes, or are findings evidence of
  self-selection of risky persons into conditions
  of homelessness

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RISKY PERSON Model

• .

HIV INFECTION
RISKY DISPOSITIONS/ PERSONALITY
RISKY BEHAVIORS Drug use Risky sex Illegal
activities
ECONOMIC Marginalization
SOCIAL Exclusion
UNSTABLE HOUSING
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OPPOSING MODEL STRUCTURAL CONTEXTS OF RISK

• Housing seen as vector -- an intermediary by
  which the pathogenic inequality that inheres in
  broader economic and political structures is
  carried to a susceptible host
• Broader processes of inequality and exclusion
  lead to the deterioration of housing situations
  and neighborhood environments for members of
  excluded groups
• Lack of housing creates or maintains pervasive
  context of risk makes it hard to avoid risky
  situations or to use risk-reducing tools and
  institutions

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Direct and Indirect Effects of Housing

• Effects of Housing include
• -- Neighborhood effects
• -- Stress producing or protecting environments
  and experiences
• -- Social capital resources or deprivations
• -- Identity and meaning
• -- Press of daily needs barrier to service
  use when available
• -- Structuring the private sphere lack of
  housing is barrier to
• forming stable partner relations

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RISKY CONTEXTS Model
Barriers to service use
Pervasive Risk Competing Needs Few Personal
Resources Few Community Resources
Economic Marginalization
Demoralization Depression Anxiety
HIV infection
Social Exclusion
UNSTABLE HOUSING
Risky BehaviorsDrug use High risk sex
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Evidence? Reduction in Risk Behavior

• Risky person model assumes behavior follows
  person - the formerly homeless who receive
  housing will continue to engage in risky
  behavior, continue to remain marginal to systems
  of care
• Test Examine change in risk behaviors
  associated with change in housing status
• For over time analysis, examined the odds of
  risk behavior associated with change in housing
  status compared to no change
• Longitudinal analysis included additional
  controls for baseline housing status, baseline
  drug or sex risk behavior, and receipt of mental
  health and/or alcohol or drug treatment in the
  interim between baseline and follow-up

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PREDICTING HARD DRUG USE NATIONAL SAMPLE
1 Odds of Time 2 drug use by change in housing
status controlling for Time 1 drug use, Time 1
housing status, demographics, economic factors,
health, mental health, and receipt of health and
supportive services
Note All relationships statistically significant
plt .01
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PREDICTING UNPROTECTED SEX LAST INTERCOURSE
1Odds of Time 2 sex exchange by change in
housing status controlling for Time 1 sex
exchange, Time 1 housing status, demographics,
economic factors, health, mental health, and
receipt of health and supportive services
Note All relationships statistically significant
plt .01 except ( ) ns
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PREDICTING SEX EXCHANGE NATIONAL SAMPLE
1 Odds of Time 2 sex exchange by change in
housing status controlling for Time 1 sex
exchange, Time 1 housing status, demographics,
economic factors, health, mental health, and
receipt of health and supportive services
Note All relationships statistically significant
plt .01 except plt .10
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Evidence? Improved medical care outcomes

• Test Examine change over time in engagement
  with medical care associated with change in
  housing status
• Findings Longitudinal analysis shows that
  unstable housing/ housing problems risk for
  dropping out of medical care or remaining out of
  care
• National study examine change in housing
  status associated with change in medical care
  indicators
• CHAIN study can examine effects of receiving
  housing assistance
• Longitudinal analyses control for
  socio-demographics (age, race/ethnicity gender)
  risk exposure group (sexual orientation, history
  of drug use) economic resources (education,
  income, primary language, incarceration
  experience), health status (CD4 count, mental
  illness) and receipt of supportive services (case
  management)

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PREDICTING T2 MEDICAL CARENational Sample
1 Odds of Time 2 outpatient visit past 6 months
by change in housing status controlling for
Time 1 outpatient use, Time 1 housing status,
demographics, economic factors, drug use, health
status, mental health, and receipt of case
management services
N 399. Relationships statistically significant
plt .05 except ()ns
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PREDICTING T2 MEDICATION USENational Sample
1 Odds of Time 2 antiretroviral medication use
by change in housing status controlling for Time
1 ARV use, Time 1 housing status, demographics,
economic factors, drug use, health status, mental
health, and receipt of case management services
N 192. Relationships statistically significant
plt .05 except ( )ns
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Access to Medical Care CHAIN NYC
N1651 individuals, 5865 observations, 1994 - 2007
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Continuity of Medical Care CHAIN NYC
N1295 individuals interviewed 2 times, 53759
observations, 1994 - 2007
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Entry into Medical Care CHAIN NYC
N557 individuals who were not in care at one or
more interviews, 720 observations, 1994 - 2007
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Summary

• HIV positive persons with housing problems are
  more likely to engage in sex and drug risk
  behaviors, are less likely to be engaged in
  appropriate medical care
• Overtime analyses show improvement in housing
  situation is associated with reduction in risk
  behaviors and positive change in medical care
  outcomes
• Data show strong and consistent relationship
  between housing and risk and medical care
  outcomes, regardless of other client
  characteristics, health status, or service use
  variables
• Findings suggest that the condition of
  homelessness, and not simply traits of homeless
  individuals, influences risk behaviors and
  service utilization

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Limitations

• Self-reported measures
• Limited information about specific sexual
  behaviors and relationships
• Timing of events not exact
• National study not probability sample,
  substantial loss to follow-up
• Findings consistent with the argument that
  housing status influences outcomes observed but
  cannot establish causality

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Policy Implications

• Provision of housing is a promising structural
  intervention to reduce the spread of HIV as well
  as improve the lives of infected persons
• More directly malleable state of housing
  situation holds more promise for intervention
  than mechanisms far antecedent in psychological
  development or closer to biological bases of
  disease
• Housing is a strategic target for intervention by
  addressing more proximal consequences of broader
  economic, social, political or policy barriers
  that affect HIV prevention and HIV care
• Expensive but offset by social and economic costs
  of ongoing HIV transmission and HIV treatment
  failure among significant proportion of HIV
  infected population

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HOUSING IS PREVENTION AND CARE
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ACKNOWLEDGEMENTS

• The CHAIN research was made possible by a series
  of grants from the US Health Resources and
  Service Administration (HRSA) under Title I of
  the Ryan White Comprehensive AIDS Resource
  Emergency (CARE) Act and contracts with the New
  York City HIV Health and Human Services Planning
  Council through the New York City Department of
  Health and Medical and Health Research
  Association of New York City.
• The national, multi-site research project is an
  inter-agency collaboration between the U.S.
  Health Resources and Services Administration
  (HRSA), Special Projects of National Significance
  (SPNS) Program, and the U.S. Department of
  Housing and Urban Development (HUD), Housing
  Opportunities for Persons with AIDS (HOPWA)
  Program of the Division of HIV/AIDS Housing.
• Additional funding for risk behavior analysis was
  provided by the Behavioral Intervention Research
  Branch, Division of HIV/AIDS Prevention,
  National Center for HIV, STD, and TB Prevention
  U.S. Centers for Disease and Prevention (CDC)
• The contents contents are solely the
  responsibility of the Researchers and do not
  necessarily represent the official views of the
  U.S. Health Resources and Services
  Administration, HUD, CDC, the City of New York,
  or the Medical and Health Research Association.