Transcript Mobilizing Knowledge: Housing is HIV Prevention and Care Summary of Research Presented at the Housing and HIV/AIDS Research Summit Series.

Mobilizing Knowledge:
Housing is HIV Prevention and Care
Summary of Research Presented at the
Housing and HIV/AIDS Research Summit Series
“If we are doing a good job on housing, we are
addressing HIV/AIDS.”
– Priya Gopalen, Rooftops Canada
Rooftops Canada works with partner organizations to help build homes and
sustainable communities in disadvantaged areas of Africa, Asia, Latin America, the
Caribbean and Eastern Europe.
Overview: Housing Policy is Health Policy
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Effectively addressing HIV risk & health care disparities requires attention to
structural factors —environmental or contextual factors that influence health
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Housing affects an individual’s ability to avoid exposure to HIV; an HIVpositive individual’s ability to avoid exposing others to HIV; and the ability to
access & adhere to care
•
There is now a large body of evidence showing that housing interventions
are an essential and cost-effective component of HIV prevention and health
care for homeless/unstably housed PLWHA
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Indeed, housing has “zoomed by” many other well-accepted health care
interventions in terms of published evidence (Dr. David Holtgrave, concluding
remarks, Summit IV)
Overview: Policy & practice implications
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HIV prevention and care strategies will not succeed without
addressing structural barriers such as homelessness & housing
instability
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Housing for persons with HIV/AIDS saves lives and taxpayer dollars,
making it is a sound health care investment
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Housing status is likely the most important characteristic of each
PLWHA who seeks services - the most significant determinant of
each PLWHA’s health and risk outcomes
Housing and HIV/AIDS Research Summit Series
•
Since 2005 the summit series has provided a regular forum for
presentation and discussion of research findings on the
relationship of housing to HIV prevention and care
•
Summit IV, held June 3-5, 2009, was the 1st North American
Summit, convened by the National AIDS Housing Coalition
(NAHC) and the Ontario HIV Treatment Network (OHTN), in
collaboration with the Johns Hopkins Bloomberg School of Public
Health
•
Summit series products include policy papers, an advocacy tool
kit and a November 2007 Housing & HIV/AIDS special issue of
the journal AIDS & Behavior
Outline of this presentation:
• Recent research findings on:
– HIV and homelessness
– Housing and HIV prevention
– Housing and health care
• Recent results from housing based interventions
– Impact of housing on health and risk outcomes
– Cost analyses of housing interventions
• Translating research into policy & practice:
•
– Policy & research action strategies from Summit IV
For all citations, Summit Series policy papers, and more info - go to:
www.nationalaidshousing.org
www.nationalaidshousing.org
Homelessness—a major risk factor for HIV infection
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Rates of HIV infection are 3 times to 16 times higher among
persons who are homeless or unstably housed, compared to
similar persons with stable housing
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3% to 14% of all homeless persons are HIV positive (10 times the
rate in the general population)
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Over time studies show that among persons at high risk for HIV
infection due to injection drug use or risky sex, those without a
stable home are more likely than others to become infected
HIV—a major risk factor for homelessness
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Up to 70% of all PLWHA report a lifetime experience of
homelessness or housing instability
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10% to 16% of all PLWHA in some communities are literally
homeless at any time —sleeping in shelters, on the street, in a car
or other place not meant for human habitation
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Many more PLWHA are unstably housed, faced with housing
problems or the threat of housing loss
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Rates of housing need remain high - as some persons get their
housing needs met others develop housing problems
Growing global awareness
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Summit IV presentations pointed to the growing global awareness of the
link between HIV and housing instability in all its forms, including:
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–
–
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Denial of property rights for women in Sub-Saharan Africa
The combination of extreme poverty and HIV stigma in Haiti
Persons made homeless by forced evictions and conflict
Economic and political migration
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Mobile populations are often excluded from care, and experience high rates
of HIV infection, morbidity and mortality
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Restrictions on HIV care based on residency status violate basic human
rights and public health principles
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“There are no illegal human beings” - Archbishop Desmond Tutu
Lack of stable housing =
poor health outcomes for PLWHA
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Homeless/unstably housed PLWHA are less likely to receive
appropriate health care & experience higher rates of opportunistic
infections, HCV and other co-morbidities
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The all-cause death rate among homeless PLWHA is five times the
death rate for housed PLWHA
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The death rate due to HIV/AIDS is among homeless PLWHA is
seven to nine times the death rate due to HIV/AIDS among the
general population
Recent findings:
Lack of stable housing = higher mortality
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Schwarcz (BMC Public Health) - study by the San Francisco
Department of Public Health of housing status at time of AIDS
diagnosis and mortality over a five year period: Homeless PLWA
experienced a significantly higher rate of death, after controlling for
medical status and other individual characteristics
•
Walley (AIDS) - study of 595 HIV+ persons with alcohol problems:
People who reported homelessness within the last 6 months had
an almost 3 times greater risk of death
Housing status predicts HIV risk behaviors
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Research shows a direct relationship between housing status and risk
behaviors among extremely low income HIV+ persons with multiple
behavioral issues
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Homeless or unstably housed persons were 2 to 6 times more likely to use
hard drugs, share needles or exchange sex than stably housed persons
with the same personal and service use characteristics
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Homeless women were 2 to 4 times as likely to have multiple sex partners
as housed indigent women - in part due to the effects of physical violence
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Harm reduction and other behavioral prevention interventions are much
less effective for participants who lack stable housing
Recent findings:
Lack of housing = greater HIV risk
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Data from 529 participants in the ongoing At Risk Youth Study in Vancouver
show significantly lower levels of condom use and greater numbers of sexual
partners among homeless youth as compared to those with more stable
housing
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Data gathered from 8,075 PLWHA as part of the US CDC's Supplement to
HIV/AIDS Surveillance (SHAS) project show that, compared to stably housed
counterparts, PLWHA who lack stable housing are:
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2.9 x more likely to engage in sex exchange in last 12 months
2 x more likely to have unprotected sex with an unknown status partner
2.3 x more like to use drugs in last 12 months
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2.75 x more likely to inject drugs
Housing is HIV Prevention
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Overtime studies show a strong association between change in
housing status and risk behavior change
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Over time, persons who improved housing status reduced risk
behaviors by half; while persons whose housing status worsened
over time were 4 times as likely to exchange sex
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Access to housing also increases access to appropriate care and
antiretroviral medications which lower viral load, reducing the risk of
transmission
Lack of stable housing = lack of treatment success
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Data from the CDC SHAS project: homeless PLWHA compared to
stably housed:
– More likely to delay entry into care and to remain outside or marginal to
HIV medical care
– Worse mental, physical & overall health
– More likely to be uninsured, hospitalized & use ER
– Lower CD4 counts & less likely to have undetectable viral load
– Fewer ever on ART, and fewer on ART currently
– Self-reported ART adherence lower
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Housing status found more significant than individual
characteristics as a predictor of health care access & outcomes
Housing improves access to
health
care
Stable housing improves health outcomes
•• Receipt
of housing services independently
Homeless/unstably housed PLWHA whose housing status
associated
with
improves over time
are: improved health care
– More likely to report HIV primary care visits, continuous care & care
access
that meets clinical practice standards
• Homeless/unstably
housed
– More likely to return to care after
drop out PLWHA whose
– More likelystatus
to be receiving
HAART
housing
improved
over time were:
•
– 5 times more likely to report a recent HIV
– outpatient
Effective HAARTvisit
(viral suppression)
–
HIV related
status
as indicated
by viral
load, CD4 count,
– Better
6 times
morehealth
likely
to( be
receiving
antilack
of co-infection with HCV or TB)
retrovirals
Increased housing stability is positively associated with:
• Controlling for demographics, health
status & receipt of case management
Housing improves access to
health
care
Recent findings:
Supportive housing dramatically reduces mortality
• Receipt of housing services independently
associated with improved health care access
• Homeless/unstably housed PLWHA whose
• Schwarcz (BMC Public Health) observational study of 676
housing
status improved over time were:
homeless PLWHA identified through the SF AIDS registry
– 5 times
more5 likely
report a recent
HIV outpatient
found
that over
years,toobtaining
supportive
housing
wasvisit
independently associated with an 80% reduction in
– 6 times more likely to be receiving anti-retrovirals
mortality.
• Controlling for demographics, health status &
receipt of case management
Housing assistance works to create stability
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Reporting by the federal HOPWA program shows high levels of stability
at low per-unit costs:
– 89% of households receiving average annual rental assistance of $3,750
remain stably housed after one year
– 79% of residents of supportive housing stably housed at an average annual
cost of $9,000
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Increasing evidence that supportive housing enables chronically
homeless persons to achieve and maintain stability despite serious
medical & psychosocial issues
Investments in housing
improve outcomes & reduce public costs
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Investments in supportive housing found to reduce emergency and inpatient
health services, criminal justice involvement, and use of other crisis services
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Seattle DESC 1811 Eastlake project for homeless people with chronic alcohol
addiction
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–
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41% reduction medical expenses
87% reduction sobering center use
45% reduction county jail bookings
Median monthly per person costs reduced from $4066 to $1492 (6 months in housing)
and $958 (12 months in housing)
NYC FUSE Initiative for frequent users jail & shelter
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Reduced jail days 52% for housed participants
Jail days increased for comparison group
Evaluating the cost-effectiveness of HIV housing
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Savings in other publicly funded services have been found to offset or
exceed the cost of housing interventions
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These cost-offset analyses support the provision of housing even
before taking into account the costs of heightened HIV risk and
treatment failure among homeless PLWHA
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Each prevented HIV infection saves over $300,000 in life-time medical
costs
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Housing instability limits the ability of individual PLWHA to access and
benefit from life-saving antiretroviral therapies
New evidence that housing assistance works to
improve HIV outcomes and save health care dollars
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Two large-scale, random controlled intervention studies examine the
impact of housing on health care utilization & outcomes among
homeless/unstably housed persons with HIV & other chronic medical
conditions
– The Chicago Housing for Health Partnership (CHHP) followed 407
chronically ill homeless persons over 18 months following discharge from
hospitals, including an HIV sub-study among 34% of participants who are
HIV+
– The Housing and Health (H&H) Study examined the impact of housing on
HIV risk behaviors, medical care and treatment adherence among 630 HIV+
persons who were homeless or unstably housed at baseline
CHHP background & methods
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“Housing first” program providing supportive housing for homeless
persons with medical issues such as HIV/AIDS, hypertension, diabetes,
cancer and other chronic illnesses
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18 month random controlled trial (RCT) studied the number of hospital,
emergency room & nursing home visits of participants in 2 groups:
– Half who received CHHP supportive housing
– Half who continued to rely on “usual care” - a piecemeal system of
emergency shelters, family & recovery programs
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Results published in JAMA (Sadowski, 2009) and APHA (Buchanan, 2009)
CHHP shows housing saves lives and money
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Housed participants:
– 3 times more likely to be stably housed at 18 months (66% vs. 21%)
– significantly fewer housing changes (2 vs. 3)
– 29% fewer hospitalizations, 29% fewer hospital days, and 24% fewer
emergency department visits than “usual care” counterparts
– Reduced nursing home days by 50%
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For every 100 persons housed, this translates annually into 49 fewer
hospitalizations, 270 fewer hospital days, and 116 fewer emergency
department visits
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CHHP cost analyses to be published this fall expected to show that
reductions in avoidable health care utilization translated into annual
savings of at least $900,000 for the 200 housed participants, after
taking into account the cost of the supportive housing
Housing improved health among HIV+ CHHP
participants
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HIV sub-study examined the impact of housing on disease progression
among the third of CHHP participants who were HIV+
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Like other study subjects, HIV+ participants were randomly assigned to
permanent supportive housing or “usual care”
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At 12 months, housed HIV+ CHHP had significantly better health
status:
– 55% of housed were alive with “intact immunity”, compared to only 34% of
HIV+ participants left to “usual care”
– Housed HIV+ participants were twice as likely to have undetectable viral
load (40%) as compared to who did not receive housing (21%)
Housing & Health Study: background & methods
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Conducted by the CDC and the HUD HOPWA program - in
Baltimore, Chicago & Los Angeles
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630 HIV+ participants were homeless (27%), doubled up (62%) other
otherwise at risk of homelessness (11%) at baseline
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All received case management, help finding housing, referral to
medical care and behavioral prevention interventions - half were
randomly selected to receive an immediate HOPWA voucher
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Data on HIV risk and health indicators collected at baseline & at 3
follow up assessments over an 18-month period
H&H vouchers = stability & improved health
• At 18 months, only 15% of voucher recipients remained
unstably housed, compared to 44% of control group members
• Compared to housed participants, and controlling for
demographics & health status, those who experienced
homelessness during follow up:
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–
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Were 2.5 times more likely to use an ER
Were 2.8 more likely to have a detectible viral load at follow-up
Reported significantly higher levels of perceived stress
Were more likely to report unprotected sex with a
negative/unknown status partner
Evaluating the “cost utility” of housing as health
care
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H&H results have made it possible for the first time to evaluate the “costutility” of housing as an HIV risk reduction & treatment intervention measured as the “cost per quality adjusted life year (QALY) saved”
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“Cost per QALY” is the measure used by health economists to compare the
“value for money” of health care interventions - to ensure that health care
dollars are being spent wisely, on treatments that work
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The cost-utility of the H&H housing is a function of the cost of services
provided, transmissions averted, medical costs saved, and life years saved
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Preliminary H&H findings show that housing is a cost effective health care
intervention for PLWHA, with a cost per QALY ($16,000) that is lower than
such widely accepted health care interventions as renal dialysis ($50,000 per
QALY) and screening mammography ($30,000 per QALY).
Cost
effectiveness
of selected
medical
Cost
Effectiveness
of Selected
interventions
Medical
Interventions
Summary of key findings on Housing & HIV
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Homelessness and unstable housing are linked to greater HIV
risk, inadequate care, poor health outcomes & early death
Studies also show strong & consistent correlations between
improved housing status and…
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–
–
–
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Reduction in HIV/AIDS risk behaviors
Access to medical care
Improved health outcomes
Savings in taxpayer dollars
Recent research shows that that housing is both effective and
cost saving as a health care intervention for homeless/unstably
housed persons with HIV & other chronic conditions
Yet housing remains the greatest
unmet service need of PLWHA
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1.2 million PLWHA in the United States—half (600,000) will need
housing assistance at some point
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The Federal Housing Opportunities for Persons with AIDS
(HOPWA) program serves only 56,627 households/year
nationwide
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There is not a single county in the US where a person who on
relies on SSI ($674 in 2009) can afford even a studio apartment
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An ongoing study of US veterans living with HIV shows that 48%
have experienced homelessness, and 11% are currently
homeless
Evidence base supports HIV housing assistance
• As a basic human right
• As a necessary component of systems of care to enable
PLWHA to manage their disease
• As an exciting new mechanism to end the AIDS crisis by
preventing new infections
• As a cost-effective public investment
Summit IV Policy Action Strategies
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•
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Implement a coordinated communication strategy to
disseminate the strong evidence base for housing as HIV
prevention and health care;
Increase opportunities for collaboration in the development,
implementation and evaluation of effective housing programs and
policies;
Mainstream human rights in HIV/AIDS prevention and care
strategies, including the basic human right to housing;
Redefine appropriate housing for PLWHA as housing that is
affordable, safe and accessible to all; and
Engage in comprehensive planning that establishes norms,
beginning with adoption of the International Declaration on
Poverty, Housing Instability and HIV.
Summit IV Research Action Strategies
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Move towards integrated cross-sector data systems to better
target, deliver and evaluate housing resources;
develop a deeper understanding of different models of
housing, including the causal mechanisms at work in effective
housing interventions;
Broaden our understanding of the unique housing needs of
special populations;
Foster community based participatory research (CBPR)
approaches;
Increase opportunities for meta-analyses of HIV/AIDS housing
needs and interventions to amplify the power of program data.
Get involved!
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Stay in touch with NAHC - www.nationalaidshousing.org
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Join the International AIDS Housing Roundtable http://groups.yahoo.com/group/iahr/
•
Endorse the International Declaration on Poverty,
Homelessness and HIV http://nationalaidshousing.org/2008/07/endorseconference/
•
Use the NAHC Policy Tool Kit
http://www.nationalaidshousing.org/policytoolkit.htm
Save the date!
North American Housing and HIV/AIDS Research Summit V
June 2nd - 5th, 2010
Toronto, Canada
Convened by
The National AIDS Housing Coalition
and
The Ontario HIV Treatment Network
in collaboration with
Johns Hopkins Bloomberg School of Public Health
For updates, go to:
http://nationalaidshousing.org/housing-hiv-regional-research-summit/
Select references - recent articles
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Buchanan, D.R. MD, Kee, R. MD, MPH, Sadowski, L.S. MD, MPH, and Garcia, D. MPH (2009).
The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized
Controlled Trial. American Journal of Public Health, 99, No 6: xx-xx, June 2009 E-published ahead
of print on April 16, 2009: http://www.ajph.org/cgi/doi/10.2105/AJPH.2008.137810
Holtgrave, D. R., Briddell, K., Little, E., Bendixen, A. V., Hooper, M., Kidder, D. P., et al. (2007).
Cost and threshold analysis of housing as an HIV prevention intervention. AIDS and Behavior,
11(6), S162-S166.
Sadowski, L., Kee, R., VanderWeele, T., & Buchanan, D. (2009). Effect of a housing and case
management program on emergency department visits and hospitalizations among chronically ill
homeless adults: A randomized trial. JAMA-Journal of the American Medical Association, 301(17),
1771.
Schwarcz, S.K., Hsu, L.C., Vittinghoff, E., Vu, A., Bamberger, J.D. and Katz, M.H. (2009). Impact
of housing in the survival of people with AIDS. BMC Public Health, 9: 220. Full text available
electronically at: http://www.biomedcentral.com/1471-2458/9/220
Stein, J. A., Nyamathi, A., & Zane, J. I. (2009). Situational, psychosocial, and physical healthrelated correlates of HIV/AIDS risk behaviors in homeless men. American Journal of Men's Health,
3(1), 25-3.
Walley, A. Y., Cheng, D. M., Libman, H., Nunes, D., Horsburgh, C. R., Saitz, R., et al. (2008).
Recent drug use, homelessness and increased short-term mortality in HIV-infected persons with
alcohol problems. AIDS, 22(3), 415-420.
Acknowledgements
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The North American Housing & HIV/AIDS Research Summit Series was convened by
the U.S. National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment
Network, in collaboration with Dr. David Holtgrave and the Department of Health,
Behavior and Society of the Johns Hopkins Bloomberg School of Public Health
Convening researchers include Dr. Holtgrave, Dr. Angela Aidala of Columbia
University, Dr. Toorjo Ghose of the University of Pennsylvania, Dr. Daniel Kidder of
the U.S. Centers for Disease Control and Prevention, and Dr. Sean Rourke and
Ruthann Tucker of the Ontario HIV Treatment Network.
Shubert Botein Policy Associates (www.shubertbotein.com) help plan and document
the Summit Series. Anne Siegler helped develop the Summit IV Briefing Book.
NAHC and the OHTN gratefully acknowledge major financial support for Summit IV
from: the AIDS Bureau of the Ontario Ministry of Health & Long Term Care; the
Canadian Institute for Health Research; the Ford Foundation; the M*A*C AIDS Fund;
the U.S. National Institutes of Health, Office of AIDS Research; the Palette Fund; the
Public Health Agency of Canada; the Corporation for Supportive Housing; Harlem
United Community AIDS Center, Inc.; Housing Works, Inc.; the U.S. National
Institutes of Mental Health; and Bailey House, Inc.