housing and hiv/aids

Housing and HIV/AIDS

Angela A. Aidala, PhDMailman School of Public Health Columbia University

Integration of Care Committee – Nov 29, 2011

Brief Summary of Research Findings

RESEARCH QUESTIONSRESEARCH QUESTIONS

What are rates of homelessness or housing What are rates of homelessness or housing instability among PLWH and have rates changed instability among PLWH and have rates changed over time? over time?

What is the relationship between housing status What is the relationship between housing status and entry and maintenance in HIV medical care? and entry and maintenance in HIV medical care?

What are additional service needs of PLWH with What are additional service needs of PLWH with unstable unstable housing?housing?

Housing (lack of housing) as a structural factor Housing (lack of housing) as a structural factor contributing to the continuing epidemic and contributing to the continuing epidemic and associated health disparitiesassociated health disparities

The C.H.A.I.N. ProjectCommunity Health Advisory & Information Community Health Advisory & Information Network (CHAIN) Project Goals:Network (CHAIN) Project Goals:

• To provide a profile of PLWH/A in New York To provide a profile of PLWH/A in New York City //and the Tri-County Region City //and the Tri-County Region

• To assess the system of HIV care – both health To assess the system of HIV care – both health and social services – from the perspective of and social services – from the perspective of people living with HIV/AIDSpeople living with HIV/AIDS

• To report on unmet needs, service utilization To report on unmet needs, service utilization trends, and outcomes to the Planning Council trends, and outcomes to the Planning Council and its Committeesand its Committees

• Make research results available to the wider Make research results available to the wider provider, consumer, and other stakeholder provider, consumer, and other stakeholder communitiescommunities

History of CHAINHistory of CHAIN

• Initially developed in 1993 as one of the Planning Initially developed in 1993 as one of the Planning Council’s evaluation resources Council’s evaluation resources

• Contract with Columbia University Public HealthContract with Columbia University Public Health

• CHAIN has recruited 4 cohorts of PLWH/ACHAIN has recruited 4 cohorts of PLWH/A - NYC I (1994-2002, n=968)- NYC I (1994-2002, n=968) - NYC II (2002-present, n=1012)- NYC II (2002-present, n=1012) - Tri-County I (2001-2007, n=482)- Tri-County I (2001-2007, n=482) - Tri-County II (2008-present, n=234- Tri-County II (2008-present, n=234))

• A Technical Review Team including A Technical Review Team including representatives of the Planning Council, its PWA representatives of the Planning Council, its PWA Advisory Group, MHRA/ Public Health Solutions, Advisory Group, MHRA/ Public Health Solutions, NYCDOHMH and (xx) Office of HIV/AIDS Planning NYCDOHMH and (xx) Office of HIV/AIDS Planning oversees CHAINoversees CHAIN

Selecting CHAIN ParticipantsSelecting CHAIN ParticipantsA 2-Step ProcessA 2-Step Process

• 11stst step: random selection of service sites step: random selection of service sites from listing of all agencies serving HIV from listing of all agencies serving HIV clientsclients Medical and Social ServiceMedical and Social Service All Boroughs (or Counties)All Boroughs (or Counties) RW Funding vs. no RWRW Funding vs. no RW

• 22ndnd step: agency staff help with random step: agency staff help with random selection of clientsselection of clients Random selection from client rostersRandom selection from client rosters Sequential enrollmentSequential enrollment

• Agency liaison obtains consent to contact, Agency liaison obtains consent to contact, CHAIN staff obtains consent for interviewCHAIN staff obtains consent for interview

• Cohort composition closely tracks Cohort composition closely tracks surveillance data/ RW client datasurveillance data/ RW client data

Recruiting CHAIN ParticipantsRecruiting CHAIN ParticipantsUnconnected to CareUnconnected to Care

• NYC CHAIN includes small samples of PLWHA NYC CHAIN includes small samples of PLWHA unconnected to careunconnected to care

• Unconnected: Aware, no medical care, no HIV case Unconnected: Aware, no medical care, no HIV case mgmt for 6+monthsmgmt for 6+months

• RDS referrals from CHAIN agency recruited RDS referrals from CHAIN agency recruited participantsparticipants

• Accompany Outreach Workers Accompany Outreach Workers

• Open recruitment and screening in street and Open recruitment and screening in street and community settingscommunity settings

• 1994 (n=48) 1998 (n=24) 2002 (n=25)1994 (n=48) 1998 (n=24) 2002 (n=25)

Collecting DataCollecting Data

• Comprehensive 2-3 hr, in-person Comprehensive 2-3 hr, in-person interview interview

• Follow-up interviews annuallyFollow-up interviews annually

• Community based interviewersCommunity based interviewers

• Interviews in homes or agency settingsInterviews in homes or agency settings

• Community-based interviewing teamCommunity-based interviewing team

• $25-$35 incentive for every interview + $25-$35 incentive for every interview + referral resourcereferral resource

• High retention rate: 80% - 95% of eligible High retention rate: 80% - 95% of eligible participants at each waveparticipants at each wave

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

Baseline information from 3191 clients from 24 projects and follow-up data from 891 clients from 16 projects

Sample: - 2/3 males (30% heterosexual, 37% gay, bisexual or questioning)- 1/2 African American, 13% Latino, 24% White, 10% Other - 4/5 income below $10,000- 1/2 ever incarcerated

Not probability sample -compares to clients in publicly funded services

National Study

HUD/HOPWA HRSA/SPNS Demonstration Projects

MEASURING HOUSING STATUSMEASURING HOUSING STATUS HOMELESSHOMELESS

-- -- homeless, no regular place to sleephomeless, no regular place to sleep -- sleeping in the street, park, abandoned building-- sleeping in the street, park, abandoned building-- in a public place (e.g. subway) not intended for sleeping-- in a public place (e.g. subway) not intended for sleeping-- in a shelter for homeless persons-- in a shelter for homeless persons-- in a SRO or welfare hotel-- in a SRO or welfare hotel-- in jail with no other address-- in jail with no other address

UNSTABLY HOUSEDUNSTABLY HOUSED

-- in transitional housing, resident treatment, halfway house -- in transitional housing, resident treatment, halfway house

-- -- temporarilytemporarily doubled up with other peopledoubled up with other people

STABLY HOUSEDSTABLY HOUSED

---- own, secure housing in regular apartment or houseown, secure housing in regular apartment or house

HOUSING PROBLEMSHOUSING PROBLEMS

• Respondent reports problem with housing or need for Respondent reports problem with housing or need for housing services at present or at any time during the housing services at present or at any time during the past 6 monthspast 6 months

• PROBLEMS DESCRIBED INCLUDE PROBLEMS DESCRIBED INCLUDE

-- homeless, no regular place to live-- homeless, no regular place to live -- urgent need to leave current housing-- urgent need to leave current housing-- cannot pay rent-- cannot pay rent---- facing eviction for any reason facing eviction for any reason -- poor quality of housing (plumbing, heat)-- poor quality of housing (plumbing, heat)-- physical access difficulties-- physical access difficulties-- dangerous, threatening neighborhood (drugs, crime)-- dangerous, threatening neighborhood (drugs, crime)-- domestic violence situation-- domestic violence situation

Housing & HIV EpidemiologyThe patterns of disease and risk for disease and death in a population

Homelessness - a major risk Homelessness - a major risk factor for HIV infectionfactor for HIV infection

Review of published literatureReview of published literature

• Rates of HIV infection are 3 - 16 x higher among Rates of HIV infection are 3 - 16 x higher among persons who are homeless or unstably housed persons who are homeless or unstably housed compared to similar persons with stable housingcompared to similar persons with stable housing

• 3% to 14% of all homeless persons are HIV 3% to 14% of all homeless persons are HIV positive (10 x the rate in the general positive (10 x the rate in the general population)population)

• Over time studies show that among persons at Over time studies show that among persons at high risk for HIV infection due to injecting drug use high risk for HIV infection due to injecting drug use or risky sex, those without a stable home are more or risky sex, those without a stable home are more likely than others to become infectedlikely than others to become infected

HIV- a major risk factor for HIV- a major risk factor for homelessnesshomelessness

• 50% to 70% of all PLWHA report a lifetime 50% to 70% of all PLWHA report a lifetime experience of homelessness or housing instabilityexperience of homelessness or housing instability

• 10% to 16% of all diagnosed PLWHA are literally 10% to 16% of all diagnosed PLWHA are literally homeless - sleeping in shelters, on the street, in a homeless - sleeping in shelters, on the street, in a car, or in an encampmentcar, or in an encampment

• Twice as many are unstably housed, have housing Twice as many are unstably housed, have housing problems, experience threat of housing lossproblems, experience threat of housing loss

• In general, medical conditions and medical costs are In general, medical conditions and medical costs are associated with housing problems for persons with associated with housing problems for persons with chronic illness – can’t pay rent, face foreclosurechronic illness – can’t pay rent, face foreclosure

FINDINGS: NYC HOUSING & HIV • Housing need among PLWHA in New York Housing need among PLWHA in New York

- 49%- 52%% of each NYC cohort were homeless or unstably housed at during the year they were

diagnosed with HIV

- 60%- 70% experienced unstable housing or homelessness at least once during the study period (1994-2002 or 2002- 2010)

- NYC rates of housing need remain fairly constant over time as some PLWH get housing needs met, others develop housing problems (35%-45% at any point in time)

- Housing is the greatest unmet service need

HOUSING STATUS AND HOUSING HOUSING STATUS AND HOUSING PROBLEMSPROBLEMS

CHAIN STUDY (Agency recruited CHAIN STUDY (Agency recruited samples)samples)

Original Original CohortCohort1994-951994-95

Refresh Refresh Cohort Cohort 1998-991998-99

New New

Cohort Cohort

2002-042002-04

Refresh Refresh Cohort Cohort 2009-102009-10

HOUSING STATUSHOUSING STATUS11

Unstable housingUnstable housing

HomelessHomeless

16%16%

19 19

19%19%

99

20%20%

10 10

26%26%

77


Homeless or unstable housing, Homeless or unstable housing,

can’t pay rent, facing eviction, can’t pay rent, facing eviction,

no heat/ plumbing, domestic no heat/ plumbing, domestic

violence, other dangerousviolence, other dangerous

situation, need accessible unit,situation, need accessible unit,

etc.etc.

38%38% 28%28% 35%35% 46%46%

1. Past 6 months

HOUSING STATUS AND HOUSING HOUSING STATUS AND HOUSING PROBLEMSPROBLEMS

CHAIN STUDY (Unconnected samples)CHAIN STUDY (Unconnected samples)Original Original CohortCohort

19951995

Refresh Refresh Cohort Cohort

19981998

New New Cohort Cohort 2004 2004

HOUSING STATUSHOUSING STATUS

Homeless or Unstable HousingHomeless or Unstable Housing64%64% 78%78% 72%72%


Homeless or unstable housing, Homeless or unstable housing,

can’t pay rent, facing eviction, can’t pay rent, facing eviction,

no heat/ plumbing, domestic no heat/ plumbing, domestic

violence, other dangerousviolence, other dangerous

situation, need accessible unit,situation, need accessible unit,

etc.etc.

54%54% 50%50% 74%74%

1. Past 6 months

Need for Housing AssistanceNeed for Housing AssistanceNYC CHAIN STUDY NYC CHAIN STUDY

2008-2008-

20092009

2009-2009-20102010

Need Permanent Housing Placement

Homeless Or temporarily doubled up, OR in temporary/transitional housing during the last 6 months

26%26% 15%15%

Need Rental Assistance

(1) Having difficulty paying rent in the past 6 months OR

(2) facing eviction and lacks income to secure housing (FMR>50% of income) OR

(3) fairly to very often there was not enough money for rent in the past 6 months OR

(4) currently receiving rental assistance (including living in a public housing)

81%81% 86%86%

Housing & HIV PreventionFactors increasing or decreasing risk for disease

Housing status predicts HIV Housing status predicts HIV riskrisk

• Multiple studies have shown a strong and Multiple studies have shown a strong and consistent relationship between housing status consistent relationship between housing status and sex and drug risk behaviors and sex and drug risk behaviors

• Ex: Homeless or unstably housed PLWHA are 2 to Ex: Homeless or unstably housed PLWHA are 2 to 6 x more likely to use hard drugs, share needles 6 x more likely to use hard drugs, share needles or exchange sex than stably housed persons with or exchange sex than stably housed persons with the same personal characteristics and service use the same personal characteristics and service use patternspatterns

• Prevention interventions are much less effective Prevention interventions are much less effective for participants who are struggling with housing for participants who are struggling with housing issues issues

• Studies show a ‘dose-relationship’ with the Studies show a ‘dose-relationship’ with the homeless at greater risk than the unstably homeless at greater risk than the unstably housed, and both of these at greater risk than housed, and both of these at greater risk than those with stable secure housingthose with stable secure housing

Example:

ODDS OF RECENT HARD DRUG USE

NYC SAMPLE NAT’L SAMPLE

RateAdjusted

OddsRatio1

RateAdjusted

OddsRatio1

STABLE HOUSING 21% 16%

UNSTABLE HOUSING 37% 1.60 35% 2.05

HOMELESS 53% 3.45 64% 5.54

1Odds of needle use past 6 mos by current housing status controlling for demographics, economic factors, risk group, health status, mental health, and receipt of health and supportive services

Note: All relationships statistically significant p< .01

Example: ODDS OF RECENT NEEDLE USE

CHAIN SAMPLE NAT’L SAMPLE

RateAdjusted

OddsRatio1

RateAdjusted

OddsRatio1


UNSTABLE HOUSING 12% 2.87 13% 2.51

HOMELESS 17% 4.74 27% 4.65

1Odds of needle use past 6 mos by current housing status controlling for demographics, economic factors, risk group, health status, mental health, and receipt of health and supportive services


ODDS OF UNPROTECTED SEX PAST 6MOS NATIONAL SAMPLE

UnadjustedOddsRatio

AdjustedOddsRatio1Rate

STABLE HOUSING 40%

UNSTABLE HOUSING 43% (1.11) (1.04)

HOMELESS 62% 2.37 2.67

1Odds of unprotected sex past 6-12 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 p< .05 except ( )=ns

ODDS OF UNPROTECTED SEX PAST 6 MOSCHAIN SAMPLE

AdjustedOddsRatio1

AdjustedOddsRatio1

RateRate


UNSTABLE HOUSING 15% (1.11) 21% 1.61

HOMELESS 16% 1.69 29% 2.30

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 p< .05 except ( )=ns

Men Women

• Overtime studies show a strong association between change in housing status and risk behavior change

• Ex: PLWHA who improved housing status reduced sex and drug risk behaviors by half while persons whose housing status worsened are 2- 4 x as likely to exchange sex, have multiple partners

• Risk reduction associated with housing controlling for socio-demographics, drug use, mental health, health status, and receipt of health and supportive services

• Access to housing also increases access to appropriate care and antiretroviral medications which lowers viral load and reduces risk of transmission

Housing is HIV Prevention

PREDICTING T2 HARD DRUG USE NATIONAL MDI SAMPLE

StartedDrug use

Stopped

Drug use

AdjustedOdds Ratio

T2 Drug Use1

NO CHANGE 7% 6%

IMPROVED HOUSING 2% 12% 0.47

WORSE HOUSING 9% 5% 1.38

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, risk group, health, mental health, and receipt of health and supportive services


PREDICTING T2 UNPROTECTED SEX LAST INTERCOURSE

Started Unprotected

Sex

StoppedUnprotected

Sex

AdjustedOdds Ratio T2 Unprotected

Sex1

NO CHANGE 25% 7%

IMPROVED HOUSING 19% 15% 0.37

WORSE HOUSING 25% 11% (1.02)

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 p< .01 except ( ) =ns

Housing & Health Care Outcomes

Lack of stable housing = lack of Lack of stable housing = lack of treatment successtreatment success

Homeless PLWHA compared to stably Homeless PLWHA compared to stably housed:housed: More likely to delay entry into care and to More likely to delay entry into care and to

remain outside or marginal to HIV medical careremain outside or marginal to HIV medical care

Fewer ever on ART, and fewer on ART currently Fewer ever on ART, and fewer on ART currently

Less adherent to treatment regimen Less adherent to treatment regimen

Lower CD4 counts & less likely to have Lower CD4 counts & less likely to have undetectable viral loadundetectable viral load

Worse mental & physical health functioningWorse mental & physical health functioning

More likely to be hospitalized & use ERMore likely to be hospitalized & use ER

0

10

20

30

40

50

No Reg SourceHIV Care

No Med Visits6+ mos

No ARVMedications

Care Not MeetPractice

Standards

Stable Unstable Homeless

Housing & Connection to Medical CareNYC CHAIN Sample

0

10

20

30

40

50

60

70

No Reg SourceHIV Care

No Med Visits6+ mos

No ARVMedications

LackComprehensive

Care

Stable Unstable Homeless

Housing & Connection to Medical CareNational Sample

Factors Associated with Low Rates of Adherent HAART Use

52 NYC Average

Percentage on HAART and adherent to regimen - NYC CHAIN cohort 2002-2010

Unstable housing reduces the Unstable housing reduces the odds of timely viral load odds of timely viral load

suppressionsuppression

Controlling for HAART use and adherence, receipt of HIV care meeting practice standards,mental health score, recent substance use, and demographics

Housing Status Predicts Housing Status Predicts Access and Maintenance in Access and Maintenance in

Health CareHealth Care Homeless/unstably housed PLWHA whose Homeless/unstably housed PLWHA whose

housing status improves over time are: housing status improves over time are:

- more likely to report HIV primary care visits, - more likely to report HIV primary care visits, continuous care, care that meets clinical continuous care, care that meets clinical practice standards practice standards

- more likely to return to care after drop out- more likely to return to care after drop out

- more likely to be receiving HAART - more likely to be receiving HAART

Housing status more significant predictor of Housing status more significant predictor of health care access & outcomes than health care access & outcomes than individual characteristics, insurance status, individual characteristics, insurance status, substance abuse and mental health co-substance abuse and mental health co-morbidities, or service utilizationmorbidities, or service utilization

Housing and Access to Medical Care CHAIN NYC

Any Medical Care

AppropriateClinical Care

HOUSING NEED (0.78) 0.74 ***

HOUSING ASSISTANCE 2.20 *** 1.45 ***

Low mental health functioning (0.86) 0.80 **

Current problem drug use (0. 84) 0.77 ***

Mental health services 1.94*** 1.38 ***

Substance abuse treatment (0.91) 1.25 *

Medical case management (1.40) (1.10)

Social services case management 2.30*** 1.66 ***

N=1651 individuals, 5865 observations, 1994 - 2007

Adjusted odds ratios also controlling for age, ethnicity income, poverty neighborhood, risk exposure group, date of HIV diagnosis, date of cohort enrollment, t-cell count, insurance status.

Continuity of HIV Medical CareCHAIN NYC

Continuity of Care

ContinuityAppropriate

Care

HOUSING NEED 0.83 * 0.78 ***

HOUSING ASSISTANCE 1.20 * 1.56 ***

Low mental health functioning (0.85) (0.84)

Current problem drug use (0.98) (0.84)

Mental health services (1.12) 1.56 ***

Substance abuse treatment (0.97) (1.16)


Social services case management (1.17) 1.32 *


N=1295 individuals interviewed 2+ times, 53759 observations, 1994 - 2007

T2 Entry into HIV Medical CareCHAIN NYC

Entry intoAny Medical

Care

Entry into AppropriateClinical Care

HOUSING NEED 0.44 ** (0.73)

HOUSING ASSISTANCE 2.15 ** 1.88 ***

Low mental health functioning (0.76) (0.74)

Current problem drug use 0.36 *** 0.69 *

Mental health services 2.79 ** (1.29)

Substance abuse treatment (1.64) (1.46)


Social services case management 2.27 * 1.84 **

N=557 individuals who were not in care at one or more interviews, 720 observations, 1994 - 2007


Housing Interventions Work

Two large-scale intervention studies examined 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 followed 407 chronically ill homeless persons over 18 months following discharge from hospitals

The Housing and Health (H&H) Study examined the impact of housing on HIV risk behaviors and medical care among 630 homeless/unstably housed PLWHA in care in Chicago, LA, Baltimore

Findings:

Housing assistance linked to improved health, mental health, and quality of life outcomes

Investment in housing is cost effective

CHHP FindingsCHHP Findings Housed participants:Housed participants:

More likely to be stably housed at 18 monthsMore likely to be stably housed at 18 months Fewer housing changesFewer housing changes Fewer hospitalizations, hospital days, ER visits, Fewer hospitalizations, hospital days, ER visits,

nursing home daysnursing home days For every 100 persons housed, this translates into 49

fewer hospitalizations, 270 fewer hospital days, and 116 fewer emergency department visits per year

Reductions in avoidable health care costs translated into cost savings for the housed participants, even after taking into account the cost of the supportive housing

Savings for HIV+ subsample = $6622 per person per year

H&H FindingsH&H Findings

At 18 months, 83% of voucher recipients At 18 months, 83% of voucher recipients had stable independent housing, had stable independent housing, compared to 51% of control group compared to 51% of control group

Compared to housed participants, and Compared to housed participants, and controlling for demographics & health controlling for demographics & health status, those who experienced status, those who experienced homelessness during follow up:homelessness during follow up:

Were significantly more likely to have a detectible viral Were significantly more likely to have a detectible viral load with prevention implications load with prevention implications

Were significantly more likely to use an ERWere significantly more likely to use an ER

Reported significantly higher levels of perceived stress Reported significantly higher levels of perceived stress which relates to quality-adjusted life expectancy which relates to quality-adjusted life expectancy

Annual Service Delivery Costs Per Client

Payor Perspective Societal Perspective

$9256 - $11651 $10048 - $14032

Number of transmissions must be averted to be cost-saving or cost-effective1

Cost-saving threshold

Cost-effective threshold

Average (1 per 19 clients) (1 per 64 clients)

H & H Study Cost Results

Medical costs saved with single transmission prevented = $300,000

Cost-per-quality-adjust-life-year-saved by H&H = approx $62, 500

H & H Results: Cost per-QALY saved approx. $63,000

Intervention Approx. cost per QALY saved

Kidney dialysis $52,000 to $129,000

Mammography, 50-69 y.o. $57,500

Colon cancer screening, 50-85 y.o. $53,600

Type 2 diabetes screening,>25 y.o. $63,000

HIV screening every 5 years $42,200

Syringe exchange Cost-saving

HIV behavioral interventions Generally cost-saving

PrEP $298,000

HIV vaccine $22,617 to $111,277

Early vs deferred HAART $15,159 to $36,301

Deferred vs no HAART $46,423

(MAC) prophylaxis $44,500

Within range of accepted standards for cost-effectiveness of public health services

EXPLANATION OF FINDINGS?

RISKY PERSONS v. CONTEXTS OF RISK

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

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

RISKY PERSON MODEL:

RISKY DISPOSITIONS/ PERSONALITY

RISKY BEHAVIORS:Drug useRisky sexIllegal activities

HIV INFECTION

UNSTABLE HOUSING

Opposing Model: STRUCTURAL CONTEXTS OF RISK

• HIV research shown that focus on individual level factors not sufficient – need address structural factors

• Structural factor - an environmental or contextual influence that affects an individual’s ability to avoid exposure to health risks, or avail of health promoting resources

Housing is itself a structural or contextual factor within which we live our lives – but also manifestation of broader, antecedent, more global structural factors

The same fundamental causes put persons at risk for poor health and for unstable/inadequate housing : political contexts, inequality of opportunities and conditions, social processes of discrimination and social exclusion

Direct and Indirect Effects of Housing

Lack of stable, secure, adequate housing:

-- Lack of protected space to maintain physical and

psychological well-being

-- Constant stress producing environments and experiences

-- Neighborhoods of disadvantage and disorder

-- Compromised identity and agency

-- Press of daily needs - barrier to service use when available

-- Structuring the private sphere – lack of housing is barrier to forming stable intimate relationships

RISKY CONTEXTS Model

Economic Marginalization

UNSTABLE HOUSING

Pervasive Risk

Competing Needs

Few Personal Resources

Few Community Resources

Risky BehaviorsDrug use

High risk sex

Demoralization

Depression

Anxiety

Barriers to service use

Social Exclusion

HIV infection Poor Health Outcomes for PLWHA

• 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 prevention and health care

• Expensive but offset by social and economic costs of poor health, inappropriate medical treatment, and treatment failure among growing numbers of persons living with HIV/AIDS or at high risk of infection

Policy & Practice Implications

HOUSING IS

PREVENTIONAND CARE

o 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 Mental Hygiene, and Medical and Health Research Association/ Public Health Solutions.

o 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.

o 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)

o Special thanks go to the interviewers and staff supporting the CHAIN program of research over the past 17+ yrs and the staff of several hundred AIDS service organizations and clinics who have taken their time to help with the NYC and/or national research projects described here

o And most especially, thanks go to the over 5,000 persons living with HIV/AIDS whose willingness to share a bit of their lives, their experiences, and their insights, has made it all possible

o The contents of this presentation are solely the responsibility of the author 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 Public Health Solutions/ Medical and Health Research Association of New York City

o To contact Dr. Aidala: [email protected]

ACKNOWLEDGEMENTS

housing and hiv/aids

Documents

chain agency

housing lack of housing

chain staff

hiv medical care

carenyc chain

housing status

housing instability

unstable housing