Daniel P. Kidder

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS.

OBJECTIVES We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS. METHODS Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive. RESULTS At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables. CONCLUSIONS Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.

HIV, Homelessness, and Public Health: Critical Issues and a Call for Increased Action

Homelessness and housing instability are significant public health issues that increase the risks of HIV acquisition and transmission and adversely affect the health of people living with HIV. This article highlights the contributions of selected papers in this special issue of AIDS and Behavior and considers them within the broader context of prior research on the associations between housing status and HIV risk, use of HIV medical care, adherence to HIV treatment, and the physical health of HIV-seropositive persons. Special recognition is given to the roles of interrelated health problems, such as substance abuse, poor mental health, and physical and sexual abuse, that often co-occur and exacerbate the challenges faced by those who are homeless or unstably housed. Taken as a whole, the findings indicate a critical need for public health programs to develop strategies that address the fundamental causes of HIV risk among homeless and unstably housed persons and, for those living with HIV, contribute to their risk of disease progression. Such strategies should include “mid-stream” and “upstream” approaches that address the underlying causes of these risks. The successful implementation of these strategies will require leadership and the formation of new partnerships on the part of public health agencies. Such efforts, however, may have significant effects on the individuals and communities most affected by HIV/AIDS.

Factors associated with adherence to highly active antiretroviral therapy in homeless or unstably housed adults living with HIV

Abstract The aim of this study is to investigate adherence to highly active antiretroviral therapy (HAART) in persons living with HIV/AIDS (PLWHA) who are homeless or unstably housed. We evaluated homeless or unstably housed PLWHA (n=644) in three US cities were enrolled in the Housing and Health Study. Using baseline data and controlling for gender, race, age, and education, we examined associations between self-reported two- and Seven-day adherence and access to healthcare, mental health, substance use, and attitudes toward HIV medical therapy. Of the 644 participants, 358 (55%) were currently on HAART. For two-day adherence, 280 (78%) reported missing no prescribed doses (100% adherence), and for seven-day adherence, 291 (81%) reported ≥90% adherence. Logistic regression analyses indicated being younger, not having health insurance, and drug use were associated with missing ≥1 dose over the past two days. Scoring lower on SF-36 mental component summary scale and having greater risk of depression (CES-D) and stress (Perceived Stress Scale) were associated with poorer adherence for both two- and seven-day outcomes. Negative attitudes toward HIV treatment were also associated with lower adherence. Adherence to HIV medications in this population is similar to other groups. Coexisting problems of access to healthcare, higher risk of mental health problems, along with poorer attitudes toward treatment are associated with increased likelihood of missing doses. Comprehensive models of HIV care that include a continuum of medical and social services are essential for treating this population.

Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV

Abstract Prior research suggests that the interconnections between substance use, HIV risk and lack of adherence to HIV medications are especially strong among homeless individuals. Thus, study of these interconnections warrants public health attention. The objectives of this paper are to describe patterns of alcohol and drug use, associations between substance use and participation in high-risk sex, and associations between substance use and adherence to HIV treatment regimens among a sample of 602 homeless or unstably housed HIV-seropositive individuals who are part of a housing-based intervention – the Housing and Health Study. Participants experienced high levels of substance use. Significant associations were found between substance use and adherence to HIV treatment medications, and between substance use and high-risk sexual practices within the entire group. Group analyses by sexual orientation/gender show that the association between substance use and treatment adherence is found primarily among heterosexual males whereas the relationship between several drugs and high-risk sexual practices is strongest among gay and bisexual men. Health professionals working with HIV-seropositive individuals should routinely ascertain housing status and screen for substance use and risky sex.

Cost and threshold analysis of housing as an HIV prevention intervention

The Housing and Health study examines the effects of permanent supportive housing for homeless and unstably housed persons living with HIV. While promising as an HIV prevention intervention, providing housing may be more expensive to deliver than some other HIV prevention services. Economic evaluation is needed to determine if investment in permanent supportive housing would be cost-saving or cost-effective. Here we ask––what is the per client cost of delivering the intervention, and how many HIV transmissions have to be averted in order to exceed the threshold needed to claim cost-savings or cost-effectiveness to society? Standard methods of cost and threshold analysis were employed. Payor perspective costs range from

Disclosure, Knowledge of Partner Status, and Condom Use Among HIV-Positive Patients Attending Clinical Care in Tanzania, Kenya, and Namibia

9,256 to

Cost-Utility Analysis of the Housing and Health Intervention for Homeless and Unstably Housed Persons Living with HIV

11,651 per client per year; societal perspective costs range from

HIV Prevention in Care and Treatment Settings: Baseline Risk Behaviors among HIV Patients in Kenya, Namibia, and Tanzania

10,048 to

CDC’s Program Evaluation Journey: 1999 to Present

14,032 per client per year. Considering that averting a new case of HIV saves an estimated

Randomized Trial of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and Unstably Housed People Living with HIV

221,365 in treatment costs, the average cost-saving threshold across the three study cities is 0.0555. Expressed another way, if just one out of every 19 Housing & Health intervention clients avoided HIV transmission to an HIV seronegative partner the intervention would be cost-saving. The intervention would be cost-effective if it prevented just one HIV transmission for every 64 clients served.