Housing as HIV Prevention and Treatment

A Study of HIV Services in Supportive Housing

Suzanne Wenzel, of the University of Southern California, delivered a lunchtime address on supportive housing and access to HIV prevention. Citing the results of CDC-sponsored studies into homelessness, she said, “There’s recognition of the systemic racism and classism that affects [the homeless] population and makes it very difficult for them to access effective care.”

Wenzel noted that US funds are increasingly directed toward permanent supportive housing rather than temporary shelters, and that her group had undertaken research to understand how HIV prevention and risk behaviors change with supportive housing. At the time of her presentation, Wenzel’s study of 24 supportive housing agencies in Los Angeles County was still underway, with a goal to recruit over 500 participants. She was able to present preliminary data based on 340 baseline and 120 three-month follow-up interviews.

Sixty percent of study participants were black, and 76% had a history of incarceration. Wenzel explained, “There is a disproportionate representation of black Americans who are homeless – that is because there is a disproportionate representation of black Americans who are impoverished… We must acknowledge the systematic and ongoing – and the legacy of – racism and discrimination in this country.”

At baseline, 53% of participants had symptoms serious enough to warrant formal assessment for post-traumatic stress disorder, and 20% had engaged in exchange sex within the past three months.

Wenzel noted that, among her sample so far, only one individual had ever been prescribed PrEP, and that few were exposed to educational interventions on safe sex and condom use.

“These are individuals who are our brothers and sisters in our communities in L A that we have failed to take full responsibility for.”

Wenzel’s group also completed individual and focus group interviews with 59 staff members from 11 supportive housing programs. Preliminary results indicate that staff did perceive HIV risk among clients (though perceived sexual activity was higher than that reported by clients themselves). When asked whether supportive housing programs address HIV risk and prevention, the plurality of providers said no, or were unsure. Whatever counselling did take place happened on a case-by-case basis.

Based on Wenzel’s data, providers had little exposure to PrEP and were unsure whether it was covered by Medicaid (Wenzel clarified that it is). They were also concerned that clients would have poor adherence to PrEP or sell the medication.

“We are not yet realizing the goal of integrated services in permanent supportive housing, at least in Los Angeles, at least based on these data,” Wenzel said. She recommended policy education for providers and the public, creating a sense of joint responsibility for HIV prevention services and offering free access to condoms in supportive housing. “Every person experiencing homelessness,” she said, “has the right to know what they are entitled to.”

A Systematic Review of the Literature on HIV and Housing

Angela Aidala, of Columbia University, presented the results of a systematic review of literature on HIV and housing, carried out in partnership with the Ontario HIV Treatment Network.

“Housing is where our economic, social and our personal lives come together.”

Aidala explained that, as defined by the World Health Organization, housing is an intermediary social determinant of health. She argued that while we should be working on global structures of inequality, such as racism, policy, class stratification, access to education, income and gender equality, we have a more direct opportunity to intervene on intermediate determinants such as housing.

In their review of housing studies, Aidala and colleagues reached beyond homelessness to consider studies on housing security and quality, as well as sense of home and place among participants. “Housing is not just a material shelter,” she explained. “It’s the broader constellation of factors that shape our daily lives.”

Researchers screened over 5,500 articles and reviewed 1,273 of those to arrive at 152 studies that met their criteria. Aidala explained that one of the challenges was in finding a clearly-defined, replicable definition of homelessness or unstable housing in these papers. She noted that, as people move in and out of different housing situations across their lives, housing is a contextual factor and not a stable trait, which increases how difficult it is to track and measure.

Of the 35 papers that looked at access to medical care and medications, 94% found that worse care was associated with homelessness or unstable housing, and 83% of those findings were statistically significant. Of the 30 papers that looked at adherence, 93% found that adherence was worse for people with unstable housing, and 80% of those results were statistically significant.

Aidala explained that papers included in this review had appropriate controls for confounding factors such as poverty, substance use and mental illness, meaning that results demonstrate an independent link between homelessness or unstable housing and poorer health outcomes.

Out of 13 papers that tracked emergency room visits and hospital stays, all found higher rates among people who were homelessness or unstably housed, and 92% of those results were statistically significant. Of the 20 papers that looked at sex and drug-related risk behaviours, all found that homelessness and unstable housing were associated with greater risk, and 80% of those results were statistically significant.

Aidala noted that her search returned only two studies where housing was provided as an intervention and that, while the results of these studies are promising (i.e. participants with housing were more likely to be on treatment and engaged with care providers), they have limited generalizability.

Considering policy implications, Aidala argued for the importance of homelessness prevention and rapid rehousing strategies, stressing that housing is among the social drivers we can intervene in immediately.

Further Information

Impact of Housing Interventions on Viral Suppression and Other Health Outcomes

Viral suppression trends among HIV-positive housing clients, New York City, 2008- 2013

Ellen Wiewel and John Rojas, Division of Disease Control, New York City Department of Health and Mental Hygiene

In recent years, US HIV treatment guidelines have recommended progressively earlier antiretroviral therapy. In 2007, guidelines recommended ART at CD4 counts <350 cells; by 2012, it was recommended that all persons with HIV be considered for ART initiation, regardless of CD4 count. New York City is an epicenter of the US HIV epidemic, where the infection disproportionately affects poor people and persons of color. Low-income NYC residents with HIV are eligible for subsidized or free housing through Housing Opportunities for Persons with AIDS (HOPWA). To better understand the impact of changing treatment guidelines and HOPWA priorities, we measured trends in viral suppression among NYC HOPWA clients between 2008 and 2013, overall and by demographic and clinical characteristics. NYC DOHMH-administered HOPWA enrollment data were merged with the DOHMH HIV surveillance registry to obtain demographics, clinical status and viral load test results for persons receiving HOPWA services during 2008-2013. The number of persons who matched to the surveillance registry and were enrolled in DOHMH-administered HOPWA programs in a given year between 2008 and 2013 ranged from 1,739 to 2,131 annually. We found that viral suppression increased markedly among NYC HOPWA clients from 2008 to 2013, particularly among clients with HIV only, potentially resulting from changes to federal treatment guidelines and an emphasis within HOPWA on suppression.


Antiretroviral therapy exposure and adherence and transitions out of homelessness among people living with HIV/AIDS who use illicit drugs in a Canadian setting

Lindsey Richardson, British Columbia Centre for Excellence in HIV/AIDS and Department of Sociology, University of British Columbia

The consequences of housing instability on engagement and retention in HIV care and clinical outcomes for people living with HIV/AIDS who use illicit drugs are increasingly well documented. However, very little is known about the potential benefits of exposure and adherence to antiretroviral therapy on the housing status of HIV-positive people who use drugs. We used longitudinal data from the AIDS Care Cohort to Evaluate Access to Survival Services (ACCESS), a long-running prospective cohort of community recruited HIV-positive people who use drugs in Vancouver. Participant data were linked to comprehensive HIV clinical monitoring and ART dispensation records provided by the centralized provincial ART dispensary and HIV clinical monitoring laboratory at the British Columbia Centre for Excellence in HIV/AIDS. Between December 2005 and November 2013, 755 participants were eligible for analyses of ART exposure with 128 (17.0%) initiating ART for the first time during the study period, and 724 participants were eligible for analyses of ART adherence, with 463 (64.0%) individuals becoming ≥95% adherent to ART at least once during the study period. In final multivariate models, new exposure to ART was positively and significantly associated with transitions out of homelessness (AOR: 2.24, 95% CI: 1.50-3.35) although this statistical relationship did not hold when the relationship was examined using a lagged ART exposure variable. ART adherence was significantly and positively associated with a transition out of homelessness in both unlagged and lagged models. These findings suggest that, in addition to supporting the clinical management of HIV infection, initiating ART and becoming adherent to ART may have significant and positive impacts on the housing status of HIV-infected PWUD.


Impact of unstable housing on HIV infections control in northern British Columbia

Robert Milligan, Regional HIV/HCV Navigator, Northern Health Authority, Prince George BC

Current research strongly links housing status as a key determinant of worsening HIV health disparities. The objective of our study was to examine the link between unstable housing and engagement in primary care and HIV viral suppression among clients of Central Interior Native Health (CINHS) in Northern British Columbia. HIV viral load levels and primary care encounter history were audited from April 2013 – May 2012 using the electronic medical record at CINHS. Housing status (stable or unstable) was determined for each patient by CINHS staff. We found that patients at CINHS who were unstably housed were not as engaged with primary care and did not experience the same level of viral load suppression as clients who were stably housed.


Supportive housing common measures: Baseline findings

Keith Hambly, Executive Director, Fife House Foundation

Six Ontario housing providers identified a need to show the impact of their housing services for people living with HIV. Sites recognized that there was little consistency in the data collected by each partner, and there was a need to develop a common set of indicators to measure changes in their clients’ health outcomes and well-being. To this end, HIV housing providers from across Ontario came together to develop the Common Measures evaluation tool. It is based on common service data collected by the housing providers and validated measures used in similar research studies that look at the health outcomes of supportive housing for people living with HIV. This is a 5-year longitudinal study that collects baseline data for clients when they enter the housing program and at 1-year intervals thereafter. The Common Measures Questionnaire contains 17 modules that are completed through client self-report. Modules look at client demographics, housing history and housing need, connection to care, other health conditions (co-morbidities), mediation adherence, alcohol and drug use, connection with the justice system, mental health, social support, quality of life, sense of belonging and mastery.


Building a dream: Recommendations for sustainable and evolving housing partnerships

Keith Hambly, Executive Director, Fife House Foundation

WoodGreen, the Wellesley Institute and Fife House have developed a unique partnership to form and operate the Wellesley Central Residences Inc. (WCRI) in Toronto, Canada. Opened in 2008, Wellesley Central Residences is a unique affordable, supportive and not-for-profit housing complex for individuals living with HIV/AIDS and frail seniors. It has 112 apartment units: 56 for people living with HIV/AIDS (operated by Fife House); and 56 for seniors (operated by WoodGreen Supportive Housing). An informal study was conducted over 6 months to document key factors in the development and maintenance of the WCRI. Interviews and focus groups were conducted with key stakeholders (board members, management, staff, and politicians) to understand key historical events as well as facilitating factors for successful housing partnership development. Using the WCRI as a case study, the key factors for the success of the WCRI partnership include: navigating different cultures and articulating shared values; passionate leadership; a facilitated process; financial and political sustainability; integration and communication; and clear agency roles and expertise.

Project S.H.O.P.: Comparison of supportive housing models for HIV-positive and at-risk chronically homeless

Julia Dickson-Gomez, Center for AIDS Intervention Research, Medical College of Wisconsin

Supportive housing—permanent, subsidized housing with supportive services—has been offered as a structural intervention to reduce HIV infection rates and improve health outcomes of HIV-positive persons. However, supportive housing is an umbrella term that is used in the literature to describe programs that differ in many factors that could make large differences in health outcomes and housing stability. The purpose of our research was to describe and measure differences in supportive housing models, and to examine the effectiveness and cost-effectiveness of supportive housing models on housing stability and health outcomes. We conducted 50 in-depth interviews with directors and front-line service providers of over 23 different supportive housing programs in the Chicago metropolitan area. Participants were asked to describe their program in terms of the clients they serve, eligibility criteria, the number and types of housing units they have, and how long the program has been in operation.


Models for integrating behavioral health, HIV health care and housing support for multiply diagnosed HIV homeless/unstably housed populations

Carole Hohl, Boston Health Care for the Homeless and Massachusetts General Hospital

Nine clinic and community based organizations and one multisite coordinating center are funded by the Health Resources & Services Administration, HIV/AIDS Bureau through its Special Programs for National Significance (SPNS) to implement and evaluate service delivery models aimed at building a medical home for multiply diagnosed HIV homeless/unstably housed populations. Models include: 1) strengthening internal systems of care by integrating behavioral health staff into the HIV care team; 2) the use of patient navigators to connect homeless patients to external behavioral health services and obtain housing in the HIV team; and 3) the use of mobile interdisciplinary teams to provide necessary medical and behavioral health care. Preliminary results of this SPNS Initiative have found that consistent, regular team communication, having a key staff member to maintain regular communication with clients, and building strong external partnerships with housing, behavioral health and HIV providers is critical for HIV-positive homeless and unstably housed populations. These models are helping to engage clients in their health care, remove barriers to care, and improve the patient experience of care.


Housing First: Innovations and Lessons Learned

Unprotected sex among homeless adults with mental illness participating in a Housing First randomized controlled trial

Milad Parpouchi, Faculty of Health Sciences, Simon Fraser University

High rates of HIV have been found among various homeless populations. Structural interventions, such as the provision of housing, are becoming increasingly prevalent. Housing First (HF) is one such type of supported housing intervention involving a combination of permanent housing and various health and social supports. Our study sought to investigate the effect of HF on unprotected sex among homeless mentally ill adults. Data for the study was obtained from the Vancouver At Home Study, which involves an RCT investigating the effect of HF on various health and social outcomes. Participants were sexually active homeless or precariously housed adults with a mental disorder (n=241). Recruitment was conducted via referral from community agencies, with 24 months of follow-up. Results showed that, compared to treatment as usual, HF was not associated with unprotected sex in a multivariable model, though past-month amphetamine use, cohabitating with a partner, and having less than high school completion were independently associated with unprotected sex. This is the first RCT of its kind.


The housing cascade provider perspective on using supportive housing data to evaluate health outcomes for people living with HIV

Danielle Strauss, Managing Director, Housing Programs, Harlem United

Since the inception of supportive housing for people living with HIV, Harlem United has been at the forefront of addressing health disparities by recognizing the need for harm reduction services for clients with HIV/AIDS plus other co-occurring disorders (e.g. substance abuse and mental health). Within our supportive housing programs, individuals are provided with stable housing in addition to harm reduction services with a full continuum of medical, mental health and social support services to stabilize health. Using our Housing First model and evaluation strategies, we are able to demonstrate how housing as an intervention for unstably housed people living with HIV successfully links clients to medical treatment, helps them remain in care, and assists them with treatment adherence to improve health outcomes. The HIV Care Cascade was adopted to create a Housing Cascade for clients enrolled in our supportive housing programs. Data provide an example of client progress through the continuum of care following placement in supportive housing.


Housing as a harm reduction strategy: Health, safety and respect

Robert Desarmia, Intensive Case Management Program Coordinator, Sandy Hill Community Health Centre

Housing is the best way to empower people who use drugs to make healthier choices. In our work, we were able to demonstrate the effectiveness of the Housing First Approach as a Harm Reduction strategy. Focusing on housing allows us to see drug users as people with dreams, goals, hobbies, skills and personalities—instead of only focusing on their drug use. We have identified the concrete tools needed to implement a Housing First Intervention with drug using communities.


Housing First and harm reduction practices

Suzanne Moore, Housing Services Manager, Caracole, Chrissy Rademacher, Clinical Supervisor, Caracole

The Shelter Plus Care housing program at Caracole is a harm reduction, housing first model, focused primarily on keeping our clients safe and in housing. Two years into this new model, we have powerful data to support that our clients are experiencing lower viral loads, fewer arrests and overdoses, and greater housing stability. The Caracole housing team includes case management, specialized housing support and optional mental health services. The team is connected to our local syringe exchange program, Planned Parenthood for testing and HIV101 education, medicated assisted treatment programs, mental health and substance abuse treatment agencies, shelters, outreach workers, and other housing programs. We are proud of our client’s successes and look forward to sharing not only our data as well as what we have learned about continued barriers, implementation, outcomes, staff challenges and client response.