Evidence into Action: Housing = HAART Access & Adherence An overview of recent research findings presented as part o

1. Evidence into Action: Housing = HAART Access & Adherence An overview of recent research findings presented as part of the North American Housing and HIV/AIDS Research Summit Series Convened by The U.S. National AIDS Housing Coalition (NAHC), and The Ontario HIV Treatment Network (OHTN), in collaboration with the Johns Hopkins Bloomberg School of Public Health Christine Campbell and Ginny Shubert July 6, 2010

2. Housing is HIV Prevention and Health Care Introduction Overview: Housing Policy is Health Policy • Effectively addressing HIV risk & health care disparities requires attention to structural factors —environmental or contextual factors that influence health • Housing affects an individual’s ability to avoid exposure to HIV; an HIV-positive 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 • Indeed, housing has “zoomed by” many other well-accepted health care interventions in terms of published evidence (Dr. David Holtgrave, concluding remarks, Summit IV)

3. Housing is HIV Prevention and Health Care Introduction Overview: Policy & practice implications • HIV prevention and care strategies will not succeed without addressing structural barriers such as homelessness & housing instability • Housing for persons with HIV/AIDS saves lives and taxpayer dollars, making it is a sound health care investment • Housing status is likely the most important characteristic of each PLWHA who seeks services - the most significant determinant of each person’s health and risk outcomes

4. Housing is HIV Prevention and Health Care Housing and Health Outcomes Lack of stable housing = lack of treatment success • 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 • Housing status found more significant than individual characteristics as a predictor of health care access & outcomes

5. NYC & National Research Studies • Community Health Advisory & Information Network • (CHAIN) Project • Multi-stage probability sampling – designed to be representative of larger population of persons living with HIV/AIDS in NYC • Includes 1661 PLWHA randomly recruited from clinics and agencies in 1994, 1998, 2002 and interviewed yearly HRSA SPNS/ HUD HOPWA Multiple Diagnoses Initiative • Interviews conducted with clients of program throughout U.S. providing health and social services to low income PLWHA • Baseline information from 3191 clients from 24 projects and follow-up data from 891 clients from 16 projects - 1996-2000

6. Housing & Connection to Medical CareNYC CHAIN Sample

7. Housing Status Predicts Access and Maintenance in Health Care Homeless/unstably housed PLWHA whose housing status improves over time are: more likely to report HIV primary care visits, continuous care, care that meets clinical practice standards more likely to return to care after drop out more likely to be receiving HAART Housing status more significant than individual characteristics as a predictor of health care access & outcomes

8. 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

9. Low-demand “Housing First” • “Housing first” models place persons with substance use and/or mental health issues directly into permanent housing without requiring sobriety • Growing evidence shows that these programs achieve positive housing, service use, health and mental health outcomes • Low-demand housing programs demonstrate that changing the environment of persons with multiple challenges can result in positive outcomes without prior individual level change to achieve “housing readiness”

10. Studies of HIV housing assistance Two large-scale 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 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 HIV+ persons Findings: Housing assistance linked to improved health, mental health, and quality of life outcomes

11. CHHP HIV Sub-Study HIV sub-study examined the impact of housing on disease progression among the 105 CHHP participants who were HIV+ (and randomized like other participants) At 12 months, housed HIV+ CHHP participants had significantly better health status: 55% of housed were alive with “intact immunity”, compared to only 34% of HIV+ left to “usual care” Housed HIV+ participants were much more likely to have undetectable viral load (36%) as compared to who did not receive housing (19%) Such impact on viral load has relevance to HIV prevention

12. H&H Findings At 18 months, 82.5% of voucher recipients had their “own place,” compared to 50.6% of control group members At 6 months, these figures were 54.2% vs. 16.0% At 12 months, these figures were 87.0% vs. 37.2% Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up: Were significantly more likely to use an ER Were significantly more likely to have a detectible viral load an outcome with HIV prevention relevance Reported significantly higher levels of perceived stress an outcome which relates to quality-adjusted life expectancy Housing is HIV Prevention and Health Care Housing Interventions Work

13. Comparative Cost of Housing as Health Care Housing is HIV Prevention and Health Care Housing Interventions Work • H&H results have made it possible for the first time to evaluate the “cost-utility” of housing as an HIV risk reduction & treatment intervention - measured as the “cost per quality adjusted life year (QALY) saved” • “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 • 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 • Preliminary H&H findings indicate that housing is a cost effective health care intervention for PLWHA, with a cost per QALY ($35,000 - $65,000) well within the range of widely accepted health care interventions such as renal dialysis ($52,000 - $129,000 per QALY).

14. How does housing compare to other public health interventions in terms of cost-effectiveness?

15. Housing/ Lack of Housing and HIV Care Research findings indicate that the condition of homelessness and not simply the traits of homeless individuals, influence risk behaviors & service utilization HIV positive persons with housing problems are less likely to be engaged in appropriate medical care Overtime analyses show improvement in housing situation associated with: HAART access; HAART adherence; and positive change in medical outcomes Data show strong & consistent relationship between housing status and medical outcomes (including reduced mortality), regardless of other individual characteristics, health status, or service use variables Housing is HIV Prevention and Health Care What the Evidence Means

16. Housing is HIV Prevention and Health Care Transforming Research into Policy Initiatives This 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

18. Acknowledgements The North American Housing & HIV/AIDS Research Summit Series is convened by the U.S. National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment Network (OHTN), in collaboration with the Department of Health, Behavior and Society of the Johns Hopkins Bloomberg School of Public Health Convening researchers include: Dr. David Holtgrave of Johns Hopkins; Dr. Angela Aidala of Columbia University; Dr. Toorjo Ghose of the University of Pennsylvania; Randy Jackson of the Canadian Aboriginal AIDS Network, Dr. Robert Hogg of the BC Centre for Excellence in HIV/AIDS; 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 Bozack helped develop the Summit V Briefing Book. Slides on CHAIN and MDIS findings are drawn from an April 2010 presentation by Dr. Angela Aidala of the Columbia University Mailman School of Public Health at the NAHC Southern Regional Housing and HIV/AIDS Research Summit in New Orleans.