Mobilizing Knowledge: Housing is HIV Prevention and Care Summary of Research Presented at the Housing and HIV/AIDS Rese

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

2. “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.

3. 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)

4. 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 PLWHA’s health and risk outcomes

5. 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

6. 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

7. Homelessness—a major risk factor for HIV infection • 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 • 3% to 14% of all homeless persons are HIV positive (10 times the rate in the general population) • 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

8. HIV—a major risk factor for homelessness • Up to 70% of all PLWHA report a lifetime experience of homelessness or housing instability • 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 • Many more PLWHA are unstably housed, faced with housing problems or the threat of housing loss • Rates of housing need remain high - as some persons get their housing needs met others develop housing problems

9. Growing global awareness • Summit IV presentations pointed to the growing global awareness of the link between HIV and housing instability in all its forms, including: • 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 • Mobile populations are often excluded from care, and experience high rates of HIV infection, morbidity and mortality • Restrictions on HIV care based on residency status violate basic human rights and public health principles • “There are no illegal human beings” - Archbishop Desmond Tutu

10. Lack of stable housing = poor health outcomes for PLWHA • Homeless/unstably housed PLWHA are less likely to receive appropriate health care & experience higher rates of opportunistic infections, HCV and other co-morbidities • The all-cause death rate among homeless PLWHA is five times the death rate for housed PLWHA • 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

11. Recent findings: Lack of stable housing = higher mortality • 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

12. Housing status predicts HIV risk behaviors • Research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues • 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 • 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 • Harm reduction and other behavioral prevention interventions are much less effective for participants who lack stable housing

13. Recent findings:Lack of housing = greater HIV risk • 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 • 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: • 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 • 2.75 x more likely to inject drugs

14. Housing is HIV Prevention • Overtime studies show a strong association between change in housing status and risk behavior change • 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 • Access to housing also increases access to appropriate care and antiretroviral medications which lower viral load, reducing the risk of transmission

15. 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

16. Housing improves access to health care Stable housing improves health outcomes • Receipt of housing services independently associated with improved health care access • Homeless/unstably housed PLWHA whose housing status improved over time were: • 5 times more likely to report a recent HIV outpatient visit • 6 times more likely to be receiving anti-retrovirals • Controlling for demographics, health status & receipt of case management • 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 • Increased housing stability is positively associated with: • Effective HAART (viral suppression) • Better HIV related health status ( as indicated by viral load, CD4 count, lack of co-infection with HCV or TB)

17. 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 housing status improved over time were: • 5 times more likely to report a recent HIV outpatient visit • 6 times more likely to be receiving anti-retrovirals • Controlling for demographics, health status & receipt of case management • Schwarcz (BMC Public Health) observational study of 676 homeless PLWHA identified through the SF AIDS registry found that over 5 years, obtaining supportive housing was independently associated with an 80% reduction in mortality.

18. Housing assistance works to create stability • 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 • Increasing evidence that supportive housing enables chronically homeless persons to achieve and maintain stability despite serious medical & psychosocial issues

19. Investments in housing improve outcomes & reduce public costs • Investments in supportive housing found to reduce emergency and inpatient health services, criminal justice involvement, and use of other crisis services • Seattle DESC 1811 Eastlake project for homeless people with chronic alcohol addiction • 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 • Reduced jail days 52% for housed participants • Jail days increased for comparison group

20. Evaluating the cost-effectiveness of HIV housing • Savings in other publicly funded services have been found to offset or exceed the cost of housing interventions • 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 • Each prevented HIV infection saves over $300,000 in life-time medical costs • Housing instability limits the ability of individual PLWHA to access and benefit from life-saving antiretroviral therapies

21. New evidence that housing assistance works to improve HIV outcomes and save health care dollars • 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

22. CHHP background & methods • “Housing first” program providing supportive housing for homeless persons with medical issues such as HIV/AIDS, hypertension, diabetes, cancer and other chronic illnesses • 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 • Results published in JAMA (Sadowski, 2009) and APHA (Buchanan, 2009)

23. CHHP shows housing saves lives and money • 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% • For every 100 persons housed, this translates annually into 49 fewer hospitalizations, 270 fewer hospital days, and 116 fewer emergency department visits • 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

24. Housing improved health among HIV+ CHHP participants • HIV sub-study examined the impact of housing on disease progression among the third of CHHP participants who were HIV+ • Like other study subjects, HIV+ participants were randomly assigned to permanent supportive housing or “usual care” • 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%)

25. Housing & Health Study: background & methods • Conducted by the CDC and the HUD HOPWA program - in Baltimore, Chicago & Los Angeles • 630 HIV+ participants were homeless (27%), doubled up (62%) other otherwise at risk of homelessness (11%) at baseline • 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 • Data on HIV risk and health indicators collected at baseline & at 3 follow up assessments over an 18-month period

26. 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: • 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

27. Evaluating the “cost utility” of housing as health care • 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 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).

28. Cost effectiveness of selected medical interventions Cost Effectiveness of Selected Medical Interventions

29. Summary of key findings on Housing & HIV • 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… • 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

30. Yet housing remains the greatest unmet service need of PLWHA • 1.2 million PLWHA in the United States—half (600,000) will need housing assistance at some point • The Federal Housing Opportunities for Persons with AIDS (HOPWA) program serves only 56,627 households/year nationwide • 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 • An ongoing study of US veterans living with HIV shows that 48% have experienced homelessness, and 11% are currently homeless

31. 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

32. Summit IV Policy Action Strategies • 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.

33. Summit IV Research Action Strategies • 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.

34. Get involved! • Stay in touch with NAHC - www.nationalaidshousing.org • 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 Kithttp://www.nationalaidshousing.org/policytoolkit.htm

35. 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/

36. Select references - recent articles • 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 health-related 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.

37. Acknowledgements • 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.