Transcript David Holtgrave: Impact of Unstable Housing and Associated Policy

Department of Health, Behavior & Society
David Holtgrave, PhD, Professor & Chair
© 2005, Johns Hopkins University. All rights reserved.
 Lindsey Carter
 Johns Hopkins Bloomberg School of Public Health
 Angela Aidala
 Columbia University Mailman School of Public Health
 Ginny Shubert
 Shubert Botein Policy Associates
 National AIDS Housing Coalition
Resident story from AIDS
Foundation of Chicago
 “[My case manager] started
talking to me. She said you got
a child. You got a lot to live for.
She’s right. I just can’t let
myself go down like this. I need
to bring myself back up.”
 After another bout of
homelessness: “My daughter
said, ‘Daddy we got to keep this
place.’”
[AFC “HOPWA, SPNS, Four Residents’
Stories, 2010”]
Office of National AIDS
Policy, White House
 ONAP’s James Albino reflecting on
his direct service work in Puerto
Rico prior to coming to the White
House: “A fair number of our
patients…were the product of
‘patient dumping’ where healthcare
providers often discharged patients
with little planning, often leaving
them homeless and on the streets
without care…”
 “Our efforts certainly testify to the
strong restorative bond between
accessible housing and HIV/AIDS
prevention, treatment and care”
[White House, ONAP blog, Dec. 23, 2009]
Overview
Briefly, Housing and
HIV
Housing and Care
Briefly, Economics of
HIV-related Housing
The Second Life Job Training Program (JTP) is
offered by Housing Works in New York for
homeless people living with HIV
http://www.housingworks.org/services/job-training/
 HIV seroprevalence is several times higher among persons
who are homeless or unstably housed
 HIV seroprevalence for homeless and marginally housed
persons was 10.5% in San Francisco (5 times higher than
general population)
[Robertson et al., AJPH 2004]
 HIV seroprevalence in New York City single adult shelter
system was 3,612 per 100,000 compared to 1,380 per 100,000
in general population
[Kerker et al., The Health of Homeless Adults in New York City, 2005]
 Persons admitted to public shelters in Philadelphia had
three year rate of subsequent AIDS diagnosis nine times
the general population
[Culhane et al., J Epidemiology & Community Health, 2001]
 In multi-site study of 2,149 persons living with HIV and
presenting for medical or social services, recent drug use,
needle use or sex exchange at baseline was 2 to 4 times
higher among homeless and unstably housed persons
 At 6 to 9-month follow up, PLWHA whose housing status
improved reduced by half drug risk behaviors; those whose
housing status worsened were significantly more likely to
exchange sex
 Similar findings from New York City Cohort Study of HIV-
positive clients in care
[Aidala, Cross, Stall, Harre, Sumartojo. AIDS & Behavior, 2005 . Aidala, et al.,
AIDS Education and Prevention, 2006. See also Supplement on Housing and
HIV/AIDS, AIDS & Behavior November 2007 ]
ODDS OF RECENT NEEDLE USE AMONG
PERSONS LIVING WITH HIV
NYC Cohort
Rate
Adjusted
Odds
Ratio1
NAT’L SAMPLE
Rate
Adjusted
Odds
Ratio1
STABLE HOUSING
4%
4%
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
All relationships statistically significant p< .01
[ Source: Aidala, et al., International Urban Health Conference, 2003; Aidala et al., AIDS & Behavior 2005 ]
PREDICTING “Time 2” HARD DRUG USE
NATIONAL Multiple Diagnosis Initiative “MDI” SAMPLE
Adjusted
Odds Ratio
T2 Drug Use1
Started
Drug use
Stopped
Drug use
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
All relationships statistically significant p< .01
[ Source: Aidala, et al., AIDS & Behavior, 2005]
 New York City Cohort Study (total sample 1994-2003)
of persons living with HIV, at baseline…
 33% were homeless or unstably housed
 51% had some indictor of housing need
 Across all interview periods, 70% indicated some
housing need at one or more time points
[Aidala et al., AIDS & Behavior. November 2007 Suppl, S101-S115]
 Ethnographic information (such as residents’ stories
from AIDS Foundation of Chicago) key for
understanding how HIV diagnoses can eventually lead
to homelessness
Housing & Connection to Medical Care:
NYC Cohort Study
50
40
30
20
10
0
No Reg Source
HIV Care
No Med Visits
6+ mos
Stable
No ARV
Medications
Unstable
Care Not Meet
Practice
Standards
Homeless
Aidala et al. 2007, Housing and Connection to HIV Medical Care. NYC DOHMH/ HIV Planning
Council publication series. Available at http://www.nyhiv.org/data_chain.html
Access to Medical Care: NYC Cohort
Any Medical
Care
Appropriate
Clinical Care
HOUSING NEED
0.70 **
0.71 ***
HOUSING ASSISTANCE
2.42 ***
1.53 ***
Low mental health functioning
(0.85)
0.80 **
Current problem drug use
0.74 *
0.73 ***
Mental health services
2.08 ***
1.43 ***
Substance abuse treatment
(0.97)
1.28 *
Medical case management
(1.38)
Social services case management
2.43 ***
(1.09)
1.70 ***
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.
N=1651 individuals, 5865 observations, 1994 – 2007
* p < .05
[ Source: Aidala et al., AIDS & Behavior, 2007 ]
** p < .01
*** p < .001
PREDICTING MEDICATION USE
National MDI Sample
Unadjusted
Odds Ratio
T2 ARV
Adjusted
Odds Ratio
T2 ARV1
3.21
6.22
(0.63)
(1.01)
NO CHANGE
IMPROVED HOUSING
WORSE HOUSING
1 Odds
of Time 2 antiretroviral medication use by change in housing status controlling for
Time 1 ARV use, Time 1 housing status, demographics, economic factors, drug use, CD4
count, mental health, and receipt of health and case management services
N= 192. Relationships statistically significant p< .05 except ( )=ns
[ Source: Aidala, et al. American Public Health Assoc, 2003 ]
Health care and Adherence to
social service
anti-retroviral
utilization
medications
Health Status
and HIV risk
behaviors
Significant
positive
association
9
5
3
No significant
association
0
0
1
Significant
negative
association
0
0
1
[ Source: Leaver et al., AIDS & Behavior, Nov 2007 Suppl ]
 CDC multisite SHAS study (n=2925; 4% homeless;
survey of persons recently reported as HIV+)
 Homeless Status AOR (95% CI), with
 Self-reported good or excellent health, 0.72 (0.56, 0.93)
 Most recent CD4 over 200, 0.83 (0.61, 1.12) ns
 Most recent VL undetectable, 0.69 (0.48, 0.99)
 Used ER past 12 months, 1.60 (1.24, 2.07)
 Was currently taking HIV meds, 0.43 (0.33, 0.55)
 Was adherent to HIV meds past 48 hours, 0.49 (0.33, 0.71)
[Source: Kidder et al., AJPH 2007; 97: 2238-2245]
 Longitudinal study, n=595, 1996-2005
 Short-term mortality associated with homelessness in
past 6 months (adjusted hazard ratio 2.92, CI 1.32, 6.44),
as well as heroin or cocaine use (2.43, CI 1.12, 5.30), even
when controlling for…
 Age
 Prior injection drug use
 CD4 cell count
 Off ART vs. on ART
 Alcohol use in past 30 days
[Source: Walley et al., AIDS 2008;22:415-420]
Figure: Kaplan-Meier Survival Curves for San Francisco AIDS Cases
Diagnosed Between 1996-2006, by Housing Status at Diagnosis
Housed
Proportion surviving
1
0.8
0.6
0.4
Homeless
Log-Rank: p<0.0001
0.2
0
0
No. at risk
Homeless 640
Housed 5913
24
48
72
96
120
204
2607
96
1703
23
571
Months
487
4637
351
3571
[ Source: Schwarcz et al. Impact of housing on the survival of persons with AIDS. BMC Public Health. 2009;9:220
http://www.biomedcentral.com/1471-2458/9/220 ]
Recent studies of cost offset

Larimer et al. (JAMA, 2009):


Seattle housing first model for persons with severe
alcohol challenges created stability, reduced
alcohol consumption, & decreased health costs
53% relative to wait-list condition
Gilmer et al. (Psych Services, 2009):

Participants in a San Diego housing first program
had increased case management and outpatient
care costs but these were nearly entirely offset by
decreases in inpatient, ER and criminal justice
system
Recent studies of cost offset (continued)

Economic Roundtable (Report: “Where We Sleep,” 2009)

Study of 10,193 persons in LA County

9186 were homeless while receiving General Relief
public Assistance

1007 exited homelessness via supportive housing

Typical public monthly cost in group experiencing
homelessness: $2897

Typical public monthly cost in supportive housing
group: $605
Randomized Trials of
“Immediate Housing Support”

Two large-scale, randomized controlled trials 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 (CHHP)
study followed 407 chronically ill homeless persons over 18
months following discharge from the hospital, including an
HIV sub-study of 105 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 (Baltimore, Los
Angeles and Chicago)
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)



Half received CHHP supportive housing
Half continued to rely on “usual care” - a piecemeal
system of emergency shelters, family & recovery
programs
Results published in JAMA (Sadowski et al., 2009) and
AJPH (Buchanan et al., 2009)
CHHP Findings

“Housed participants:

More likely to be stably housed at 18 months

Fewer housing changes

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 showed that reductions in avoidable
health care utilization translated into cost savings for
the housed participants, even after taking into account
the cost of the supportive housing
(Cost aspects of study described in Wall Street Journal)
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 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 much more likely to
have undetectable viral load (36%) as compared to who
did not receive housing (19%)
H&H Findings

Compared to housed participants, and controlling
for demographics & health status, those who
experienced homelessness during follow up (astreated analyses):

Were significantly more likely to use an ER

Were significantly more likely to have a
detectible viral load

Reported significantly higher levels of
perceived stress - an outcome related to
quality- adjusted life expectancy
Percent
Housing Status: Own Place
100
90
80
70
60
50
40
30
20
10
0
87
54
82
51
37
16
4
BL
Group x Time = p < .001
6 Mos
12 Mos
18 Mos
Rent Asst
Cust Care
Percentage
Viral Load:
As Treated
90
80
70
60
50
40
30
20
79
61
1+ Nights
0 Nights
10
0
Detectable Viral Load
OR = 2.66, CI = 1.73, 4.09
Emergency Room Visits:
As Treated
60
Percentage
50
49
40
30
29
20
10
0
1+ ER Visits
OR = 2.51, CI = 1.71, 3.67
1+ Nights
0 Nights
Source: http://www.hud.gov/offices/cpd/aidshousing/
 The HEARTH Act signed into law by President Obama in May
2009, mandated that United States Interagency Council on
Homelessness (USICH) produce a “national strategic plan” to
end homelessness to Congress
 The USICH is at this very moment releasing at the White House
the nation’s first comprehensive strategy to prevent and end
homelessness titled "Opening Doors: The Federal Strategic Plan
to Prevent and End Homelessness"
 The Council is an independent agency composed of 19 Cabinet
Secretaries and agency heads that coordinates the federal
response to homelessness
[Source: White House Office of Urban Affairs website,
http://www.whitehouse.gov/administration/eop/oua ]