Abstract
Though housing instability is linked to poor HIV health outcomes, studies that assess the HIV treatment cascade by housing status are limited. Using data from a multi-site Retention in Care initiative we constructed HIV treatment cascades for participants (n=463) of five grantee sites. We found no significant differences in viral suppression at follow-up among participants who were unstably housed at enrollment (49%) as compared to those who were stably housed at enrollment (54%). Among participants with available data at 6- or 12-month follow-up, 94% were engaged in care, 90% were retained in, 94% were on ART, and 71% had suppressed viral load. Some site-level differences were noted; at two of the sites participants who were stably housed were more likely to be retained in care and on ART. Overall, findings demonstrated that_participants moved successfully through the HIV treatment cascade regardless of housing status at enrollment, suggesting that evidence-based support and services to help people living with HIV/AIDS can help mitigate barriers to engagement in care associated with lack of stable housing.
Keywords: HIV treatment cascade, housing instability, homelessness, people living with HIV/AIDS, retention in care
Introduction
The ultimate goal of HIV care is suppression of viral load to levels at which life expectancy is extended, health and wellbeing are dramatically improved, and transmission is virtually impossible (1–3). Viral load suppression requires that people living with HIV (PLWH) remain engaged in care, which involves not only diagnosis and initial linkage to treatment but also receipt of antiretroviral treatment (ART) and retention in HIV care (1, 4). However, PLWH drop off at every step of the engagement “cascade,” resulting in less than 30% PLWH having viral suppression (1, 4, 5).
Initial estimates of the HIV treatment cascade in the U.S. included all PLWH, but recently researchers have characterized the treatment cascade for various subgroups of PLWH, including children, sex workers, migrant populations, men who have sex with men, transgender women, those involved with the criminal justice system, and a number of other sub-populations (6–25). These subgroup analyses are critical for identifying and understanding disparities in access to HIV care. However, studies that assess the HIV treatment cascade by housing status are limited. A study recently examined treatment outcomes for PLWH who received housing supports via the federal Housing Opportunities for People with AIDS (HOPWA) program, comparing participants to a random sample of PLWH who were not HOPWA recipients. This study found significant increases in retention in care for the intervention group, however, no differences in rates of viral suppression were noted (26). In addition, the study was limited to a specific subset of PLWH, namely, those receiving HOPWA support.
Understanding the impact of housing status on the HIV treatment cascade is important given well-documented associations between homelessness and HIV outcomes. There is significant evidence that housing instability is associated with poorer HIV health outcomes (2, 27–37). A systematic review of studies published through March 2014 examining the relationship between HIV outcomes and housing status found that homelessness and/or unstable housing was associated with lower rates of HIV primary care use, less antiretroviral uptake, lower adherence to antiretroviral treatment regimens, and worse health outcomes (CD4 counts, viral load, HIV-related symptoms, opportunistic infections, and mortality) as compared to PLWH who were stably housed (29). Increasing housing supports within a community is associated with improved survival among PLWH experiencing homelessness (38). Moreover, housing instability has particularly detrimental effects on HIV outcomes among vulnerable or marginalized subpopulations of PLWH, such as transgender women (20, 39) and individuals who have experienced incarceration (40).
Given the strong link between HIV outcomes, homelessness, and continuing unmet housing needs for this population, housing remains the leading identified priority for PLWH (41). Since homelessness is a barrier to engagement and viral load suppression, interventions to reduce homelessness have enormous public health potential (35, 42). A recent modeling study demonstrated that eliminating homelessness among PLWH who use injection drugs would increase viral suppression by 82.3% (from 22.0% to 40.1%) among the homeless in that population (43). Characterizing the HIV treatment cascade for PLWH who experience homelessness or housing instability and identifying whether the provision of housing supports increases movement to later stages in the cascade would be of great value in developing and targeting effective housing interventions for PLWH.
AIDS United’s Retention in Care (RiC) Initiative was a three-year partnership with the M·A·C AIDS Fund to develop and evaluate innovative models for HIV retention in care in the United States. This study outlines findings from a convenience sample of all study participants who were enrolled in the RiC programs. The aim of this paper is to describe results of the RiC interventions, to characterize participants who were stably and unstably housed at enrollment into the RiC program, and compare movement through the HIV treatment cascade for RiC participants by housing status at enrollment.
Methods
From 2013 to 2016, seven organizations throughout the U.S. were funded by AIDS United and the MAC AIDS Fund’s Retention in Care (RiC) Initiative to provide HIV-related retention in care services, particularly for PLWH living in poverty who were aware of their HIV status but not engaged in HIV care or support. RiC focused on marginalized populations with the goals of identifying their distal and proximal barriers to care, developing interventions to address identified barriers, and implementing innovative methods of engaging and retaining them in care. Funded programs were those that used innovative, evidence-based approaches to remove barriers to care, which are described in more detail in Table 1. The five participating sites for whom data were available for the analysis below were included in this paper.
Table 1:
RiC Sites, Program Description, and Housing-Specific Supports
| Organization, Program, Location | Population Served | Eligibility Criteria | Recruitment | Description of RiC-Funded Services | Housing Supports Offered by Program |
|---|---|---|---|---|---|
| BOOM!Health, Bronx Health Connect, Bronx, NY | Individuals who use substances and the homeless | People living with HIV who were 18 years of age or older, newly diagnosed or out of care with a history of substance use or homelessness | Medical outreach by a registered nurse, in-reach, partnership with mobile testing services, referrals | An intensive outreach program that used a harm reduction approach to provide a range of services including health navigation, peer support, adherence reminders, and counseling. | For clients with housing instability or homelessness, referrals were placed by the RiC team to an internal housing assistance program. This internal housing program, not funded by the RiC grant, facilitated placement and retention via external housing programs. |
| Christie’s Place, CHANGE for Women, San Diego, CA | Women who have experienced trauma | Women living with HIV who resided in San Diego county who self-report experiences of trauma | Community outreach by peers, referrals from partner agencies, inreach | A program that built on trauma-informed and gender-responsive models of care to address the structural barriers to care faced by women living with HIV, by creating a network of partnership organizations and helping women to access medical care, social services, and substance use and mental health supports. | Housing referrals provided via strong collaborations with other providers. Education and skills-building regarding housing access was provided as part of the work of case managers and peer navigators. These supportive services were funded by the RiC grant. |
| Institute for Public Health Innovation, Total Health Partners, Prince George’s County, MD | Individuals living in poverty and sub-optimally housed | People living with HIV who were newly diagnosed, out of care, or in care but low income, unemployed, or unstably housed | Referrals from case managers working at partner agencies | A Community Health Worker intervention that provided personalized assistance to PLWHA who had dropped out of care or were sub-optimally engaged in care, to assist them in participating and remaining in medical care. | Education regarding housing stability was part of the continuum of services provided by CHWs and funded by the RiC grant. Heart to Hand, the organization that housed the IPHI program, also operated a small transitional housing program that was not RiC funded. |
| The Open Door, Inc., Client-Centered Representative Payee, Pittsburgh, PA | Individuals who use substances and the homeless or unstably housed | People living with HIV who were over the age of 18 with histories of housing instability or homelessness | Referrals from partner organizations | A harm reduction housing stability program that provided client-centered representative payee services to help clients manage income and pay rent and bills on time, enabling them to reduce stress and chaos and thus prioritize medical care and adherence. Housing stability supported through financial management was a primary goal of this RiC site. | All RiC participants received Client-Centered Representative Payee services. Transitional housing was provided to some RiC participants by the organization. Additional housing education and referrals provided via collaborations with other providers (not RiC-funded). |
| University of Virginia Positive Links Charlottesville, VA | Rural residents | People living with HIV in rural Virginia who were treatment naive or out of care | Referred by counselors affiliated with the UVA Health System or Virginal AIDS Service Organizations within the UVA Ryan White Clinic catchment area | A smartphone app that supported PLWH with HIV education and management tools, wellness promotion strategies, and support through: social support via a positive virtual community, self-monitoring of adherence and wellness behaviors, and warm technology that extends care beyond clinic visits. | None, except incidental support through participant message boards. In addition, access to a smartphone simplified participants’ abilities to complete housing and other applications. |
Selection of sites was based on burden of need, geographic region, strength of approach, and ability to conduct rigorous evaluation. The interventions delivered by each site varied by local need, but each organization was required to provide strategies that had at least preliminary evidence of effectiveness. The most commonly used strategies included care coordination, peer and patient navigation, community health workers, and motivational interviewing. In addition, each of the sites developed collaborative networks to strengthen local systems of care. A description of RiC-funded services provided by each site is included in Table 1.
The programs served people living with HIV who faced significant barriers to HIV care, such as substance misuse or disorder, homelessness, trauma, or rural residence. Enrollment criteria varied by site based on the population served. Two sites limited enrollment to individuals who were newly diagnosed (defined as a diagnosis in the past three months) or out of care (defined as a gap in care for six months or failing to have two visits with a prescribing provider within one year at least 90 days apart). Outreach to community based organizations and medical providers, referrals from partner agencies and in-reach were the most common recruitment strategies. (Table 1) Four of the five grantee sites used RiC funds to mitigate structural barriers to care. For these sites, participants who identified housing stability as a barrier to care were supported through a range of supportive services including housing education and skills building, referrals to other providers, and assistance with completing housing assistance applications. Only one program, The Open Door, specified housing stability as its primary RiC goal. This organization provides Client-Centered Representative Payee services (financial management) to ensure that participants’ rent and utility payments were made on a monthly basis in order to prevent eviction and homelessness.
Researchers from a large academic research institution oversaw a multi-site evaluation strategy wherein the sites conducted local evaluation, extracting data from electronic health records and participant self-report, which then were used as part of the national evaluation. Self-report data were collected via a client assessment tool, which was administered by program staff either in person or over the phone. Participant-level data collected at each site were related to twelve overarching assessment domains including participant demographics, linkage to care, case management, participant needs and barriers, perceived stigma, general health, retention in care, viral load, CD4, and ART. Housing status was captured at baseline by asking “Which of the following best describes your current living situation?” If a respondent provided more than one answer, interviewers were instructed to ask “Where did you sleep last night?” (35). All answers other than “Your own place” or a “Room, apartment or house that is your own” were coded as unstable housing.
To assess participant engagement in HIV care, we constructed HIV treatment cascades for each program individually and for all the RiC programs combined. We then assessed the outcomes along the HIV treatment cascade by housing status at enrollment into the RiC program. Engagement in HIV care was defined has having one visit with an HIV medical provider with prescribing privileges after enrollment into the program (44). Retention in HIV care was defined as having two visits at least ninety days apart in the past twelve months (45). To assess use of ART, participants were asked “Are you currently taking any antiretroviral medicines for your HIV?” (46). Participants were considered virally suppressed if they had a viral load less than or equal to 200 copies/mL (47). Data on HIV medical visits and viral suppression were abstracted from medical records and lab records. For construction of the HIV treatment cascades, participants were considered retained, on ART or virally suppressed if they met the above definitions at either 6- or 12-month follow-up. Client-level data were collected at each RiC program location, analyzed, entered into standardized Excel spreadsheets and then sent, in aggregate, to the external evaluator for the RiC programs. Differences in baseline characteristics by housing status and differences along the HIV treatment cascade by housing status were assessed using chi-squared and Fisher’s exact tests. All analyses were completed in Microsoft Excel.
All data collection activities by sites independently underwent IRB review prior to execution. Evaluation activities conducted by the institution overseeing evaluation activities were determined to be non-human subjects research.
Results
Four hundred and sixty-three participants were enrolled in the five RiC programs included here. Participant descriptive data stratified by housing status at enrollment are shown in Table 2. The majority of participants were over the age of 40 (64%), Black or Hispanic race/ethnicity (79%), unemployed or disabled (73%) and reported that their most likely mode for HIV acquisition was heterosexual contact (52%). Forty-six percent of participants were male, 49% were female, and 4% were transgender (male-to-female). At enrollment, 56% of participants were retained in care and 54% of participants were virally suppressed. When we assessed differences by housing status at enrollment, we found differences by age, gender, and transmission category. Unstably housed participants were most likely to be younger, male, and report men who have sex with men (MSM) as their transmission category.
Table 2:
Characteristics of RiC Participants by Housing Status (n=452)*
| Unstably housed | Stably housed | Total | |
|---|---|---|---|
| Participant Characteristics | |||
| Total | 163 | 289 | 452 |
| Age^ | |||
| 18-24 | 23 (0.14) | 19 (0.07) | 42 (0.09) |
| 25-29 | 19 (0.12) | 20 (0.07) | 39 (0.09) |
| 30-39 | 32 (0.20) | 47 (0.16) | 79 (0.17) |
| 40-49 | 61 (0.37) | 89 (0.31) | 150 (0.33) |
| 50+ | 28 (0.17) | 114 (0.39) | 142 (0.31) |
| Missing | 0 (0.00) | 0 (0.00) | 0 (0.00) |
| Race | |||
| Black, non-Hispanic | 80 (0.49) | 150 (0.52) | 230 (0.51) |
| Hispanic | 51 (0.31) | 74 (0.26) | 125 (0.28) |
| White, non-Hispanic | 22 (0.13) | 37 (0.13) | 59 (0.13) |
| Not Black, Hispanic, or White | 9 (0.06) | 28 (0.10) | 37 (0.08) |
| Missing | 1 (0.01) | 0 (0.00) | 1 (0.00) |
| Sex/Gender^ | |||
| Male | 95 (0.58) | 115 (0.40) | 210 (0.46) |
| Female | 61 (0.37) | 162 (0.56) | 223 (0.49) |
| Transgender M to F | 7 (0.04) | 12 (0.04) | 19 (0.04) |
| Missing | 0 (0.00) | 0 (0.00) | 0 (0.00) |
| Employment | |||
| Employed full time | 15 (0.09) | 38 (0.13) | 53 (0.12) |
| Employed part-time | 12 (0.07) | 24 (0.08) | 36 (0.08) |
| Disabled for work | 47 (0.29) | 93 (0.32) | 140 (0.31) |
| Unemployed | 78 (0.48) | 113 (0.39) | 191 (0.42) |
| Other | 11 (0.07) | 19 (0.07) | 30 (0.07) |
| Don’t know | 0 (0.00) | 2 (0.01) | 2 (0.00) |
| Transmission category^ | |||
| MSM | 53 (0.33) | 61 (0.21) | 114 (0.25) |
| IDU | 21 (0.13) | 17 (0.06) | 38 (0.08) |
| Heterosexual | 71 (0.44) | 166 (0.57) | 237 (0.52) |
| Other** | 18 (0.11) | 45 (0.16) | 63 (0.14) |
| Retained in HIV care at enrollment | |||
| Yes | 85 (0.52) | 168 (0.58) | 253 (0.56) |
| No | 21 (0.13) | 43 (0.15) | 64 (0.14) |
| Missing/unknown | 57 (0.35) | 78 (0.27) | 135 (0.30) |
| Viral suppression at enrollment | |||
| Yes | 82 (0.50) | 161 (0.56) | 243 (0.54) |
| No | 36 (0.22) | 88 (0.30) | 124 (0.27) |
| Missing/unknown | 45 (0.28) | 40 (0.14) | 85 (0.19) |
Total n=452 for this analysis. 11 individuals were not included because of missing data on housing status.
Statistically different at p<0.05, Chi Square with Fishers Exact, “Missing/unknown” data category excluded for significance testing
Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
When we assessed movement along the HIV treatment cascade for all participants (Table 3), we found that 401 were engaged in HIV care, 321 were retained in HIV care at either six or twelve months follow-up, 296 had an ART prescription at either six or twelve months follow-up, and 240 were virally suppressed at either six or twelve months follow-up. We constructed the HIV treatment cascade in two ways. First, we assumed that individuals with missing data were not engaged in HIV care (e.g. Missing=No). Taking this approach, we calculated that 87% (401/463) were engaged in HIV care, 69% (321/463) were retained in HIV care, 64% (296/463) were on ART, and 52% (240/463) had a suppressed viral load. At either six or twelve months follow-up, retention in care data was not available for 23%, ART data was not available for 32%, and viral suppression was not available for 27% of participants. There were no significant differences in age, race, gender, or transmission category between those with and without missing data on viral suppression at follow-up. When we limited our analyses to participants with available data, we found that 94% (401/428) were engaged in HIV care, 90% (321/355) were retained in HIV care, 94% (296/316) were on ART, and 71% (240/336) had a suppressed viral load. A comparison of the HIV treatment cascade among those who were and were not unstably housed at enrollment did not yield any significant differences when we combined data across all RiC programs (Table 4). Among those who were unstably housed, 87% were engaged in care, 71% were retained in care, 63% were on ART, and 49% were virally suppressed. By way of comparison, 87% of stably housed participants were engaged in HIV care, 68% were retained in care, 65% were on ART, and 54% were virally suppressed. At the site level, there were differences in retention at one site (Christie’s Place) and difference in ART at two sites (Christie’s Place and BOOM!Health). Specifically, participants who were stably housed were more likely to be retained in care and on ART. These sites were two of the three programs that addressed housing more directly post-RiC enrollment.
Table 3:
HIV Treatment Cascade by RiC Program Site
| Engaged in Care | Retained in Care | ART | Suppressed Viral Load (SVL) | |
|---|---|---|---|---|
| All Sites Combined (n=463) | ||||
| Yes | 401 | 321 | 296 | 240 |
| No | 27 | 34 | 20 | 96 |
| Unknown/missing | 35 | 108 | 147 | 127 |
| BOOM!Health (n=136) | ||||
| Yes | 103 | 59 | 57 | 50 |
| No | 6 | 0 | 1 | 32 |
| Unknown/missing | 27 | 77 | 78 | 54 |
| Christies Place (n=115) | ||||
| Yes | 114 | 100 | 81 | 57 |
| No | 1 | 0 | 6 | 30 |
| Unknown/missing | 0 | 15 | 28 | 28 |
| Institute for Public Health Innovation (n=95) | ||||
| Yes | 76 | 56 | 60 | 48 |
| No | 11 | 26 | 9 | 10 |
| Unknown/missing | 8 | 13 | 26 | 37 |
| The Open Door (n=40) | ||||
| Yes | 34 | 36 | 35 | 29 |
| No | 6 | 1 | 2 | 3 |
| Unknown/missing | 0 | 3 | 3 | 8 |
| University of Virginia (n=77) | ||||
| Yes | 74 | 70 | 63 | 56 |
| No | 3 | 7 | 2 | 21 |
| Unknown/missing | 0 | 0 | 12 | 0 |
Table 4:
HIV Treatment Cascade by Housing Status
| Total | Engaged in HIV Care | X2, P-value | Retained in HIV Care | X2, P-value | ART | X2, P-value | Suppressed Viral Load | X2, P-value | |
|---|---|---|---|---|---|---|---|---|---|
| All Sites Combined | (n=463) | (n=401) | (n=321) | (n=296) | (n=240) | ||||
| Housing status | |||||||||
| Unstably housed | 192 (0.41) | 167 (0.87) | (0.00,1.00) | 136 (0.71) | (0.39,0.54 | 121 (0.63) | (0.12,0.77) | 95 (0.49) | (1.00,0.34) |
| Stably housed | 260 (0.56) | 226 (0.87) | 177 (0.68) | 168 (0.65) | 141 (0.54) | ||||
| Unknown/missing | 11 (0.02) | 8 (0.73) | 8 (0.73) | 7 (0.64) | 4 (0.36) | ||||
| BOOM!Health | |||||||||
| Housing status | (n=136) | (n=103) | (n=59) | (n=57) | (n=50) | ||||
| Unstably housed | 60 (0.44) | 45 (0.75) | (0.03,1.00) | 21 (0.35) | (3.07,0.09) | 19 (0.32) | (4.63,0.04) | 18 (0.30) | (2.11,0.16) |
| Stably housed | 76 (0.56) | 58 (0.76) | 38 (0.50) | 38 (0.50) | 32 (0.42) | ||||
| Unknown/missing | 0 (0.00) | 0 (0.00) | 0 (0.00) | 0 (0.00) | 0 (0.00) | ||||
| Christies Place | |||||||||
| Housing status | (n=115) | (n=114) | (n=100) | (n=81) | (n=57) | ||||
| Unstably housed | 40 (0.35) | 40 (1.00) | NA | 27 (0.68) | (21.81,0.00) | 21 (0.53) | (8.88,0.01) | 16 (0.40) | (3.27,0.08) |
| Stably housed | 69 (0.60) | 69 (1.00) | 68 (0.99) | 55 (0.80) | 40 (0.58) | ||||
| Unknown/missing | 6 (0.05) | 5 (0.83) | 5 (0.83) | 5 (0.83) | 1 (0.17) | ||||
| Institute for Public Health Innovation | |||||||||
| Housing status | (n=95) | (n=76) | (n=56) | (n=60) | (n=48) | ||||
| Unstably housed | 27 (0.28) | 22 (0.81) | (0.03,1.00) | 15 (0.56) | (0.28,0.65) | 16 (0.59) | (0.39,0.63) | 11 (0.41) | (1.31,0.36) |
| Stably housed | 65 (0.68) | 52 (0.80) | 40 (0.62) | 43 (0.66) | 35 (0.54) | ||||
| Unknown/missing | 3 (0.03) | 2 (0.67) | 1 (0.33) | 1 (0.33) | 2 (0.67) | ||||
| The Open Door | |||||||||
| Housing status | (n=40) | (n=34) | (n=36) | (n=35) | (n=29) | ||||
| Unstably housed | 16 (0.40) | 13 (0.81) | (0.76,0.63) | 14 (0.88) | (0.11,1.00) | 14 (0.88) | (0.11,1.00) | 12 (0.75) | (0.02,1.00) |
| Stably housed | 22 (0.55) | 20 (0.91) | 20 (0.91) | 20 (0.91) | 16 (0.73) | ||||
| Unknown/missing | 2 (0.05) | 1 (0.50) | 2 (1.00) | 1 (0.50) | 1 (0.50) | ||||
| UVA | |||||||||
| Housing status | (n=77) | (n=74) | (n=70) | (n=63) | (n=56) | ||||
| Unstably housed | 20 (0.26) | 18 (0.90) | (2.69,0.16) | 18 (0.90) | (0.03,1.00) | 17 (0.85) | (0.18,1.0 0) | 14 (0.70) | (0.10,0.78) |
| Stably housed | 57 (0.74) | 56 (0.98) | 52 (0.91) | 46 (0.81) | 42 (0.74) | ||||
| Unknown/missing | 0 (0.00) | 0 (0.00) | 0 (0.00) | 0 (0.00) | 0 (0.00) |
Discussion
While many studies have documented that “housing is healthcare” for people living with HIV, our study adds to the existing literature by assessing differences in movement along the HIV treatment cascade among participants of a retention in care program who were and were not stably housed at enrollment. When we combined data across all program locations we found no differences in viral suppression at follow-up among participants who were unstably housed at program enrollment (49%) as compared to those who were stably housed at enrollment (54%). This finding was also seen at each of the five sites. In addition, all of the programs demonstrated viral suppression percentages among their marginalized client populations (range 61%-91%) that compare favorably with other similar programs (48, 49). It is important to note that for two sites, we did find significant differences in engagement in HIV care by housing status. At these sites, individuals who were stably housed were more likely to be retained and to be on ART. This finding is consistent with the literature, which has shown that unstable housing is associated with a lack of regular visits for HIV primary medical care and one of the most important factors limiting ART use (50). Unfortunately our study was not designed to answer questions about the contextual, intervention, or implementation factors that might have contributed to these differences or why differences were seen in retention and adherence but not viral suppression. This represents an area where future inquiry is needed.
A recent study tracked treatment outcomes for PLWH who received housing supports via the federal Housing Opportunities for People with AIDS (HOPWA) program, comparing participants to a random sample of PLWH who were not HOPWA recipients. While this study found significant increases in retention in care for the intervention group, no differences were found in rates of viral suppression (26). Nonetheless, a systematic review of 152 studies that examined associations between housing and clinical outcomes (including treatment adherence and viral suppression) found an independent effect of housing on HIV health outcomes for homeless or formerly homeless PLWH (29). Clearly, housing instability is a structural factor that limits efforts to increase the number of PLWH who are virally suppressed. In the absence of full remediation of homelessness, other types of housing support such as financial management, health navigation, and warm handoffs to partner agencies that provide supportive housing may help unstably housed PLWH engage in HIV care in the short term. Additional information is needed to understand how to best integrate strategies to reduce unstable housing and homelessness into existing evidence-based engagement in HIV care interventions, even while we continue to find ways to end homelessness. Given the well-documented associations between housing instability and poor clinical outcomes for PLWH, there is also a need for larger-scale, well-controlled trials that study the efficacy of innovative structural interventions, such as representative payee services, on engagement in HIV care.
There are a number of limitations inherent to this study. Since nonprofit funding is often dependent on organizational factors (51), the degree of organizational capacity that enabled these agencies to compete for RiC funding may mean that they are not be representative of all HIV service organizations in the US. In addition, it is important to note that making direct comparisons across sites is not appropriate given differences in program models, populations served, geographic locations, and variability in rental housing market conditions.
Two of the seven grantee sites did not have housing data available and therefore were not able to be included in the study. In addition, participants were recruited to the study via a convenience sample, introducing selection bias. The generalizability of our study findings beyond our study population is not known. Most programs had small sample sizes with considerable missing data at follow-up, further restricting our ability to accurately interpret results. In addition, our study was limited by missing data on treatment cascade variables at follow-up. Unfortunately it was beyond the scope of this study to ascertain why these data were missing. Prior research suggests that incomplete data on engagement in HIV care are due to a number of reasons, including out-of-care status, seeking care at different locations locally, relocating to a new area, death, and incarceration (8). Our study looked at housing status at a fixed point in time, program enrollment. Housing status is not a fixed trait and changes over time. Therefore, it is likely that participants who were unstably housed at enrollment became stably housed during the program and it is also possible that participants who were stably housed at enrollment may have become unstably housed. Longitudinal studies are needed to better understand the relationship between housing status and HIV care engagement over time.
Furthermore, it was beyond the scope of these analyses to be able to assess if there were differences in housing status between those with and without missing data on the measures of the HIV care continuum. This could bias our results, as individuals without housing at follow-up may be more likely to have missing data at follow-up. In addition, our study might be subject to misclassification bias due to the survey question used to assess housing status. Feedback from program representatives suggests that the criteria for “stable housing” is not consistently understood or used. For example, The Open Door provided transitional housing directly to some participants and while some residents referred to this as “my own place” (which would be interpreted as stably housed), others called this “transitional housing” (unstably housed). Validated standardized housing measures that are incorporated into a full range of HIV care and supportive service programs are needed to fully understand the interplay between housing and optimal clinical outcomes.
With each study that addresses housing instability and health outcomes it becomes increasingly clear that there is a strong relationship between social determinants of health and HIV clinical outcomes (2, 26, 29, 32, 34, 52). While many urban areas have housing programs, these are often not sufficient to meet the prevailing need (53). Cities with multi-year waitlists for housing support typically have numerous PLWH who are not only unstably housed, but also likely to be highly infectious (54, 55), which means that stable housing is important to improving clinical outcomes for PLWH and reducing secondary transmission of HIV.
Conclusion
Until housing is assured for all individuals it will be important to provide additional structural interventions to mitigate the effects of unstable housing. Our findings indicate that participants in the RiC program successfully moved through the HIV treatment cascade regardless of housing status at the start of the program. This suggests that programs such as RiC which provide evidence-based support and services to help PLWH can help mitigate barriers to engagement in care associated with lack of stable housing.
Acknowledgements:
The authors would like to express their gratitude to the Retention in Care sites and their dedicated staff who participated in this project, and especially to Dr. Maria Caban from BOOM!Health for her help conceptualizing this paper.
Funding: This study was funded by AIDS United in partnership with the M·A·C AIDS Fund. Dr. Maulsby’s effort on the preparation of this manuscript was supported in part by a grant from National Institute of Mental Health (1K01MH111388-01A1).
Compliance with Ethical Standards
Conflict of Interest: The authors declare that they have no conflicts of interest.
Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent: All data collection activities by sites independently underwent IRB review prior to execution. Evaluation activities conducted by the institution overseeing evaluation activities were determined to be non-human subjects research.
References
- 1.Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases. 2011;52(6). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bhunu CP. Assessing the impact of homelessness on HIV/AIDS transmission dynamics. Cogent Mathematics. 2015;2(1):1021602. [Google Scholar]
- 3.Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hall HI, Tang T, Westfall AO, Mugavero MJ. HIV care visits and time to viral suppression, 19 U.S. jurisdictions, and implications for treatment, prevention and the national HIV/AIDS strategy. PLoS One. 2013;8(12):e84318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Gray KM, Cohen SM, Hu X, Li J, Mermin J, Hall HI. Jurisdiction level differences in HIV diagnosis, retention in care, and viral suppression in the United States. J Acquir Immune Defic Syndr. 2014;65(2):129–32. [DOI] [PubMed] [Google Scholar]
- 6.Barnighausen T The HIV treatment cascade and antiretroviral impact in different populations. Curr Opin HIV AIDS. 10 United States2015. p. 391–4. [DOI] [PubMed] [Google Scholar]
- 7.Bobat R, Archary M, Lawler M. An update on the HIV treatment cascade in children and adolescents. Curr Opin HIV AIDS. 2015;10(6):411–9. [DOI] [PubMed] [Google Scholar]
- 8.Buskin SE, Kent JB, Dombrowski JC, Golden MR. Migration distorts surveillance estimates of engagement in care: results of public health investigations of persons who appear to be out of HIV care. Sex Transm Dis. 2014;41(1):35–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Edun B, Iyer M, Albrecht H, Weissman S. The South Carolina HIV Cascade of Care. South Med J. 2015;108(11):670–4. [DOI] [PubMed] [Google Scholar]
- 10.Horberg MA, Hurley LB, Klein DB, Towner WJ, Kadlecik P, Antoniskis D, et al. The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System. AIDS Patient Care STDS. 2015;29(11):582–90. [DOI] [PubMed] [Google Scholar]
- 11.Iroh PA, Mayo H, Nijhawan AE. The HIV Care Cascade Before, During, and After Incarceration: A Systematic Review and Data Synthesis. Am J Public Health. 2015;105(7):e5–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Lessells RJ, Swaminathan S, Godfrey-Faussett P. HIV treatment cascade in tuberculosis patients. Curr Opin HIV AIDS. 2015;10(6):439–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Mangal JP, Rimland D, Marconi VC. The continuum of HIV care in a Veterans’ Affairs clinic. AIDS Res Hum Retroviruses. 2014;30(5):409–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Maulsby C, Charles V, Kinsky S, Riordan M, Jain K, Holtgrave D. Positive Charge: Filling the Gaps in the U.S. HIV Continuum of Care. AIDS Behav. 2015;19(11):2097–107. [DOI] [PubMed] [Google Scholar]
- 15.Milloy MJ, Montaner JS, Wood E. Incarceration of people living with HIV/AIDS: implications for treatment-as-prevention. Curr HIV/AIDS Rep. 2014;11(3):308–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Nijhawan AE. Infectious Diseases and the Criminal Justice System. Am J Med Sci. 2016;352(4):399–407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Phelps BR, Ahmed S, Amzel A, Diallo MO, Jacobs T, Kellerman SE, et al. Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview. Aids. 2013;27 Suppl 2:S207–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Risher K, Mayer KH, Beyrer C. HIV treatment cascade in MSM, people who inject drugs, and sex workers. Curr Opin HIV AIDS. 2015;10(6):420–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Saghayam S, Wanke C. The impact of nutritional status and nutrition supplementation on outcomes along the HIV treatment cascade in the resource-limited setting. Curr Opin HIV AIDS. 2015;10(6):472–6. [DOI] [PubMed] [Google Scholar]
- 20.Santos GM, Wilson EC, Rapues J, Macias O, Packer T, Raymond HF. HIV treatment cascade among transgender women in a San Francisco respondent driven sampling study. Sex Transm Infect. 2014;90(5):430–3. [DOI] [PubMed] [Google Scholar]
- 21.Shaw S, Amico KR. Antiretroviral Therapy Adherence Enhancing Interventions for Adolescents and Young Adults 13-24 Years of Age: A Review of the Evidence Base. J Acquir Immune Defic Syndr. 2016;72(4):387–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Tanser F, Barnighausen T, Vandormael A, Dobra A. HIV treatment cascade in migrants and mobile populations. Curr Opin HIV AIDS. 2015;10(6):430–8. [DOI] [PubMed] [Google Scholar]
- 23.Vagenas P, Azar MM, Copenhaver MM, Springer SA, Molina PE, Altice FL. The Impact of Alcohol Use and Related Disorders on the HIV Continuum of Care: a Systematic Review : Alcohol and the HIV Continuum of Care. Curr HIV/AIDS Rep. 2015;12(4):421–36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions. Alcohol Clin Exp Res. 2016;40(10):2056–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Zanoni BC, Mayer KH. The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. AIDS Patient Care STDS. 2014;28(3):128–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Terzian AS, Irvine MK, Hollod LM, Lim S, Rojas J, Shepard CW. Effect of HIV Housing Services on Engagement in Care and Treatment, New York City, 2011. AIDS Behav. 2015;19(11):2087–96. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Leaver CA, Bargh G, Dunn JR, Hwang SW. The effects of housing status on health-related outcomes in people living with HIV: a systematic review of the literature. AIDS Behav. 2007;11(6 Suppl):85–100. [DOI] [PubMed] [Google Scholar]
- 28.Aidala A, Lee G, Abramson D, Messeri P, Sigeler A. Housing need, housing assistance, and connection to HIV medical care. AIDS Behav. 2007;11(Suppl):S101–S15. [DOI] [PubMed] [Google Scholar]
- 29.Aidala A, Wilson MG, Shubert V, Gogolishvili D, Globerman J, Rueda S, et al. Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review. Am J Public Health. 2016;106(1):95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Milloy MJ, Marshall BD, Montaner J, Wood E. Housing status and the health of people living with HIV/AIDS. Curr HIV/AIDS Rep. 2012;9(4):364–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Friedman MS, Marshal MP, Stall R, Kidder DP, Henny KD, Courtenay-Quirk C, et al. Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV. AIDS Care. 2009;21(6):692–700. [DOI] [PubMed] [Google Scholar]
- 32.Kidder DP, Wolitski RJ, Royal S, Aidala A, Courtenay-Quirk C, Holtgrave DR, et al. Access to housing as a structural intervention for homeless and unstably housed people living with HIV: rationale, methods, and implementation of the housing and health study. AIDS Behav. 2007;11(6 Suppl):149–61. [DOI] [PubMed] [Google Scholar]
- 33.Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health. 2007;97(12):2238–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Royal SW, Kidder DP, Patrabansh S, Wolitski RJ, Holtgrave DR, Aidala A, et al. Factors associated with adherence to highly active antiretroviral therapy in homeless or unstably housed adults living with HIV. AIDS Care. 2009;21(4):448–55. [DOI] [PubMed] [Google Scholar]
- 35.Wolitski R, Kidder D, Pals S, Royal S, Aidala A, Stall R, et al. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav. 2010;14(3):493–503. [DOI] [PubMed] [Google Scholar]
- 36.Wolitski R, Kidder D, Fenton K. HIV, homelessness, and public health: critical issues and a call for increased action. AIDS Behav. 2007;11(6 Suppl):167–71. [DOI] [PubMed] [Google Scholar]
- 37.Thakarar K, Morgan JR, Gaeta JM, Hohl C, Drainoni M-L. Homelessness, HIV, and Incomplete Viral Suppression. Journal of Health Care for the Poor and Underserved. 2016;27(1):145–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Khanijow K, Hirozawa A, Ancock B, Hsu LC, Bamberger J, Schwarcz SK. Difference in Survival between Housed and Homeless individuals with HIV, San Francisco, 2002-2011. J Health Care Poor Underserved. 2015;26(3):1005–18. [DOI] [PubMed] [Google Scholar]
- 39.Dowshen N, Nguyen GT, Gilbert K, Feiler A, Margo KL. Improving transgender health education for future doctors. Am J Public Health. 2014;104(7):e5–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Lim S, Harris TG, Nash D, Lennon MC, Thorpe LE. All-cause, drug-related, and HIV-related mortality risk by trajectories of jail incarceration and homelessness among adults in New York City. Am J Epidemiol. 2015;181(4):261–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Lennon CA, Pellowski JA, White AC, Kalichman SC, Finitsis DJ, Turcios-Cotto V, et al. Service priorities and unmet service needs among people living with HIV/AIDS: results from a nationwide interview of HIV/AIDS housing organizations. AIDS Care. 2013;25(9):1083–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Buchanan D, Kee R, Sadowski LS, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. Am J Public Health. 2009;99 Suppl 3:S675–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Marshall BD, Elston B, Dobrer S, Parashar S, Hogg RS, Montaner JS, et al. The population Impact of eliminating homelessness on HIV viral suppression among people who use drugs. Aids. 2015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Giordano TP, Gifford AL, White AC Jr., Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44(11):1493–9. [DOI] [PubMed] [Google Scholar]
- 45.Mugavero M, Westfall A, Zinski A, Davila J, Drainoni M, Gardner L, et al. Measuring Retention in HIV Care: The Elusive Gold Standard. Journal of acquired immune deficiency syndromes (1999). 2012;61(5):574–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Blair JM, McNaghten AD, Frazier EL, Skarbinski J, Huang P, Heffelfinger JD. Clinical and behavioral characteristics of adults receiving medical care for HIV infection --- Medical Monitoring Project, United States, 2007. MMWR Surveill Summ. 2011;60(11):1–20. [PubMed] [Google Scholar]
- 47.Mugavero M, Davila J, Nevin C, Giordano T. From access to engagement: measuring retention in outpatient HIV clinical care. AIDS Patient Care STDS. 2010;24(10):607–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Gardner LI, Giordano TP, Marks G, Wilson TE, Craw JA, Drainoni ML, et al. Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics. Clin Infect Dis. 2014;59(5):725–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Enriquez M, Farnan R, Cheng AL, Almeida A, Del Valle D, Pulido-Parra M, et al. Impact of a bilingual/bicultural care team on HIV-related health outcomes. J Assoc Nurses AIDS Care. 2008;19(4):295–301. [DOI] [PubMed] [Google Scholar]
- 50.Aidala AA, Wilson MG, Shubert V, Gogolishvili D, Globerman J, Rueda S, et al. Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review. Am J Public Health. 2016;106(1):e1–e23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Stone MM, Hager MA, Griffin JJ. Organizational characteristics and funding environments: A study of a population of United Way–affiliated nonprofits. Public Administration Review. 2001;61(3):276–89. [Google Scholar]
- 52.Cornelius T, Jones M, Merly C, Welles B, Kalichman MO, Kalichman SC. Impact of food, housing, and transportation insecurity on ART adherence: a hierarchical resources approach. AIDS Care. 2017;29(4):449–57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.The 2016 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development Office of Community Planning and Development; 2016. [Google Scholar]
- 54.Marshall BD, Kerr T, Shoveller JA, Patterson TL, Buxton JA, Wood E. Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth. Health Place. 2009;15(3):753–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Pellowski JA, Kalichman SC, Matthews KA, Adler N. A pandemic of the poor: social disadvantage and the U.S. HIV epidemic. Am Psychol. 2013;68(4):197–209. [DOI] [PMC free article] [PubMed] [Google Scholar]