Numerous studies link a lack of stable housing to a spiral of disproportionate risks, among them injuries, poor nutrition, asthma, mental illness, and HIV. And for people living with HIV (PLWH), experiencing homelessness correlates strongly with inadequate access to medical care and low rates of adherence to antiretroviral therapy (ART) and retention in care—all resulting in worse health outcomes.
“Stable housing is important because it enables factors that tend to keep PLWH, and others, healthy,” said Elizabeth Topper Golub, Ph.D., M.Ed., M.P.H., a clinical HIV researcher at the Johns Hopkins Bloomberg School of Public Health and coauthor of a 2018 study on the impact of unstable housing on HIV treatment biomarkers. (The study determined that unstable housing produced clinically meaningful negative health impacts among HIV-positive women in the U.S.) “For example, unstable housing often means a lack of social support, inability to remain in HIV care, and poor adherence to HIV treatment, all of which are associated with poor clinical outcomes. People without consistently stable housing often have lower CD4+ cell counts and a lower probability of viral suppression, as compared to those who do have stable housing,” Golub explained.
A retrospective, cross-sectional chart study published in the January 2021 issue of the journal AIDS Care adds to the growing body of evidence that stable housing leads to better clinical outcomes and improved health care utilization for PLWH. Researchers from Massachusetts College of Pharmacy and Health Sciences, Boston University School of Public Health, and the Boston Health Care for the Homeless Program investigated the impact of housing status (assessed at multiple time points) on a range of HIV-related clinical outcomes including viral suppression, CD4 counts, and use of HIV outpatient and medical respite care facilities in the community. (Medical respite facilities offer medical care for persons experiencing homelessness who are too frail to recover from a physical illness or injury on the streets, but are not sick enough to receive inpatient care at a hospital.)
The study, led by Anela Stanic, Pharm.D., an associate professor of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences, compared PLWH with consistently stable housing (CSH) to PLWH who did not have CSH. The statistical team used multivariable and propensity weighted analyses to assess outcomes with adjustment for potential group differences. Of the 208 participants, 88 (42%) had CSH and 120 (58%) were in the non-CSH group. The study found rates of viral suppression and high mean CD4 counts were significantly greater among participants with CSH compared to those without CSH. Those with CSH went for nursing visits less than half as many times as those without CSH and were less likely to need care at medical respite facilities—and if they were admitted, their length of stay was about half that of people without CSH.
An Urgent Need for Affordable Housing
“The study by Stanic and colleagues is another contribution to what advocates have known since the beginning of the epidemic,” said Angela A. Aidala, Ph.D., a research scientist in the Department of Sociomedical Sciences at Columbia University and the lead author of an oft-cited 2016 systematic review of studies assessing the impact of housing status on medical care and health outcomes among PLWH. “Not only literal homelessness, but the lack of stable, secure, adequate, and affordable housing is a major factor affecting engagement in care, treatment adherence, and clinical outcomes for PLWH,” said Aidala.
“Chronic stress, competing financial priorities, transiency, and the press of daily needs among PLWH without housing, or whose housing is inadequate or unaffordable, won’t be solved by biomedical interventions. Housing is health care and prevention,” added Aidala, echoing the mantra of advocates for stable, affordable, quality housing for PLWH.
Aidala’s observations underscore the policy implications of the Stanic study findings. Stanic and colleagues insist that housing should be regarded not only as health care, but as preventive care as well. They further note that the Housing Opportunities for Persons With AIDS (HOPWA) program is currently the only federal program that provides funding to states, localities, and nonprofit organizations to support housing programs for low-income PLWH and is a successful model for improving outcomes among PLWH.
Additionally, the study’s authors note that the Affordable Care Act, aka Obamacare, has allowed new models of payment and delivery to address housing needs in the context of health care settings. These include accountable care organizations (ACOs) and Medicare managed care organizations (MCOs), which in some states are starting to address housing as a key correlate of health. The concern, however, note Stanic and colleagues, is that the legislation providing for these promising models always faces the threat of repeal by Congress (or, one might add, inadequate funding). The authors underscore the urgency for federal, state, and local policymakers and other stakeholders participating in HIV treatment and prevention efforts to continue working to expand funding for both housing and supportive services for PLWH.