Impact of Unstable Housing on Adherence Not Enough to Justify Deferring ART

A systematic review and meta-analysis has confirmed that individuals who are homeless or in transient housing are more likely to have sub-optimal adherence to antiretroviral therapy (ART). But, the results of separate studies were mixed and, when analyzed together, the magnitude of the effect was small.

While the treatment guidelines of the U.S. Department of Health and Human Services (HHS) urge clinicians to address factors known to affect adherence such as unstable housing, the study suggests that housing problems do not need to be resolved before starting ART. "The finding challenges the view that unstable housing is incompatible with adherence, and questions the potential benefit of deferring ART initiation until the patient's housing circumstances are improved," write Rebecca Arden Harris, M.D., and colleagues in the Journal of Acquired Immunity Deficiency Syndromes.

It has been estimated by the U.S. Department of Housing and Urban Development Office of HIV/AIDS Housing that around 12% of all people living with HIV in the United States have an unmet housing need. Another recent review in the American Journal of Public Health concluded that unstable housing and homelessness are barriers to the sound medical management of HIV, and it is plausible that housing difficulties could make adherence more challenging.

For individuals struggling with poverty and housing problems, efforts to adhere to medication may compete with other survival needs, such as obtaining food and shelter. Frequent changes of neighborhood may mean individuals lose touch with their providers or need to change providers. For people with unstable housing, it may be more difficult to maintain routines; while medication may need to be taken with food, this may not always be possible; carrying medication or storing it in shared accommodation may threaten a person's privacy.

Moreover people with unstable or no housing may be facing other challenges such as social isolation, substance use or mental illness, which could also impact adherence and engagement with health care.

But the observational studies that might substantiate these concerns had never been the subject of a meta-analysis. The authors set out to examine and test as precisely as possible the potential relationship between housing stability and ART adherence among people living with HIV.

To be included, studies needed to be observational, conducted in the United States, classify each patient's housing status, measure adherence and report statistical tests in detail. The researchers say they took a "conservative approach" to study selection, excluding studies that used subjective or imprecise measures.

Studies that were included typically compared patients who were homeless or in unstable housing (in a shelter, car, hotel, another person's home, etc.) with individuals who were not homeless or unstably housed. A few compared patients with more or less housing stability. Adherence was typically measured by self-report, with a few studies using unannounced pill counts or monitoring by an electronic device on a pill bottle.

While the literature search initially identified 164 articles, only 10 met all the inclusion criteria. Original studies were published between 2003 and 2015 and were conducted in a range of settings and mostly urban areas. The ten studies enrolled 10,556 individuals.

Results were mixed: Five studies showed a positive association between housing stability and ART adherence; five studies showed no association; and none showed a negative association.

In the meta-analysis, the overall effect size was positive (standardized mean difference = 0.15, 95% confidence interval = 0.02-0.29).

The researchers note that an effect size of 0.2 is usually considered small (0.5 is medium and 0.8 is large). The largest effect size in any of the studies included was 0.57.

A series of sensitivity and sub-group analyses, including assessing studies by methodological quality, confirmed the finding.

"Our results suggest an increased risk of nonadherence in patients living on the streets or in transient housing compared to those in more stable arrangements, but the magnitude of the effect was small," the authors conclude.

Previous literature reviews -- including the one published earlier in the year in the American Journal of Public Health -- concluded that there is a strong association between housing and adherence. However, those authors did not have as strict of inclusion criteria or use the rigorous methods of meta-analysis.

ART guidelines from the HHS mention unstable housing along with substance use, untreated mental illness and other unfavorable social circumstances as factors that have been associated with poor adherence.

While the guidelines authors are clear that social and behavioral challenges are not reasons to withhold antiretroviral therapy from a patient, they do suggest that it might be best to deal with problems that could impact adherence first. "It is important to discuss strategies to optimize adherence and retention in care with patients before ART initiation," say the guidelines. "ART initiation may need to be briefly delayed to resolve issues identified during such discussions."

The authors of the new review question this: "Given the results of the meta-analysis, the recommendation that ties ART-readiness to housing should be reconsidered."