HIV, homelessness, and public health: critical issues and a call for increased action

The association between use of non-injection drug implements and hepatitis C virus antibody status in homeless and marginally housed persons in San Francisco

BACKGROUND

Up to 17,000 persons in the USA became infected with hepatitis C virus (HCV) in 2007, and many cases have unknown transmission routes. To date research on transmission of HCV via shared implements used to snort or smoke non-injection drugs has been inconclusive.

METHODS

We tested stored sera for HCV antibodies (anti-HCV) in a large population-based study of homeless and marginally housed persons in San Francisco. We examined the association between sharing implements used for snorting and smoking drugs and anti-HCV while controlling for sociodemographic variables in those who denied ever injecting drugs (n = 430). We also examined the association of anti-HCV status with history of incarceration, tattoo and piercing history, sexual history and alcohol consumption.

RESULTS

Seventeen percent of our sample was anti-HCV positive. We found no statistically significant associations with sharing implements used to smoke or snort drugs with anti-HCV status in our various multivariate models. There was a statistically significant negative association between ever snorting cocaine and anti-HCV status (adjusted odds ratio: 0.39; 95% confidence interval: 0.21-0.73). There were no other statistically significant associations with any other measured covariates in multivariate analyses.

CONCLUSIONS

Our findings suggest that sharing implements to snort or smoke drugs is not a significant risk factor for anti-HCV-positive status.

HIV seroprevalence among orphaned and homeless youth: no place like home

OBJECTIVES

We evaluated the combined influences of orphaned status and homelessness on HIV seroprevalence and risk among street-involved Ukrainian youth in 2008.

DESIGN

Systematic, multicity, community-based, cross-sectional assessment.

METHODS

Time-location sampling was used to identify eligible youth aged 15-24 after city-wide mapping of 91 sites where street-involved youth gathered in Odessa, Kiev, and Donetsk. Universal sampling identified 961 youth in 74 randomly selected sites; 97% consented. Youth reporting one or both parents dead were classified as orphaned; those without a stable residence or sleeping outside their residence at least two nights per week were classified as homeless. Trained staff provided HIV counseling and rapid testing via mobile vans. Adjusted odds ratios (AORs) were calculated using logistic regression, accounting for intracluster homogeneity.

RESULTS

We found 32% (300 of 929) were both orphaned and homeless; 48% either (but not both) homeless [37% (343 of 929)] or orphaned [11% (104 of 929)]; and [20% (182 of 929)] neither orphaned nor homeless. HIV seroprevalences were 7% for neither orphaned/homeless; 16 and 17%, respectively, for either orphaned/homeless; 28% for both orphaned/homeless (P for trend <0.0001). AORs for HIV infection were 1 for neither; 2.3 and 2.4 for either homeless [95% confidence interval (CI) 1.7-2.9] or orphaned (CI 1.8-3.3); 3.3 for both orphaned/homeless (CI 2.3-4.4). Ever-use of injection drugs increased from 15 to 32 to 48% for those who neither, either, or both orphaned and homeless, respectively (P for trend <0.0001).

CONCLUSIONS

One of four youths who were both homeless and orphaned was HIV-infected; these youths were significantly more likely to be HIV infected and to report injection drug use than those with adequate housing and living parents.

Social stability and HIV risk behavior: evaluating the role of accumulated vulnerability

This study evaluated a cumulative and syndromic relationship among commonly co-occurring vulnerabilites (homelessness, incarceration, low-income, residential transition) in association with HIV-related risk behaviors among 635 low-income women in Baltimore. Analysis included descriptive statistics, logistic regression, latent class analysis and latent class regression. Both methods of assessing multidimensional instability showed significant associations with risk indicators. Risk of multiple partners, sex exchange, and drug use decreased significantly with each additional domain. Higher stability class membership (77%) was associated with decreased likelihood of multiple partners, exchange partners, recent drug use, and recent STI. Multidimensional social vulnerabilities were cumulatively and synergistically linked to HIV risk behavior. Independent instability measures may miss important contextual determinants of risk. Social stability offers a useful framework to understand the synergy of social vulnerabilities that shape sexual risk behavior. Social policies and programs aiming to enhance housing and overall social stability are likely to be beneficial for HIV prevention.

Collection of social determinant of health measures in U.S. national surveillance systems for HIV, viral hepatitis, STDs, and TB

Challenges exist in the study of social determinants of health (SDH) because of limited comparability of population-based U.S. data on SDH. This limitation is due to differences in disparity or equity measurements, as well as general data quality and availability. We reviewed the current SDH variables collected for HIV, viral hepatitis, sexually transmitted diseases, and tuberculosis at the Centers for Disease Control and Prevention through its population-based surveillance systems and assessed specific system attributes. Results were used to provide recommendations for a core set of SDH variables to collect that are both feasible and useful. We also conducted an environmental literature scan to determine the status of knowledge of SDH as underlying causes of disease and to inform the recommended core set of SDH variables.

Sticking to it: the effect of maximally assisted therapy on antiretroviral treatment adherence among individuals living with HIV who are unstably housed

Housing is a known determinant of health behaviors, which includes adherence to Antiretroviral Therapy (ART). Within the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) study, unstable housing is inversely associated with adherence. Several comprehensive adherence support services have emerged to improve adherence for unstably housed or otherwise vulnerable populations. The Maximally Assisted Therapy (MAT) program in Vancouver, British Columbia uses a multidisciplinary approach to support HIV-positive clients with a history of addictions or mental illness, many of whom also experience episodic homelessness. This study investigated the association between antiretroviral adherence and use of support services, including the MAT program, amongst people living with HIV and AIDS who are unstably housed in the LISA sample. Of the 212 unstably housed participants, those who attended the MAT program were 4.76 times more likely to be ≥95% adherent (95% CI 1.72-13.13; P = 0.003) than those who did not. The findings suggest that in the absence of sustainable housing solutions, programs such as MAT play an important role in supporting treatment adherence in this population.

Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review

BACKGROUND

Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status.

METHODS

A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality.

RESULTS

Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations.

CONCLUSIONS

These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.

Homelessness and adherence to antiretroviral therapy among a cohort of HIV-infected injection drug users

Homelessness is prevalent among HIV-infected injection drug users (IDU) and may adversely affect access and adherence to antiretroviral therapy (ART). There are limited descriptions of the effect of homelessness on adherence to ART in long-term cohorts of HIV-infected IDU. We used data from a community-recruited prospective cohort of HIV-infected IDU, including comprehensive ART dispensation records, in a setting where HIV care is free. We examined the relationship between the homelessness measured longitudinally, and the odds of ≥95% adherence to ART using generalized estimating equations logistic regression modeling adjusting for sociodemographics, drug use, and clinical variables. Between May 1996 and September 2008, 545 HIV-infected IDU were recruited and eligible for the present study. The median follow-up duration was 23.8 months (IQR 8.5-91.6 months) contributing 2,197 person-years of follow-up. At baseline, homeless participants were slightly younger (35.8 vs. 37.9 years, p = 0.01) and more likely to inject heroin at least daily (37.1% vs. 24.6%. p = 0.004) than participants who had housing. The multivariate model revealed that homelessness (adjusted odds ratio [AOR] 0.66; 95% CI: 0.53-0.84) and frequent heroin use (AOR 0.40; 95% CI: 0.30-0.53) were significantly and negatively associated with ART adherence, whereas methadone maintenance was positively associated (AOR 2.33; 95% CI: 1.86-2.92). Sub-optimal ART adherence was associated with homelessness and daily injection heroin use among HIV-infected IDU. Given the survival benefit of ART, it is critical to develop and evaluate innovative strategies such as supportive housing and methadone maintenance to address these risk factors to improve adherence.

Transforming social structures and environments to help in HIV prevention

Interest in social and structural interventions for HIV prevention is growing. Such approaches modify social norms, institutions, laws, and policies to reduce vulnerability and create environments in which individuals can protect themselves against HIV infection. Examples include expanding access to sterile syringes for injecting drug users and subsidizing stable housing for low-income people. Evidence of the effectiveness of such interventions is emerging despite scientific and political obstacles to their development, implementation, and evaluation. The U.S. government can help build the evidence base for such interventions. It can also implement those with demonstrated or promising results as part of a cost-effective HIV prevention strategy domestically and globally.

Estimated future HIV prevalence, incidence, and potential infections averted in the United States: a multiple scenario analysis

OBJECTIVES

To estimate the potential future burden of HIV in the United States under different intervention scenarios.

METHODS

We modeled future HIV incidence, prevalence, and infections averted using 2006 estimates of HIV incidence (55,400 new infections per year), prevalence (1,107,000 persons living with HIV), and transmission rate (5.0 per 100 persons living with HIV). We modeled 10-year trends for 3 base-case scenarios (steady incidence, steady transmission rate, declining transmission rate based on the 2000-2006 trend) and 2 intensified HIV intervention scenarios (50% reduction in transmission rate within 10 and 5 years).

RESULTS

Base-case scenarios predicted HIV prevalence increases of 24%-38% in 10 years. Reducing the transmission rate by 50% within 10 years reduces incidence by 40%; prevalence increases 20% to an estimated 1,329,000 persons living with HIV. Halving the transmission rate within 5 years reduces incidence by 46%; prevalence increases 13%, to 1,247,000. Although in year 10 incidence is similar regardless of the intervention time frame, more infections are averted when halving the transmission rate within 5 years.

CONCLUSIONS

HIV prevalence will likely increase creating additional demands for health care services. These analyses are instructive for setting HIV prevention goals for the nation and assessing potential cost savings of intensified HIV prevention efforts.

No evidence of increased sexual risk behaviour after initiating antiretroviral therapy among people who inject drugs

OBJECTIVE

Although antiretroviral therapy (ART) dramatically reduces viral load and improves survival among HIV-infected injection drug users (IDUs), several short-term studies have raised concerns that ART initiation may result in increases in sexual risk behaviour among IDUs.

DESIGN

We used data from a long-running cohort of HIV-positive IDUs to examine whether ART initiation was associated with increases in several measures of sexual risk behaviour. The date of ART initiation was determined through a validated linkage to a centralized ART dispensation pharmacy.

METHODS

We used generalized linear mixed-effects modelling to examine whether sexual activity, unprotected intercourse, and multiple sexual partnerships were more likely in the 12-month period following ART initiation.

RESULTS

Among 457 individuals who were ART naive at baseline, the median age was 34 [interquartile range (IQR) 28-41] and 202 (44.2%) were women. Between May 1996 and April 2008, 260 (56.7%) participants initiated ART. In multivariate analyses, ART initiation was not associated with sexual activity [adjusted odds ratio (AOR) = 0.87, 95% confidence interval (CI) 0.60-1.25], unprotected intercourse (AOR = 0.82, 95% CI 0.51-1.31), or multiple sexual partnerships (AOR = 0.93, 95% CI 0.61-1.40).

CONCLUSION

In this study of HIV-positive IDUs, we failed to detect an increase in sexual risk behaviour during the period following ART initiation. In light of this evidence, and given the known positive effect of ART on survival and its potential role in reducing HIV transmission, concerns regarding potential increases in sexual risk-taking should not undermine the delivery of ART to IDUs.

Antiretroviral use among active injection-drug users: the role of patient-provider engagement and structural factors

HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U.S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.

Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV

Homelessness affects HIV risk and health, but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS. Homeless/unstably housed people living with HIV/AIDS (N = 630) were randomly assigned to immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance or customary care. Self-reported data, CD4, and HIV viral load were collected at baseline, 6, 12, and 18 months. Results showed that housing status improved in both groups, with greater improvement occurring in the treatment group. At 18 months, 51% of the comparison group had their own housing, limiting statistical power. Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health; significant differential change benefiting the treatment group was observed for depression and perceived stress. Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization, mental health, and physical health. HOPWA rental assistance improves housing status and, in some cases, health outcomes of homeless and unstably housed people living with HIV/AIDS.

Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV

Prior research suggests that the interconnections between substance use, HIV risk and lack of adherence to HIV medications are especially strong among homeless individuals. Thus, study of these interconnections warrants public health attention. The objectives of this paper are to describe patterns of alcohol and drug use, associations between substance use and participation in high-risk sex, and associations between substance use and adherence to HIV treatment regimens among a sample of 602 homeless or unstably housed HIV-seropositive individuals who are part of a housing-based intervention--the Housing and Health Study. Participants experienced high levels of substance use. Significant associations were found between substance use and adherence to HIV treatment medications, and between substance use and high-risk sexual practices within the entire group. Group analyses by sexual orientation/gender show that the association between substance use and treatment adherence is found primarily among heterosexual males whereas the relationship between several drugs and high-risk sexual practices is strongest among gay and bisexual men. Health professionals working with HIV-seropositive individuals should routinely ascertain housing status and screen for substance use and risky sex.

The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV

HIV-related stigma negatively affects the lives of persons living with HIV/AIDS (PLWHA). Homeless/unstably housed PLWHA experience myriad challenges and may be particularly vulnerable to the effects of HIV-related stigma. Homeless/unstably housed PLWHA from 3 U.S. cities (N = 637) completed computer-assisted interviews that measured demographics, self-assessed physical and mental health, medical utilization, adherence, HIV disclosure, and risk behaviors. Internal and perceived external HIV stigma were assessed and combined for a total stigma score. Higher levels of stigma were experienced by women, homeless participants, those with a high school education or less, and those more recently diagnosed with HIV. Stigma was strongly associated with poorer self-assessed physical and mental health, and perceived external stigma was associated with recent non-adherence to HIV treatment. Perceived external stigma was associated with decreased HIV disclosure to social network members, and internal stigma was associated with drug use and non-disclosure to sex partners. Interventions are needed to reduce HIV-related stigma and its effects on the health of homeless/unstably housed PLWHA.

Intentional abstinence among homeless and unstably housed persons living with HIV/AIDS

Some persons living with HIV/AIDS (PLWHA) engage in periods of sexual abstinence. Baseline data from a larger study of homeless/unstably housed PLWHA indicated that 20% (125/644) intentionally abstained from sex in the past 90 days. Reasons included: (1) 'not interested' (n = 78); (2) did not want to infect someone (n = 46); and (3) did not have a partner (n = 37). Abstinence was less likely among all who had a main partner. Among men who have sex with men (MSM), abstinence was less likely among those with a detectable viral load. It was more likely among heterosexual men who were experiencing current housing problems and who had at least a high school education. Among women, abstinence was less likely among African Americans and those whose social networks were more aware of their HIV status. Better understanding of motivations to abstain may improve how programs serving PLWHA address this issue.

A review of the Centers for Disease Control and Prevention's response to the HIV/AIDS crisis among Blacks in the United States, 1981-2009

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

Hospitalized HIV-infected patients in the era of highly active antiretroviral therapy

We interviewed 1038 HIV-positive inpatients in public hospitals in Miami, Florida, and Atlanta, Georgia, to examine patient factors associated with use of HIV care, use of antiretroviral therapy, and unprotected sexual intercourse. Multivariate analyses and multiple logistic regression models showed that use of crack cocaine and heavy drinking were associated with never having had an HIV-care provider, high-risk sexual behavior, and not receiving antiretroviral therapy. Inpatient interventions that link and retain HIV-positive persons in primary care services could prevent HIV transmission and unnecessary hospitalizations.

Housing status and HIV risk behaviors among homeless and housed persons with HIV

OBJECTIVES

To compare drug, alcohol, and sexual HIV transmission risk behaviors of homeless and housed people living with HIV/AIDS.

METHODS

Data were from 8075 respondents in a cross-sectional, multisite behavioral survey of adults recently reported to have HIV infection.

RESULTS

At interview, 310 respondents (4%) were homeless. Compared with homeless respondents, housed respondents were more likely to be sexually active (past 12 months). However, sexually active homeless respondents had more sex partners (lifetime and past 12 months), greater sex exchange for money or drugs (lifetime and past 12 months), and greater unprotected vaginal or anal sex with an unknown serostatus partner. Homeless respondents were more likely to have possible alcohol abuse (lifetime), used drugs (last 12 months), and injected drugs (lifetime and past 12 months). After controlling for potential confounding variables, housing status remained a significant predictor of number of sex partners (past 12 months), sex exchange (lifetime and past 12 months), unprotected sex with unknown status partner, and all drug and alcohol use variables.

CONCLUSIONS

Homeless people living with HIV/AIDS are more likely to have ever or recently engaged in substance use and HIV transmission risk behaviors. Findings underscore the need to provide HIV prevention services to homeless persons and address their housing needs.

Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth

The role that environmental factors play in driving HIV and STI transmission risk among street-involved youth has not been well examined. We examined factors associated with number of sex partners using quasi-Poisson regression and consistent condom use using logistic regression among participants enroled in the At Risk Youth Study (ARYS). Among 529 participants, 253 (47.8%) reported multiple partners while only 127 (24.0%) reported consistent condom use in the past 6 months. Homelessness was inversely associated with consistent condom use (adjusted odds ratio [aOR]=0.47, p=0.008), while unstable housing was positively associated with greater numbers of sex partners (adjusted incidence rate ratio [aIRR]=1.44, p=0.010). These findings indicate the need for interventions which modify environmental factors that drive risk among young street-involved populations.

Evaluation of bias in HIV seroprevalence estimates from national household surveys

OBJECTIVES

To evaluate HIV seroprevalence estimates from demographic and health surveys (DHS) and AIDS indicator surveys (AIS) for potential bias because of non-response and exclusion of non-household population groups.

METHODS

Data are from 14 DHS/AIS surveys with HIV testing, conducted during 2003-6. Blood samples were collected and analysed for HIV using standard laboratory and quality control procedures. HIV prevalence among non-tested adults was predicted based on multivariate statistical models of HIV for those who were interviewed and tested, using a common set of predictor variables. Estimates of the size of non-household populations in national censuses were used to assess potential bias because of their exclusion in the household surveys under different assumptions about proportion of adults and HIV prevalence in non-household populations.

RESULTS

Non-tested men had significantly higher predicted HIV prevalence than those tested in eight of the 14 countries, while non-tested women had significantly higher predicted prevalence than those tested in seven of the 14 countries. Effects of non-response were somewhat stronger in lower-prevalence countries. The overall effect of non-response on observed national HIV estimates was small and insignificant in all countries. Estimated effects of exclusion of non-household population groups were generally small, even in concentrated epidemics in India and Cambodia under the scenario that 75% of the non-household population was adults having 20 times greater HIV prevalence than adults in household surveys.

CONCLUSIONS

Non-response and the exclusion of non-household population groups tend to have small, insignificant effects on national HIV seroprevalence estimates obtained from household surveys.

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS

OBJECTIVES

We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS.

METHODS

Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive.

RESULTS

At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables.

CONCLUSIONS

Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.