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Ali A, Groot G, April M, MacPhee M, Witham S, Alimezelli H, Carr T. Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation. BMJ Open 2024; 14:e075194. [PMID: 38740498 PMCID: PMC11097874 DOI: 10.1136/bmjopen-2023-075194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan. OBJECTIVES The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme. DESIGN AND SETTING Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team. PARTICIPANTS 11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews. INTERVENTIONS Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations. RESULTS CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum's harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a 'safe' home-like setting. Underlying mechanisms that contributed to participants' success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health. CONCLUSIONS Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.
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Affiliation(s)
- Anum Ali
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Gary Groot
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Melissa April
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Maura MacPhee
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Hubert Alimezelli
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Tracey Carr
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Filippone P, Serrano S, Campos S, Freeman R, Cluesman SR, Israel K, Amos B, Cleland CM, Gwadz M. Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV. Int J Equity Health 2023; 22:168. [PMID: 37649049 PMCID: PMC10466874 DOI: 10.1186/s12939-023-01992-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects. METHODS Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis. RESULTS Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience. CONCLUSIONS To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.
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Affiliation(s)
- Prema Filippone
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Samantha Serrano
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Stephanie Campos
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Robin Freeman
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Sabrina R Cluesman
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Khadija Israel
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Brianna Amos
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA
| | - Charles M Cleland
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY, 10016, USA
| | - Marya Gwadz
- New York University Silver School of Social Work, 1 Washington Place North, New York, NY, 10003, USA.
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Zhao Y, Shannon K, Buxton JA, Ti L, Genovy TA, Braschel M, Pick N, Kestler M, Deering K. Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada. AIDS Behav 2023; 27:2271-2284. [PMID: 36729293 PMCID: PMC10564463 DOI: 10.1007/s10461-022-03957-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 02/03/2023]
Abstract
We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.
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Affiliation(s)
- Yinong Zhao
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Kate Shannon
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Jane A Buxton
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Disease Control, Vancouver, Canada
| | - Lianping Ti
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Theresa Anne Genovy
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada
| | - Melissa Braschel
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada
| | - Neora Pick
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Oak Tree Clinic, BC Women's Hospital, Vancouver, Canada
| | - Mary Kestler
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Oak Tree Clinic, BC Women's Hospital, Vancouver, Canada
| | - Kathleen Deering
- Centre for Gender and Sexual Health Equity, University of British Columbia, Vancouver, Canada.
- Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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Gouse I, Walters S, Miller-Archie S, Singh T, Lim S. Evaluation of New York/New York III permanent supportive housing program. EVALUATION AND PROGRAM PLANNING 2023; 97:102245. [PMID: 36764060 DOI: 10.1016/j.evalprogplan.2023.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/05/2023] [Accepted: 01/27/2023] [Indexed: 06/18/2023]
Abstract
In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007-2017) from the NY/NY III evaluation team, to analyze this program's impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.
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Affiliation(s)
- Isabel Gouse
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 7th Floor, Queens, NY 11101, USA.
| | - Sarah Walters
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 7th Floor, Queens, NY 11101, USA
| | - Sara Miller-Archie
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 7th Floor, Queens, NY 11101, USA
| | - Tejinder Singh
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 7th Floor, Queens, NY 11101, USA
| | - Sungwoo Lim
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 7th Floor, Queens, NY 11101, USA
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Miller-Archie SA, Walters SC, Bocour A, Moore MS, Wiewel E, Singh T, Lim S. The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection. J Infect Dis 2022; 226:S363-S371. [PMID: 36208165 PMCID: PMC9547527 DOI: 10.1093/infdis/jiac292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/08/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection. METHODS We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility. RESULTS We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years. CONCLUSIONS Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.
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Affiliation(s)
- Sara A Miller-Archie
- Correspondence: S. A. Miller-Archie, MPH, New York City Department of Health and Mental Hygiene, Division of Epidemiology, 4209 28th St., Long Island City, NY 11101 ()
| | - Sarah C Walters
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Angelica Bocour
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Miranda S Moore
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ellen Wiewel
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Tejinder Singh
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Sungwoo Lim
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
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Lin CH, Moore A, Henderson SO. A Missing Piece of Diabetes Management: A Correctional Health Perspective. JOURNAL OF CORRECTIONAL HEALTH CARE 2022; 28:190-192. [PMID: 35506978 DOI: 10.1089/jchc.20.06.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A cross-sectional study was conducted in January 2020 to evaluate type 1 diabetes (T1D) management during and between incarcerations at the Los Angeles County Jail. Inclusion criteria were men with a T1D diagnosis who had been incarcerated twice within 5 years with at least two hemoglobin A1c values during each incarceration and a minimum of 3 months in the community between incarcerations. The primary outcome was the percentage change in A1c after release compared with the A1c during incarcerations. Five patients met inclusion criteria. During the first and second incarcerations, mean A1c was reduced by 13% and 9.6%, respectively. While in the community, mean A1c increased by 14%. These results highlight the importance of comprehensive reentry programs for patients with T1D, including linkage to community resources for diabetes management, so health gains made during incarceration are not lost.
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Affiliation(s)
- Cindy H Lin
- Los Angeles County Department of Health Services, Correctional Health Services, Los Angeles, California, USA
| | - Alia Moore
- Los Angeles County Department of Health Services, Correctional Health Services, Los Angeles, California, USA
| | - Sean O Henderson
- Los Angeles County Department of Health Services, Correctional Health Services, Los Angeles, California, USA
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Onapa H, Sharpley CF, Bitsika V, McMillan ME, MacLure K, Smith L, Agnew LL. The physical and mental health effects of housing homeless people: A systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:448-468. [PMID: 34423491 DOI: 10.1111/hsc.13486] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/26/2021] [Accepted: 06/07/2021] [Indexed: 05/25/2023]
Abstract
Housing is a significant determinant of health and is widely accepted as a key solution to address some of the health disparities that exist among the homeless. It is estimated that 150 million people worldwide are homeless, and approximately 1.8 billion lack adequate housing. However, understanding of how housing has a positive impact on the health of the homeless remains unclear and underdeveloped. This systematic review investigates intervention studies that report on the physical and mental health effects of housing homeless persons. A search of PubMed, PsycINFO, EBSCOHost-Academic Search Complete and the Cochrane Library was conducted for peer-reviewed articles published in English from 1999 to 2020 that had a combination of at least one housing intervention and health outcome, with a homeless sample. Three previous reviews and 24 studies were included for analysis. Most of the studies (n = 20) encompassed permanent supportive housing interventions that emphasised placing homeless people with mental illness directly into affordable housing with access to support services. The primary health outcomes reported were general physical and mental health, well-being, and quality of life. Despite inconsistent findings and significant issues identified in the reviewed literature, housing (in the short term) improves some aspects of health in homeless populations with human immunodeficiency virus, anxiety and depression.
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Affiliation(s)
- Hebaat Onapa
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Christopher F Sharpley
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Vicki Bitsika
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Mary E McMillan
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
| | | | - Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Linda L Agnew
- Brain-Behaviour Research Group, School of Science and Technology, University of New England, Armidale, NSW, Australia
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Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, Tsemberis S. Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review. Drug Alcohol Depend 2021; 228:109052. [PMID: 34601279 DOI: 10.1016/j.drugalcdep.2021.109052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First. METHODS A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use. RESULTS A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work. CONCLUSIONS Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.
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Affiliation(s)
- Nick Kerman
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada.
| | - Alexia Polillo
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada; University of Toronto, Department of Psychiatry, 250 College Street, 8th Floor, Toronto, Ontario, M5T 1R8, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, V6Z 2A9, Canada; University of British Columbia, Department of Medicine, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sophia Gran-Ruaz
- University of Ottawa, School of Psychology, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, Ontario, K1N 6N5, Canada
| | - Cathi Savage
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Charlie Felteau
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Sam Tsemberis
- Pathways Housing First Institute, 1328 2nd Street, Santa Monica, CA, 90403, United States
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Lekas HM, Lewis C, Lunden S, Olender SA, Rosen-Metsch L. Single Room Occupancy Residence: Processes Linking Housing to Not Engaging in HIV Outpatient Care. AIDS Behav 2021; 25:2644-2656. [PMID: 33743114 DOI: 10.1007/s10461-021-03225-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/28/2022]
Abstract
Homelessness and housing instability undermine engagement in medical care, adherence to treatment and health among persons with HIV/AIDS. However, the processes by which unstable and unsafe housing result in adverse health outcomes remain understudied and are the focus of this manuscript. From 2012 to 2014, we conducted qualitative interviews among inpatients with HIV disengaged from outpatient care (n = 120). We analyzed the content of the interviews with participants who reported a single room occupancy (SRO) residence (n = 44), guided by the Health Lifestyle Theory. Although SROs emerged as residences that were unhygienic and conducive to drug use and violence, participants remained in the SRO system for long periods of time. This generated experiences of living instability, insecurity and lack of control that reinforced a set of tendencies (habitus) and behaviors antithetical to adhering to medical care. We called for research and interventions to transform SROs into housing protective of its residents' health and wellbeing.
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Affiliation(s)
- Helen-Maria Lekas
- Division of Social Solutions and Services Research, Nathan S. Kline Institute for Psychiatric Research, 140 Old Orangeburg Road, Bldg. 35, Orangeburg, NY, USA.
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA.
| | - Crystal Lewis
- Division of Social Solutions and Services Research, Nathan S. Kline Institute for Psychiatric Research, 140 Old Orangeburg Road, Bldg. 35, Orangeburg, NY, USA
- Department of Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Sara Lunden
- Benjamin N. Cardoso School of Law, Yeshiva University, New York, NY, USA
| | - Susan Aileen Olender
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Rosen-Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
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10
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Fletcher-Hildebrand S, Alimezelli H, Carr T, Lawson K, Ali A, Groot G. Understanding the impact of a residential housing programme for people living with HIV/AIDS: a realist evaluation protocol. BMJ Open 2021; 11:e044522. [PMID: 33820789 PMCID: PMC8030488 DOI: 10.1136/bmjopen-2020-044522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Housing instability and homelessness are significant barriers to medical treatment for people living with HIV/AIDS. For these individuals, lack of stable housing and stigma is associated with insufficient access to care, poor adherence to medication and higher cost burdens to the healthcare system. This protocol reports on the efforts to evaluate Sanctum V.1.0, a hospice and transitional care home for adults with HIV/AIDS in Saskatoon, Saskatchewan, Canada. The current project was developed out of a need to identify how Sanctum V.1.0 produces varying programme outcomes to assist in endeavours to replicate the programme in other geographic locations. METHODS AND ANALYSIS A realist evaluation will be conducted to explore how and why Sanctum V.1.0 is successful or unsuccessful, in which circumstances and for whom. Rather than explore the degree to which a programme is effective, realist evaluations seek to uncover mechanisms that explain processual links between programme inputs and outcomes. The completed first phase of the project involved the development of an initial realist programme theory. Phases 2 and 3 will consist of methods to test, refine and validate the initial theory using various data sources. ETHICS AND DISSEMINATION Ethics approval was obtained from the institutional review board at the University of Saskatchewan on 2 July 2020. Results will be disseminated according to stakeholders' desires.
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Affiliation(s)
| | - Hubert Alimezelli
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Tracey Carr
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Karen Lawson
- Psychology, University of Saskatchewan College of Arts and Science, Saskatoon, Saskatchewan, Canada
| | - Anum Ali
- Community Health and Epidemiology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Gary Groot
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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11
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Quinn KG, DiFranceisco W, Spector A, Bendixen A, Peters A, Dickson-Gomez J. The Effect of Various Supportive Housing Models on ART Adherence Among Persons Living With HIV in Supportive Housing. Med Care 2021; 59:S124-S131. [PMID: 33710084 PMCID: PMC7958970 DOI: 10.1097/mlr.0000000000001336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Providing permanent supportive housing to chronically homeless persons living with human immunodeficiency virus (PLH) contributes to improved human immunodeficiency virus (HIV) outcomes, including adherence to antiretroviral therapy (ART). This study seeks to understand whether certain components of housing, namely intensity of case management and specialized HIV housing programs, affects ART adherence for PLH in supportive housing. METHODS From 2015 to 2019 we conducted quantitative assessments with 157 PLH in supportive housing at baseline, 6-, 12-, and 18-month postbaseline to identify factors associated with ART adherence. General Estimating Equations for repeated measures were performed to assess bivariate and multivariate measures. RESULTS Two thirds of PLH in supportive housing reported 95% or greater adherence to ART. Multivariate analyses indicate that neither intensity of case management services nor specialized housing for PLH were associated with greater ART adherence. Greater time since diagnosis was positively associated with ART adherence. Greater depressive symptoms and African American race were negatively associated with ART adherence. CONCLUSIONS Study findings reveal that although prior research has established the importance of receipt of housing for homeless PLH, the type or intensity of case management services associated with that housing may not be as important as simply being housed. Our results highlight the importance of considering mental health and more recent HIV diagnosis when developing treatment and case management plans to enhance residents' ART adherence.
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Affiliation(s)
- Katherine G Quinn
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research
| | - Wayne DiFranceisco
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research
| | - Antoinette Spector
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Julia Dickson-Gomez
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
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12
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Housing Subsidies and Housing Stability are Associated with Better HIV Medical Outcomes Among Persons Who Experienced Homelessness and Live with HIV and Mental Illness or Substance Use Disorder. AIDS Behav 2020; 24:3252-3263. [PMID: 32180090 DOI: 10.1007/s10461-020-02810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Among 958 applicants to a supportive housing program for low-income persons living with HIV (PLWH) and mental illness or a substance use disorder, we assessed impacts of housing placement on housing stability, HIV care engagement, and viral suppression. Surveillance and administrative datasets provided medical and residence information, including stable (e.g., rental assistance, supportive housing) and unstable (e.g., emergency shelter) government-subsidized housing. Sequence analysis identified a "quick stable housing" pattern for 67% of persons placed by this program within 2 years, vs. 28% of unplaced. Compared with unplaced persons not achieving stable housing quickly, persons quickly achieving stable housing were more likely to engage in care, whether placed (per Poisson regression, ARR: 1.14;95% CI 1.09-1.20) or unplaced (1.19;1.13-1.25) by this program, and to be virally suppressed, whether placed (1.22;1.03-1.44) or unplaced (1.26, 1.03-1.56) by this program. Housing programs can help homeless PLWH secure stable housing quickly, manage their infection, and prevent transmission.
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13
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Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies. Curr HIV/AIDS Rep 2020; 17:259-267. [PMID: 32382919 DOI: 10.1007/s11904-020-00488-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology. RECENT FINDINGS Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.
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14
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Gheibi Z, Dianatinasab M, Haghparast A, Mirzazadeh A, Fararouei M. Gender difference in all-cause mortality of people living with HIV in Iran: findings from a 20-year cohort study. HIV Med 2020; 21:659-667. [PMID: 32876392 DOI: 10.1111/hiv.12940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Gender differences in the efficacy of treatment and the mortality of HIV-infected patients have not yet been fully elucidated. For the first time, we used data from a 20-year cohort of people living with HIV (PLWH) in four provinces (Fars, Bushehr, Bandar Abbas, and Kohgiluyeh and Boyer-Ahmad) in the southern part of Iran to assess the gender difference in all-cause mortality in PLWH in Iran. METHODS We analysed data for 1216 patients aged ≥ 15 years who were diagnosed with HIV/AIDS between 1997 and 2017. Three hundred and fourteen (25.8%) were women. RESULTS The death rate from all causes among women was 13.7% vs. 43.8% among men (P < 0.001). All-cause mortality was significantly associated with gender [the adjusted hazard ratio (aHR) for men compared with women was 3.20], not being on antiretroviral therapy (ART) compared with being on ART at the last visit (aHR 5.42), older age (aHR 1.03), delayed HIV diagnosis compared with early diagnosis (aHR 1.72), history of incarceration (aHR 1.57), higher log CD4 count at diagnosis (aHR 0.54), and prophylaxis for Pneumocystis pneumonia (aHR 0.09). CONCLUSIONS The results of this 20-year cohort study suggest that gender is an important predictor of survival among HIV-infected patients. Improving early HIV diagnosis and early ART initiation in men, as well as increased access to hepatitis C virus treatment are needed to increase the survival rate of HIV-infected patients in Iran.
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Affiliation(s)
- Z Gheibi
- Department of Epidemiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M Dianatinasab
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran.,Department of Complex Genetics and Epidemiology, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - A Haghparast
- School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Mirzazadeh
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - M Fararouei
- Shiraz HIV/AIDS Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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15
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Hessol NA, Eng M, Vu A, Pipkin S, Hsu LC, Scheer S. A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco. BMC Public Health 2019; 19:1440. [PMID: 31675932 PMCID: PMC6825332 DOI: 10.1186/s12889-019-7817-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/21/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND San Francisco has implemented several programs addressing the needs of two large vulnerable populations: people living with HIV and those who are homeless. Assessment of these programs on health outcomes is paramount for reducing preventable deaths. METHODS Individuals diagnosed with HIV/AIDS and reported to the San Francisco Department of Public Health HIV surveillance registry, ages 13 years or older, who resided in San Francisco at the time of diagnosis, and who died between January 1, 2002, and December 31, 2016 were included in this longitudinal study. The primary independent variable was housing status, dichotomized as ever homeless since diagnosed with HIV, and the dependent variables were disease-specific causes of death, as noted on the death certificate. The Cochran-Armitage test measured changes in the mortality rates over time and unadjusted and adjusted Poisson regression models measured prevalence ratios (PR) and 95% confidence intervals (CI) for causes of death. RESULTS A total of 4158 deceased individuals were included in the analyses: the majority were male (87%), ages 40-59 years old at the time of death (64%), non-Hispanic White (60%), men who have sex with men (54%), had an AIDS diagnosis prior to death (87%), and San Francisco residents at the time of death (63%). Compared to those who were housed, those who were homeless were more likely to be younger at time of death, African American, have a history of injecting drugs, female or transgender, and were living below the poverty level (all p values < 0.0001). Among decedents who were SF residents at the time of death, there were declines in the proportion of deaths due to AIDS-defining conditions (p < 0.05) and increases in accidents, cardiomyopathy, heart disease, ischemic disease, non-AIDS cancers, and drug overdoses (p < 0.05). After adjustment, deaths due to mental disorders (aPR = 1.63, 95% CI 1.24, 2.14) were more likely and deaths due to non-AIDS cancers (aPR = 0.63, 95% CI 0.44, 0.89) were less likely among those experiencing homelessness. CONCLUSIONS Additional efforts are needed to improve mental health services to homeless people with HIV and prevent mental-health related mortality.
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Affiliation(s)
- Nancy A Hessol
- Department of Clinical Pharmacy, University of California, 3333 California Street, Suite 420, San Francisco, CA, 94118, USA.
| | - Monica Eng
- Department of Clinical Pharmacy, University of California, 3333 California Street, Suite 420, San Francisco, CA, 94118, USA
| | - Annie Vu
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Sharon Pipkin
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Ling C Hsu
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Susan Scheer
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
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Homelessness at diagnosis is associated with death among people with HIV in a population-based study of a US city. AIDS 2019; 33:1789-1794. [PMID: 31259765 DOI: 10.1097/qad.0000000000002287] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE San Francisco, California, has experienced a 44% reduction in new HIV diagnoses since 2013 supported by its 'Getting to Zero' initiative; however, the age-adjusted mortality rate in people with HIV (PWH) has not decreased. We sought to identify factors associated with death among PWH in San Francisco. DESIGN Population-based incidence-density case-control study. METHODS Among PWH in the San Francisco HIV surveillance registry, a random sample of 48 decedents from 1 July 2016 to 31 May 2017 were each matched to two to three controls who were alive at the date of death (108 controls matched on age and time since diagnosis). Covariates included demographics, substance use, housing status, medical conditions, and care indicators from the study population. We used matched-pair conditional logistic regression to examine factors associated with mortality. RESULTS Of the 156 PWH in the study, 14% were African-American, 14% Latino, and 8% female sex. In adjusted analysis, factors associated with higher odds of death included: homelessness at HIV diagnosis [adjusted odds ratio (AOR) = 27.4; 95% confidence interval (CI) = 3.0-552.1], prior-year IDU (AOR = 10.2; 95% CI = 1.7-128.5), prior-year tobacco use (AOR = 7.2; 95% CI = 1.7-46.9), being off antiretroviral therapy at any point in the prior year (AOR = 6.8; 95% CI = 1.1-71.4), and being unpartnered vs. married/partnered (AOR = 4.7; 95% CI = 1.3-22.0). CONCLUSION People homeless at HIV diagnosis had 27-fold higher odds of death compared with those with housing; substance use and retention on antiretroviral therapy in the prior year are other important intervenable factors. New strategies to address these barriers, and continued investment in supportive housing and substance use treatment, are needed.
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