Social, structural and behavioral determinants of overall health status in a cohort of homeless and unstably housed HIV-infected men

'You feel how you look': Exploring the impacts of unmet water, sanitation, and hygiene needs among rural people experiencing homelessness and their intersection with drug use

Existing literature attests to water, sanitation, and hygiene (WASH) inequities among people experiencing homelessness (PEH) in the United States, but there is a dearth of research on such issues in rural areas. Homelessness is an emerging public health concern in rural areas where homelessness is on the rise, infectious disease outbreaks are becoming increasingly common, and PEH face unique WASH-related challenges compared to their urban counterparts. We conducted an exploratory study to understand the impacts of unmet WASH needs among rural PEH and their intersection with drug use through in-depth interviews (n = 10). Eligible participants were 18 years or older, lived in one of five Central Appalachian counties, and had experienced homelessness in the previous six months. Using thematic analysis, we identified factors that inhibit WASH access, and adverse health and well-being outcomes that result from unmet WASH needs. We also explore how WASH experiences compare among rural PEH who self-reported drug use to those who did not. Our findings revealed that factors at multiple levels inhibited WASH access, including stigma and place-based characteristics, which contributed to the adverse physical, mental, and emotional health of PEH. Comparisons between PEH who used drugs to those that did not revealed the intricate relationship between WASH, homelessness, and substance use in communities impacted by the opioid epidemic. Expanded WASH facilities that are safe and available with no prerequisites can address inadequate access among rural PEH and collaboration with harm reduction services may be advantageous to reach those who inject drugs.

The effect of homelessness on viral suppression in an underserved metropolitan area of middle Tennessee: potential implications for ending the HIV epidemic

BACKGROUND

A wealth of scientific evidence supports the effectiveness of HIV prophylaxis and treatment. Homelessness is strongly associated with the health status and viral suppression among underserved populations and can undermine the national plan to eliminate HIV by 2030. This retrospective observational study examined the extent in which homelessness affects HIV treatment in an underserved urban area of Middle Tennessee in 2014-2019.

RESULTS

Among 692 HIV-seropositive patients, the proportion of homeless patients increased from 13.5% in 2014 to 27.7% in 2019, thrice the national average for HIV-seropositive people (8.4%) and twice that of HIV positive patients who are participating in Ryan White programs nationwide (12.9%). Our findings suggest that homeless patients were half as likely to achieve viral suppression as compared to those who had a permanent/stable home [OR 0.48 (0.32-0.72), p-value < 0.001].

CONCLUSION

Our study indicates that homelessness may play an important role in viral suppression among persons living with HIV/AIDS in Middle Tennessee.

Hand hygiene during the COVID-19 pandemic among people experiencing homelessness-Atlanta, Georgia, 2020

People experiencing homelessness are at risk for coronavirus disease 2019 (COVID-19) and may experience barriers to hand hygiene, a primary recommendation for COVID-19 prevention. We conducted in-depth interviews with 51 people experiencing sheltered and unsheltered homelessness in Atlanta, Georgia during May 2020 to August 2020 to (1) describe challenges and opportunities related to hand hygiene and (2) assess hand hygiene communication preferences. The primary hand hygiene barrier reported was limited access to facilities and supplies, which has disproportionately impacted people experiencing unsheltered homelessness. This lack of access has reportedly been exacerbated during COVID-19 by the closure of public facilities and businesses. Increased access to housing and employment were identified as long-term solutions to improving hand hygiene. Overall, participants expressed a preference for access to facilities and supplies over hand hygiene communication materials.

Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness

BACKGROUND

People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients.

OBJECTIVE

To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness.

DESIGN

This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals.

PARTICIPANTS

Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission.

MAIN MEASURES

Unplanned all-cause readmission to the study hospital within 90 days of discharge.

KEY RESULTS

Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23).

CONCLUSION

Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.

What Racism Has to Do with It: Understanding and Reducing Sexually Transmitted Diseases in Youth of Color

Sexually transmitted diseases (STDs) are high in populations of color compared to Whites. High-risk sexual behaviors are widely viewed as the key contributors to the levels of STDs, especially in adolescents and young adults. This article situates the sexual risk behaviors of Black, Indigenous, and other young people of color within the framework of racism. It begins with an overview of racial inequities in common STDs and shows how racism gives rise to several risk factors for high-risk sexual behaviors. These risk factors for STDs identified in prior research are best understood as adaptations to the challenges and constraints faced by youth in socially disadvantaged environments. Both social adversity and the mental health problems that it triggers can lead to risky sexual behaviors. Drawing on findings from prior research with youth of color, this paper describes the needed interventions that can markedly reduce STDs and their risk factors. It also describes needed research on interventions that could contribute to the knowledge and understanding of the adverse conditions fueled by racism that affect youth of color, their health, and their communities.

Health-related quality of life and related factors among chronically homeless adults living in different permanent supportive housing models: a cross-sectional study

PURPOSE

Permanent supportive housing (PSH) is an effective intervention to improve residential stability and reduce the utilization of costlier healthcare services for the chronically homeless. However, there has been little focus on health-related quality of life (HRQL) once they enter PSH, and the potential influence of other factors including the PSH model. Study results can shed light on the HRQL of the PSH population and inform strategies to improve PSH program effectiveness in this area.

METHODS

In this cross-sectional study, survey methods were used to assess the HRQL of PSH residents in the Chicago metropolitan area. The survey also included questions on socio-demographics, health behaviors, housing and neighborhood characteristics, and housing satisfaction. The SF-36 was used to obtain physical (PCS) and mental component summary (MCS) scores for HRQL. Other variables were selected using the Wilson and Cleary HRQL model. Statistical analyses included summary statistics, bivariate analyses, and fully adjusted linear regression models.

RESULTS

The study sample included 855 adults currently in PSH. The sample was predominantly African American men with an average age of 53 years. Mean scores for PCS and MCS were 39.4 and 46.1, respectively, (out of 100). In adjusted analyses, older age and being on disability were associated with worse PCS. Having HIV was associated with better PCS. Being non-Hispanic Black, living in fixed-sited housing, and being in PSH for longer durations were associated with better MCS. More depressive symptoms was associated with worse PCS and MCS.

CONCLUSION

While both aspects of the PSH model (housing configuration and service provision) were initially associated with HRQL in unadjusted analyses, housing configuration was the only PSH model variable that remained significant once accounting for other factors. Depressive symptomology and the social environment also appear to be important correlates of HRQL and are potential areas to target in PSH programs.

Knowledge and Attitudes About Pre-Exposure Prophylaxis Among Young Adults Experiencing Homelessness in Seven U.S. Cities

PURPOSE

Evidence suggests that young adults experiencing homelessness (YEH) are at elevated risk of HIV compared to housed youth. Given the limited research on pre-exposure prophylaxis (PrEP) awareness among YEH, this study examined their PrEP knowledge and attitudes.

METHODS

Data from a cross-sectional survey among YEH (ages 18-26) (n = 1,427) in seven U.S. cities were used to assess their knowledge and attitudes regarding PrEP to inform HIV prevention efforts.

RESULTS

Participants were primarily male youth of color. The mean age was 20.9years. While 66% felt at risk for HIV, only 14% strongly agreed that they try to protect themselves from getting infected with HIV. Most (84%) were eligible for PrEP based on risk, yet only 29% had knowledge of PrEP. Despite this, 59% reported they were likely/extremely likely to take PrEP. Access to free PrEP (55%), HIV testing (72%), healthcare (68%), and one-on-one (62%), and text messaging support (57%) were rated as very/extremely important for PrEP uptake and adherence.

CONCLUSIONS

The results of this study suggest missed opportunities to prevent new HIV infections among YEH. Efforts to increase PrEP uptake among this population should consider provider- and system-level interventions to increase PrEP awareness, decrease PrEP-associated healthcare costs, improve access to PrEP providers, and provide in-person and text messaging support.

Exploring social ecological pathways from resilience to quality of life among women living with HIV in Canada

Resilience, positive growth in contexts of stress and adversity, is shaped by social ecological factors. Among people living with HIV, resilience is associated with myriad positive health benefits and improved health-related quality of life (HR-QoL). Identifying contextual factors associated with resilience among women living with HIV (WLWH) is particularly important as this population experiences many stressors and inequalities. We examined social-ecological factors associated with resilience and its relationship with HR-QoL among WLWH. We utilized baseline survey data from a national cohort of WLWH (n = 1424) in Canada. We conducted structural equation modelling using maximum likelihood estimation methods to test the direct effects of social support and women-centred HIV care (WCHC) on resilience, and the direct effects of resilience on mental and physical HR-QoL. We also tested the indirect effects of resilience on HR-QoL via HIV disclosure concerns and economic insecurity. Participant median age was 43 years (IQR = 35-50); most participants were women of colour (29% Black; 22% Indigenous; 7% other ethnicities; 41% Caucasian). Social support and WCHC were associated with increased resilience. The direct path from resilience to mental HR-QoL was significant, accounting for the mediation effects of economic insecurity and social support. The direct path from resilience to physical HR-QoL was significant, accounting for the mediation effects of economic insecurity. Economic insecurity partially mediated the relationship between resilience and mental HR-QoL and physical HR-QoL. HIV disclosure concerns partially mediated the relationship between resilience and mental-HR-QoL. Model fit indices suggested that the model fit the data well (χ2[14] = 160.378, P < 0.001; CFI = 0.987; RMSE = 0.048 [90% CI:0.042-0.080]; SRMR = 0.036). Findings suggest social (social support) and structural (WCHC) factors increase resilience. While resilience is associated with improved HR-QoL, social (HIV disclosure concerns) and structural (economic insecurity) factors partially mediate these associations and threaten HR-QoL. Multi-level interventions can address social ecological contexts to advance resilience and HR-QoL among WLWH.

Characterizing Alcohol Use Behaviors among Homeless Men and Women

Objectives: In this study, we characterized alcohol use behaviors by sex among sheltered homeless adults and explored associations with health and readiness to change drinking behaviors. Methods: Participants (N = 581; 63.7% men; Mage = 43.6, 29.4% white) self-reported alcohol use and readiness to change drinking behaviors. Sex differences were analyzed via Wilcoxon ranksum, chi-square tests, logistic regression, and ANCOVAs. Results: Overall, 38.5% of the sample met criteria for current at-risk drinking, 39.7% self-reported a history of alcohol problems, and 22.9% reported having a formal alcohol use disorder (AUD) diagnosis. Among current alcohol users, 83.8% reported at-risk drinking. Men had more drinks per drinking day, more drinks per week, and more drinking days per week when compared to women. No sex differences were found for at-risk drinking, self-reported alcohol problems, probable alcohol abuse/dependence, AUD diagnosis, readiness to change drinking, or recent alcohol/substance abuse counseling. Conclusions: High rates of at-risk drinking were found among alcohol users. Homeless men and women did not exhibit differences in several manifestations of problematic alcohol use. Alcohol use interventions might be equally appealing to both sexes given equivalent readiness to change drinking; however, rates of recent treatment receipt were low.

Unmet basic needs negatively affect health-related quality of life in people aging with HIV: results from the Positive Spaces, Healthy Places study

Background

Basic needs (e.g., food security and stable housing) are important determinants of health and well-being, yet their impact on health-related quality of life (HRQoL) in the context of HIV and aging has not been systematically investigated.

Methods

Multiple linear regression models examined the relationship between unmet basic needs, and physical and mental HRQoL by age strata (20-34, 35-49 and 50+) in a cross-sectional sample of 496 people living with HIV in Ontario, Canada.

Results

An overwhelming majority of participants (87%) reported unmet needs related to food, clothing or housing. The prevalence of unmet basic needs in the two older groups appeared to be lower than among younger participants, but the difference did not reach statistical significance. The presence of unmet basic needs predicted substantially lower mean physical health and mental health summary scores in the two oldest groups. Notably, age moderated the influence of unmet basic needs on HRQoL.

Conclusions

The availability and accessibility of food security, appropriate clothing and stable housing for people living with HIV who are aging need to become a higher priority for program planners and decision makers.

Subsistence difficulties are associated with more barriers to quitting and worse abstinence outcomes among homeless smokers: evidence from two studies in Boston, Massachusetts

Background

Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study.

Methods

We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence.

Results

Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p < 0.001) but not with cessation readiness or confidence. A dose-response relationship was observed for most barriers, particularly psychosocial barriers. Among RCT participants, greater baseline subsistence difficulties predicted less smoking abstinence during follow-up in a dose-response fashion. In adjusted analyses, individuals with the highest level of subsistence difficulty had one-third the odds of being abstinent during follow-up compared to those without subsistence difficulties (OR 0.33, 95% CI 0.11–0.93) despite making a similar number of quit attempts.

Conclusions

Homeless smokers with greater subsistence difficulties perceive more barriers to quitting and are less likely to do so despite similar readiness, confidence, and attempts. Future studies should assess whether addressing subsistence difficulties improves cessation outcomes in this population.

Trial registration

ClinicalTrials.gov: NCT02565381.

Racial Inequities in HIV Prevalence and Composition of Risk Networks Among People Who Inject Drugs in HIV Prevention Trial Network 037

BACKGROUND

HIV prevention interventions in the United States have failed to eliminate racial inequities. Here, we evaluate factors associated with racial inequities in HIV prevalence among people who inject drugs using HIV Prevention Trial Network 037 data.

METHODS

We measured racial homophily (ie, all members share the same race), being in an HIV+ network (network with ≥1 HIV+ member), and drug and sex risk behaviors. A 2-level logistic regression with a random intercept evaluated the association between being in an HIV+ network and race adjusting for individual-level and network-level factors.

RESULTS

Data from 232 index participants and 464 network members were included in the analysis. Racial homophily was high among blacks (79%) and whites (70%); 27% of all-black, 14% of all-white, and 23% of racially mixed networks included HIV+ members. Sex risk was similar across networks, but needle sharing was significantly lower in all-black (23%) compared with all-white (48%) and racially mixed (46%) networks. All-black [adjusted odds ratio (AOR), 3.6; 95% confidence interval (CI), 1.4 to 9.5] and racially mixed (AOR, 2.0; 95% CI: 1.1 to 3.7) networks were more likely to include HIV+ network members; other factors associated with being in HIV+ network included homelessness (AOR, 2.0; 95% CI, 1.2 to 3.2), recent incarceration (AOR, 0.4; 95% CI, 0.2 to 0.7), and cocaine injection (AOR, 1.7; 95% CI, 1.0 to 2.7). Risk behaviors were not associated with being in an HIV+ network.

CONCLUSION

Despite having lower drug risk behavior, all-black networks disproportionately included HIV+ members. HIV prevention interventions for people who inject drugs need to go beyond individual risk and consider the composition of risk networks.

HIV-related stigma, racial discrimination, and gender discrimination: Pathways to physical and mental health-related quality of life among a national cohort of women living with HIV

Social inequities compromise health-related quality of life (HR-QoL) among women living with HIV (WLWH). Little is known about health impacts of intersecting stigma based on HIV status, race and gender among WLWH or potential mechanisms to promote HR-QoL. We tested pathways from multiple types of stigma (HIV-related, racial, gender) to physical and mental HR-QoL utilizing baseline survey data from a national cohort of WLWH in Canada (2013-2015). Structural equation modeling was conducted using maximum likelihood estimation methods to test the direct effects of HIV-related stigma, racial discrimination, and gender discrimination on HR-QoL and indirect effects via social support and economic insecurity, adjusting for socio-demographic factors. Among 1425 WLWH (median age: 43years [IQR=35-50]), HIV-related stigma and gender discrimination had significant direct effects on mental HR-QoL. Social support mediated the relationship between HIV-related stigma and mental HR-QoL, accounting for 22.7% of the effect. Social support accounted for 41.4% of the effect of gender discrimination on mental HR-QoL. Economic insecurity accounted for 14.3% of the effect of HIV-related stigma, and 42.4% of the effect of racial discrimination, on physical HR-QoL. Fit indices suggest good model fit (χ²[1]=3.319, p=0.069; CFI=0.998; RMSEA=0.042 (90% CI: 0-0.069); SRMR=0.004). Findings reveal complex relationships between intersecting stigma and HR-QoL. Strategies that address intersecting stigma and economic insecurity among WLWH may prevent the harmful impacts of HIV-related stigma and gender discrimination on physical HR-QoL. Increasing social support may mitigate the impacts of stigma on mental health. Findings can inform multi-level interventions to promote health and wellbeing among WLWH.

Use of national standards to monitor HIV care and treatment in a high prevalence city-Washington, DC

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.

Personal Hygiene Practices among Urban Homeless Persons in Boston, MA

Persons experiencing homelessness in the United States experience significant barriers to self-care and personal hygiene, including limited access to clean showers, laundry and hand washing facilities. While the obstacles to personal hygiene associated with homelessness may increase risk of infectious disease, hygiene-related behaviors among people experiencing homelessness has received limited attention. We conducted a cross-sectional study of individuals experiencing homelessness in Boston, MA (n = 194) to identify hygiene-related self-care practices and risk factors for reduced hygiene in this population. Most participants (72%) reported taking a daily shower. More than 60% reported hand washing with soap five or more times each day, and use of hand sanitizer was widespread (89% reported using sanitizer in the last week). A majority (86%) used a laundromat or laundry machine to wash clothing, while 14% reported washing clothing in the sink. Heavy drinking, injection drug use, and sleeping outdoors were identified as significant risk factors for reduced hygiene practices. People experiencing homelessness who also engage in these activities may be among the most difficult to reach for intervention, yet targeted efforts may decrease illness risk associated with reduced hygiene. Housed friends and family play a critical role in assisting homeless individuals maintain hygiene by providing showers and laundry facilities.

Psychosocial correlates of nutritional status among people living with HIV on antiretroviral therapy: A matched case-control study in Central zone of Tigray, Northern Ethiopia

BACKGROUND

Malnutrition hastens progression to Acquired Human Immunodeficiency Syndromes (AIDS) related illnesses; undermines adherence and response to antiretroviral therapy (ART) in resource-poor settings. However, nutritional status of people living with HIV (PLHIV) can be affected by various psychosocial factors which have not been well explored in Ethiopia. Therefore, the objective of this study was to determine psychosocial correlates of nutritional status among people living with HIV (PLHIV) on ART in Central zone of Tigray, Northern Ethiopia.

METHODS

A matched case-control study design was conducted to assess psychosocial correlates of nutritional status among PLHIV on ART. Data were collected by an interviewer-administered technique using structured pre-tested questionnaire, record review using a checklist and anthropometric measurements. Cases were selected by simple random sampling and controls purposively to match the selected cases. Conditional logistic regression was used to compute relevant associations by STATA version 12.

RESULTS

The psychosocial factors independently associated with malnutrition were ever consuming alcohol after starting ART [AOR = 4.7, 95% CI: 1.8-12.3], ever smoking cigarette after starting ART [AOR = 7.6, 95% CI: 2.3-25.5], depression [AOR = 2.8, 95% CI: 1.3, 6.1], not adhering to ART [AOR = 6.8,95% CI: 2.0-23.0] and being in the second lowest wealth quintile [AOR = 4.3,95% CI: 1.1-17.7].

CONCLUSION

Ever consuming alcohol and ever smoking cigarette after starting ART, depression, not adhering to ART and being in the second lowest wealth quintile were significantly associated with malnutrition. Therefore; policies, strategies, and programs targeting people living with HIV should consider psychosocial factors that can impact nutritional status of people living with HIV enrolled on ART.

A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada

African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ² (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.

Explanatory Models and Illness Experience of People Living with HIV

Research into explanatory models of disease and illness typically explores people's conceptual understanding, and emphasizes differences between patient and provider models. However, the explanatory models framework of etiology, time and mode of onset of symptoms, pathophysiology, course of sickness, and treatment is built on categories characteristic of biomedical understanding. It is unclear how well these map onto people's lived experience of illness, and to the extent they do, how they translate. Scholars have previously studied the experience of people living with HIV through the lenses of stigma and identity theory. Here, through in-depth qualitative interviews with 32 people living with HIV in the northeast United States, we explored the experience and meanings of living with HIV more broadly using the explanatory models framework. We found that identity reformation is a major challenge for most people following the HIV diagnosis, and can be understood as a central component of the concept of course of illness. Salient etiological explanations are not biological, but rather social, such as betrayal, or living in a specific cultural milieu, and often self-evaluative. Given that symptoms can now largely be avoided through adherence to treatment, they are most frequently described in terms of observation of others who have not been adherent, or the resolution of symptoms following treatment. The category of pathophysiology is not ordinarily very relevant to the illness experience, as few respondents have any understanding of the mechanism of pathogenesis in HIV, nor much interest in it. Treatment has various personal meanings, both positive and negative, often profound. For people to engage successfully in treatment and live successfully with HIV, mechanistic explanation is of little significance. Rather, positive psychological integration of health promoting behaviors is of central importance.

Structural Determinants of Antiretroviral Therapy Use, HIV Care Attendance, and Viral Suppression among Adolescents and Young Adults Living with HIV

Background

The authors examined associations between structural characteristics and HIV disease management among a geographically diverse sample of behaviorally and perinatally HIV-infected adolescents and young adults in the United States.

Methods

The sample included 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) who were linked to care through 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions Units. All completed audio computer–assisted self-interview surveys. Chart abstraction or blood draw provided viral load data. Geographic-level variables were extracted from the United States Census Bureau (e.g., socioeconomic disadvantage, percent of Black and Latino households, percent rural) and Esri Crime (e.g., global crime index) databases as Zip Code Tabulation Areas. AIDSVu data (e.g., prevalence of HIV among youth) were extracted at the county-level. Using HLM v.7, the authors conducted means-as-outcomes random effects multi-level models to examine the association between structural-level and individual-level factors and (1) being on antiretroviral therapy (ART) currently; (2) being on ART for at least 6 months; (3) missed HIV care appointments (not having missed any vs. having missed one or more appointments) over the past 12 months; and (4) viral suppression (defined by the corresponding assay cutoff for the lower limit of viral load at each participating site which denoted nondetectability vs. detectability).

Results

Frequencies for the 4 primary outcomes were as follows: current ART use (n = 1120, 59.23%); ART use for ≥6 months (n = 861, 45.53%); at least one missed HIV care appointment (n = 936, 49.50); and viral suppression (n = 577, 30.51%). After adjusting for individual-level factors, youth living in more disadvantaged areas (defined by a composite score derived from 2010 Census indicators including percent poverty, percent receiving public assistance, percent of female, single-headed households, percent unemployment, and percent of people with less than a high school degree) were less likely to report current ART use (OR: 0.85, 95% CI: 0.72–1.00, p = .05). Among current ART users, living in more disadvantaged areas was associated with greater likelihood of having used ART for ≥6 months. Participants living in counties with greater HIV prevalence among 13–24 year olds were more likely to report current ART use (OR: 1.32, 95% CI: 1.05–1.65, p = .02), ≥6 months ART use (OR: 1.32, 95% CI: 1.05–1.65, p = .02), and to be virally suppressed (OR: 1.50, 95% CI: 1.20–1.87, p = .001); however, youth in these areas were also more likely to report missed medical appointments (OR: 1.32, 95% CI: 1.07–1.63, p = .008).

Conclusions

The findings underscore the multi-level and structural factors associated with ART use, missed HIV care appointments, and viral suppression for adolescents and young adults in the United States. Consideration of these factors is strongly recommended in future intervention, clinical practice, and policy research that seek to understand the contextual influences on individuals’ health behaviors.

The population impact of eliminating homelessness on HIV viral suppression among people who use drugs

OBJECTIVE

We sought to estimate the change in viral suppression prevalence if homelessness were eliminated from a population of HIV-infected people who use drugs.

DESIGN

Community-recruited prospective cohort of HIV-infected people who use drugs in Vancouver, Canada. Behavioural information was collected at baseline and linked to a province-wide HIV/AIDS treatment database. The primary outcome was viral suppression (<50 copies/ml) measured during subsequent routine clinical care.

METHODS

We employed an imputation-based marginal modelling approach. First, we used modified Poisson regression to estimate the relationship between homelessness and viral suppression (adjusting for sociodemographics, substance use, addiction treatment, and other confounders). Then, we imputed an outcome probability for each individual while manipulating the exposure (homelessness). Population viral suppression prevalence under realized and 'housed' scenarios were obtained by averaging these probabilities across the study population. Bootstrapping was conducted to calculate 95% confidence limits.

RESULTS

Of 706 individuals interviewed between January 2005 and December 2013, the majority were men (66.0%), of white race/ethnicity (55.1%), and had a history of injection drug use (93.6%). At first study visit, 223 (31.6%) reported recent homelessness, and 37.8% were subsequently identified as virally suppressed. Adjusted marginal models estimated a 15.1% relative increase [95% confidence interval (CI) 9.0-21.7%) in viral suppression in the entire population - to 43.5% (95% CI 39.4-48.2%) - if all homeless individuals were housed. Among those homeless, eliminating this exposure would increase viral suppression from 22.0 to 40.1% (95% CI 35.1-46.1%), an 82.3% relative increase.

CONCLUSION

Interventions to house homeless, HIV-positive individuals who use drugs could significantly increase population viral suppression. Such interventions should be implemented as a part of renewed HIV/AIDS prevention and treatment efforts.

Homelessness, HIV, and Incomplete Viral Suppression

BACKGROUND

The importance of HIV viral suppression is widely known, however few studies have examined the effects of homelessness on HIV viral suppression.

METHODS

The study included HIV-seropositive patients in a health care for the homeless program (HCH). Electronic medical record data for 138 patients were analyzed to compare demographic characteristics, health characteristics, and utilization by housing status. For the 95 individuals with available HIV viral loads, multivariable logistic analysis was performed to examine factors associated with incomplete viral suppression.

RESULTS

The adjusted odds ratio of incomplete HIV viral load suppression was 3.84 times higher in homeless compared with housed (95% CI 1.36- 10.36) individuals. Illicit drug use and combined antiretrovirals (cART) were associated with HIV viral suppression.

CONCLUSIONS

Homelessness predicted incomplete HIV viral suppression. Stable housing may improve viral suppression and access to cART. Drug use was associated with viral suppression, likely because of patient engagement with on-site addiction services.

Structural community factors and sub-optimal engagement in HIV care among low-income women in the Deep South of the USA

This study describes the ways in which poverty and other structural factors create a risk environment for sub-optimal engagement in HIV care among low-income women living with HIV in the Southern USA, contributing to existing health disparities. We conducted a qualitative study in 2012, involving in-depth interviews with 14 stakeholders (service providers and representatives of community-based organisations) and 7 focus-group discussions with 46 women living with HIV (89% African American). A thematic approach in the context of the social ecological model guided data analysis. Data were coded and analysed using NVivo qualitative software. The findings suggested that structural community factors, such as poverty, poor employment opportunities, limited access to healthcare resources, stigma, transportation challenges and access to illicit substances, may work independently and in synergy to impact women's health seeking behaviour and decision-making, thereby influencing their ability to engage in HIV care. Interventions designed to improve engagement in HIV care should address structural factors to bolster low-income women's ability to engage in care.

Methods to Obtain a Representative Sample of Ryan White-Funded Patients for a Needs Assessment in Los Angeles County: Results from a Replicable Approach

The Health Resources and Services Administration requires that jurisdictions receiving Ryan White (RW) funding justify need, set priorities, and provide allocations using evidence-based methods. Methods and results from the 2011 Los Angeles Coordinated HIV/AIDS Needs Assessment-Care (LACHNA-Care) study are presented. Individual-level weights were applied to expand the sample from 400 to 18 912 persons, consistent with the 19 915 clients in the system. Awareness, need, and utilization for medical outpatient care were high (>90%). Other services (eg, child care) had limited awareness (21%). Majority of participants reported at least 1 service gap (81%). Lack of insurance (risk ratio [RR] = 3.0, 95% confidence interval [CI]: 1.5-6.2), substance use (RR = 2.9, 95% CI: 1.3-6.4), and past lapses in medical care (RR = 2.8, 95% CI: 1.3-5.9) were associated with gaps. Within clusters, past incarceration was associated with gaps for housing (RR = 13.5, 95% CI: 3.5-52.1), transportation (RR = 3.2, 95% CI: 1.2-8.4), and case management (RR = 4.0, 95% CI: 1.3-12.2). Applied methods resulted in representative data instrumental to RW program planning efforts.

Implementation challenges for long-acting antivirals as treatment

PURPOSE OF REVIEW

Long-acting injectable antiretroviral therapy (ART) formulations hold great promise in helping to close the significant gap between efficacy and effectiveness in HIV treatment by eliminating the requirement for lifelong daily pills. However, significant systems-level and individual challenges to implementation of long-acting ART in HIV treatment are anticipated.

RECENT FINDINGS

Studies of long-acting ART formulations are burgeoning, but the drugs are still in early phases of investigation and key knowledge gaps in pharmacokinetics and pharmacodynamics, as well as their effectiveness in settings with the largest burden of HIV disease and in key populations, remain. Extrapolating from the literature on implementation barriers to using long-acting contraception on a global scale, we explore the implementation barriers to rolling-out long-acting ART, including country approval and endorsements; prioritization of patient populations for preferred use, clinic infrastructure requirements, steady supply chains, decentralization of care, provider and patient training programs, and laboratory monitoring; and the need to examine patient preferences and conduct rigorous implementation science research to effectively scale-up this intervention.

SUMMARY

Long-acting ART for HIV treatment harbors exciting potential to shift treatment paradigms. Current knowledge gaps in the use of these agents remain, leading to multiple anticipated systems-level and individual-level barriers to implementation. Addressing these gaps and barriers will help fulfill the promise of these agents against the pandemic.

Correlates of hospital use in homeless and unstably housed women: the role of physical health and pain

PURPOSE

To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical health and pain.

METHODS

We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used.

RESULTS

Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio [OR], 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations.

CONCLUSIONS

Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.

The phenomenon of low-frequency heroin injection among street-based urban poor: drug user strategies and contexts of use

BACKGROUND

Dominant public health and medical discourse has relied on a pharmacocentric conception of heroin use-that is, the notion that heroin users inject compulsively to stave off physical and psychological withdrawal. Previous research disputes this claim suggesting that other patterns of heroin use, such as occasional, recreational, or controlled use are possible. In our previous cross-sectional epidemiological research, we identified the phenomenon of low frequency heroin injection (low-FHI), among street-based drug users. The goal of the current study was to qualitatively assess and contextualise this phenomenon over time among a sample of street-based low-FHI.

METHODS

29 low-FHI and 25 high frequency heroin injectors (high-FHI) were followed for 2 years, during which they participated in a series of in-depth interviews. Qualitative data were coded using an inductive analysis approach. As similarities and differences between participants were discovered, transcripts were queried for supportive quotations as well as negative cases.

RESULTS

We found the social context among low-FHI and high-FHI to be similar with the exception of their patterns of heroin use. Thus, we focused this analysis on understanding motivations for and management of low-FHI. Two major categories of low-FHI emerged from the data: maintenance and transitioning low-FHI. Maintenance low-FHI sustained low-FHI over time. Some of these heroin users were circumstantial low-FHI, who maintained low-FHI as a result of their social networks or life events, and others maintained low-FHI purposefully. Transitioning low-FHI did not sustain low use throughout the study. We found that heroin use patterns frequently shift over time and these categories help identify factors impacting drug use within particular moments in an individual's life.

CONCLUSIONS

Given the various patterns of heroin use that were identified in this study, when working with IDUs, one must assess the specifics of heroin use patterns including drug preferences, desire for substance abuse treatment, as well as basic physical and mental health care needs.

Community-based accompaniment and psychosocial health outcomes in HIV-infected adults in Rwanda: a prospective study

We examined whether the addition of community-based accompaniment to Rwanda's national model for antiretroviral treatment (ART) was associated with greater improvements in patients' psychosocial health outcomes during the first year of therapy. We enrolled 610 HIV-infected adults with CD4 cell counts under 350 cells/μL initiating ART in one of two programs. Both programs provided ART and required patients to identify a treatment buddy per national protocols. Patients in one program additionally received nutritional and socioeconomic supplements, and daily home-visits by a community health worker ("accompagnateur") who provided social support and directly-observed ingestion of medication. The addition of community-based accompaniment was associated with an additional 44.3 % reduction in prevalence of depression, more than twice the gains in perceived physical and mental health quality of life, and increased perceived social support in the first year of treatment. Community-based accompaniment may represent an important intervention in HIV-infected populations with prevalent mental health morbidity.

Illness appraisals and depression in the first year after HIV diagnosis

Illness appraisals provide important context to help understand the way individuals cope with chronic illness. In the present study, a qualitative approach to the analysis of HIV diagnosis experience narratives in a sample of 100 people newly diagnosed with HIV revealed five groups that differed in their initial illness appraisals: HIV as Chronic Illness, Concern about Dying, Stigmatization, Threat to Identity, and Other Threats Overshadow HIV. When compared on quantitatively measured depressive mood, the groups differed on level and trajectory over the course of the first year post-diagnosis. Although the experience of living with HIV has changed significantly with the advent of effective Antiretroviral Therapies (ART), there were a number of similarities between the appraisals of this group of participants who were diagnosed post ART and groups who were diagnosed before ART became widely available. Posttest counselors and other HIV service providers should take individual differences in illness appraisals into account in order to help newly HIV-positive clients manage their healthcare and cope adaptively with their diagnosis.

Does effective depression treatment alone reduce secondary HIV transmission risk? Equivocal findings from a randomized controlled trial

Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.

Sexual healthcare preferences among gay and bisexual men: a qualitative study in San Francisco, California

Background

Research on gay and other men who have sex with men's (G/MSM) preferences for sexual healthcare services focuses largely on HIV testing and to some extent on sexually transmitted infections (STI). This research illustrates the frequency and location of where G/MSM interface with the healthcare system, but it does not speak to why men seek care in those locations. As HIV and STI prevention strategies evolve, evidence about G/MSM's motivations and decision-making can inform future plans to optimize models of HIV/STI prevention and primary care.

Methods

We conducted a phenomenological study of gay men's sexual health seeking experiences, which included 32 in-depth interviews with gay and bisexual men. Interviews were transcribed verbatim and entered into Atlas.ti. We conducted a Framework Analysis.

Findings

We identified a continuum of sexual healthcare seeking practices and their associated drivers. Men differed in their preferences for separating sexual healthcare from other forms of healthcare (“fragmentation”) versus combining all care into one location (“consolidation”). Fragmentation drivers included: fear of being monitored by insurance companies, a desire to seek non-judgmental providers with expertise in sexual health, a desire for rapid HIV testing, perceiving sexual health services as more convenient than primary care services, and a lack of healthcare coverage. Consolidation drivers included: a comfortable and trusting relationship with a provider, a desire for one provider to oversee overall health and those with access to public or private health insurance.

Conclusions

Men in this study were likely to separate sexual healthcare from primary care. Based on this finding, we recommend placing new combination HIV/STI prevention interventions within sexual health clinics. Furthermore, given the evolution of the financing and delivery of healthcare services and in HIV prevention, policymakers and clinicians should consider including more primary care services within sexual healthcare settings.

Learning to account for the social determinants of health affecting homeless persons

CONTEXT

Intersecting social determinants of health constrain access to care and treatment adherence among homeless populations. Because clinicians seldom receive training in the social determinants of health, they may be unprepared to account for or address these factors when developing treatment strategies for homeless individuals.

OBJECTIVES

This study explored: (i) clinicians' preparedness to provide care responsive to the social determinants of health in homeless populations, and (ii) the steps taken by clinicians to overcome shortcomings in their clinical training in regard to the social determinants of health.

METHODS

Qualitative interviews were conducted with doctors (n = 6) and nurses (n = 18) in six Canadian cities. Participants had at least 2 years of experience in providing care to homeless populations. Interview transcripts were analysed using methods of constant comparison.

RESULTS

Participants highlighted how, when first providing care to this population, they were unprepared to account for or address social determinants shaping the health of homeless persons. However, participants recognised the necessity of addressing these factors to situate care within the social and structural contexts of homelessness. Participants' accounts illustrated that experiential learning was critical to increasing capacity to provide care responsive to the social determinants of health. Experiential learning was a continuous process that involved: (i) engaging with homeless persons in multiple settings and contexts to inform treatment strategies; (ii) evaluating the efficacy of treatment strategies through continued observation and critical reflection, and (iii) adjusting clinical practice to reflect observations and new knowledge.

CONCLUSIONS

This study underscores the need for greater emphasis on the social determinants of health in medical education in the context of homelessness. These insights may help to inform the development and design of service-learning initiatives that integrate understandings of the social determinants of health, and thus potentially improve the readiness of clinicians to address the complex factors that shape the health of homeless populations.

Housing status and the health of people living with HIV/AIDS

Individuals who are homeless or living in marginal conditions have an elevated burden of infection with HIV. Existing research suggests the HIV/AIDS pandemic in resource-rich settings is increasingly concentrated among members of vulnerable and marginalized populations, including homeless/marginally-housed individuals, who have yet to benefit fully from recent advances in highly-active antiretroviral therapy (HAART). We reviewed the scientific evidence investigating the relationships between inferior housing and the health status, HAART access and adherence and HIV treatment outcomes of people living with HIV/AIDS (PLWHA.) Studies indicate being homeless/marginally-housed is common among PLWHA and associated with poorer levels of HAART access and sub-optimal treatment outcomes. Among homeless/marginally-housed PLWHA, determinants of poorer HAART access/adherence or treatment outcomes include depression, illicit drug use, and medication insurance status. Future research should consider possible social- and structural-level determinants of HAART access and HV treatment outcomes that have been shown to increase vulnerability to HIV infection among homeless/marginally-housed individuals. As evidence indicates homeless/marginally-housed PLWHA with adequate levels of adherence can benefit from HAART at similar rates to housed PLWHA, and given the individual and community benefits of expanding HAART use, interventions to identify HIV-seropositive homeless/marginally-housed individuals, and engage them in HIV care including comprehensive support for HAART adherence are urgently needed.

Food insecurity is associated with greater acute care utilization among HIV-infected homeless and marginally housed individuals in San Francisco

BACKGROUND

Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals.

OBJECTIVE

We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits.

METHODS

HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use).

RESULTS

Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR) = 2.16, 95 % confidence interval (CI) = 1.50-3.09] and ED visits (AOR = 1.71, 95 % CI = 1.06-2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR = 1.41, 95 % CI = 0.99-2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR = 1.56, 95 % CI = 1.06-2.30), ED visits (AOR = 1.57, 95 % CI = 1.22-2.03), and outpatient visits (AOR = 1.68, 95 % CI = 1.20-2.17).

CONCLUSIONS

Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.

Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda

BACKGROUND

Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone.

METHODS

We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations.

RESULTS

Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09-.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03-1.27; P = .01).

CONCLUSIONS

These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms.

Specific psychiatric correlates of acute care utilization among unstably housed HIV-positive adults

The role of specific psychiatric diagnoses in emergency department use and/or inpatient hospitalizations (acute care) has not been extensively examined among HIV-infected, unstably housed persons. A community-recruited sample of 284 HIV-infected, unstably housed adults completed the Diagnostic Interview Schedule for DSM-IV. One-third of participants screened positive for major depression and stimulant use disorders. Sleeping on the street [adjusted odds ratio (AOR) = 4.21], major depression (AOR = 2.88) and stimulant use disorders (AOR = 4.45) were associated with greater odds of acute care use. Housing and effective treatment of depression and stimulant use disorders may decrease use of acute care services in this population.