1. Delay, Drop-Out, and Connection to Medical Care: Focus on SRO Residents. Angela Aidala and Sara Berk Mailman School of Public Health, Columbia University Needs Assessment Committee May 27, 2008

2. INTRODUCTION Persons living in SROs are disproportionately affected by HIV but are often outside or marginal to systems of HIV care Persons living in SROs are disproportionately affected by HIV but are often outside or marginal to systems of HIV care What can the CHAIN Study tell us about SRO residents and associations between SRO residency and access and engagement with HIV primary care? What can the CHAIN Study tell us about SRO residents and associations between SRO residency and access and engagement with HIV primary care? Three data sources: Three data sources: - Ongoing cohort study of CHAIN agency recruited sample - Ongoing cohort study of CHAIN agency recruited sample - Separate effort to locate and interview PLWHA outside of care - Separate effort to locate and interview PLWHA outside of care - Interviews with providers from programs targeting PLWHA outside of care - Interviews with providers from programs targeting PLWHA outside of care

3. NYC C.H.A.I.N. STUDY Community Health Advisory & Information Network (CHAIN) Project PProject of the NYC HIV Health and Human Services Planning Council P Multi-stage probability sampling : Random selection of medical and soc svc agencies Recruit random sample of clients within agencies P Includes 1661 PLWHA recruited from clinics and agencies in 1994, 1998, 2002 P In-person comprehensive (2-3hr) interview every 6–12 mos P Strong community support – 80-90% interview rate

4. Delayers Study  HIV positives who delay 4+ months to med care - 1994-1995 CHAIN Cohort (n=247 delayers) - 2001-2002 CHAIN Cohort (n=174 delayers)  Quantitative and qualitative interview data - demographics, health status, service need/use - narrative descriptions: Why delay? Why drop out?  Key informant interviews - providers serving groups at risk for delay  Focus groups with clients DELAYERS/UNCONNECTED PLWHA

5. Unconnected Study  Aware, no medical care, no case mgmt 6+months - 1995 n=48 unconnected - 1999 n=24 unconnected; 26 marginal - 2003 n=25 unconnected; 35 marginal n=36 high risk HIV - and out of care  Recruited through outreach in street and community settings and referrals from agency recruited participants  Quantitative and qualitative interview data - demographics, health status, service need/use - narrative descriptions: Why delay? Why drop out? DELAYERS/UNCONNECTED PLWHA

6. FINDING THE UNCONNECTED # Sites Visited # Persons Screened HIV + Unconnected to Care SRO OUTREACH 512 6 (50%) STREET OUTREACH 1517113 ( 8%) OTHER: Needle Exchg Soup Kitchen Mobil Med Van Drop-in Center 7118 6 ( 5%) TOTALS2730125 (8%)

7. SRO RESIDENTS  Classify CHAIN Participants based on coding descriptions of current and recent housing  Cross-check against addresses  SRO Resident = PLWHA who c urrently or in the 6 months prior to interview, lived in an SRO or ‘welfare hotel’  Focus on CHAIN Participants who were SRO residents at the time of baseline interview, 2002  10% of the entire sample had lived in an SRO; of these one in four had multiple SRO stays

8. PATTERNS OF SRO RESIDENCY  10% of the entire 2002 agency-recruited sample had lived in an SRO during the study period  Most PLWHA report one period of SRO residency but one in four with any SRO experience had multiple SRO stays  Fewer PLWHA report living in an SRO than at earlier periods of the CHAIN study  Those found in SROs during most recent interview periods are more likely to be PLWHA with multiple SRO stays

9. COMPARING SRO RESIDENTS Comparing SRO residents to PLWHA with no SRO experience  More likely to be male (74%); <35yrs old; have very low incomes; jail experience  Differences by borough of current residence: more often Manhattan or Bronx  Big difference transiency: 58% v. 7% changed addresses 2+ time past 6 months  No differences: race/ethnicity; hs grad; ever worked; currently working

10. COMPARING SRO RESIDENTS Comparing SRO residents to PLWHA with no SRO experience  No difference in risk exposure group, history of problem drug use (heroin/ coke/ crack)  Big differences in patterns of problem drug use: - More likely to have a history of frequent use (17% v 5% used heroin/coke/crack weekly or more often) - More likely to have a history of frequent use (17% v 5% used heroin/coke/crack weekly or more often) - More often current users (57% v 23%) - More often current users (57% v 23%)  More likely to report unsafe sex esp. men with hetero partners (14% v 5%) esp. men with hetero partners (14% v 5%)

11. Connection to Medical Care SRO Residents No SRO Experience total sample n= (69)(624)sig No regular source of medical care before HIV dx 73%60%** Delayed entry into HIV care 32%28% Dropped out of care 1 30%20%* Dropped out because dissatisfied with care 2 32% 32%26% Note: Most recent CHAIN cohort, 2002. 1.Stopped going to the doctor for 6 months or longer 2.Among those who ever dropped out of care

12. Connection to Medical Care SRO Residents No SRO Experience total sample n= (69)(624) No medical provider for HIV 7%3%# Lacks comprehensive primary care 1 35%23%* Care does not meet clinical practice standards 2 42%25%** 1+ Visit to ER past 6mo 1+ Visit to ER past 6mo39%32% Hospital inpatient past 6 mos 29%18%* Note: Most recent CHAIN cohort, 2002. 1.Care that coordinated, comprehensive, and provides 24hr access in case of medical emergency 2. Based on number of visits, diagnostic tests, and ARVs if needed

13. Health Outcomes and Perceived Service Need SRO Residents No SRO Experience total sample n= (69)(624) CD4 T-cell count <200 38%22%** Viral load < 10K or ‘bad’ Viral load < 10K or ‘bad’38%19%*** Health functioning indicates impairment 64%57%** Low mental health functioning Low mental health functioning55%65%# Self-report need for mental health services 20%12%* Self-report need for AOD treatment/ services 68%51%** Note: Most recent CHAIN cohort, 2002.

14. PREDICTORS OF CONNECTION TO CARE P SRO residence  Co-morbidities: Low mental health functioning, current drug user  Health status: T-cell count  Housing services: Assistance with housing needs past 6 months or receipt of rental assistance  Supportive services: Mental health services, drug treatment, medical case management, social service case management, transportation services  Socio-demographics: Age, ethnicity, education, income <$7500 yr, living in poverty neighborhood, risk exposure group  Date of HIV diagnosis, date of cohort enrollment

15. ANALYSIS  Logistical regression used to compare the odds of medical care outcome associated with SRO residence v. other housing  Also examine receipt of housing assistance vs. no assistance  Adjusted odds ratios show odds of outcomes controlling for mental health and substance use co-morbidities, receipt of supportive services, socio-demographics, and time period  Each interview with each participant provides opportunity to examine which predictors are associated with medical care outcomes -1660 individuals interviewed 1-8 times for a total of over 5000 observation points  Models constructed using GEE procedures to adjust for dependency among multiple observations contributed by the same individual

16. Access to Medical Care Medical care Medical care meets clinical practice standards SRO Residence SRO Residence 0.55 * 0.55 * 1.03 1.03 Low mental health functioning Low mental health functioning 0.82 #0.84 Current problem drug use Current problem drug use0.95 0.92 Mental health services Mental health services 1.48 ** 1.47 ** Substance abuse treatment Substance abuse treatment 1.131.08 Medical case management Medical case management 1.44* 1.44* 1.29 1.29 Social services case management Social services case management 1.21 0.96 Housing assistance Housing assistance 1.81 *** N=571 individuals, 1650 observations, 2002 - 2008

17. SUMMARY  PLWHA residing in SROs have multiple needs for clinical and supportive services in addition to housing needs and appear to recognize their need especially for mental health and drug treatment services  SRO residents significantly more likely than other PLWHA to be marginally connected to HIV medical care – to out of care or not receiving care that meets minimum clinical practice standards P SRO residents have lower CD4 counts and higher viral loads than other PLWHA and are more likely to be hospitalized. P SRO residency remains a significant predictor of receiving appropriate clinical care controlling for individual characteristics or clinical status, or receipt of case management, mental health, drug treatment, or other supportive services P Receipt of housing assistance and mental health services are significant predictors of receiving care that meets good clinical practice standards and reduces the significance of SRO residency

18. CONCLUSIONS  Findings provide strong and consistent evidence that : -- housing needs are a significant barrier to receipt of appropriate HIV medical care and continuity of care over time -- receipt of housing assistance has a direct impact on improved medical care outcomes for persons living with HIV/AIDS  Any decrease in funding to provide housing assistance for PLWHA would seem ill advised  Improving access to housing will improve access to and effectiveness of HIV medical care and treatment  Housing 'expensive' but studies show more than offset by savings associated with reduced emergency and inpatient services, treatment failure, and decreased risk of HIV transmission

19. ACKNOWLEDGEMENTS This research was made possible by a series of grants from the US Health Resources and Service Administration (HRSA) under Title I of the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act and contracts with the New York City HIV Health and Human Services Planning Council through the New York City Department of Health and Medical and Health Research Association of New York City. Its contents are solely the responsibility of the Researchers and do not necessarily represent the official views of the U.S. Health Resources and Services Administration, the City of New York, or the Medical and Health Research Association. Special thanks is due to the 1661 persons living with HIV who have participated in the CHAIN Project and shared their experiences with us. Contact: aaa1@columbia.edu