1. Housing Stability/Instability and Entry and Maintenance in Medical Care Angela Aidala, Gunjeong Lee Mailman School of Public Health, Columbia University CHAIN Data Day Presentation June 5, 2008

2. INTRODUCTION Policy and funding changes restricts ability to address housing needs of PLWH Policy and funding changes restricts ability to address housing needs of PLWH - RW Modernization Act of 2006 limits funds for ‘non-core’ services - HOPWA funding less than 2004 levels Providers and consumers concerned will affect housing, medical care and health outcomes for PLWH Providers and consumers concerned will affect housing, medical care and health outcomes for PLWH - Fair Market Rent (FMR) for 1BR in NYC =$949 - “Affordable” for income >$3000 mo - Few PLWH can maintain regular employment at $3000 mo - SSI =$710/mo Average SSD =$750/mo

3. STUDY QUESTIONS What are rates of homelessness or housing instability among PLWH in NYC and have rates changed over time? What are rates of homelessness or housing instability among PLWH in NYC and have rates changed over time? What is the relationship between housing status and entry and maintenance in HIV medical care? What is the relationship between housing status and entry and maintenance in HIV medical care? What are additional service needs of PLWH with unstable housing? What are additional service needs of PLWH with unstable housing?

4. MEASURING HOUSING STATUS  HOMELESS -- sleeping in the street, park, abandoned building -- in a public place (e.g. subway) not intended for sleeping -- in a drop in center or shelter for homeless persons -- in a limited stay SRO or welfare hotel with no services -- in jail with no other address  UNSTABLY HOUSED -- in transitional housing, residential treatment, halfway house -- doubled up with other people  STABLY HOUSED --own, permanent housing in regular apartment or house

5. HOUSING PROBLEMS/ NEEDS  Answers to question : In the last 6 months, have you had a problem or needed assistance with housing? (If YES) Please tell me about your need for assistance with housing or the problem you had. ____________________________________________________

6. PATTERNS OF HOUSING NEED

7. HOUSING & HIV EPIDEMIOLOGY Housing needs are widespread among PLWH Housing needs are widespread among PLWH -- 52% of the 2002 NYC cohort were homeless or unstably housed during the year they were diagnosed with HIV -- At any point in time 25-35% of all PLWH are homeless or unstably housed – even more report housing problems -- In NYC, 60% experienced unstable housing or homelessness at least once over the course of their illness -- From system perspective NYC rates of housing need remain fairly constant over time as some PLWH get housing needs met, others develop housing problems

8. HOUSING STATUS AND HOUSING PROBLEMS CHAIN STUDY (Agency recruited samples) Original Cohort 1994-95 Refresh Cohort 1998-99 New Cohort 2002-04 RECENT EXPERIENCE 1 RECENT EXPERIENCE 1 Unstable housing Unstable housing Homeless Homeless 16% 16%19 19% 19%9 20% 20%10 HOUSING PROBLEMS Homeless or unstable housing, Homeless or unstable housing, can’t pay rent, facing eviction, can’t pay rent, facing eviction, no heat/ plumbing, domestic no heat/ plumbing, domestic violence, other dangerous violence, other dangerous situation, need accessible unit, situation, need accessible unit, etc. etc.38%28%35% 1. Past 6 months

9. HOUSING STATUS AND HOUSING PROBLEMS CHAIN STUDY (Unconnected sample) Original Cohort 1995 Refresh Cohort 1998 New Cohort 2004 HOUSING STATUS HOUSING STATUS Homeless of Unstable Housing Homeless of Unstable Housing64%78%72% HOUSING PROBLEMS Homeless or unstable housing, Homeless or unstable housing, can’t pay rent, facing eviction, can’t pay rent, facing eviction, no heat/ plumbing, domestic no heat/ plumbing, domestic violence, other dangerous violence, other dangerous situation, need accessible unit, situation, need accessible unit, etc. etc.54%50%74%

10. Aggregate Rates of Housing Need Remain High Aggregate Rates of Housing Need Remain High Rate of Housing Service Need by Date of Interview – 1994 thru 1996 Rate of Housing Service Need by Date of Interview – 2001 thru 2003

11. Rates of Housing Need Remain High As some persons get their housing needs met others develop housing problems -- Loss of income due to progressive inability to maintain employment -- Growing disparities between income and rent requirements -- Relationship breakup including leaving abusive situations -- Loss of spouse/partner to HIV related death or disability -- Loss of shared housing options with disclosure of HIV -- Disease progression requiring accessible facilities -- Policy requirements that limit residence in temporary or transitional programs

12. HOUSING & MEDICAL CARE

13. HOUSING STATUS AND ENTRY INTO CARE Housing Situation at Time of HIV Diagnosis Stable Own Place Temp Doubled Up Shelter Temp Housing Jail or Prison On the Street Delayed Entry to HIV Medical Care 4+ months after 4+ months after diagnosis diagnosis (average delay (average delay 12-18 moths) 12-18 moths)27%26%23%40%44%

14. Reasons Given for Delayed Entry into Care % In denial about being HIV infected, didn’t want to face it In denial about being HIV infected, didn’t want to face it33 Was doing drugs, relapsed Was doing drugs, relapsed18 Felt fine, wasn’t sick, no symptoms Felt fine, wasn’t sick, no symptoms14 Believed I was going to die anyway Believed I was going to die anyway9 Was homeless, had no money (competing needs) Was homeless, had no money (competing needs)7 Fear, uncertainty Fear, uncertainty7 Did not want HIV medications Did not want HIV medications6 Did not know where to go Did not know where to go6 Total sample of delayers, most recent NYC cohort (n=157) Thematic coding of client descriptions of reasons for delayed into HIV medical care Multiple responses possible

15. HOUSING & MEDICAL CARE  Unstable housing leads to discontinuous care - recent breaks in care, dropping in and out of care and/or changing providers often  Homeless or unstably housed individuals are less likely than other PLWHS to be receiving medical care that meets minimum clinical practice guidelines  Homelessness /unstable housing is one of the most important barriers limiting the use of antiretroviral combination therapy  High viral load, recent opportunistic infection, and hospitalizationfor HIV related disease are associated with homelessness/ unstable housing

16. Reasons Given for Not Being in Care among the Unconnected % Homeless, other competing needs Homeless, other competing needs27 Feel fine, not sick, no symptoms 19 Doing drugs, relapsed Doing drugs, relapsed13 Do not want HIV medications/ want to stop medications Do not want HIV medications/ want to stop medications11 Did not want HIV medications, wanted to discontinue meds Did not want HIV medications, wanted to discontinue meds11 Tired of it, was fed up, wanted a break Tired of it, was fed up, wanted a break9 Disruption in care – program closed, doctor left, I moved Disruption in care – program closed, doctor left, I moved8 Total sample outside of care (n=25) Thematic coding of client descriptions of reasons for never accessing medical care or dropping out of care Multiple responses possible

17. IMPORTANCE OF HOUSING SERVICES

18. Housing Assistance and Services Make a Differences Housing Assistance and Services Make a Differences  Accessing agency- based housing services improves one’s chance of securing stable, adequate housing  The strongest predictor of obtaining housing and of staying in housing is receipt of rental subsidy  Supportive services are as important as rental assistance successfully maintaining stable housing  PLWHA receiving housing assistance face numerous health and personal resource challenges that would limit access to stable housing

19. Challenges and Resources of PLWH Receiving Rental Assistance Challenges and Resources of PLWH Receiving Rental Assistance  43% Not enough money for food, utilities, or un- reimbursed medical care needs at least once past 6 months  53% Household income from all sources <$7500 yr  57% Physical health functioning =“disabled”  48% Have mental health needs  42% Less than high school education  43% No work for wages 5yrs or more

20. CONCLUSIONS  Findings provide strong and consistent evidence that : -- The need for housing assistance has not diminished over time and remains at 30-40% of all PLWH -- The need for housing assistance has not diminished over time and remains at 30-40% of all PLWH -- 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 would present serious challenges to PLWH and the HIV care system  Improving access to housing will improve access to and effectiveness of HIV medical care and treatment

21. 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