© 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society David Holtgrave, PhD, Professor & Chair

Lindsey Carter Lindsey Carter Johns Hopkins Bloomberg School of Public Health Angela Aidala Angela Aidala Columbia University Mailman School of Public Health Ginny Shubert Ginny Shubert Shubert Botein Policy Associates National AIDS Housing Coalition National AIDS Housing Coalition

Resident story from AIDS Foundation of Chicago “[My case manager] started talking to me. She said you got a child. You got a lot to live for. She’s right. I just can’t let myself go down like this. I need to bring myself back up.” After another bout of homelessness: “My daughter said, ‘Daddy we got to keep this place.’” [AFC “HOPWA, SPNS, Four Residents’ Stories, 2010”] ONAP’s James Albino reflecting on his direct service work in Puerto Rico prior to coming to the White House: “A fair number of our patients…were the product of ‘patient dumping’ where healthcare providers often discharged patients with little planning, often leaving them homeless and on the streets without care…” “Our efforts certainly testify to the strong restorative bond between accessible housing and HIV/AIDS prevention, treatment and care” [White House, ONAP blog, Dec. 23, 2009] Office of National AIDS Policy, White House

Briefly, Housing and HIV Housing and Care Briefly, Economics of HIV-related Housing The Second Life Job Training Program (JTP) is offered by Housing Works in New York for homeless people living with HIV

HIV seroprevalence is several times higher among persons who are homeless or unstably housed HIV seroprevalence for homeless and marginally housed persons was 10.5% in San Francisco (5 times higher than general population) [Robertson et al., AJPH 2004] HIV seroprevalence in New York City single adult shelter system was 3,612 per 100,000 compared to 1,380 per 100,000 in general population [Kerker et al., The Health of Homeless Adults in New York City, 2005] Persons admitted to public shelters in Philadelphia had three year rate of subsequent AIDS diagnosis nine times the general population [Culhane et al., J Epidemiology & Community Health, 2001]

In multi-site study of 2,149 persons living with HIV and presenting for medical or social services, recent drug use, needle use or sex exchange at baseline was 2 to 4 times higher among homeless and unstably housed persons At 6 to 9-month follow up, PLWHA whose housing status improved reduced by half drug risk behaviors; those whose housing status worsened were significantly more likely to exchange sex Similar findings from New York City Cohort Study of HIV- positive clients in care [Aidala, Cross, Stall, Harre, Sumartojo. AIDS & Behavior, Aidala, et al., AIDS Education and Prevention, See also Supplement on Housing and HIV/AIDS, AIDS & Behavior November 2007 ]

ODDS OF RECENT NEEDLE USE AMONG PERSONS LIVING WITH HIV NYC CohortNAT’L SAMPLE Rate Adjusted Odds Ratio 1 Rate Adjusted Odds Ratio 1 STABLE HOUSING4% UNSTABLE HOUSING12%2.8713%2.51 HOMELESS17%4.7427% Odds of needle use past 6 mos by current housing status controlling for demographics, economic factors, risk group, health status, mental health, and receipt of health and supportive services [ Source: Aidala, et al., International Urban Health Conference, 2003; Aidala et al., AIDS & Behavior 2005 ] All relationships statistically significant p<.01

PREDICTING “Time 2” HARD DRUG USE NATIONAL Multiple Diagnosis Initiative “MDI” SAMPLE Started Drug use Stopped Drug use Adjusted Odds Ratio T2 Drug Use 1 NO CHANGE7%6% IMPROVED HOUSING2%12%0.47 WORSE HOUSING9%5% Odds of Time 2 drug use by change in housing status controlling for Time 1 drug use, Time 1 housing status, demographics, economic factors, risk group, health, mental health, and receipt of health and supportive services All relationships statistically significant p<.01 [ Source: Aidala, et al., AIDS & Behavior, 2005]

New York City Cohort Study (total sample ) of persons living with HIV, at baseline… 33% were homeless or unstably housed 51% had some indictor of housing need Across all interview periods, 70% indicated some housing need at one or more time points [Aidala et al., AIDS & Behavior. November 2007 Suppl, S101-S115] Ethnographic information (such as residents’ stories from AIDS Foundation of Chicago) key for understanding how HIV diagnoses can eventually lead to homelessness

Housing & Connection to Medical Care: NYC Cohort Study Aidala et al. 2007, Housing and Connection to HIV Medical Care. NYC DOHMH/ HIV Planning Council publication series. Available at

Access to Medical Care : NYC Cohort Any Medical Care Appropriate Clinical Care HOUSING NEED 0.70 ** 0.71 *** HOUSING ASSISTANCE 2.42 *** 1.53 *** Low mental health functioning (0.85)0.80 ** Current problem drug use 0.74 * 0.73 *** Mental health services2.08 ***1.43 *** Substance abuse treatment (0.97) 1.28 * Medical case management (1.38) (1.09) Social services case management2.43 ***1.70 *** N=1651 individuals, 5865 observations, 1994 – 2007 * p <.05 ** p <.01 *** p <.001 Adjusted odds ratios also controlling for age, ethnicity income, poverty neighborhood, risk exposure group, date of HIV diagnosis, date of cohort enrollment, t-cell count, insurance status. [ Source: Aidala et al., AIDS & Behavior, 2007 ]

PREDICTING MEDICATION USE National MDI Sample Unadjusted Odds Ratio T2 ARV Adjusted Odds Ratio T2 ARV 1 NO CHANGE IMPROVED HOUSING WORSE HOUSING(0.63)(1.01) 1 Odds of Time 2 antiretroviral medication use by change in housing status controlling for Time 1 ARV use, Time 1 housing status, demographics, economic factors, drug use, CD4 count, mental health, and receipt of health and case management services N= 192. Relationships statistically significant p<.05 except ( ) =ns [ Source: Aidala, et al. American Public Health Assoc, 2003 ]

Health care and social service utilization Adherence to anti-retroviral medications Health Status and HIV risk behaviors Significant positive association 953 No significant association 001 Significant negative association 001 [ Source: Leaver et al., AIDS & Behavior, Nov 2007 Suppl ]

CDC multisite SHAS study (n=2925; 4% homeless; survey of persons recently reported as HIV+) Homeless Status AOR (95% CI), with Self-reported good or excellent health, 0.72 (0.56, 0.93) Most recent CD4 over 200, 0.83 (0.61, 1.12) ns Most recent VL undetectable, 0.69 (0.48, 0.99) Used ER past 12 months, 1.60 (1.24, 2.07) Was currently taking HIV meds, 0.43 (0.33, 0.55) Was adherent to HIV meds past 48 hours, 0.49 (0.33, 0.71) [ Source: Kidder et al., AJPH 2007; 97: ]

Longitudinal study, n=595, Short-term mortality associated with homelessness in past 6 months (adjusted hazard ratio 2.92, CI 1.32, 6.44), as well as heroin or cocaine use (2.43, CI 1.12, 5.30), even when controlling for… Age Prior injection drug use CD4 cell count Off ART vs. on ART Alcohol use in past 30 days [Source: Walley et al., AIDS 2008;22: ]

Homeless Housed Homeless Housed No. at risk [ Source: Schwarcz et al. Impact of housing on the survival of persons with AIDS. BMC Public Health. 2009;9:220 ]

Recent studies of cost offset  Larimer et al. (JAMA, 2009):  Seattle housing first model for persons with severe alcohol challenges created stability, reduced alcohol consumption, & decreased health costs 53% relative to wait-list condition  Gilmer et al. (Psych Services, 2009):  Participants in a San Diego housing first program had increased case management and outpatient care costs but these were nearly entirely offset by decreases in inpatient, ER and criminal justice system

Recent studies of cost offset (continued)  Economic Roundtable (Report: “Where We Sleep,” 2009)  Study of 10,193 persons in LA County  9186 were homeless while receiving General Relief public Assistance  1007 exited homelessness via supportive housing  Typical public monthly cost in group experiencing homelessness: $2897  Typical public monthly cost in supportive housing group: $605

Randomized Trials of “Immediate Housing Support”  Two large-scale, randomized controlled trials examined the impact of housing on health care utilization & outcomes among homeless/unstably housed persons with HIV & other chronic medical conditions  The Chicago Housing for Health Partnership (CHHP) study followed 407 chronically ill homeless persons over 18 months following discharge from the hospital, including an HIV sub-study of 105 participants who are HIV+  The Housing and Health (H&H) Study examined the impact of housing on HIV risk behaviors, medical care and treatment adherence among 630 HIV+ persons who were homeless or unstably housed at baseline (Baltimore, Los Angeles and Chicago)

CHHP Background & Methods  “Housing first” program providing supportive housing for homeless persons with medical issues such as HIV/AIDS, hypertension, diabetes, cancer and other chronic illnesses  18 month random controlled trial (RCT)  Half received CHHP supportive housing  Half continued to rely on “usual care” - a piecemeal system of emergency shelters, family & recovery programs  Results published in JAMA (Sadowski et al., 2009) and AJPH (Buchanan et al., 2009)

CHHP Findings  “Housed participants:  More likely to be stably housed at 18 months  Fewer housing changes  29% fewer hospitalizations, 29% fewer hospital days, and 24% fewer emergency department visits than “usual care” counterparts  Reduced nursing home days by 50%  For every 100 persons housed, this translates annually into 49 fewer hospitalizations, 270 fewer hospital days, and 116 fewer emergency department visits  CHHP cost analyses showed that reductions in avoidable health care utilization translated into cost savings for the housed participants, even after taking into account the cost of the supportive housing (Cost aspects of study described in Wall Street Journal)

CHHP HIV Sub-Study  HIV sub-study examined the impact of housing on disease progression among the 105 CHHP participants who were HIV+ (and randomized like other participants)  At 12 months, housed HIV+ CHHP had significantly better health status:  55% of housed were alive with “intact immunity”, compared to only 34% of HIV+ participants left to “usual care”  Housed HIV+ participants were much more likely to have undetectable viral load (36%) as compared to who did not receive housing (19%)

H&H Findings  Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up (as- treated analyses):  Were significantly more likely to use an ER  Were significantly more likely to have a detectible viral load  Reported significantly higher levels of perceived stress - an outcome related to quality- adjusted life expectancy

Housing Status: Own Place Group x Time = p <.001 Percent

Viral Load: As Treated OR = 2.66, CI = 1.73, 4.09

Emergency Room Visits: As Treated OR = 2.51, CI = 1.71, 3.67

Source:

The HEARTH Act signed into law by President Obama in May 2009, mandated that United States Interagency Council on Homelessness (USICH) produce a “national strategic plan” to end homelessness to Congress The USICH is at this very moment releasing at the White House the nation’s first comprehensive strategy to prevent and end homelessness titled "Opening Doors: The Federal Strategic Plan to Prevent and End Homelessness" The Council is an independent agency composed of 19 Cabinet Secretaries and agency heads that coordinates the federal response to homelessness [Source: White House Office of Urban Affairs website, ]