Mobilizing Knowledge: Housing as Healthcare Summary of Research Presented at the Housing and HIV/AIDS Research Summit Series National AIDS Housing Coalition Breakout: Housing Update AIDS Drug Assistance Program Crisis Summit Washington, DC July 6, 2010

“If we are doing a good job on housing, we are addressing HIV/AIDS.” – Priya Gopalen, Rooftops Canada Rooftops Canada works with partner organizations to help build homes and sustainable communities in disadvantaged areas of Africa, Asia, Latin America, the Caribbean and Eastern Europe.

Overview: Housing Policy is Health Policy Effectively addressing HIV risk and health care disparities requires attention to structural factors — environmental or contextual factors that influence health behaviors and outcomes Housing affects an individual’s ability to avoid exposure to HIV; an HIV- positive individual’s ability to avoid exposing others to HIV; and the ability to access and adhere to care There is now a large body of evidence showing that housing interventions are an essential and cost-effective component of HIV prevention and health care for homeless/unstably housed PLWHA Indeed, housing has “zoomed by” many other well-accepted health care interventions in terms of published evidence (Dr. David Holtgrave, concluding remarks, Summit IV)

Overview: Policy & Practice Implications HIV prevention and care strategies will not succeed without addressing structural barriers such as homelessness and housing instability Housing for persons with HIV/AIDS saves lives and taxpayer dollars, making it a sound health care investment Housing status is likely the most important characteristic of each PLWHA who seeks services - the most significant determinant of each PLWHA’s health and risk outcomes

Housing & HIV/AIDS Research Summit Series Since 2005, the Research Summit series has provided a regular forum for presentation and discussion of research findings on the relationship of housing to HIV prevention and care Summit V, held June 2-4, 2010, was the 2 nd North American Summit, convened by the National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment Network (OHTN), in collaboration with the Johns Hopkins Bloomberg School of Public Health Summit Series products include policy papers, the NAHC Policy Toolkit and a November 2007 Housing & HIV/AIDS special issue of the journal AIDS & Behavior

Outline of this Presentation: Recent research findings on: –HIV and homelessness –Housing and HIV prevention –Housing and health care Recent results from housing based interventions –Impact of housing on health and risk outcomes –Cost analyses of housing interventions Translating research into policy and practice: –Policy and research action strategies from the ONAP meeting on housing For all citations, policy papers, and other information, visit

Homelessness— A Major Risk Factor for HIV Infection Rates of HIV infection are up to 16 times higher among persons who are homeless or unstably housed, compared to similar persons with stable housing Up to 14% of all homeless persons are HIV positive (10 times the rate in the general population) Over time studies show that among persons at high risk for HIV infection due to injection drug use or risky sex, those without a stable home are more likely than others to become infected

HIV— A Major Risk Factor for Homelessness Up to 70% of all PLWHA report a lifetime experience of homelessness or housing instability 10% to 16% of all PLWHA in some communities are literally homeless at any time —sleeping in shelters, on the street, in a car or other place not meant for human habitation Many more PLWHA are unstably housed, faced with housing problems or the threat of housing loss Rates of housing need remain high - as some persons get their housing needs met others develop housing problems

Growing Local & Global Awareness Summit V presentations pointed to the growing global awareness of the link between HIV and housing instability in all its forms, including: –Majority of HIV Medicaid dollars used by unstably housed PLWHA in Chicago and NYC –Expanding supportive housing to formerly incarcerated individuals in Canada –Strategies for rural housing solutions in the Southern United States –Mainstreaming HIV/AIDS into human settlements development in Africa Mobile populations are often excluded from care, and experience high rates of HIV infection, morbidity and mortality Restrictions on HIV care based on residency status violate basic human rights and public health principles “There are no illegal human beings” - Archbishop Desmond Tutu

Lack of Stable Housing = Poor Health Outcomes for PLWHA Homeless/unstably housed PLWHA are less likely to receive appropriate health care and experience higher rates of opportunistic infections, HCV and other co-morbidities The all-cause death rate among homeless PLWHA is 5 times the death rate for housed PLWHA, while the death rate due to HIV/AIDS is among homeless PLWHA is 7 to 9 times the death rate due to HIV/AIDS among the general population Walley’s (AIDS) study of 595 HIV+ persons with alcohol problems found that people who reported homelessness within the last 6 months had an almost 3 times greater risk of death

Lack of Stable Housing = Greater HIV Risk Data from 529 participants in the ongoing At Risk Youth Study in Vancouver show significantly lower levels of condom use and greater numbers of sexual partners among homeless youth as compared to those with more stable housing Data gathered from 8,075 PLWHA as part of the US CDC's Supplement to HIV/AIDS Surveillance (SHAS) project show that, compared to stably housed counterparts, PLWHA who lack stable housing are: –2.9 x more likely to engage in sex exchange in last 12 months –2 x more likely to have unprotected sex with an unknown status partner –2.3 x more like to use drugs in last 12 months –2.75 x more likely to inject drugs

Lack of Stable Housing = Lack of Treatment Success Data from the CDC SHAS project: homeless PLWHA compared to stably housed: –More likely to delay entry into care and to remain outside or marginal to HIV medical care –Worse mental, physical and overall health –More likely to be uninsured, hospitalized and use ER –Lower CD4 counts and less likely to have undetectable viral load –Fewer currently or ever on ART –Lower self-reported ART adherence Housing status found more significant than individual characteristics as a predictor of health care access & outcomes

Housing Status Predicts HIV Risk Behaviors Research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues Homeless or unstably housed persons were 2 to 6 times more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal and service use characteristics Homeless women were 2 to 4 times as likely to have multiple sex partners as housed indigent women - in part due to the effects of physical violence Harm reduction and other behavioral prevention interventions are much less effective for participants who lack stable housing

Housing is HIV Prevention Long-term studies show a strong association between change in housing status and risk behavior change Over time, persons who improved housing status reduced risk behaviors by half; while persons whose housing status worsened over time were 4 times as likely to exchange sex Access to housing also increases access to appropriate care and antiretroviral medications which lower viral load, reducing the risk of transmission

Housing improves access to health care Receipt of housing services independently associated with improved health care access Homeless/unstably housed PLWHA whose housing status improved over time were: –5 times more likely to report a recent HIV outpatient visit –6 times more likely to be receiving anti- retrovirals Controlling for demographics, health status & receipt of case management Stable Housing Improves Health Outcomes Homeless/unstably housed PLWHA whose housing status improves over time are: –More likely to report HIV primary and continuous care visits that meet clinical practice standards –More likely to return to care after dropping out –More likely to be receiving HAART Increased housing stability is positively associated with: –Effective HAART (viral suppression) –Better HIV-related health (viral load, CD4 count, lack of HCV or TB) Schwarcz’s (BMC Public Health) observational study of 676 homeless PLWHA found that over 5 years, obtaining supportive housing was independently associated with an 80% reduction in mortality.

Housing Assistance Works to Create Stability Reporting by the federal HOPWA program shows high levels of stability at low per-unit costs: –89% of households receiving average annual rental assistance of $3,750 remain stably housed after one year –79% of residents of supportive housing stably housed at an average annual cost of $9,000 Increasing evidence that supportive housing enables chronically homeless persons to achieve and maintain stability despite serious medical and psychosocial issues

Investments in Housing Improve Outcomes & Reduce Public Costs Investments in supportive housing found to reduce emergency and inpatient health services, criminal justice involvement, and use of other crisis services Seattle DESC 1811 Eastlake project for homeless people with chronic alcohol addiction –41% reduction medical expenses –87% reduction sobering center use –45% reduction county jail bookings –Median monthly per person costs reduced from $4066 to $1492 (6 months in housing) and $958 (12 months in housing) NYC FUSE Initiative for frequent users jail & shelter –Reduced jail days 52% for housed participants –Jail days increased for comparison group

Evaluating the Cost-Effectiveness of HIV Housing Savings in other publicly funded services have been found to offset or exceed the cost of housing interventions These cost-offset analyses support the provision of housing even before taking into account the costs of heightened HIV risk and treatment failure among homeless PLWHA Each prevented HIV infection saves over $300,000 in life-time medical costs Housing instability limits the ability of individual PLWHA to access and benefit from life-saving antiretroviral therapies

New Evidence that Housing Assistance Works to Improve HIV Outcomes & Save Health Care Dollars Two large-scale, random controlled intervention studies examine the impact of housing on health care utilization and outcomes among homeless/unstably housed persons with HIV and other chronic medical conditions –The Chicago Housing for Health Partnership (CHHP) followed 407 chronically ill homeless persons over 18 months following discharge from hospitals, including an HIV sub-study among 34% of 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

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) studied the number of hospital, emergency room & nursing home visits of participants in 2 groups: –Half who received CHHP supportive housing –Half who continued to rely on “usual care” - a piecemeal system of emergency shelters, family & recovery programs Results published in JAMA (Sadowski, 2009) and APHA (Buchanan, 2009)

CHHP Shows Housing Saves Lives & Money Housed participants: –3 times more likely to be stably housed at 18 months (66% vs. 21%) –significantly fewer housing changes (2 vs. 3) –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 to be published this fall expected to show that reductions in avoidable health care utilization translated into annual savings of at least $900,000 for the 200 housed participants, after taking into account the cost of the supportive housing

Housing Improved Health among HIV+ CHHP Participants HIV sub-study examined the impact of housing on disease progression among the third of CHHP participants who were HIV+ Like other study subjects, HIV+ participants were randomly assigned to permanent supportive housing or “usual care” 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 twice as likely to have undetectable viral load (40%) as compared to who did not receive housing (21%)

Housing & Health Study: Background & Methods Conducted by the CDC and the HUD HOPWA program in Baltimore, Chicago and Los Angeles 630 HIV+ participants were homeless (27%), doubled up (62%) other otherwise at risk of homelessness (11%) at baseline All received case management, help finding housing, referral to medical care and behavioral prevention interventions - half were randomly selected to receive an immediate HOPWA voucher Data on HIV risk and health indicators collected at baseline & at 3 follow up assessments over an 18-month period

H&H Vouchers = Stability & Improved Health At 18 months, only 15% of voucher recipients remained unstably housed, compared to 44% of control group members Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up: –Were 2.5 times more likely to use an ER –Were 2.8 more likely to have a detectible viral load at follow-up –Reported significantly higher levels of perceived stress –Were more likely to report unprotected sex with a negative/unknown status partner

Evaluating the “Cost Utility” of Housing as Health Care H&H results have made it possible for the first time to evaluate the “cost- utility” of housing as an HIV risk reduction and treatment intervention - measured as the “cost per quality adjusted life year (QALY) saved” “Cost per QALY” is the measure used by health economists to compare the “value for money” of health care interventions to ensure that health care dollars are being spent wisely, on treatments that work The cost-utility of the H&H housing is a function of the cost of services provided, transmissions averted, medical costs saved, and life years saved Preliminary H&H findings show that housing is a cost effective health care intervention for PLWHA, with a cost per QALY ($16,000) that is lower than such widely accepted health care interventions as renal dialysis ($50,000 per QALY) and screening mammography ($30,000 per QALY).

Cost effectiveness of selected medical interventions Cost Effectiveness of Selected Medical Interventions

Summary of Key Findings on Housing & HIV Homelessness and unstable housing are linked to greater HIV risk, inadequate care, poor health outcomes and early death Studies also show strong and consistent correlations between improved housing status and… –Reduction in HIV/AIDS risk behaviors –Access to medical care –Improved health outcomes –Savings in taxpayer dollars Recent research shows that that housing is both effective and cost saving as a health care intervention for homeless/unstably housed persons with HIV and other chronic conditions

Yet Housing Remains the Greatest Unmet Service Need of PLWHA 1.1 million PLWHA in the United States—half (550,000) will need housing assistance at some point The Federal Housing Opportunities for Persons with AIDS (HOPWA) program serves only 58,000 households per year nationwide There is not a single county in the US where a person who on relies on SSI ($674 in 2009) can afford even a studio apartment An ongoing study of US veterans living with HIV shows that 48% have experienced homelessness, and 11% are currently homeless

Evidence base Supports HIV Housing Assistance As a basic human right As a necessary component of systems of care to enable PLWHA to manage their disease As an exciting new mechanism to end the AIDS crisis by preventing new infections As a cost-effective public investment

Recommendations from the ONAP Consultation on Housing & HIV Prevention & Care Priority: Reducing HIV incidence 1.Recognize, support, and fund housing as an evidence-based prevention strategy 2.Set specific prevention goals for reducing HIV incidence through housing interventions, based on mathematical modeling that quantifies the anticipated impact of housing status on HIV transmission 3.Evaluate housing as HIV prevention to ensure that overall goals are achieved

Recommendations from the ONAP Consultation on Housing & HIV Prevention & Care Priority: Increasing access to care and optimizing health outcomes 1.Acknowledge that housing is HIV health care for PLWHA who lack stable housing 2.Promote local planning to meet the housing needs of PLWHA 3.Base federal planning on real housing need among PLHWA with an immediate goal of making 141,570 new units of housing available to PLWHA nationwide by the end of 2012 (during President Obama’s first term)

Recommendations from the ONAP Consultation on Housing & HIV Prevention & Care Priority: Reducing HIV-related health disparities 1.Adopt a fully and adequately funded evidence-based, public health approach that identifies and limits policy and other barriers to housing assistance for persons living with and at heightened risk of HIV 2.Target existing resources to those most vulnerable 3.Develop coordinated financing and evaluation mechanisms for housing interventions that take into consideration the cross-systems savings realized through improved health outcomes and avoidance of costly crisis care services and employ this approach to support expanded housing resources, such as a federal voucher entitlement for disabled persons living on fixed incomes 4.Increase federal investments in affordable housing to meet real needs; in order to end the AIDS epidemic, we must end homelessness

Get involved! Stay in touch with NAHC - Join the International AIDS Housing Roundtable Endorse the International Declaration on Poverty, Housing Instability and HIV Use the NAHC Policy Toolkit

Save the date! Housing and HIV/AIDS: Bridging the Gap Official Satellite of the International AIDS Conference July 18, 2010 Reed Messe Wien Room MR 10 Vienna Austria Convened by The International AIDS Housing Roundtable, a project of the National AIDS Housing Coalition, with the generous support of the Ford Foundation For updates, go to:

Select references - recent articles Buchanan, D.R. MD, Kee, R. MD, MPH, Sadowski, L.S. MD, MPH, and Garcia, D. MPH (2009). The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial. American Journal of Public Health, 99, No 6: xx-xx, June 2009 E-published ahead of print on April 16, 2009: Holtgrave, D. R., Briddell, K., Little, E., Bendixen, A. V., Hooper, M., Kidder, D. P., et al. (2007). Cost and threshold analysis of housing as an HIV prevention intervention. AIDS and Behavior, 11(6), S162-S166. Sadowski, L., Kee, R., VanderWeele, T., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. JAMA-Journal of the American Medical Association, 301(17), Schwarcz, S.K., Hsu, L.C., Vittinghoff, E., Vu, A., Bamberger, J.D. and Katz, M.H. (2009). Impact of housing in the survival of people with AIDS. BMC Public Health, 9: 220. Full text available electronically at: Stein, J. A., Nyamathi, A., & Zane, J. I. (2009). Situational, psychosocial, and physical health- related correlates of HIV/AIDS risk behaviors in homeless men. American Journal of Men's Health, 3(1), Walley, A. Y., Cheng, D. M., Libman, H., Nunes, D., Horsburgh, C. R., Saitz, R., et al. (2008). Recent drug use, homelessness and increased short-term mortality in HIV-infected persons with alcohol problems. AIDS, 22(3),

Acknowledgements The North American Housing & HIV/AIDS Research Summit Series was convened by the U.S. National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment Network, in collaboration with Dr. David Holtgrave and the Department of Health, Behavior and Society of the Johns Hopkins Bloomberg School of Public Health Convening researchers include Dr. Holtgrave, Dr. Angela Aidala of Columbia University, Dr. Toorjo Ghose of the University of Pennsylvania, Dr. Daniel Kidder of the U.S. Centers for Disease Control and Prevention, and Dr. Sean Rourke and Ruthann Tucker of the Ontario HIV Treatment Network. Shubert Botein Policy Associates ( help plan and document the Summit Series. NAHC and the OHTN gratefully acknowledge major financial support for Summit V from: the AIDS Bureau of the Ontario Ministry of Health & Long Term Care; the Public Health Agency of Canada; the U.S. National Institutes of Health, Office of AIDS Research; Broadway Cares/Equity Fights AIDS; M*A*C AIDS Fund; CIHR Centre for REACH in HIV/AIDS; the Palette Fund; the Corporation for Supportive Housing; Harlem United Community AIDS Center, Inc.; Housing Works, Inc.; Bailey House, Inc.; AIDS Services of Dallas; and the Toronto Community Housing Corporation.