1. © 2005, Johns Hopkins University. All rights reserved. Department of Health, Behavior & Society David Holtgrave, PhD, Professor & Chair

2. Overview  Examples of studies of cost offset due to housing provision  Mechanisms of housing as HIV prevention  Relative cost-effectiveness of housing as a structural intervention

3. Recent studies of cost offset  Larimer et al. (JAMA, 2009):  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

4. 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

5. Mechanisms of housing as HIV prevention  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

6. 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)

7. 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 previously described in Wall Street Journal)

8. 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%)  Such impact on viral load has relevance to HIV prevention

9. H&H Study: Background & Methods  Conducted by CDC and HUD HOPWA program - in Baltimore, Chicago & 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 and at 3 follow up assessments over an 18-month period  Results just published in AIDS & Behavior, 2009

10. H&H Findings  At 18 months, 82.5% of voucher recipients had their “own place,” compared to 50.6% of control group members  At 6 months, these figures were 54.2% vs. 16.0%  At 12 months, these figures were 87.0% vs. 37.2%  Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up:  Were significantly more likely to use an ER  Were significantly more likely to have a detectible viral load  an outcome with HIV prevention relevance  Reported significantly higher levels of perceived stress  an outcome which relates to quality-adjusted life expectancy

11. H&H Study: Typical Annual Service Delivery Costs Per Client (AIDS & Behavior, 2007) CityPayor Perspective Costs Societal Perspective Costs Baltimore$9256$10048 Chicago$11651$14032 Los Angeles$10639$12785

12. How many transmissions must be averted to be cost-saving or cost-effective? (AIDS & Behavior, 2007) Cost-saving threshold Cost-effective threshold Baltimore.0454 (23).0128 (78) Chicago.0634 (16).0179 (56) LA.0578 (18).0163 (62) Average.0555 (1 per 19 clients).0157 (1 per 64 clients)

13. Did H&H achieve the thresholds?  To transmit HIV, let’s make a simplifying assumption that there needs to be some detectable viral load (and of course some risk behavior)  Applying this to H&H as-treated analysis indicates that 8.2% of persons with housing might possibly transmit, but 10.5% of persons without housing could potentially transmit (a difference of about 2.4%) [(.1332*.614) – (.1332*.791)]  Let’s also assume a mean of 3.81 sexual partnerships per year in H&H for HIV+ persons who had any seronegative or unknown serostatus partners, and a one-year, per-partnership transmission probability of 17.4%  So,.024*3.81*.174 equals roughly.0157 HIV transmission averted for each housed client in a given year  Cost-per-quality-adjust-life-year-saved is appox. $62,493

14. Sensitivity Analysis in H&H Number of QALYs Saved Per HIV Transmission Averted (input parameter) Cost-Utility Ratio 5.33 {base case} $62,493 {base case} 7.50$48,337 11.23$34,780

15. How does housing compare to other public health interventions in terms of cost-effectiveness? InterventionApprox. cost per QALY saved (varies by study) Kidney dialysis$52,000 to $129,000 Mammography, 50-69 y.o.$57,500 Colon cancer screening, 50-85 y.o.$53,600 Type 2 diabetes screening,>25 y.o.$63,000 HIV screening every 5 years$42,200 Syringe exchangeCost-saving HIV behavioral interventionsGenerally cost-saving PrEP$298,000 HIV vaccine$22,617 to $111,277 Early vs deferred HAART$15,159 to $36,301 Deferred vs no HAART$46,423 Mycobacterium avium complex (MAC) prophylaxis $44,500

16. Evaluating HIV Housing: Conclusions  Results of economic evaluation studies of housing indicate it is either cost-saving or within the range of interventions generally considered to be “cost-effective” and “well accepted” by society  Each prevented HIV infection saves hundreds of thousands of dollars in life-time medical costs, and even more importantly, years of (quality- adjusted) life  Evidence indicates housing is an effective and efficient HIV care and prevention strategy