1. Housing and HIV/AIDS Angela A. Aidala, PhD Mailman School of Public Health Columbia University Integration of Care Committee – Nov 29, 2011 Brief Summary of Research Findings

2. RESEARCH QUESTIONS What are rates of homelessness or housing instability among PLWH and have rates changed over time? What are rates of homelessness or housing instability among PLWH 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? Housing (lack of housing) as a structural factor contributing to the continuing epidemic and associated health disparities Housing (lack of housing) as a structural factor contributing to the continuing epidemic and associated health disparities

3. The C.H.A.I.N. Project Community Health Advisory & Information Network (CHAIN) Project Goals: To provide a profile of PLWH/A in New York City //and the Tri-County Region To provide a profile of PLWH/A in New York City //and the Tri-County Region To assess the system of HIV care – both health and social services – from the perspective of people living with HIV/AIDS To assess the system of HIV care – both health and social services – from the perspective of people living with HIV/AIDS To report on unmet needs, service utilization trends, and outcomes to the Planning Council and its Committees To report on unmet needs, service utilization trends, and outcomes to the Planning Council and its Committees Make research results available to the wider provider, consumer, and other stakeholder communities Make research results available to the wider provider, consumer, and other stakeholder communities

4. History of CHAIN Initially developed in 1993 as one of the Planning Council’s evaluation resources Initially developed in 1993 as one of the Planning Council’s evaluation resources Contract with Columbia University Public Health Contract with Columbia University Public Health CHAIN has recruited 4 cohorts of PLWH/A CHAIN has recruited 4 cohorts of PLWH/A - NYC I (1994-2002, n=968) - NYC I (1994-2002, n=968) - NYC II (2002-present, n=1012) - NYC II (2002-present, n=1012) - Tri-County I (2001-2007, n=482) - Tri-County I (2001-2007, n=482) - Tri-County II (2008-present, n=234) - Tri-County II (2008-present, n=234) A Technical Review Team including representatives of the Planning Council, its PWA Advisory Group, MHRA/ Public Health Solutions, NYCDOHMH and (xx) Office of HIV/AIDS Planning oversees CHAIN A Technical Review Team including representatives of the Planning Council, its PWA Advisory Group, MHRA/ Public Health Solutions, NYCDOHMH and (xx) Office of HIV/AIDS Planning oversees CHAIN

5. Selecting CHAIN Participants A 2-Step Process 1 st step: random selection of service sites from listing of all agencies serving HIV clients 1 st step: random selection of service sites from listing of all agencies serving HIV clients Medical and Social Service Medical and Social Service All Boroughs (or Counties) All Boroughs (or Counties) RW Funding vs. no RW RW Funding vs. no RW 2 nd step: agency staff help with random selection of clients 2 nd step: agency staff help with random selection of clients Random selection from client rosters Random selection from client rosters Sequential enrollment Sequential enrollment Agency liaison obtains consent to contact, CHAIN staff obtains consent for interview Agency liaison obtains consent to contact, CHAIN staff obtains consent for interview Cohort composition closely tracks surveillance data/ RW client data Cohort composition closely tracks surveillance data/ RW client data

6. Recruiting CHAIN Participants Unconnected to Care NYC CHAIN includes small samples of PLWHA unconnected to care NYC CHAIN includes small samples of PLWHA unconnected to care Unconnected: Aware, no medical care, no HIV case mgmt for 6+months Unconnected: Aware, no medical care, no HIV case mgmt for 6+months RDS referrals from CHAIN agency recruited participants RDS referrals from CHAIN agency recruited participants Accompany Outreach Workers Accompany Outreach Workers Open recruitment and screening in street and community settings Open recruitment and screening in street and community settings 1994 (n=48) 1998 (n=24) 2002 (n=25) 1994 (n=48) 1998 (n=24) 2002 (n=25)

7. Collecting Data Comprehensive 2-3 hr, in-person interview Comprehensive 2-3 hr, in-person interview Follow-up interviews annually Follow-up interviews annually Community based interviewers Community based interviewers Interviews in homes or agency settings Interviews in homes or agency settings Community-based interviewing team Community-based interviewing team $25-$35 incentive for every interview + referral resource $25-$35 incentive for every interview + referral resource High retention rate: 80% - 95% of eligible participants at each wave High retention rate: 80% - 95% of eligible participants at each wave

8. HRSA SPNS/ HUD HOPWA Multiple Diagnoses Initiative Interviews conducted with clients of demonstration projects providing health and social services to low income persons infected with HIV in 1996-2000 Baseline information from 3191 clients from 24 projects and follow-up data from 891 clients from 16 projects Sample: - 2/3 males (30% heterosexual, 37% gay, bisexual or questioning) - 1/2 African American, 13% Latino, 24% White, 10% Other - 4/5 income below $10,000 - 1/2 ever incarcerated Not probability sample -compares to clients in publicly funded services National Study

9. HUD/HOPWA HRSA/SPNS Demonstration Projects

10. MEASURING HOUSING STATUS  HOMELESS -- homeless, no regular place to sleep -- homeless, no regular place to sleep -- sleeping in the street, park, abandoned building -- sleeping in the street, park, abandoned building -- in a public place (e.g. subway) not intended for sleeping -- in a shelter for homeless persons -- in a SRO or welfare hotel -- in jail with no other address  UNSTABLY HOUSED -- in transitional housing, resident treatment, halfway house -- temporarily doubled up with other people  STABLY HOUSED --own, secure housing in regular apartment or house

11. HOUSING PROBLEMS Respondent reports problem with housing or need for housing services at present or at any time during the past 6 months Respondent reports problem with housing or need for housing services at present or at any time during the past 6 months PROBLEMS DESCRIBED INCLUDE PROBLEMS DESCRIBED INCLUDE -- homeless, no regular place to live -- homeless, no regular place to live -- urgent need to leave current housing -- urgent need to leave current housing -- cannot pay rent --facing eviction for any reason -- poor quality of housing (plumbing, heat) -- physical access difficulties -- dangerous, threatening neighborhood (drugs, crime) -- domestic violence situation

12. Housing & HIV Epidemiology The patterns of disease and risk for disease and death in a population

13. Homelessness - a major risk factor for HIV infection Review of published literature Rates of HIV infection are 3 - 16 x higher among persons who are homeless or unstably housed compared to similar persons with stable housing Rates of HIV infection are 3 - 16 x higher among persons who are homeless or unstably housed compared to similar persons with stable housing 3% to 14% of all homeless persons are HIV positive (10 x the rate in the general population) 3% to 14% of all homeless persons are HIV positive (10 x the rate in the general population) Over time studies show that among persons at high risk for HIV infection due to injecting drug use or risky sex, those without a stable home are more likely than others to become infected Over time studies show that among persons at high risk for HIV infection due to injecting drug use or risky sex, those without a stable home are more likely than others to become infected

14. HIV- a major risk factor for homelessness 50% to 70% of all PLWHA report a lifetime experience of homelessness or housing instability 50% to 70% of all PLWHA report a lifetime experience of homelessness or housing instability 10% to 16% of all diagnosed PLWHA are literally homeless - sleeping in shelters, on the street, in a car, or in an encampment 10% to 16% of all diagnosed PLWHA are literally homeless - sleeping in shelters, on the street, in a car, or in an encampment Twice as many are unstably housed, have housing problems, experience threat of housing loss Twice as many are unstably housed, have housing problems, experience threat of housing loss In general, medical conditions and medical costs are associated with housing problems for persons with chronic illness – can’t pay rent, face foreclosure In general, medical conditions and medical costs are associated with housing problems for persons with chronic illness – can’t pay rent, face foreclosure

15. FINDINGS: NYC HOUSING & HIV Housing need among PLWHA in New York Housing need among PLWHA in New York - 49%- 52% of each NYC cohort were homeless or unstably housed at during the year they were diagnosed with HIV - 60%- 70% experienced unstable housing or homelessness at least once during the study period (1994-2002 or 2002- 2010) - NYC rates of housing need remain fairly constant over time as some PLWH get housing needs met, others develop housing problems (35%-45% at any point in time) -Housing is the greatest unmet service need

16. HOUSING STATUS AND HOUSING PROBLEMS CHAIN STUDY (Agency recruited samples) Original Cohort 1994-95 Refresh Cohort 1998-99 New Cohort 2002-04 Refresh Cohort 2009-10 HOUSING STATUS 1 HOUSING STATUS 1 Unstable housing Unstable housing Homeless Homeless 16% 16%19 19% 19%9 20% 20%1026%7 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%46% 1. Past 6 months

17. HOUSING STATUS AND HOUSING PROBLEMS CHAIN STUDY (Unconnected samples) Original Cohort 1995 Refresh Cohort 1998 New Cohort 2004 HOUSING STATUS Homeless or Unstable Housing Homeless or 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% 1. Past 6 months

18. Need for Housing Assistance NYC CHAIN STUDY 2008- 2008-2009 2009- 2010 Need Permanent Housing Placement Homeless Or temporarily doubled up, OR in temporary/transitional housing during the last 6 months26%15% Need Rental Assistance (1) Having difficulty paying rent in the past 6 months OR (2) facing eviction and lacks income to secure housing (FMR>50% of income) OR (3) fairly to very often there was not enough money for rent in the past 6 months OR (4) currently receiving rental assistance (including living in a public housing)81%86%

19. Housing & HIV Prevention Factors increasing or decreasing risk for disease

20. Housing status predicts HIV risk Multiple studies have shown a strong and consistent relationship between housing status and sex and drug risk behaviors Multiple studies have shown a strong and consistent relationship between housing status and sex and drug risk behaviors Ex: Homeless or unstably housed PLWHA are 2 to 6 x more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal characteristics and service use patterns Ex: Homeless or unstably housed PLWHA are 2 to 6 x more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal characteristics and service use patterns Prevention interventions are much less effective for participants who are struggling with housing issues Prevention interventions are much less effective for participants who are struggling with housing issues Studies show a ‘dose-relationship’ with the homeless at greater risk than the unstably housed, and both of these at greater risk than those with stable secure housing Studies show a ‘dose-relationship’ with the homeless at greater risk than the unstably housed, and both of these at greater risk than those with stable secure housing

21. Example: ODDS OF RECENT HARD DRUG USE NYC SAMPLENAT’L SAMPLE Rate Adjusted Odds Ratio 1 Rate Adjusted Odds Ratio 1 STABLE HOUSING21%16% UNSTABLE HOUSING37%1.6035%2.05 HOMELESS53%3.4564%5.54 1 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 Note: All relationships statistically significant p<.01

22. Example: ODDS OF RECENT NEEDLE USE CHAIN SAMPLENAT’L SAMPLE Rate Adjusted Odds Ratio 1 Rate Adjusted Odds Ratio 1 STABLE HOUSING4% UNSTABLE HOUSING12%2.8713%2.51 HOMELESS17%4.7427%4.65 1 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 Note: All relationships statistically significant p<.01

23. ODDS OF UNPROTECTED SEX PAST 6MOS NATIONAL SAMPLE Unadjusted Odds Ratio Adjusted Odds Ratio 1 Rate STABLE HOUSING40% UNSTABLE HOUSING43%(1.11)(1.04) HOMELESS62%2.372.67 1 Odds of unprotected sex past 6-12 mos by baseline housing status controlling for demographics economic factors, health status, mental health, receipt of health and supportive services Note: All relationships statistically significant p<.05 except ( )=ns

24. ODDS OF UNPROTECTED SEX PAST 6 MOS CHAIN SAMPLE Adjusted Odds Ratio 1 Adjusted Odds Ratio 1 Rate STABLE HOUSING13% UNSTABLE HOUSING15%(1.11)21%1.61 HOMELESS16%1.6929%2.30 1 Odds of unprotected sex past 6 mos by baseline housing status controlling for demographics economic factors, health status, mental health, receipt of health and supportive services Note: All relationships statistically significant p<.05 except ( )=ns MenWomen

25. Overtime studies show a strong association between change in housing status and risk behavior change Ex: PLWHA who improved housing status reduced sex and drug risk behaviors by half while persons whose housing status worsened are 2- 4 x as likely to exchange sex, have multiple partners Risk reduction associated with housing controlling for socio-demographics, drug use, mental health, health status, and receipt of health and supportive services Access to housing also increases access to appropriate care and antiretroviral medications which lowers viral load and reduces risk of transmission Housing is HIV Prevention

26. PREDICTING T2 HARD DRUG USE NATIONAL 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%1.38 1 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 Note: All relationships statistically significant p<.01

27. PREDICTING T2 UNPROTECTED SEX LAST INTERCOURSE Started Unprotected Sex Stopped Unprotected Sex Adjusted Odds Ratio T2 Unprotected Sex 1 NO CHANGE25%7% IMPROVED HOUSING19%15%0.37 WORSE HOUSING25%11%(1.02) 1 Odds of Time 2 sex exchange by change in housing status controlling for Time 1 sex exchange, Time 1 housing status, demographics, economic factors, health, mental health, and receipt of health and supportive services Note: All relationships statistically significant p<.01 except ( ) =ns

28. Housing & Health Care Outcomes

29. Lack of stable housing = lack of treatment success  Homeless PLWHA compared to stably housed: More likely to delay entry into care and to remain outside or marginal to HIV medical care More likely to delay entry into care and to remain outside or marginal to HIV medical care Fewer ever on ART, and fewer on ART currently Fewer ever on ART, and fewer on ART currently Less adherent to treatment regimen Less adherent to treatment regimen Lower CD4 counts & less likely to have undetectable viral load Lower CD4 counts & less likely to have undetectable viral load Worse mental & physical health functioning Worse mental & physical health functioning More likely to be hospitalized & use ER More likely to be hospitalized & use ER

30. Housing & Connection to Medical Care NYC CHAIN Sample

31. Housing & Connection to Medical Care National Sample

32. Factors Associated with Low Rates of Adherent HAART Use 52 NYC Average Percentage on HAART and adherent to regimen - NYC CHAIN cohort 2002-2010

33. Unstable housing reduces the odds of timely viral load suppression Controlling for HAART use and adherence, receipt of HIV care meeting practice standards, mental health score, recent substance use, and demographics

34. Housing Status Predicts Access and Maintenance in Health Care  Homeless/unstably housed PLWHA whose housing status improves over time are: - more likely to report HIV primary care visits, continuous care, care that meets clinical practice standards - more likely to return to care after drop out - more likely to be receiving HAART  Housing status more significant predictor of health care access & outcomes than individual characteristics, insurance status, substance abuse and mental health co- morbidities, or service utilization

35. Housing and Access to Medical Care CHAIN NYC Any Medical Care Appropriate Clinical Care HOUSING NEED(0.78) 0.74 *** HOUSING ASSISTANCE 2.20 *** 1.45 *** Low mental health functioning (0.86)0.80 ** Current problem drug use(0. 84) 0.77 *** Mental health services 1.94***1.38 *** Substance abuse treatment(0.91) 1.25 * Medical case management(1.40) (1.10) Social services case management 2.30*** 1.66 *** N=1651 individuals, 5865 observations, 1994 - 2007 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.

36. Continuity of HIV Medical Care CHAIN NYC Continuity of Care Continuity Appropriate Care HOUSING NEED 0.83 * 0.78 *** HOUSING ASSISTANCE 1.20 * 1.56 *** Low mental health functioning (0.85) (0.84) Current problem drug use (0.98) (0.84) Mental health services (1.12)1.56 *** Substance abuse treatment (0.97) (1.16) Medical case management (0.89) (1.23) Social services case management (1.17)1.32 * 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. N=1295 individuals interviewed 2+ times, 53759 observations, 1994 - 2007

37. T2 Entry into HIV Medical Care CHAIN NYC Entry into Any Medical Care Entry into Appropriate Clinical Care HOUSING NEED 0.44 ** (0.73) HOUSING ASSISTANCE 2.15 ** 1.88 *** Low mental health functioning (0.76) (0.74) Current problem drug use 0.36 *** 0.69 * Mental health services 2.79 ** (1.29) Substance abuse treatment (1.64) (1.46) Medical case management (1.35) (0.78) Social services case management 2.27 *1.84 ** N=557 individuals who were not in care at one or more interviews, 720 observations, 1994 - 2007 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.

38. Housing Interventions Work

39. Two large-scale intervention studies 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 followed 407 chronically ill homeless persons over 18 months following discharge from hospitals  The Housing and Health (H&H) Study examined the impact of housing on HIV risk behaviors and medical care among 630 homeless/unstably housed PLWHA in care in Chicago, LA, Baltimore Findings:  Housing assistance linked to improved health, mental health, and quality of life outcomes  Investment in housing is cost effective

40. CHHP Findings Housed participants: Housed participants: More likely to be stably housed at 18 months More likely to be stably housed at 18 months Fewer housing changes Fewer housing changes Fewer hospitalizations, hospital days, ER visits, nursing home days Fewer hospitalizations, hospital days, ER visits, nursing home days For every 100 persons housed, this translates into 49 fewer hospitalizations, 270 fewer hospital days, and 116 fewer emergency department visits per year Reductions in avoidable health care costs translated into cost savings for the housed participants, even after taking into account the cost of the supportive housing Savings for HIV+ subsample = $6622 per person per year

42. H&H Findings At 18 months, 83% of voucher recipients had stable independent housing, compared to 51% of control group At 18 months, 83% of voucher recipients had stable independent housing, compared to 51% of control group Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up: Compared to housed participants, and controlling for demographics & health status, those who experienced homelessness during follow up: Were significantly more likely to have a detectible viral load with prevention implications Were significantly more likely to have a detectible viral load with prevention implications Were significantly more likely to use an ER Were significantly more likely to use an ER Reported significantly higher levels of perceived stress which relates to quality-adjusted life expectancy Reported significantly higher levels of perceived stress which relates to quality-adjusted life expectancy

43. Annual Service Delivery Costs Per Client Payor PerspectiveSocietal Perspective $9256 - $11651$10048 - $14032 Number of transmissions must be averted to be cost-saving or cost-effective 1 Cost-saving threshold Cost-effective threshold Average(1 per 19 clients)(1 per 64 clients) H & H Study Cost Results Medical costs saved with single transmission prevented = $300,000  Cost-per-quality-adjust-life-year-saved by H&H = approx $62, 500

44. H & H Results: Cost per-QALY saved approx. $63,000 InterventionApprox. cost per QALY saved 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 (MAC) prophylaxis$44,500 Within range of accepted standards for cost-effectiveness of public health services

45. EXPLANATION OF FINDINGS?

46. RISKY PERSONS v. CONTEXTS OF RISK  Need to understand the causal direction and the mechanisms linking housing and behaviors that put people at risk for HIV infection and/or poor medical care outcomes  Does housing status influence individual risk behaviors and medical care outcomes, or are findings evidence of self-selection of “risky persons” into conditions of homelessness  RISKY PERSON MODEL: RISKY DISPOSITIONS/ PERSONALITY RISKY BEHAVIORS: Drug use Risky sex Illegal activities HIV INFECTION UNSTABLE HOUSING

47. Opposing Model: STRUCTURAL CONTEXTS OF RISK HIV research shown that focus on individual level factors not sufficient – need address structural factors Structural factor - an environmental or contextual influence that affects an individual’s ability to avoid exposure to health risks, or avail of health promoting resources Housing is itself a structural or contextual factor within which we live our lives – but also manifestation of broader, antecedent, more global structural factors The same fundamental causes put persons at risk for poor health and for unstable/inadequate housing : political contexts, inequality of opportunities and conditions, social processes of discrimination and social exclusion

48. Direct and Indirect Effects of Housing  Lack of stable, secure, adequate housing: -- Lack of protected space to maintain physical and psychological well-being --Constant stress producing environments and experiences -- Neighborhoods of disadvantage and disorder --Compromised identity and agency -- Press of daily needs - barrier to service use when available -- Structuring the private sphere – lack of housing is barrier to forming stable intimate relationships

49. RISKY CONTEXTS Model Economic Marginalization UNSTABLE HOUSING Pervasive Risk Competing Needs Few Personal Resources Few Community Resources Risky Behaviors Drug use High risk sex Demoralization Depression Anxiety Barriers to service use Social Exclusion HIV infection Poor Health Outcomes for PLWHA

50. Provision of housing is a promising structural intervention to reduce the spread of HIV as well as improve the lives of infected persons More directly malleable ‘state’ of housing situation holds more promise for intervention than mechanisms far antecedent in psychological development or closer to biological bases of disease Housing is a strategic target for intervention by addressing more proximal consequences of broader economic, social, political or policy barriers that affect prevention and health care Expensive but offset by social and economic costs of poor health, inappropriate medical treatment, and treatment failure among growing numbers of persons living with HIV/AIDS or at high risk of infection Policy & Practice Implications

51. HOUSING IS PREVENTION AND CARE

52. o The CHAIN 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 Mental Hygiene, and Medical and Health Research Association/ Public Health Solutions. o The national, multi-site research project is an inter-agency collaboration between the U.S. Health Resources and Services Administration (HRSA), Special Projects of National Significance (SPNS) Program, and the U.S. Department of Housing and Urban Development (HUD), Housing Opportunities for Persons with AIDS (HOPWA) Program of the Division of HIV/AIDS Housing. o Additional funding for risk behavior analysis was provided by the Behavioral Intervention Research Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention; U.S. Centers for Disease and Prevention (CDC) o Special thanks go to the interviewers and staff supporting the CHAIN program of research over the past 17+ yrs and the staff of several hundred AIDS service organizations and clinics who have taken their time to help with the NYC and/or national research projects described here o And most especially, thanks go to the over 5,000 persons living with HIV/AIDS whose willingness to share a bit of their lives, their experiences, and their insights, has made it all possible o The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official views of the U.S. Health Resources and Services Administration, HUD, CDC, the City of New York, or Public Health Solutions/ Medical and Health Research Association of New York City o To contact Dr. Aidala: aaa1@columbia.edu ACKNOWLEDGEMENTS