1. www.ohtn.on.ca www.nationalaidshousing.org Evidence into Action: Housing = HAART Access & Adherence An overview of recent research findings presented as part of the North American Housing and HIV/AIDS Research Summit Series Convened by The U.S. National AIDS Housing Coalition (NAHC), and The Ontario HIV Treatment Network (OHTN), in collaboration with the Johns Hopkins Bloomberg School of Public Health Christine Campbell and Ginny Shubert July 6, 2010

2. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care Introduction Overview: Housing Policy is Health Policy Effectively addressing HIV risk & health care disparities requires attention to structural factors —environmental or contextual factors that influence health 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 & 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)

3. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care Introduction Overview: Policy & practice implications HIV prevention and care strategies will not succeed without addressing structural barriers such as homelessness & housing instability Housing for persons with HIV/AIDS saves lives and taxpayer dollars, making it is 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 person’s health and risk outcomes

4. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care What the Evidence Shows Summary of key findings on Housing & HIV Homelessness and unstable housing are linked to greater HIV risk, inadequate care, poor health outcomes & early death Studies also show strong & 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 & other chronic conditions

5. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care Housing and Health Outcomes 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 & overall health –More likely to be uninsured, hospitalized & use ER –Lower CD4 counts & less likely to have undetectable viral load –Fewer ever on ART, and fewer on ART currently –Self-reported ART adherence lower Housing status found more significant than individual characteristics as a predictor of health care access & outcomes

6. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care Housing and Health Outcomes Stable housing improves health outcomes 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 Increased housing stability is positively associated with: –Effective HAART (viral suppression) –Better HIV related health status ( as indicated by viral load, CD4 count, lack of co-infection with HCV or TB) Placement is supportive housing has been found to reduce mortality among homeless PLWHA by as much as 80% over time.

7. NYC & National Research Studies Community Health Advisory & Information Network (CHAIN) Project  Multi-stage probability sampling – designed to be representative of larger population of persons living with HIV/AIDS in NYC  Includes 1661 PLWHA randomly recruited from clinics and agencies in 1994, 1998, 2002 and interviewed yearly HRSA SPNS/ HUD HOPWA Multiple Diagnoses Initiative  Interviews conducted with clients of program throughout U.S. providing health and social services to low income PLWHA  Baseline information from 3191 clients from 24 projects and follow-up data from 891 clients from 16 projects - 1996-2000

8. Housing & Connection to Medical Care NYC CHAIN Sample

9. 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 than individual characteristics as a predictor of health care access & outcomes

10. PREDICTING T2 MEDICATION USE National MDI Sample Unadjusted Odds Ratio T2 ARV Adjusted Odds Ratio T2 ARV 1 NO CHANGE IMPROVED HOUSING3.21 6.22 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, health status, mental health, and receipt of case management services N= 192. Relationships statistically significant p<.05 except ( ) =ns

11. Access to Medical Care : CHAIN NYC 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 Adjust 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.

12. 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

13. Low-demand “Housing First ” “ Housing first” models place persons with substance use and/or mental health issues directly into permanent housing without requiring sobriety Growing evidence shows that these programs achieve positive housing, service use, health and mental health outcomes Low-demand housing programs demonstrate that changing the environment of persons with multiple challenges can result in positive outcomes without prior individual level change to achieve “housing readiness”

14. Studies of HIV housing assistance Two large-scale intervention studies examine 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 HIV+ persons Findings: Housing assistance linked to improved health, mental health, and quality of life outcomes

15. 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)

16. 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)

17. 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 participants had significantly better health status: –55% of housed were alive with “intact immunity”, compared to only 34% of HIV+ 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

18. www.ohtn.on.ca www.nationalaidshousing.org Housing & Health 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 Housing is HIV Prevention and Health Care Housing Interventions Work

19. www.ohtn.on.ca www.nationalaidshousing.org 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 Housing is HIV Prevention and Health Care Housing Interventions Work

20. www.ohtn.on.ca www.nationalaidshousing.org Comparative Cost 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 & 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 indicate that housing is a cost effective health care intervention for PLWHA, with a cost per QALY ($35,000 - $65,000) well within the range of widely accepted health care interventions such as renal dialysis ($52,000 - $129,000 per QALY). Housing is HIV Prevention and Health Care Housing Interventions Work

21. www.ohtn.on.ca www.nationalaidshousing.org 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

22. www.ohtn.on.ca www.nationalaidshousing.org Housing/ Lack of Housing and HIV Care  Research findings indicate that the condition of homelessness and not simply the traits of homeless individuals, influence risk behaviors & service utilization  HIV positive persons with housing problems are less likely to be engaged in appropriate medical care  Overtime analyses show improvement in housing situation associated with: HAART access; HAART adherence; and positive change in medical outcomes  Data show strong & consistent relationship between housing status and medical outcomes (including reduced mortality), regardless of other individual characteristics, health status, or service use variables Housing is HIV Prevention and Health Care What the Evidence Means

23. www.ohtn.on.ca www.nationalaidshousing.org Housing is HIV Prevention and Health Care Transforming Research into Policy Initiatives This 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

24. www.ohtn.on.ca www.nationalaidshousing.org

25. www.ohtn.on.ca www.nationalaidshousing.org Acknowledgements The North American Housing & HIV/AIDS Research Summit Series is convened by the U.S. National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment Network (OHTN), in collaboration with the Department of Health, Behavior and Society of the Johns Hopkins Bloomberg School of Public Health Convening researchers include: Dr. David Holtgrave of Johns Hopkins; Dr. Angela Aidala of Columbia University; Dr. Toorjo Ghose of the University of Pennsylvania; Randy Jackson of the Canadian Aboriginal AIDS Network, Dr. Robert Hogg of the BC Centre for Excellence in HIV/AIDS; 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 (www.shubertbotein.com) help plan and document the Summit Series. Anne Bozack helped develop the Summit V Briefing Book.www.shubertbotein.com Slides on CHAIN and MDIS findings are drawn from an April 2010 presentation by Dr. Angela Aidala of the Columbia University Mailman School of Public Health at the NAHC Southern Regional Housing and HIV/AIDS Research Summit in New Orleans.