AIDS and Behavior

, Volume 14, Issue 3, pp 493–503 | Cite as

Randomized Trial of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and Unstably Housed People Living with HIV

  • Richard J. Wolitski
  • Daniel P. Kidder
  • Sherri L. Pals
  • Scott Royal
  • Angela Aidala
  • Ron Stall
  • David R. Holtgrave
  • David Harre
  • Cari Courtenay-Quirk
  • for the Housing and Health Study Team
Original Paper

Abstract

Homelessness affects HIV risk and health, but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS. Homeless/unstably housed people living with HIV/AIDS (N = 630) were randomly assigned to immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance or customary care. Self-reported data, CD4, and HIV viral load were collected at baseline, 6, 12, and 18 months. Results showed that housing status improved in both groups, with greater improvement occurring in the treatment group. At 18 months, 51% of the comparison group had their own housing, limiting statistical power. Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health; significant differential change benefiting the treatment group was observed for depression and perceived stress. Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization, mental health, and physical health. HOPWA rental assistance improves housing status and, in some cases, health outcomes of homeless and unstably housed people living with HIV/AIDS.

Keywords

Housing Homeless persons HIV seropositivity Health status Mental health Health services accessibility Randomized controlled trial Sexual behavior 

Notes

Acknowledgments

We would like to thank the many people who made this study a success. In addition to the authors of this paper, the Housing and Health Study members (in alphabetical order) include Arturo Bendixen (AIDS Foundation of Chicago), Kate Briddell (City of Baltimore, Department of Housing and Community Development), Shahry Deyhimy (City of Los Angeles Housing Department), Paul Dornan (HUD), Myrna Hooper (Housing Authority of the City of Los Angeles), Jennafer Kwait (Research Triangle Institute, RTI), Fred Licari (RTI), Shirley Nash (City of Chicago Department of Public Health), William Rudy (HUD), Esther Sumartojo (CDC), and David Vos (HUD). We would also like to acknowledge the contributions of Rusty Bennett, Maria Caban, Sylvia Cohn, Lynne Cooper, Jay Cross, Maria DiGregorio, Clyde Hart, Kirk Henny, Kelly Kent, Lee Lam, Joyce Moon Howard, Noelle Richa, Danny Ringer, Randy Russell, Ruth Schwartz, Tom Spira, and Jun Zhang. Dr Wolitski and Dr Pals had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Sumartojo, Stall, Aidala, and Harre initially conceptualized the study. All of the authors made substantial contributions to the design of the study, assessment instruments, and intervention protocols. Kidder was the CDC technical monitor for the study. Royal oversaw data collection. Pals designed (with input from all authors) and conducted the statistical analyses. Wolitski drafted the manuscript. All of the authors provided input into the interpretation of results and provided critical review of drafts of the manuscript for important intellectual content. Funding for the research study was provided by the Centers for Disease Control and Prevention to RTI under contract 200-2001-0123, Task 9 and funding for permanent supportive housing rental assistance was provided by the Department of Housing and Urban Development. Data collection was approved by the Office of Management and Budget (0920-0628).

References

  1. 1.
    Krieger J, Higgins D. Housing and health: time again for public health action. Am J Public Health. 2002;92:758–68.CrossRefPubMedGoogle Scholar
  2. 2.
    Martens WH. A review of physical and mental health in homeless persons. Public Health Rev. 2001;29:13–33.PubMedGoogle Scholar
  3. 3.
    Institute of Medicine. Homelessness, health and human needs. Washington, DC: National Academy Press, Institute of Medicine; 1988.Google Scholar
  4. 4.
    Shaw M. Housing and public health. Ann Rev Public Health. 2004;25:397–418.CrossRefGoogle Scholar
  5. 5.
    Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med. 2005;29:311–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Wolitski RJ, Kidder DP, Fenton KA. HIV, homelessness, and public health: Critical issues and a call for increased action. AIDS Behav. 2007;11(6 Supp):167–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Aidala AA, Sumartojo E. Why housing? AIDS Behav. 2007;11(6 Supp):1–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Allen DM, Lehmn S, Green TA, et al. HIV infection among homeless adults and runaway youth, United States, 1989–1992. AIDS. 1994;8:1593–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Culhane DP, Gollub E, Kuhn R, Shapner M. The co-occurrence of AIDS and homelessness: results from the integration of administrative databases for AIDS surveillance and public shelter utilization in Philadelphia. J Epidemiol Community Health. 2001;55:515–20.CrossRefPubMedGoogle Scholar
  10. 10.
    Estebanez PE, Russell NK, Aguilar MD, Beland F, Zunzunegui MV. Women, drugs and HIV/AIDS: results of a multicentre European study. Intl J Epidemiol. 2000;29:734–43.CrossRefGoogle Scholar
  11. 11.
    Zolopa AR, Hahn JA, Gorter R, et al. HIV and tuberculosis infection in San Francisco’s homeless adults—prevalence and risk factors in a representative sample. JAMA. 1994;272:455–61.CrossRefPubMedGoogle Scholar
  12. 12.
    Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, and medication adherence in homeless and housed people living with HIV. Am J Public Health. 2007;97:2238–45.CrossRefPubMedGoogle Scholar
  13. 13.
    Leaver CA, Bargh G, Dunn JR, Hwang SW. The effects of housing status on health-related outcomes in people living with HIV: a systematic review of the literature. AIDS Behav. 2007;11(6 Supp):85–100.CrossRefPubMedGoogle Scholar
  14. 14.
    Smith MY, Rapkin BD, Winkel G, Springer C, Chahabra R, Feldman IS. Housing status and health care service utilization among low-income persons with HIV/AIDS. J Gen Intern Med. 2000;15:731–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Aidala AA, Lee G, Abramson DM, Messeri P, Siegler A. Housing need, housing assistance, and connection to HIV medical care. AIDS Behav. 2007;11(6 Supp):101–15.CrossRefPubMedGoogle Scholar
  16. 16.
    Royal SW, Kidder DP, Parabansh S, et al. Factors associated with adherence to highly active antiretroviral therapy in homeless and unstably housed adults living with HIV. AIDS Care. 2009;21:448–55.CrossRefPubMedGoogle Scholar
  17. 17.
    Kidder DP, Wolitski RJ, Pals SL, Campsmith ML. Housing status and HIV risk behaviors among homeless and unstably housed persons with HIV. J Acquir Immune Defic. 2008;49:451–5.CrossRefGoogle Scholar
  18. 18.
    Aidala A, Cross JE, Stall R, Harre D, Sumartojo E. Housing status and HIV risk behaviors: Implications for prevention and policy. AIDS Behav. 2005;9:251–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Metraux S, Metzger DS, Culhane DP. Homelessness and HIV risk behaviors among injection drug users. J Urban Health. 2004;81:618–29.PubMedGoogle Scholar
  20. 20.
    Friedman MS, Marshal MP, Stall R, et al. Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV. AIDS Care. 2009;21:692–700.CrossRefPubMedGoogle Scholar
  21. 21.
    Coady MH, Latka MH, Thiede H, et al. Housing status and associated differences in HIV risk behaviors among young injection drug users (IDUs). AIDS Behav. 2007;11:854–63.CrossRefPubMedGoogle Scholar
  22. 22.
    Wenzel SL, Tucker JS, Elliott MN, Hambarsoomians K. Sexual risk among impoverished women: Understanding the role of housing status. AIDS Behav. 2007;11(6 Supp):9–20.CrossRefPubMedGoogle Scholar
  23. 23.
    Kidder DP, Wolitski RJ, Royal S, et al. Access to housing as a structural intervention for homeless and unstably housed people living with HIV: rationale, methods, and implementation of the housing and health study. AIDS Behav. 2007;11(6 suppl):149–61.CrossRefPubMedGoogle Scholar
  24. 24.
    Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases—a randomized controlled trial. JAMA. 1998;280:1161–7.CrossRefPubMedGoogle Scholar
  25. 25.
    DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Bethesda, MD: National Institutes of Health; 2006. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentsGL.pdf. Accessed April 24, 2007.
  26. 26.
    Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10:77–84.PubMedGoogle Scholar
  27. 27.
    Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapam S, Oskamp S, editors. The social psychology of health: Claremont symposium on applied social psychology. Newbury Park: Sage; 1988.Google Scholar
  28. 28.
    Ware JE, Kosinski M, Dewey JE. How to score version 2 of the SF-36® Health Survey. Lincoln, RI: QualityMetric Inc.; 2000.Google Scholar
  29. 29.
    Wolitski RJ, Parsons JT, Gomez CA, et al. Prevention with gay and bisexual men living with HIV: rationale and methods of the Seropositive Urban Men’s Intervention Trial (SUMIT). AIDS. 2005;19(suppl 1):S1–11.CrossRefPubMedGoogle Scholar
  30. 30.
    Rubin DB. Multiple imputation for nonresponse in surveys. New York: Wiley; 1987.CrossRefGoogle Scholar
  31. 31.
    SAS Institute. SAS/STAT software for PC (version 9.1). Carey, NC: SAS Institute; 2003.Google Scholar
  32. 32.
    West SG, Duan N, Pequegnat W, et al. Alternatives to the randomized controlled trial. Am J Public Health. 2008;98:1359–66.CrossRefPubMedGoogle Scholar
  33. 33.
    Stein JA, Gelberg L. Comparability and representativeness of clinical homeless, community homeless, and domiciled clinic samples: physical and mental health, substance use, and health service utilization. Health Psychol. 1997;16:155–62.CrossRefPubMedGoogle Scholar
  34. 34.
    Wong YL, Piliavin I. Stressors, resources, and distress among homeless persons: a longitudinal analysis. Soc Sci Med. 2001;52:1029–42.CrossRefPubMedGoogle Scholar
  35. 35.
    Lyles CM, Kay LS, Crepaz N, et al. Best-evidence interventions: findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. Am J Public Health. 2007;97:133–43.CrossRefPubMedGoogle Scholar
  36. 36.
    Shubert V, Bernstine N. Moving from fact to policy: housing is HIV prevention and health care. AIDS Behav. 2007;11(6 Suppl):172–81.CrossRefPubMedGoogle Scholar
  37. 37.
    Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009;301:1771–8.CrossRefPubMedGoogle Scholar

Copyright information

© GovernmentEmployee: Department of Health and Human Services, Centers for Disease Control and Prevention 2009

Authors and Affiliations

  • Richard J. Wolitski
    • 1
  • Daniel P. Kidder
    • 1
  • Sherri L. Pals
    • 1
  • Scott Royal
    • 2
  • Angela Aidala
    • 3
  • Ron Stall
    • 4
  • David R. Holtgrave
    • 5
  • David Harre
    • 6
  • Cari Courtenay-Quirk
    • 1
  • for the Housing and Health Study Team
  1. 1.Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB PreventionCenters for Disease Control and PreventionAtlantaUSA
  2. 2.Abt AssociatesBethesdaUSA
  3. 3.Mailman School of Public HealthColumbia UniversityNew YorkUSA
  4. 4.School of Public HealthUniversity of PittsburghPittsburghUSA
  5. 5.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  6. 6.Department of Housing and Urban DevelopmentWashingtonUSA

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