AIDS and Behavior

, Volume 11, Supplement 2, pp 149–161 | Cite as

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

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


Homelessness and unstable housing have been associated with HIV risk behavior and poorer health among persons living with HIV/AIDS (PLWHA), yet prior research has not tested causal associations. This paper describes the challenges, methods, and baseline sample of the Housing and Health Study, a longitudinal, multi-site, randomized controlled trial investigating the effects of providing immediate rental housing assistance to PLWHA who were homeless or at severe risk of homelessness. Primary outcomes included HIV disease progression, medical care access and utilization, treatment adherence, mental and physical health, and risks of transmitting HIV. Across three study sites, 630 participants completed baseline sessions and were randomized to receive either immediate rental housing assistance (treatment group) or assistance finding housing according to local standard practice (comparison group). Baseline sessions included a questionnaire, a two-session HIV risk-reduction counseling intervention, and blood sample collection to measure CD4 counts and viral load levels. Three follow-up visits occurred at 6, 12, and 18 months after baseline. Participants were mostly male, Black, unmarried, low-income, and nearly half were between 40 and 49 years old. At 18 months, 84% of the baseline sample was retained. The retention rates demonstrate the feasibility of conducting scientifically rigorous housing research, and the baseline results provide important information regarding characteristics of this understudied population that can inform future HIV prevention and treatment efforts.


Homeless Housing HIV Structural intervention Cost effectiveness 


  1. Aidala, A., Cross, J. E., Stall, R., Harre, D., & Sumartojo, E. (2005). Housing status and HIV risk behaviors: Implications for prevention and policy. AIDS and Behavior, 9, 251–265.PubMedCrossRefGoogle Scholar
  2. Allen, D. M., Lehman, S., Green, T. A., Lindegren, M. L., Onorato, I. M., Forrester, W., et al. (1994). HIV infection among homeless adults and runaway youth, United States, 1989–1992. AIDS, 8, 1593–1598.PubMedCrossRefGoogle Scholar
  3. Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural interventions in public health. AIDS, 14, S11–S21.PubMedCrossRefGoogle Scholar
  4. Boekeloo, B. O., Schiavo, L., Rabin, D., Conlon, R. T., Jordan, C. S., & Mundt, D. J. (1994). Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: Audio vs. written questionnaires. American Journal of Public Health, 84, 754–760.PubMedGoogle Scholar
  5. Buchanan, D. R., & Miller, F. G. (2006). A public health perspective on research ethics. Journal of Medical Ethics, 32, 729–733.PubMedCrossRefGoogle Scholar
  6. Burt, M., Aron, L. Y., & Lee, E. (2001). Helping America’s homeless: Emergency shelter or affordable housing? Washington, DC: Urban Institute Press.Google Scholar
  7. Camasso, M. J. (2003). Quality of life perception in transitional housing demonstration projects: An examination of psychosocial impact. Brief Treatment and Crisis Intervention, 3, 99–118.CrossRefGoogle Scholar
  8. Centers for Disease Control, Prevention. (2005). HIV/AIDS surveillance report, 2004 (Vol. 16). Atlanta, GA: US Department of Health and Human Services, CDC.Google Scholar
  9. Centers for Disease Control & Prevention. (2006). Comprehensive risk counseling and services (CRCS) implementation manual. Retrieved January 22, 2007 from
  10. Corsi, K. F., VanHunnik, B., Kwiatkowski, C. F., & Booth, R. E. (2006). Computerized tracking and follow-up techniques in longitudinal research with drug users. Health Services and Outcomes Research Methodology, 6, 101–110.CrossRefGoogle Scholar
  11. Crepaz, N., Lyles, C., Wolitski, R., Passin, W., Rama, S., Herbst, J., et al. (2006). Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS, 20, 143–157.PubMedCrossRefGoogle Scholar
  12. Culhane, D. P., Gollub, E., Kuhn, R., & Shpaner, M. (2001). The co-occurrence of AIDS and homelessness: Results from the integration of administrative databases for AIDS surveillance and public shelter utilisation in Philadelphia. Journal of Epidemiology and Community Health, 55, 515–520.PubMedCrossRefGoogle Scholar
  13. Dail, P. W. (2001). Introduction and concluding observations: Special Issue on Homelessness. American Behavioral Scientist, 45(6), 6–13.CrossRefGoogle Scholar
  14. Dodd, R. Y. (2004). Current safety of the blood supply in the United States. International Journal of Hematology, 80, 301–305.PubMedCrossRefGoogle Scholar
  15. Estebanez, P. E., Russell, N. K., Aguilar, M. D., Beland, F., & Zunzunegui, M. V. (2000). Women, drugs and HIV/AIDS: Results of a multicentre European study. International Journal of Epidemiology, 29, 734–743.PubMedCrossRefGoogle Scholar
  16. Fournier, A. M., Tyler, R., Iwasko, N., LaLota, M., Shultz, J., & Greer, P. J. (1996). Human immunodeficiency virus among the homeless in Miami: A new direction for the HIV epidemic. American Journal of Medicine, 100, 582–584.PubMedCrossRefGoogle Scholar
  17. Holtgrave, D. R., Briddell, K., Little, E., Bendixen, A. V., Hooper, M., Kidder, D. P., Wolitski, R. J., Harre, D., Royal, S., Aidala, A., for the Housing and Health Study Team (this issue). Cost and threshold analysis of housing as an HIV prevention intervention. AIDS and Behavior (this issue).Google Scholar
  18. Hwang, S. W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to improve the health of the homeless: A systematic review. American Journal of Preventive Medicine, 29(4), 311–319.PubMedCrossRefGoogle Scholar
  19. Janssen, R. S., Holtgrave, D. R., Valdiserri, R. O., Shepherd, M., Gayle, H. D., & De Cock, K. M. (2001). The Serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. American Journal of Public Health, 91(7), 1019–1024.PubMedCrossRefGoogle Scholar
  20. Kamb, M. L., Fishbein, M., Douglas, J. M., Rhodes, F., Rogers, J., Bolan, G., et al. (1998). Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Journal of the American Medical Association, 280, 1161–1167.PubMedCrossRefGoogle Scholar
  21. Kidder, D. P., Wolitski, R. J., Campsmith, M. L., & Nakamura, G. V. (in press). Health status, health care use, medication use, and medication adherence in homeless people living with HIV/AIDS. American Journal of Public Health.Google Scholar
  22. Kissinger, P., Rice, J., Farley, T., Trim, S., Jewitt, K., Margavio, V., et al. (1999). Application of computer-assisted interviews to sexual behavior research. American Journal of Epidemiology, 149, 950–954.PubMedGoogle Scholar
  23. Knowlton, A., Arnsten, J., Eldred, L., Wilkinson, J., Gourevitch, M., Shade, S., et al. (2006). Individual, interpersonal, and structural correlates of effective HAART use among urban active injection drug users. Journal of Acquired Immune Deficiency Syndromes, 41(4), 486–492.PubMedCrossRefGoogle Scholar
  24. Kurth, A. E., Martin, D. P., Golden, M. R., Weiss, N. S., Heagerty, P. J., Spielberg, F., et al. (2004). A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the self history. Sexually Transmitted Diseases, 31, 719–726.PubMedCrossRefGoogle Scholar
  25. Mercier, C., Fournier, L., & Peladeau, N. (1992). Program evaluation of services for the homeless: Challenges and strategies. Evaluation and Program Planning, 15, 417–426.CrossRefGoogle Scholar
  26. Mofenson, L. M. (2002). U.S. Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1 infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. MMWR Morbidity and Mortality Weekly Report, 51, 1–38.Google Scholar
  27. Mowbray, C. T., Cohen, E., & Bybee, D. (1993). The challenge of outcome evaluation in homeless services: Engagement as an intermediate outcome measure. Evaluation and Program Planning, 16, 337–346.CrossRefGoogle Scholar
  28. Newman, J. C., Des Jarlais, D. C., Turner, C. F., Gribble, J., Cooley, P., & Paone, D. (2002). The differential effects of face-to-face and computer interview modes. American Journal of Public Health, 92, 294–297.PubMedGoogle Scholar
  29. Orwin, R. G., Scott, C. K., & Arieira, C. R. (2003). Transitions through homelessness and factors that predict them: Residential outcomes in the Chicago Target Cities treatment sample. Evaluation and Program Planning, 26, 379–392.CrossRefGoogle Scholar
  30. O’Toole, T. P., Gibbon, J. L., Hanusa, B. H., Freyder, P. J., Conde, A. M., & Fine, M. J. (2004). Self-reported changes in drug and alcohol use after becoming homeless. American Journal of Public Health, 94, 830–835.PubMedGoogle Scholar
  31. Paris, N. M., East, R. T., & Toomey, K. E. (1996). HIV seroprevalence among Atlanta’s homeless. Journal of Health Care for the Poor and Underserved, 7, 83–93.PubMedGoogle Scholar
  32. Parker, R. G., Easton, D., & Klein, C. H. (2000). Structural barriers and facilitators in HIV prevention: A review of international research. AIDS, 14, S22–S32.PubMedCrossRefGoogle Scholar
  33. Perlis, T. E., Des Jarlais, D. C., Friedman, S. R., Arasteh, K., & Turner, C. F. (2004). Audio-computerized self-interviewing versus face-to-face interviewing for research data collection at drug abuse treatment programs. Addiction, 99, 885–896.PubMedCrossRefGoogle Scholar
  34. Riley, E. D., Robnett, T. J., Vlahov, D., Vertefeuille, J., Strathdee, S. A., & Chaisson, R. E. (2000). Computer-assisted self-interviewing for HIV and tuberculosis risk factors among injection drug users participating in a needle exchange program. American Journal of Epidemiology, 151, S55.Google Scholar
  35. Schutt, R. K., Rosenheck, R. E., Penk, W. E., Drebing, C. E., & Seibyl, C. L. (2005). The social environment of transitional work and residence programs: Influences on health and functioning. Evaluation and Program Planning, 28, 291–300.CrossRefGoogle Scholar
  36. Shlay, J. C., Blackburn, D., O’Keefe, K., Raevsky, C., Evans, M., & Cohn, D. L. (1996). Human immunodeficiency virus seroprevalence and risk assessment of a homeless population in Denver. Sexually Transmitted Diseases, 23, 304–311.PubMedCrossRefGoogle Scholar
  37. Sumartojo, E. (2000). Structural factors in HIV prevention: Concepts, examples, and implications for research. AIDS, 14, S3–S10.PubMedCrossRefGoogle Scholar
  38. Toro, P. A. (2006). Trials, tribulations, and occasional jubilations while conducting research with homeless children, youth, and families. Merrill-Palmer Quarterly, 52(2), 343–364.CrossRefGoogle Scholar
  39. Torres, R. A., Mani, S., Altholtz, J., & Brickner, P. W. (1990). Human immunodeficiency virus infection among homeless men in a New York City shelter: Association with Mycobacterium tuberculosis infection. Archives of Internal Medicine, 150, 2030–2036.PubMedCrossRefGoogle Scholar
  40. U.S. Department of Housing and Urban Development (2000). National evaluation of the housing opportunities for persons with AIDS program (HOPWA). Washington, DC: HUD Office of Policy Development and Research.Google Scholar
  41. Walters, A. S. (1999). HIV prevention in street youth. Journal of Adolescent Medicine, 25, 187–198.Google Scholar
  42. Wright, J. D., Allen, T. L., & Devine, J. A. (1995). Tacking non-traditional populations in longitudinal studies. Evaluation and Program Planning, 18, 267–277.CrossRefGoogle Scholar
  43. Zolopa, A. R., Hahn, J. A., Gorter, R., Miranda, J., & Wlodarczyk, D. (1994). HIV and tuberculosis infection in San Francisco’s homeless adults. Journal of the American Medical Association, 272, 455–461.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Daniel P. Kidder
    • 1
  • Richard J. Wolitski
    • 1
  • Scott Royal
    • 2
  • Angela Aidala
    • 3
  • Cari Courtenay-Quirk
    • 1
  • David R. Holtgrave
    • 4
  • David Harre
    • 5
  • Esther Sumartojo
    • 6
  • Ron Stall
    • 7
  • for the Housing and Health Study Team
  1. 1.Division of HIV/AIDS Prevention, National Center for HIV/AIDS, 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.Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA
  5. 5.Department of Housing and Urban DevelopmentWashingtonUSA
  6. 6.National Center on Birth Defects and Developmental DisabilitiesCenters for Disease Control and PreventionAtlantaUSA
  7. 7.School of Public HealthUniversity of PittsburghPittsburghUSA

Personalised recommendations