Housing Stability/Instability andEntry and Maintenance in Medical

Care

Angela Aidala, Gunjeong LeeMailman School of Public Health, Columbia University

CHAIN Data Day Presentation

June 5, 2008

INTRODUCTIONINTRODUCTION

Policy and funding changes restricts ability to address Policy and funding changes restricts ability to address housing needs of PLWHhousing needs of PLWH

- - RW Modernization Act of 2006 limits funds for ‘non-core’ RW Modernization Act of 2006 limits funds for ‘non-core’ servicesservices

-- HOPWA funding less than 2004 levelsHOPWA funding less than 2004 levels

Providers and consumers concerned will affect housing, Providers and consumers concerned will affect housing, medical care and health outcomes for PLWHmedical care and health outcomes for PLWH

- - Fair Market Rent (FMR) for 1BR in NYC =$949Fair Market Rent (FMR) for 1BR in NYC =$949

- - “Affordable” for income >$3000 mo“Affordable” for income >$3000 mo

- - Few PLWH can maintain regular employment at $3000 moFew PLWH can maintain regular employment at $3000 mo

- - SSI =$710/mo Average SSD =$750/moSSI =$710/mo Average SSD =$750/mo

STUDY QUESTIONSSTUDY QUESTIONS

What are rates of homelessness or housing What are rates of homelessness or housing instability among PLWH in NYC and have rates instability among PLWH in NYC and have rates changed over time? changed over time?

What is the relationship between housing status What is the relationship between housing status and entry and maintenance in HIV medical care? and entry and maintenance in HIV medical care?

What are additional service needs of PLWH with What are additional service needs of PLWH with unstable unstable housing?housing?

MEASURING HOUSING STATUSMEASURING HOUSING STATUS

HOMELESSHOMELESS

-- 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 public place (e.g. subway) not intended for sleeping

-- in a drop in center or shelter for homeless persons-- in a drop in center or shelter for homeless persons

-- in a limited stay SRO or welfare hotel with no services-- in a limited stay SRO or welfare hotel with no services

-- in jail with no other address-- in jail with no other address

UNSTABLY HOUSEDUNSTABLY HOUSED

-- in transitional housing, residential treatment, halfway house -- in transitional housing, residential treatment, halfway house

-- doubled up with other people -- doubled up with other people

STABLY HOUSEDSTABLY HOUSED

---- own, permanent housing in regular apartment or houseown, permanent housing in regular apartment or house

HOUSING PROBLEMS/ NEEDSHOUSING PROBLEMS/ NEEDS

Answers to questionAnswers to question: :

In the last 6 months, have you had a problem or In the last 6 months, have you had a problem or needed assistance with housing?needed assistance with housing?

(If YES) (If YES) Please tell me about your need for assistance with Please tell me about your need for assistance with

housing or the problem you had.housing or the problem you had.

____________________________________________________

____________________________________________________

____________________________________________________

PATTERNS OF HOUSING NEED

HOUSING & HIV EPIDEMIOLOGYHOUSING & HIV EPIDEMIOLOGY

Housing needs are widespread among PLWHHousing needs are widespread among PLWH

-- -- 52% of the 2002 NYC cohort were homeless or unstably 52% of the 2002 NYC cohort were homeless or unstably housed during the year they were diagnosed with HIVhoused during the year they were diagnosed with HIV

-- At any point in time 25-35% of all PLWH are homeless or -- At any point in time 25-35% of all PLWH are homeless or unstably housed – even more report housing problemsunstably housed – even more report housing problems

-- In NYC, 60% experienced unstable housing or homelessness at -- In NYC, 60% experienced unstable housing or homelessness at least once over the course of their illnessleast once over the course of their illness

-- From system perspective NYC rates of housing need remain -- From system perspective NYC rates of housing need remain fairly constant over time as some PLWH get housing needs met, fairly constant over time as some PLWH get housing needs met, others develop housing problemsothers develop housing problems

HOUSING STATUS AND HOUSING HOUSING STATUS AND HOUSING

PROBLEMSPROBLEMSCHAIN STUDY (Agency recruited CHAIN STUDY (Agency recruited

samples)samples)Original Original CohortCohort

1994-951994-95

Refresh Refresh Cohort Cohort 1998-991998-99

New New Cohort Cohort

2002-042002-04

RECENT EXPERIENCERECENT EXPERIENCE11

Unstable housingUnstable housing

HomelessHomeless

16%16%

19 19

19%19%

99

20%20%

10 10

HOUSING PROBLEMSHOUSING 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 dangerousviolence, other dangerous

situation, need accessible unit,situation, need accessible unit,

etc.etc.

38%38% 28%28% 35%35%

1. Past 6 months

HOUSING STATUS AND HOUSING HOUSING STATUS AND HOUSING PROBLEMSPROBLEMS

CHAIN STUDY (Unconnected sample)CHAIN STUDY (Unconnected sample)

Original Original CohortCohort

19951995

Refresh Refresh Cohort Cohort

19981998

New New Cohort Cohort

20042004

HOUSING STATUSHOUSING STATUS

Homeless of Unstable HousingHomeless of Unstable Housing64%64% 78%78% 72%72%

HOUSING PROBLEMSHOUSING 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 dangerousviolence, other dangerous

situation, need accessible unit,situation, need accessible unit,

etc.etc.

54%54% 50%50% 74%74%

Aggregate Rates of Housing Need Remain Aggregate Rates of Housing Need Remain HighHigh

0

10

20

30

40

50

12/ 94 3/ 95 6/ 95 9/ 95 12/ 95 3/ 96 6/ 96 9/ 96 12/ 96

0

10

20

30

40

50

12/ 01 3/ 02 6/ 02 9/ 02 12/ 02 3/ 03 6/ 03 9/ 03 12/ 03

Rate of Housing Service Need by Date of Interview – 1994 thru 1996

Rate of Housing Service Need by Date of Interview – 2001 thru 2003

Rates of Housing Need Remain Rates of Housing Need Remain HighHigh

As some persons get their housing needs met others develop housing problems

-- Loss of income due to progressive inability to maintain employment

-- Growing disparities between income and rent requirements

-- Relationship breakup including leaving abusive situations

-- Loss of spouse/partner to HIV related death or disability

-- Loss of shared housing options with disclosure of HIV

-- Disease progression requiring accessible facilities

-- Policy requirements that limit residence in temporary or transitional programs

HOUSING & MEDICAL CARE

HOUSING STATUS AND ENTRY INTO CAREHOUSING STATUS AND ENTRY INTO CARE

Housing Situation at Time of HIV DiagnosisHousing Situation at Time of HIV Diagnosis

StableStableOwn Own PlacePlace

Temp Temp Doubled Doubled

UpUp

Shelter Shelter Temp Temp

HousingHousingJail or Jail or PrisonPrison

On the On the StreetStreet

Delayed Entry Delayed Entry

to HIV Medical Careto HIV Medical Care 4+ months after 4+ months after diagnosisdiagnosis (average delay(average delay 12-18 moths)12-18 moths)

27%27% 26%26% 23%23% 40%40% 44%44%

Reasons Given for Delayed Entry into Care

%%

In denial about being HIV infected, didn’t want to face itIn denial about being HIV infected, didn’t want to face it 3333

Was doing drugs, relapsedWas doing drugs, relapsed 1818

Felt fine, wasn’t sick, no symptomsFelt fine, wasn’t sick, no symptoms 1414

Believed I was going to die anywayBelieved I was going to die anyway 99

Was homeless, had no money (competing needs)Was homeless, had no money (competing needs) 77

Fear, uncertaintyFear, uncertainty 77

Did not want HIV medicationsDid not want HIV medications 66

Did not know where to goDid not know where to go 66

Total sample of delayers, most recent NYC cohort (n=157)Total sample of delayers, most recent NYC cohort (n=157)

Thematic coding of client descriptions of reasons for delayed into HIV medical care Multiple responses possible

HOUSING & MEDICAL CARE

Unstable housing leads to discontinuous care - recent breaks in care, dropping in and out of care and/or changing providers often

Homeless or unstably housed individuals are less likely than other PLWHS to be receiving medical care that meets minimum clinical practice guidelines

Homelessness /unstable housing is one of the most important barrierslimiting the use of antiretroviral combination therapy

High viral load, recent opportunistic infection, and hospitalization for HIV related disease are associated with homelessness/ unstable housing

Reasons Given for Not Being in Care among the Unconnected

%%

Homeless, other competing needsHomeless, other competing needs 2727

Feel fine, not sick, no symptomsFeel fine, not sick, no symptoms 1919

Doing drugs, relapsedDoing drugs, relapsed 1313

Do not want HIV medications/ want to stop medicationsDo not want HIV medications/ want to stop medications 1111

Did not want HIV medications, wanted to discontinue medsDid not want HIV medications, wanted to discontinue meds 1111

Tired of it, was fed up, wanted a breakTired of it, was fed up, wanted a break 99

Disruption in care – program closed, doctor left, I moved Disruption in care – program closed, doctor left, I moved 88

Total sample outside of care (n=25)

Thematic coding of client descriptions of reasons for never accessing medical care or dropping out of care

Multiple responses possible

IMPORTANCE OF HOUSING SERVICES

Housing Assistance and Services Housing Assistance and Services Make a Differences Make a Differences

Accessing agency- based housing services improves one’s chance of securing stable, adequate housing

The strongest predictor of obtaining housing and of staying in housing is receipt of rental subsidy

Supportive services are as important as rental assistance successfully maintaining stable housing

PLWHA receiving housing assistance face numerous health and personal resource challenges that would limit access to stable housing

Challenges and Resources of PLWH Challenges and Resources of PLWH Receiving Rental Assistance Receiving Rental Assistance

43% Not enough money for food, utilities, or un- reimbursed medical care needs at least once past 6 months

53% Household income from all sources <$7500 yr

57% Physical health functioning =“disabled”

48% Have mental health needs

42% Less than high school education

43% No work for wages 5yrs or more

CONCLUSIONSCONCLUSIONS

Findings provide strong and consistent evidence thatFindings provide strong and consistent evidence that ::

-- The need for housing assistance has not diminished over time -- The need for housing assistance has not diminished over time and remains at 30-40% of all PLWH and remains at 30-40% of all PLWH

-- housing needs are a significant barrier to receipt of -- housing needs are a significant barrier to receipt of appropriate HIV medical care and continuity of care over time appropriate HIV medical care and continuity of care over time

-- receipt of housing assistance has a direct impact on -- receipt of housing assistance has a direct impact on improved improved medical care outcomes for persons living medical care outcomes for persons living with HIV/AIDSwith HIV/AIDS

Any decrease in funding to provide housing assistance Any decrease in funding to provide housing assistance would present serious challenges to PLWH and the HIV would present serious challenges to PLWH and the HIV care system care system

Improving access to housing will improve access to and Improving access to housing will improve access to and effectiveness of HIV medical care and treatmenteffectiveness of HIV medical care and treatment

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

This 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 Medical and Health Research Association of New York City

Its contents are solely the responsibility of the Researchers and do not necessarily represent the official views of the U.S. Health Resources and Services Administration, the City of New York, or the Medical and Health Research Association..

Special thanks is due to the 1661 persons living with HIV who have participated in the CHAIN Project and shared their experiences with us.

Contact: aaa1@columbia.edu