Women with HIV Face Rising Health Risks in Unstable Housing

Women who are HIV-positive and have unstable housing arrangements face an increased risk of experiencing a detectable viral load and a low CD4 cell count, according to new research.

According to the study results, women who were homeless or had inadequate shelter saw a decrease of 8.1 percentage points in the likelihood of viral suppression and a reduction of 7.8 percentage points in the probability of having adequate CD4 cells.

When investigators considered funding for housing allocated to people living with HIV in their calculations, unstable housing reduced viral suppression by 51 percentage points and decreased the likelihood of adequate CD4 cells by 53 percentage points.

“This study reiterates the concept of ‘housing is health,’’’ corresponding author Omar Galarraga, PhD (Health Economics), associate professor, Brown University, told MD Magazine®. “It provides further empiric evidence that addressing these social determinants of health during a medical visit are likely as important in impacting clinical outcomes as addressing blood pressure or blood sugar levels.”

Because the existing literature was not clear on the effect of stable housing on HIV outcomes, he and Galarraga his colleagues decided to investigate.

“It is surprising how some issues that appear to be almost common sense—eg, ‘not having a roof over your head is bad for you’—are not so easy to prove with rigorous methods, even when there is very detailed and comprehensive data,” he said.

Galarraga and investigators from a dozen US universities and medical centers considered 3 routes by which unstable housing can impact individuals with HIV: time use, health depletion, and income reduction.

They posited that for patients with HIV, the effort of looking for housing reduces the time they spend on medical appointments and their ability to regularly take medication. Unstable housing introduces further stress and mental health issues to an already vulnerable population. And lack of housing impacts an individual’s finances due to its correlation with unsteady employment and low income.

To examine these issues, the investigators accessed the Women's Interagency HIV Study (WIHS) database. WIHS, the largest cohort of women living with HIV in the United States, includes participants in Brooklyn and the Bronx, New York; Chicago; Washington, DC; Los Angeles, and San Francisco.

The team assessed the relationship between unstable housing and 2 key HIV biomarkers: a detectable viral load of above 200 HIV RNA copies/ml, and a CD4 cell count of fewer than 350 cells/microliter.

The authors considered 3082 WIHS participants who had received care between 1995 and 2015. About 30% of the participants had completed high school and one-quarter attended some college. More than half (57%) were African American. Thirty percent had injected drugs, while 72% had used non-injected recreational drugs. Unstable housing included living on the street, a beach, a shelter, a welfare hostel, a jail, a correctional facility, or a halfway house in the previous 12 months.

“The WIHS data allowed us to test the time use channels,” Galarraga explained.

The results revealed that “the patients experiencing unstable housing had worse HIV treatment outcomes and they also had decreased use of health care providers, and mental health/counseling providers, and less continuous care,” according to Galarraga.

The investigators supplemented the WIHS information with data from the US Housing and Urban Development (HUD) / Housing Opportunities for People with AIDS (HOPWA) program and US Centers for Disease Control and Prevention (CDC) HIV surveillance data.

“This allowed us to have detailed longitudinal data for more than 3000 women for over 20 years,” Galarraga said.

This analysis showed that the probability of unstable housing fell with increased funding from HOPWA, which provides money for housing to individuals with HIV. Lower HOPWA funding allocations were strongly associated with an increased likelihood of unstable housing, the authors wrote.

“The availability of actual HOPWA funds per person newly infected with HIV is a good predictor of unstable housing,” Galarraga explained. “This variable allowed us to measure the negative impact of unstable housing on HIV treatment outcomes.”

When asked about his hopes for this investigation and future studies, Galarraga said rigorous research can inform public policies to improve public health.

“Housing vouchers and other housing assistance such as HOPWA and other interventions to make housing more affordable for low-income populations, and HIV-positive populations in particular, should be considered,” he said.

That’s true not only for the housing benefits such programs confer, but also for the clinical benefits gained by patients and their loved ones, he added.

The study, “The effect of unstable housing on HIV treatment biomarkers: An instrumental variables approach,” is published in Social Science & Medicine.