In the JournalsPerspective

HIV patients with unstable housing make frequent acute-care visits

Study findings showed that people with HIV who are experiencing homelessness or unstable housing have higher rates of acute-care visits than those with stable housing, and researchers suggested that targeted interventions employed during these visits may “create opportunities to improve care.”

“Homelessness and unstable housing are associated with poor health outcomes for people living with HIV, including worse retention in HIV care and inadequate virologic suppression,” Angelo Clemenzi-Allen, MD, a clinical fellow in the AIDS Research Institute at the University of California, San Francisco, and colleagues wrote.

Housing study

Between February and August 2017, Clemenzi-Allen and colleagues collected self-reported living conditions — categorized as stable, unstable or homeless — from patients at Ward 86, a large safety-net HIV clinic at San Francisco General Hospital and the oldest dedicated HIV clinic in the country.

Respondents were recorded as having stable living conditions if they lived in a rented or owned home, or at a hotel or single-room occupancy. Unstable living conditions meant they lived at a treatment or transitional program or were staying with a friend — “couch-surfing,” as Clemenzi-Allen and colleagues called it. Homelessness was defined as living in a homeless shelter, outdoors or in a vehicle.

Using these data, the researchers examined the impact of housing status and HIV primary care adherence on acute-care use. Data regarding health care use were extracted from electronic health care records starting 90 days before completion of the housing status survey until November 2017.

According to the study, the analysis included 1,198 patients, of whom 25% were experiencing homelessness or unstable housing. Clemenzi-Allen and colleagues observed a statistically significant increase in the incident rate ratio (IRR) for urgent care visits (IRR = 1.35; 95% CI, 1.1-1.66), ED visits (IRR = 2.12; 95% CI, 1.44-3.13), and hospitalizations (IRR = 1.75; 95% CI, 1.1-2.77) as a result of unstable housing. They found “even greater increases” in urgent care visits (IRR = 1.75; 95% CI, 1.29-2.39), ED visits (IRR = 4.18; 95% CI, 2.77-6.30) and hospitalizations (IRR = 3.18; 95% CI, 2.03-4.97) associated with homelessness.

“The frequency of urgent-care visits among [people with HIV who experience homelessness or unstable housing] emphasizes the need to explore novel ways to provide primary care — even at urgent-care visits — to ultimately improve treatment outcomes,” Clemenzi-Allen and colleagues wrote.

Housing status and virologic suppression

In a previously published study, Clemenzi-Allen and colleagues from the University of California, San Francisco, and San Francisco’s Department of Public Health, investigated the impact of housing status on HIV treatment outcomes and found a strong association between housing and virologic suppression rates among people with HIV.

Specifically, according to the study, living outdoors was associated with the lowest likelihood of virologic suppression, with just 42% of such patients being virologically suppressed. Housing instability in general was associated with lower rates of virologic suppression when compared with those with stable housing.

“The impact of housing instability was the strongest predictor of virologic suppression, despite controlling for other sociodemographic information, which provides further evidence of the centrality of housing status to support both individual and public health outcomes associated with the expansion of ART,” Clemenzi-Allen told Infectious Disease News.

He added that “housing status predicted virologic nonsuppression across a continuum of housing instability when compared to those stably housed, which provides evidence that improvements in housing status along the continuum of housing instability (ie, from on the streets to shelters, shelter to couch-surfing, couch surfing to rehab facilities) could be associated with improvements in virologic suppression.”

Clemenzi-Allen and colleagues recommended creating opportunities to improve care for people with HIV who are experiencing homelessness or unstable housing by implementing interventions at acute-care visits.

“This research has laid the groundwork for a multicomponent clinic-based intervention to improve retention in care and virologic suppression for homeless and unstably housed patients living with HIV at Ward 86 in San Francisco,” Clemenzi-Allen said. – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures

Study findings showed that people with HIV who are experiencing homelessness or unstable housing have higher rates of acute-care visits than those with stable housing, and researchers suggested that targeted interventions employed during these visits may “create opportunities to improve care.”

“Homelessness and unstable housing are associated with poor health outcomes for people living with HIV, including worse retention in HIV care and inadequate virologic suppression,” Angelo Clemenzi-Allen, MD, a clinical fellow in the AIDS Research Institute at the University of California, San Francisco, and colleagues wrote.

Housing study

Between February and August 2017, Clemenzi-Allen and colleagues collected self-reported living conditions — categorized as stable, unstable or homeless — from patients at Ward 86, a large safety-net HIV clinic at San Francisco General Hospital and the oldest dedicated HIV clinic in the country.

Respondents were recorded as having stable living conditions if they lived in a rented or owned home, or at a hotel or single-room occupancy. Unstable living conditions meant they lived at a treatment or transitional program or were staying with a friend — “couch-surfing,” as Clemenzi-Allen and colleagues called it. Homelessness was defined as living in a homeless shelter, outdoors or in a vehicle.

Using these data, the researchers examined the impact of housing status and HIV primary care adherence on acute-care use. Data regarding health care use were extracted from electronic health care records starting 90 days before completion of the housing status survey until November 2017.

According to the study, the analysis included 1,198 patients, of whom 25% were experiencing homelessness or unstable housing. Clemenzi-Allen and colleagues observed a statistically significant increase in the incident rate ratio (IRR) for urgent care visits (IRR = 1.35; 95% CI, 1.1-1.66), ED visits (IRR = 2.12; 95% CI, 1.44-3.13), and hospitalizations (IRR = 1.75; 95% CI, 1.1-2.77) as a result of unstable housing. They found “even greater increases” in urgent care visits (IRR = 1.75; 95% CI, 1.29-2.39), ED visits (IRR = 4.18; 95% CI, 2.77-6.30) and hospitalizations (IRR = 3.18; 95% CI, 2.03-4.97) associated with homelessness.

“The frequency of urgent-care visits among [people with HIV who experience homelessness or unstable housing] emphasizes the need to explore novel ways to provide primary care — even at urgent-care visits — to ultimately improve treatment outcomes,” Clemenzi-Allen and colleagues wrote.

Housing status and virologic suppression

In a previously published study, Clemenzi-Allen and colleagues from the University of California, San Francisco, and San Francisco’s Department of Public Health, investigated the impact of housing status on HIV treatment outcomes and found a strong association between housing and virologic suppression rates among people with HIV.

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Specifically, according to the study, living outdoors was associated with the lowest likelihood of virologic suppression, with just 42% of such patients being virologically suppressed. Housing instability in general was associated with lower rates of virologic suppression when compared with those with stable housing.

“The impact of housing instability was the strongest predictor of virologic suppression, despite controlling for other sociodemographic information, which provides further evidence of the centrality of housing status to support both individual and public health outcomes associated with the expansion of ART,” Clemenzi-Allen told Infectious Disease News.

He added that “housing status predicted virologic nonsuppression across a continuum of housing instability when compared to those stably housed, which provides evidence that improvements in housing status along the continuum of housing instability (ie, from on the streets to shelters, shelter to couch-surfing, couch surfing to rehab facilities) could be associated with improvements in virologic suppression.”

Clemenzi-Allen and colleagues recommended creating opportunities to improve care for people with HIV who are experiencing homelessness or unstable housing by implementing interventions at acute-care visits.

“This research has laid the groundwork for a multicomponent clinic-based intervention to improve retention in care and virologic suppression for homeless and unstably housed patients living with HIV at Ward 86 in San Francisco,” Clemenzi-Allen said. – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures

    Perspective
    Wendy S. Armstrong

    Wendy S. Armstrong

    On Feb. 5, President Trump announced in his State of the Union address that the United States was embarking on a new initiative to end the HIV epidemic in the next 10 years. This plan highlights the need to diagnose those with HIV, treat the infection rapidly and effectively, prevent HIV in those at risk, respond to clusters of infections and expand the HIV workforce. This is an exciting and ambitious goal. Reaching this goal, however, will require addressing social determinants of health and reimagining the delivery of health care in ways not previously widely employed. This study highlights these needs with two important lessons for clinicians and policy experts. First, those who care for persons living with HIV and others in marginalized groups know that housing is health care. Those with unstable housing and homelessness are more likely to use acute-care settings and have lower primary care visit adherence. Unfortunately, acute-care settings are not able to provide the continuity required for successful treatment of HIV infection, including case management and additional services needed to optimize retention in care. This leads to the second lesson: our current health care systems — which often require transportation at specific times to a set location for primary care visits — work poorly for those who are unstably housed or homeless. We must design a health care system that serves the people rather than the people serving the system. This may require enhancing outreach efforts and moving the clinic to the those in need with mobile units. In addition, flexible scheduling, robust case management, resources to address unmet needs (like food insecurity) and other innovations to improve access to care are necessary. In order for the president’s initiative to work, a commitment to addressing these social determinants of health and ensuring access to care, even in nontraditional settings, is an absolute requirement.

    • Wendy S. Armstrong, MD
    • Professor of medicine,
      Emory University School of Medicine

    Disclosures: Armstrong reports no relevant financial disclosures.