Housing as Healthcare
Abstract Format : Providing stable housing to those with need can be challenging, but can reduce chronic homelessness and improve health outcomes, including for persons living with HIV (PLWH). Rapid re-housing aims to connect people to stable (permanent supportive or independent) housing as quickly as possible, followed-up with support services. Best practices for this approach are evolving. We randomized low-income, homeless PLWH in New York City to either 1) the Enhanced Housing Placement Assistance (EHPA) program, i.e., immediate assignment to a case manager to rapidly re-house the client and provide 12 months of housing stability-related case management onsite at the patient’s residence, or 2) usual services, i.e., referral to a New York City housing placement program for low-income HIV-positive persons and housing stability-related case management at program offices, which were terminated on average within three months. Housing and HIV health outcomes were compared between two arms at 12 months post-enrollment.
Methods : PLWH were recruited door-to-door in 2012-2013 from 22 emergency housing facilities for single adults with HIV. Data came from baseline questionnaires, and the New York City HIV surveillance registry (for viral loads) and other administrative databases through 12 months post-enrollment. Differences between study arms were assessed using Chi-square for baseline characteristics, Kaplan-Meier curves and Cox proportional hazards model for time from enrollment to stable housing placement, and conditional logistic regression for HIV viral suppression (viral load ≤200 copies/mL).
Results : The majority of study participants were male, Black or Hispanic, ≥40 years old, disabled or unemployed, and chronically homeless. Baseline characteristics were balanced between the two arms, except for viral suppression, history of incarceration, and enrollment in Social Security Income (SSI) or Social Security Disability Income (SSDI) benefits programs. In terms of housing placement, EHPA participants were placed more quickly than usual-services participants: 25% of EHPA participants were placed by 150 days after enrollment, while the same placement proportion took usual services participants 243 days (logrank p = 0.02); Cox proportional hazards models showed that by 12 months post-enrollment, EHPA participants had 80% higher rates of placement compared to usual services participants (adjusted hazards ratio = 1.8, 95% confidence interval [CI] = 1.2-2.8). EHPA participants also had greater viral suppression improvement than usual services participants: from baseline to 12 months post-enrollment, the proportion virally suppressed increased from 28% to 47% among EHPA participants (p < 0.01), but increased five percentage points among usual services participants (52% vs. 57%, p = 0.6); a significant interaction term of time and arm in conditional logistic regression showed that the improvements in viral suppression among EHPA participants were more than twice those among the usual service arm, adjusted for unbalanced baseline covariates (adjusted odds ratio = 2.1, 95% CI = 1.1-4.1).
Conclusions : EHPA resulted in quicker housing placement and greater increases in viral suppression than usual services. However, the latter finding is tempered by the baseline percentage virally suppressed among EPHA participants being much lower than in the control group and the most recent level remaining somewhat lower than those not in EHPA. With this limitation, the results suggest that rapid-rehousing with extended at-residence case management may be more appropriate than standard housing placement assistance in NYC at improving stable housing and viral suppression among homeless adults with HIV.