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DEGREE OF HOUSING INSTABILITY SHOWS INDEPENDENT “DOSE-RESPONSE” WITH HIV SUPPRESSION
Angelo A. Clemenzi-Allen1, Elvin Geng1, Katerina A. Christopoulos1, Hali Hammer2, Susan P. Buchbinder2, Diane V. Havlir1, Monica Gandhi1
1University of California San Francisco, San Francisco, CA, USA,2San Francisco Department of Public Health, San Francisco, CA, USA
Housing instability is associated with worse clinical outcomes among people living with HIV (PLHIV), but housing status is often dichotomized to homeless vs not without a nuanced evaluation of the continuum of unstable housing. We evaluated the association of multiple levels of housing status and virologic suppression (VS) among PLHIV in a large clinic-based cohort.
We collected self-reported housing status data in a safety-net HIV clinic in San Francisco ('Ward 86') from 2/1/17-7/21/17. Patients circled current housing status at check-in on a pictorial survey depicting 6 different living arrangements: 1) Rent/Own; 2) Treatment/Transitional Program; 3) Hotel/Single Room Occupancy (SRO); 4) Staying with Friend; 5) Homeless Shelter; 6) Outdoors/In Vehicle. Viral loads (VL) performed ±90 days of survey completion were abstracted from the medical record. We defined viral suppression (VS) as HIV-RNA level <200 copies/mL. Patients without VL measures in this window were categorized as non-suppressed. We calculated the odds of VS in each strata of housing status via logistic regression adjusting for age, gender, and race/ethnicity. Sensitivity analyses excluding participants with missing VL and also counting them as suppressed were performed.
1,222 patients completed the survey, of whom 39 had no VLs within the pre-specified window. Median age was 50 years (IQR 41 to 57); 13% were female; 40% white, 25% black, 26% Latino, 9% other. Across a continuum of housing types, VS rates ranged from 86% (rent/own) to 44% (outdoors) (Figure). Greater housing instability was associated with lower rates of VS in a 'dose-response' fashion. The adjusted odds of VS among participants with unstable living arrangements (SRO/hotel, living with friend, shelter, outdoors) were each statistically significantly lower compared to those who rented/owned (all p-values<0.005), except when comparing those in treatment/transitional housing to those who rent/own (p-value 0.84). Results were unchanged in both sensitivity analyses.
We demonstrate strong associations between dwelling type and VS among PLHIV across a continuum of unstable housing arrangements. Although living outdoors is associated with the lowest proportion of VS, other forms of instability (including living in a shelter, 'couch-surfing', and being in an SRO) are also associated with lower levels of VS compared to being housed. Interventions are needed to increase VS among PLHIV across a spectrum of unstable housing arrangements.