Rapid rehousing support for homeless people living with HIV improves housing and HIV outcomes

Homeless people with HIV who are provided with rapid rehousing and intensive, tailored case management are placed in stable housing more quickly and are twice as likely to be virally suppressed when compared to individuals receiving standard homelessness support, according to research conducted in New York City and published in AIDS and Behavior.

The rapid rehousing intervention involved intensive case management and support to overcome potential obstacles to stable housing and viral suppression, such as mental health problems and substance abuse. Support was temporary, lasting 12 months.

“Results from this trial suggest that how a rapid re-housing program is implemented can potentially impact housing and health outcomes among homeless populations,” comment the authors. “The overall importance of placing participants as quickly as possible in housing was captured in this study.”

Glossary

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

matched

In a case-control study, a process to make the cases and the controls comparable with respect to extraneous factors. For example, each case is matched individually with a control subject on variables such as age, sex and HIV status. 

referral

A healthcare professional’s recommendation that a person sees another medical specialist or service.

standard of care

Treatment that experts agree is appropriate, accepted, and widely used for a given disease or condition. In a clinical trial, one group may receive the experimental intervention and another group may receive the standard of care.

Homelessness is a widespread problem in the US, especially for people with HIV. Lack of stable, secure or adequate housing has been associated with poorer HIV-related, overall health and social outcomes.

Housing in New York City (NYC) is among the most expensive in the US, and people with HIV often face multiple barriers to finding affordable, secure and appropriate housing, such as stigma, mental and physical health problems, substance abuse, a history of imprisonment and institutional racism.

A team of investigators therefore wanted to see if a rapid rehousing initiative involving short-term intensive case management had a positive impact on both housing outcomes and viral suppression.

They designed a study involving 236 homeless adults living with HIV in NYC. Recruited from HIV homelessness shelters across the city between 2012 and 2013, participants were randomised to receive the rapid rehousing or standard homelessness support.

Individuals in the rapid rehousing group were immediately assigned a case manager. The case manager worked to quickly identify affordable and appropriate housing, travelled with participants to housing appointments and viewings, ensured that individuals received assistance with moving and rent, and delivered intensive housing stabilisation services (for example substance abuse, mental illness, financial management) for up to a year post enrolment.

Individuals in the standard-of-care group received referral to an organisation engaged by NYC authorities to find housing for individuals with HIV. Housing stabilisation services were provided as needed and usually ended within three months of enrolment. Individuals assigned to the standard-of-care arm had to travel to housing programme offices to access services.

Participants were followed for 12 months post-enrolment. Outcomes were speed and rate of placement in stable housing and the rate of viral load suppression, data which were accessed through registries.

Ten people died during the study and one individual could not be matched to HIV registry databases, leaving a final study population of 225 people.

The majority were male, black or Hispanic, aged 40 years and older, medically unfit for work, and in chronic housing need. Over three-quarters had a history of incarceration, over half had a mental health diagnosis and over 80% reported substance abuse in the year prior to enrolment. Almost all were enrolled in HIV care, but just 40% were virally suppressed and the majority had a CD4 cell count below 350 cells/mm3.

Individuals assigned to the rapid rehousing initiate were significantly more likely to have been placed in stable housing within 12 months compared to those who received the standard of care (45% vs 32%, p = 0.02). It took 150 days to place a quarter of people in the rapid rehousing group into stable housing. It took almost 100 days longer (243) to achieve the same outcome for a quarter of individuals in the standard-of-care group.

Provision of rapid rehousing support was associated with an 80% higher rate of housing placement (aHR = 1.8; 95% CI, 1.1-2.8).

As regards HIV-related outcomes, 97% of people in both study groups were in HIV care at the 12-month follow-up point.

A significant improvement in the proportion of people with viral suppression was observed among those assigned to rapid rehousing, from 28% at baseline to 47% at the end of follow-up (p < 0.01). The rate of viral suppression in the standard-of-care group increased modestly from 52% to 57%. (One limitation of the study is that the two study groups were unbalanced in their baseline viral suppression, despite randomisation.)

The rate of improvement in viral suppression was twice as high in the rapid rehousing group (aOR = 2.1; 95% CI, 1.1-4.1).

The authors conclude that their study showed that, compared with usual housing services for people with HIV, immediate case management lasting up to a year is associated with higher rates of housing placement and a greater rate of improvement in viral suppression.

References

Towe VL et al. A randomized controlled trial of a rapid re-housing intervention for homeless persons living with HIV/AIDS: impact on housing and HIV medical outcomes. AIDS and Behavior, online edition: https://doi.org/10.1007/s10461-019-02461-4.