标题：The Influence of Housing Status on the HIV Continuum of Care: Results From a Multisite Study of Patient Navigation Models to Build a Medical Home for People Living With HIV Experiencing Homelessness
摘要：Objectives. To examine the effect of patient navigation models on changes in housing status and its subsequent effects on HIV outcomes for 700 people living with HIV (PLWH) who were unstably housed with co-occurring substance use and psychiatric disorders across 9 demonstration sites in the United States between the years of 2013 and 2017. Methods. Self-reported housing status was collected at baseline, and at 6 and 12 months during the intervention. HIV outcomes included linkage and retention in care, antiretroviral therapy prescription, and viral suppression collected via chart review. Results. In the 12 months after the intervention, 59.6% transitioned to more stable housing. Compared with those who became or remained unstably housed, participants with greater stability achieved significantly higher rates of retention (adjusted odds ratio [AOR] = 2.12; 95% confidence interval [CI] = 1.11, 4.05), were more likely to be prescribed antiretroviral therapy (AOR = 2.06; 95% CI = 1.62, 2.63), and had higher rates of viral suppression (AOR = 1.62; 95% CI = 1.03, 2.55). Conclusions. The use of patient navigators to create a network of services for PLWH who are unstably housed can improve housing stability and lead to improvements in HIV-related outcomes. Recent data on the progress toward the goals of the National HIV/AIDS Strategy for 2020 found that homelessness rose among people living with HIV (PLWH), from 7.9% to 9.0%, moving away from the objective to reduce homelessness to no more than 5%. 1 This trend is alarming given the strong evidence that stable housing is associated with reduced HIV risk behaviors, increased engagement in care, better adherence to antiretroviral therapy, and improved survival. 2–8 Finding strategies to reverse this trend is paramount given that housing or shelter is a priority need affecting an estimated one third of out-of-care PLWH. 9 The Health Resources and Services Administration Special Projects of National Significance Initiative “Building Medical Homes for Multiply Diagnosed HIV-Positive Homeless Populations” (HRSA Homeless Initiative) was designed to address the growing unmet need for housing and reduce the disparity in viral suppression rates among PLWH who experience homelessness, in accordance with the National HIV/AIDS Strategy’s objective to support comprehensive, coordinated patient-centered care for PLWH. 1,10,11 The HRSA Homeless Initiative had 4 primary goals: (1) improve timely entry, engagement, and retention in HIV care and supportive services; (2) build and maintain sustainable linkages to mental health, substance use treatment, and HIV primary care; (3) increase access to stable or permanent housing; and (4) create a patient-centered medical home (PCMH) for PLWH who experience homelessness. Nine sites were funded to create this PCMH and common elements included (1) the use of dedicated navigators or care coordinators (“patient navigators”) to outreach and provide intensive individual and system coordination to reduce barriers to care and treatment and address unmet housing, food, and other needs; (2) mobile interdisciplinary care teams or colocation of services in shelter clinics or substance use treatment facilities to increase access to comprehensive HIV care and behavioral health services; and (3) partnerships with housing providers to obtain housing and housing assistance. The intervention was adapted to meet the specific needs of the population served and the local context. Some sites also provided funding for short-term emergency housing assistance. Limited evidence exists for the effectiveness of PCMH models on HIV health outcomes for PLWH who experience homelessness. 12 Studies have shown that navigation and case management models can increase engagement in care for PLWH exiting jails or at discharge from hospitalization. 13–16 For PLWH experiencing homelessness, patient navigators can play a key role in the PCMH by forging relationships with providers, supporting patient self-management of their illness, and assisting with housing stability. 17 We aimed to assess the HRSA Homeless Initiative on housing status and subsequent effects on HIV health outcomes for PLWH who experience homelessness.
