摘要：Objectives. To examine patterns of and factors associated with housing stability over time among people living with HIV (PLWH) experiencing homelessness with co-occurring substance use and mental health disorders enrolled in a patient-centered medical home (PCMH) intervention. Methods. Between September 2013 and February 2017, we ascertained housing trajectories among PLWH in 9 sites in the United States by conducting interviews at baseline, 6, and 12 months after and dichotomized them as improved consistently versus did not improve consistently. We identified covariates affecting housing stability using the socioecological model. Results. Forty-three percent (n = 198) experienced consistent housing improvement. Participants with history of mental health diagnosis (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.02, 2.35; P = .04) or trauma (AOR = 1.72; 95% CI = 1.22, 2.41; P = .006) had improved housing status; those with recent injecting drug use (AOR = 0.41; 95% CI = 0.19, 0.90; P = .03) had less consistent housing improvement. Conclusions. Improved housing stability may possibly reflect the importance of PCMH interventions that integrate housing, health, and behavioral services with patient navigators to address complex needs of PLWH experiencing homelessness. For people living with HIV (PLWH), housing status is one of the main determinants affecting HIV health outcomes. 1,2 Engagement in care, 3 health outcomes (viral load and CD4), 4,5 antiretroviral therapy adherence, 6 and quality of life measures 7 are all improved with housing stability. PLWH experiencing homelessness or unstable housing are more likely to frequent emergency departments, be hospitalized, and be uninsured. 6,8 They are also less likely to receive treatment of substance use or psychiatric disorders, 9,10 and, in general, people who are homeless and use drugs are at increased risk for nonfatal overdose 11 and early death. 12 Although we have seen improvements in HIV outcomes in the last few years and a reduction in disparities, PLWH with unstable housing continue to have poorer retention in care and viral suppression. 13 Moreover, factors associated with transitioning from homelessness to more stable housing include a reduction in alcohol and illicit drug use and improved mental health status. 7 Although there are indisputable benefits of housing stability on HIV and behavioral health outcomes, measures of housing stability vary. Most rely on dichotomous distinctions of the presence or absence of housing, or on a continuum from “no access to housing of reasonable quality (complete instability)” to “access to housing of reasonable quality in the absence of threats (complete stability).” 14 (p965), 15 Yet few studies have considered trajectories of unstable housing and homelessness among PLWH over time. 7 There is a need to capture these dynamic transitions, especially for persons who have been chronically homeless. Housing instability and transitioning in and out of care can lead to poor health, 16 inadequate health care utilization, and lower viral suppression rates. 7,17 To address this gap in the literature, we examined the key correlates associated with moving along the housing continuum from homelessness or unstable housing to stable housing. We used a socioecological framework 18,19 on a subsample of PLWH experiencing housing instability enrolled in a Health Resources and Services Administration (HRSA)-funded Special Projects of National Significance initiative. We hypothesized that certain individual, interpersonal, community, and structural factors affect housing stability over time. These factors include, for example, influences such as interpersonal violence, site location, income security, unmet health care needs, barriers to care, housing cost as a percentage of income, and insurance status. Our goal was to identify opportunities for policies and programs to support a pathway to stable housing for at-risk PLWH based on an intervention to create a patient-centered medical home to reduce barriers to care and improve HIV outcomes.
