This paper examines housing as a contextual factor affecting drug and sexual risk behaviors among HIV positive people using pooled interview data from 2149 clients presenting for services at 16 medical and social service agencies participating in a multi-site evaluation study. The odds of recent drug use, needle use or sex exchange at the baseline interview was 2–4 times as high among the homeless and unstably housed compared to persons with stable housing. Follow-up data collected 6–9 months after baseline showed that change in housing status was associated with change in risk behaviors. Persons whose housing status improved between baseline and follow-up significantly reduced their risks of drug use, needle use, needle sharing and unprotected sex by half in comparison to individuals whose housing status did not change. In addition, for clients whose housing status worsened between baseline and follow-up, their odds of recently exchanging sex was over five times higher than for clients whose housing status did not change. The provision of housing is a promising structural intervention to reduce the spread of HIV.
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The demonstration projects were selected by separate HRSA or HUD national competitions in 1996–97. Projects included in the present analysis were located in Anchorage, AK, Baltimore, MD, Bridgeport, CT, Boston, MA, Chicago, IL, Durham, NC, Houston, TX, Jersey City, NJ, Long Beach, CA, Miami, FL, Newark, NJ, New York, NY, Oakland, CA, Pine Bluff, AK, Providence, RI, San Antonio, TX, Santa Cruz, CA, and Seattle WA. The number of clients enrolled at each site for which data were contributed to the multi-site data set ranged from 12 to 535 (median 75).
For example, the most comprehensive, longitudinal study of HIV positive individuals in the United States, the National HIV Cost and Services Utilization Study (HCSUS), sampled HIV-infected adults who had visited a private doctor's office, community clinic, or hospital-based clinic within an 8 week recruitment period (See Frankel et al.,1999). Persons receiving HIV care from emergency departments and medical providers in military, prison, drug treatment, or homeless service settings were excluded. Thus, persons living with HIV who were not in medical care or receiving care in non-traditional settings were not represented; those making infrequent or irregular visits were likely under represented.
Multilevel logistic regression modeling is an appropriate analysis for clustered data of the sort collected for the multi-site evaluation database (level 1: clients, level 2: projects). Unfortunately, however, a number of projects restricted their samples to individuals who were unstably housed or homeless or who had used hard drugs in the past 6 months. Restrictions of this sort, possibly unique to the demonstration projects, create invariance in the dependent variable or key independent variables and will force a significant number of projects to literally drop out of both fixed or random effects model estimation. In addition to practical issues in working with agency data, we also had concerns about the validity of the standard errors that we would obtain from a multilevel modeling approach as our data did not meet suggested minimal requirements (See Hox, 1998).
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ACKNOWLEDGMENTS
Funding for this analysis was provided by the Centers for Disease Control and Prevention (CDC), Divisions of HIV/AIDS Prevention. The multi-site research project is an inter-agency collaboration between the U.S. Health Resources and Services Administration (HRSA), Special Projects of National Significance (SPNS) Program, and the U.S. Department of Housing and Urban Development (HUD), Housing Opportunities for Persons with AIDS (HOPWA) Program. Special thanks is due to the 34 agencies and the thousands of individual persons living with HIV who have participated in the multi-site project and shared their experiences with us. This paper draws upon “The Impact of Housing on HIV Risk Behavior,” presented at the 2001 National HIV Prevention Conference, Atlanta, GA, and portions were also presented at the XIV International AIDS Conference, Barcelona, Spain, 2002, the Prevention 2003 Conference, Atlanta, GA, and the AIDS Housing Conference, Washington, DC, 2003.
This work is dedicated to the memory of Keith Cylar. Keith was co-founder and co-president of Housing Works and a tireless leader for activism and advocacy by people with HIV and AIDS in America and around the world.
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Aidala, A., Cross, J.E., Stall, R. et al. Housing Status and HIV Risk Behaviors: Implications for Prevention and Policy. AIDS Behav 9, 251–265 (2005). https://doi.org/10.1007/s10461-005-9000-7
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DOI: https://doi.org/10.1007/s10461-005-9000-7