The Institutional Review Board at the University of California, San Francisco approved all study procedures. Participants completed interviews at enrollment and every six months for up to three years. Interviews were conducted in a private space by a trained interviewer. Socially sensitive questions, including those regarding drug use and violence, were administered by audio computer-assisted self-interviewing ; all other questions were interviewer administered. The study was heuristically informed by the Behavioral Model for Vulnerable Populations. In accordance with this model, the predisposing domain included age, race/ethnicity, housing type/living conditions, incarceration, violence and substance use. The enabling domain included income, health insurance, food security, and social support; for the purposes of the current study, we also included a variable to indicate whether data for each study visit occurred before or after universal ART was introduced in San Francisco . The health services domain included outpatient health care visits, HIV case management and general health case management. We did not include a need domain, which accounts for health conditions that necessitate care and treatment, because all participants were HIV-infected and assumed to have a similar level of need with regard to suppressed viral load. The dependent variable in the current analysis was unsuppressed VL ,grow rack systems measured during routine clinical care independent of the study. Only VLs measured within three months following a study interview were included in the current analysis.
Participants who had data available from at least one interview and one subsequent VL assessment were included. We obtained San Francisco HIV surveillance system VL data, which included electronic medical records from Department of Public Health clinics, as well as clinics affiliated with the University of California, San Francisco . Independent variables included whether each VL measure was assessed after the introduction of universal ART , a SFDPH policy recommending ART for all infected persons regardless of CD4+ T-cell count. Outside of race/ethnicity, independent variables were time-dependent and based on conditions during the six months prior to each interview. Independent variables represented factors specific to low-income women which have influenced health outcomes in prior studies. They include age; income; incarceration ; food insecurity; instrumental social support; intimate partner violence or non-intimate partner violence; uninterrupted health insurance ; any outpatient health care visits or case management; any use of cocaine, methamphetamine, heroin, alcohol, cannabis or opioid analgesics. In addition, we measured the number of nights in the 6 months prior to each study visit that the participant spent sleeping in a public place, a shelter or a low-income single-room occupancy hotel as continuous variables. The current study did not implement an intervention and the outcome of interest was current VL, not change in VL. We therefore did not adjust for prior VL as doing so would adjust for the effect of interest. In addition, to avoid over-adjustment bias, we did not control for other measures of HIV disease status with potential reciprocal relationships.
We compared baseline characteristics of study participants by the presence of at least one unsuppressed VL over the follow-up period using chi-square and Wilcoxon tests as appropriate. Logistic models were used to assess correlates of unsuppressed VL. We used generalized estimating equation models with robust standard errors to account for within-participant correlation of repeated measures over time, and independence working correlation. Following the theoretical framework of the Behavioral Model for Vulnerable Populations, a series of models sequentially added variables in each of the three domains , beginning with predisposing factors . At each step, backward selection was used to remove variables in the most recently added domain with p-values >0.1. All analyses were done using Stata Version 15.0 .Within a sample of 150 WLWH, 120 had at least one VL measurement within three months following a study visit and a total of 508 VL measures were obtained from the electronic medical record within the study window. A median of three VL assessments was obtained for each participant . Comparing baseline characteristics of individuals included in the analysis to study participants who had no VL measurements available for the three-month study window , those included in the analysis were more likely to have an HIV case manager . We observed no other statistically significant differences by study factors presented here. The mean participant age was 47 and 72% of participants were women of color . Only two participants were newly diagnosed . During the six months prior to baseline, 17% of individuals were incarcerated, almost 70% reported food insecurity, 85% had uninterrupted health insurance, 60% had ≥1 outpatient health care visit and 71% had an HIV case manager.
Violence perpetrated by someone who was not a primary intimate partner was experienced more than twice as often as violence perpetrated by a primary intimate partner . Almost half of participants used cocaine, alcohol or cannabis, while approximately 20% reported use of methamphetamine, heroin or painkillers. In the 6 months prior to the baseline study visit, the mean number of nights spent sleeping on the street or in a public place was 12.6 ; the mean number of nights spent sleeping in a shelter was 5.2 ; and the mean number of nights spent sleeping in an SRO hotel was 62 . There was less than 20% correlation between the number of nights spent sleeping on the street, in a shelter or in an SRO hotel. We therefore analyzed the effects of these conditions separately. Unsuppressed VL was detected in 60% of participants during the study period and 19% were unsuppressed at all visits. Among 262 VL measurements followed by at least one subsequent VL measurement, 14.5% were unsuppressed. Adjusted analysis showed that only factors from the predisposing domain were significantly associated with subsequent unsuppressed viral load in the next 3 months . Specifically, the odds of unsuppressed VL decreased 26% for every 10 years of age , translating to higher VL suppression with increasing age. Unsuppressed VL increased 11% for every 10 nights spent sleeping on the street , 16% for every 10 nights spent sleeping in a shelter and 4% for every 10 nights in an SRO . Odds were almost four-fold higher among individuals who experienced any recent incarceration and 54% higher among cannabis users . Race/ethnicity, income, social support, violence, other drugs and recent use of outpatient health care did not reach statistical significance in adjusted analysis. In a well-resourced U.S. city where 72-88% of HIV-positive patients achieve viral suppression [57, 58], only 40% of women with a history of housing instability achieved viral suppression at all time points during the three-year study period. The high proportion of viremic individuals has implications for patient health and for compromising “Treatment as Prevention” efforts, which rely on viral suppression to curb new infections. Most participants received recent outpatient health care and case management, and neither form of care predicted viral suppression. In addition, several enabling factors known to predict VL in other HIV populations, including income, consistent health insurance and food insecurity were not significant predictors of viremia in this sample. Consequent to the absence of significant associations,indoor plant growing racks there was no evidence to suggest that enabling factors or health care mediated the effects of predisposing factors on detectable viremia in this population. On the other hand, multiple types of living conditions and incarceration significantly predicted future unsuppressed VL. While case management and other strategies to promote retention in care are important for persons living with HIV, results presented here indicate that they are insufficient to ensure sustained viral suppression among women who sleep in public areas, shelters or SROs, or who have recently been incarcerated.Findings presented here are complementary to research indicating that disparities in ART use and adherence are largely explained by social and structural issues associated with poverty. They are also consistent with a recent nationwide U.S. study that not only implicates the broad problem of poverty, but spotlights homelessness as a key predictor of unsuppressed V. Taken together, the existing research suggests that studies failing to account for housing type as an important predictor of viral suppression in low-income WLWH are incomplete, and interventions as well as health care delivery that fail to integrate housing needs are unlikely to achieve optimal results. Collectively, the existing evidence shows a critical need for comprehensive services to address the underlying context of poverty. However, comprehensive services will not be enough until risks across various living conditions are acknowledged and stable housing in achieved.
Considered together with prior studies showing that the strongest correlate of incarceration among unstably housed women is homelessness, and the strongest predictors of ART non-use include homelessness, results presented here confirm the centrality of homelessness in HIV outcomes and associated factors. Results further extend this existing knowledge by indicating several important points about housing instability and living conditions. First, we saw a dose-response between the number of nights spent sleeping on the street and unsuppressed viral load, and similar associations for number of nights spent in a shelter or SRO. This means that it is not only the initial impact of becoming homeless or the state of being homeless that influences this relationship, rather every additional night spent in these venues continues to increase the odds of detectable viral load. Our estimates therefore suggest that, while the odds of detectable viremia increase by 11% for a women who spends a single night sleeping on the street, they increase by 77% for a women who spends a week sleeping on the street. Second, sleeping on the street and sleeping in a shelter are not highly correlated in this sample. While our data do not allow an analysis of pathways or mechanisms, results may suggest that low-income WLWH are unsheltered in different ways, and the different ways women are unsheltered carry their own unique risks for unsuppressed viral load. Third, on average, women spend twice as long seeping on the street as sleeping in a shelter, suggesting the importance of street-based services. Fourth, while the magnitude of association is lower, nights spent in a low-income SRO hotel also significantly increase the odds of unsuppressed VL. This finding is consistent with prior research showing high rates of poor health outcomes linked to SROs. Collectively, findings emphasize the importance of considering different housing types and living conditions beyond a simple assessment of homeless vs. not homeless. Considering results in the context of increases in U.S. homelessness over the past five years makes our findings especially concerning and indicates a critical need to implement interventions that target multiple types of living conditions. The finding that recently incarcerated participants were more likely to present with an unsuppressed VL extends research regarding HIV-positive, justice-involved persons. The evidence to date suggests that U.S. jails are important sites for HIV care engagement, increasing the likelihood of HIV-positive individuals achieving viral suppression during incarceration. However, despite high rates of viral suppression during incarceration, research also shows that many individuals do not fill prescriptions following release, and become disconnected from care or non-adherent to medications during reentry to community life. This is especially concerning for women because our prior work with low-income women shows that homelessness has a strong association with incarceration. Thus, women experiencing homelessness or incarceration may be likely to experience both, and the combination may exacerbate barriers to viral suppression. Among the few studies regarding HIV and justice-involved individuals to report gender-specific results, Beckwith et al. show that fewer women receive HIV medications during incarceration than men. The current study did not obtain information on viral suppression during incarceration, but results suggest that, even after adjusting for homelessness, unsuppressed VL was more common among recently incarcerated women. This finding may reflect the low rate of HIV medication use during women’s incarceration reported by Beckwith et al.. Considered alongside prior research, it may also signal effect modification. For example, although our data do not permit a test of this hypothesis, incarceration may improve HIV clinical care and outcomes among women who are not consistently engaged in care before detention, but may be detrimental to those who are consistently engaged in care due to disruptions from incarceration. Further clinical research is needed to mitigate the risk of detectable viremia among recently incarcerated WLWH. Results presented here are similar to those from a study by Anderson et al. of low-income WLWH in Baltimore, Maryland.