Delay, Drop-Out, and Connectionto Medical Care: Focus on

SRO Residents.

Angela Aidala and Sara BerkMailman School of Public Health, Columbia University

Needs Assessment Committee

May 27, 2008

INTRODUCTIONINTRODUCTION

Persons living in SROs are disproportionately affected by HIV Persons living in SROs are disproportionately affected by HIV but are often outside or marginal to systems of HIV carebut are often outside or marginal to systems of HIV care

What can the CHAIN Study tell us about SRO residents and What can the CHAIN Study tell us about SRO residents and associations between SRO residency and access and associations between SRO residency and access and engagement with HIV primary care?engagement with HIV primary care?

Three data sources:Three data sources:

- - Ongoing cohort study of CHAIN agency recruited sampleOngoing cohort study of CHAIN agency recruited sample

- Separate effort to locate and interview PLWHA outside of care- Separate effort to locate and interview PLWHA outside of care

- Interviews with providers from programs targeting PLWHA outside - Interviews with providers from programs targeting PLWHA outside of careof care

NYC C.H.A.I.N. STUDYNYC C.H.A.I.N. STUDY

Community Health Advisory & Information Network Community Health Advisory & Information Network (CHAIN) Project(CHAIN) Project

PProject of the NYC HIV Health and Human Services Planning Project of the NYC HIV Health and Human Services Planning CouncilCouncil

P Multi-stage probability samplingMulti-stage probability sampling::Random selection of medical and soc svc agenciesRandom selection of medical and soc svc agenciesRecruit random sample of clients within agencies Recruit random sample of clients within agencies

P Includes 1661 PLWHAIncludes 1661 PLWHA recruited from clinics and agencies in recruited from clinics and agencies in 1994, 1998, 20021994, 1998, 2002

P In-person comprehensive (2-3hr) interview every 6–12 mosIn-person comprehensive (2-3hr) interview every 6–12 mos

P Strong community support – 80-90% interview rateStrong community support – 80-90% interview rate

Delayers Study

HIV positives who delay 4+ months to med care- 1994-1995 CHAIN Cohort (n=247 delayers)- 2001-2002 CHAIN Cohort (n=174 delayers)

Quantitative and qualitative interview data- demographics, health status, service need/use

- narrative descriptions: Why delay? Why drop out?

Key informant interviews

- providers serving groups at risk for delay

Focus groups with clients

DELAYERS/UNCONNECTED DELAYERS/UNCONNECTED PLWHAPLWHA

Unconnected Study Aware , no medical care, no case mgmt

6+months- 1995 n=48 unconnected- 1999 n=24 unconnected; 26 marginal- 2003 n=25 unconnected; 35 marginal n=36 high risk HIV - and out of care

Recruited through outreach in street and community settings and referrals from agency recruited participants

Quantitative and qualitative interview data- demographics, health status, service need/use

- narrative descriptions: Why delay? Why drop out?

DELAYERS/UNCONNECTED DELAYERS/UNCONNECTED PLWHAPLWHA

FINDING THE UNCONNECTEDFINDING THE UNCONNECTED

# Sites Visited

# Persons Screened

HIV + Unconnected

to Care

SRO OUTREACH

5 12 6 (50%)

STREETOUTREACH

15 171 13 ( 8%)

OTHER:Needle ExchgSoup KitchenMobil Med VanDrop-in Center

7 118 6 ( 5%)

TOTALS 27 301 25 (8%)

SRO RESIDENTSSRO RESIDENTS

Classify CHAIN Participants based on coding Classify CHAIN Participants based on coding descriptions of current and recent housingdescriptions of current and recent housing

Cross-check against addressesCross-check against addresses

SRO Resident = PLWHA who cSRO Resident = PLWHA who currently or urrently or in the 6 in the 6 months prior to interview, lived in an SRO or ‘welfare months prior to interview, lived in an SRO or ‘welfare hotel’ hotel’

Focus on CHAIN Participants who were SRO residents Focus on CHAIN Participants who were SRO residents at the time of baseline interview, 2002at the time of baseline interview, 2002

10% of the entire sample had lived in an SRO; of these 10% of the entire sample had lived in an SRO; of these one in four had multiple SRO staysone in four had multiple SRO stays

PATTERNS OF SRO RESIDENCYPATTERNS OF SRO RESIDENCY

10% of the entire 2002 agency-recruited sample had 10% of the entire 2002 agency-recruited sample had lived in an SRO during the study periodlived in an SRO during the study period

Most PLWHA report one period of SRO residency Most PLWHA report one period of SRO residency but one in four with any SRO experience had but one in four with any SRO experience had multiple SRO stays multiple SRO stays

Fewer PLWHA report living in an SRO than at Fewer PLWHA report living in an SRO than at earlier periods of the CHAIN study earlier periods of the CHAIN study

Those found in SROs during most recent interview Those found in SROs during most recent interview periods are more likely to be PLWHA with multiple SRO periods are more likely to be PLWHA with multiple SRO staysstays

COMPARING SRO RESIDENTS COMPARING SRO RESIDENTS

Comparing SRO residents to PLWHA with no Comparing SRO residents to PLWHA with no SRO experienceSRO experience

More likely to be male (74%); <35yrs old; have very More likely to be male (74%); <35yrs old; have very low incomes; jail experiencelow incomes; jail experience

Differences by borough of current residence: more Differences by borough of current residence: more often Manhattan or Bronxoften Manhattan or Bronx

Big difference transiency: 58% v. 7% changed Big difference transiency: 58% v. 7% changed addresses 2+ time past 6 months addresses 2+ time past 6 months

No differences: race/ethnicity; hs grad; ever No differences: race/ethnicity; hs grad; ever worked; currently workingworked; currently working

COMPARING SRO RESIDENTS COMPARING SRO RESIDENTS

Comparing SRO residents to PLWHA with no Comparing SRO residents to PLWHA with no SRO experienceSRO experience

No difference in risk exposure group, history of No difference in risk exposure group, history of problem drug use (heroin/ coke/ crack)problem drug use (heroin/ coke/ crack)

Big differences in patterns of problem drug use: Big differences in patterns of problem drug use:

- - More likely to have a history of frequent use (17% More likely to have a history of frequent use (17% v v 5% used heroin/coke/crack weekly or more 5% used heroin/coke/crack weekly or more often)often)

- More often current users (57% v 23%)- More often current users (57% v 23%)

More likely to report unsafe sexMore likely to report unsafe sex esp. men with hetero partners (14% v 5%)esp. men with hetero partners (14% v 5%)

Connection to Medical CareConnection to Medical Care

SRO SRO ResidentsResidents

No SRO No SRO ExperienceExperience

total sample n=total sample n= (69)(69) (624)(624) sigsig

No regular source of medical No regular source of medical care before HIV dxcare before HIV dx

73%73% 60%60% ****

Delayed entry into HIV careDelayed entry into HIV care 32%32% 28%28%

Dropped out of careDropped out of care11 30%30% 20%20% **

Dropped out because Dropped out because dissatisfied with caredissatisfied with care22

32%32% 26%26%

Note: Most recent CHAIN cohort, 2002.

1. Stopped going to the doctor for 6 months or longer

2. Among those who ever dropped out of care

Connection to Medical CareConnection to Medical Care

SRO SRO ResidentsResidents

No SRO No SRO ExperienceExperience

total sample n=total sample n= (69)(69) (624)(624)

No medical provider for HIVNo medical provider for HIV 7%7% 3%3% ##

Lacks comprehensive primary Lacks comprehensive primary carecare11

35%35% 23%23% **

Care does not meet clinical Care does not meet clinical practice standardspractice standards22

42%42% 25%25% ****

1+ Visit to ER past 6mo1+ Visit to ER past 6mo 39%39% 32%32%

Hospital inpatient past 6 mosHospital inpatient past 6 mos 29%29% 18%18% **

Note: Most recent CHAIN cohort, 2002.

1. Care that coordinated, comprehensive, and provides 24hr access in case of medical emergency

2. Based on number of visits , diagnostic tests, and ARVs if needed

Health Outcomes and Perceived Service Health Outcomes and Perceived Service NeedNeed

SRO SRO ResidentsResidents

No SRO No SRO ExperienceExperience

total sample n=total sample n= (69)(69) (624)(624)

CD4 T-cell count <200CD4 T-cell count <200 38%38% 22%22% ****

Viral load < 10K or ‘bad’Viral load < 10K or ‘bad’ 38%38% 19%19% ******

Health functioning indicates Health functioning indicates impairmentimpairment

64%64% 57%57% ****

Low mental health Low mental health functioningfunctioning

55%55% 65%65% ##

Self-report need for mental Self-report need for mental health services health services

20%20% 12%12% **

Self-report need for AOD Self-report need for AOD treatment/ services treatment/ services

68%68% 51%51% ****

Note: Most recent CHAIN cohort, 2002.

PREDICTORS OF CONNECTION TO PREDICTORS OF CONNECTION TO CARECARE

P SRO residence SRO residence

Co-morbidities: Low mental health functioning, current drug userCo-morbidities: Low mental health functioning, current drug user

Health status: T-cell count Health status: T-cell count

Housing services: Assistance with housing needs past 6 months Housing services: Assistance with housing needs past 6 months or receipt of rental assistanceor receipt of rental assistance

Supportive services: Mental health services, drug treatment, Supportive services: Mental health services, drug treatment, medical case management, social service case management, medical case management, social service case management, transportation servicestransportation services

Socio-demographics: Age, ethnicity, education, income Socio-demographics: Age, ethnicity, education, income <$7500 yr, living in poverty neighborhood, risk exposure group<$7500 yr, living in poverty neighborhood, risk exposure group

Date of HIV diagnosis, date of cohort enrollmentDate of HIV diagnosis, date of cohort enrollment

ANALYSISANALYSIS

Logistical regression used to compare the odds of medical care outcome associated with SRO residence v. other housing

Also examine receipt of housing assistance vs. no assistance

Adjusted odds ratios show odds of outcomes controlling for mental health and substance use co-morbidities, receipt of supportive services, socio-demographics, and time period

Each interview with each participant provides opportunity to examinewhich predictors are associated with medical care outcomes -1660 individuals interviewed 1-8 times for a total of over 5000 observation points

Models constructed using GEE procedures to adjust for dependency among multiple observations contributed by the same individual

Access to Medical CareAccess to Medical Care

Medical care Medical care meets clinical practice meets clinical practice

standardsstandards

SRO ResidenceSRO Residence 0.55 *0.55 * 1.03 1.03

Low mental health functioningLow mental health functioning 0.82 # 0.84

Current problem drug useCurrent problem drug use 0.95 0.92

Mental health servicesMental health services 1.48 ** 1.47 **

Substance abuse treatmentSubstance abuse treatment 1.13 1.08

Medical case managementMedical case management 1.44*1.44* 1.29 1.29

Social services case managementSocial services case management 1.21 0.96

Housing assistanceHousing assistance 1.81 ***

N=571 individuals, 1650 observations, 2002 - 2008

SUMMARYSUMMARY PLWHA residing in SROs have multiple needs for clinical and PLWHA residing in SROs have multiple needs for clinical and supportive services in addition to housing needs and appear to supportive services in addition to housing needs and appear to recognize their need especially for mental health and drug treatment recognize their need especially for mental health and drug treatment servicesservices

SRO residents significantly more likely than other PLWHA to be SRO residents significantly more likely than other PLWHA to be marginally connected to HIV medical care – to out of care or not marginally connected to HIV medical care – to out of care or not receiving care that meets minimum clinical practice standards receiving care that meets minimum clinical practice standards

P SRO residents have lower CD4 counts and higher viral loads than SRO residents have lower CD4 counts and higher viral loads than other PLWHA and are more likely to be hospitalized. other PLWHA and are more likely to be hospitalized.

P SRO residency remains a significant predictor of receiving SRO residency remains a significant predictor of receiving appropriate clinical care controlling for individual characteristics or appropriate clinical care controlling for individual characteristics or clinical status, or receipt of case management, mental health, drug clinical status, or receipt of case management, mental health, drug treatment, or other supportive servicestreatment, or other supportive services

P Receipt of housing assistance and mental health services are Receipt of housing assistance and mental health services are significant predictors of receiving care that meets good clinical significant predictors of receiving care that meets good clinical practice standards and reduces the significance of SRO residencypractice standards and reduces the significance of SRO residency

CONCLUSIONSCONCLUSIONS Findings provide strong and consistent evidence thatFindings provide strong and consistent evidence that ::

-- housing needs are a significant barrier to receipt of -- housing needs are a significant barrier to receipt of appropriate HIV medical care and continuity of care over time appropriate HIV medical care and continuity of care over time

-- receipt of housing assistance has a direct impact on -- receipt of housing assistance has a direct impact on improved improved medical care outcomes for persons living medical care outcomes for persons living with HIV/AIDS with HIV/AIDS

Any decrease in funding to provide housing assistance for Any decrease in funding to provide housing assistance for PLWHA would seem ill advisedPLWHA would seem ill advised

Improving access to housing will improve access to and Improving access to housing will improve access to and effectiveness of HIV medical care and treatmenteffectiveness of HIV medical care and treatment

Housing 'expensive' but studies show more than offset by Housing 'expensive' but studies show more than offset by savings associated with reduced emergency and inpatient savings associated with reduced emergency and inpatient services, treatment failure, and decreased risk of HIV services, treatment failure, and decreased risk of HIV

transmissiontransmission

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

This research was made possible by a series of grants from the US Health Resources and Service Administration (HRSA) under Title I of the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act and contracts with the New York City HIV Health and Human Services Planning Council through the New York City Department of Health and Medical and Health Research Association of New York City

Its contents are solely the responsibility of the Researchers and do not necessarily represent the official views of the U.S. Health Resources and Services Administration, the City of New York, or the Medical and Health Research Association..

Special thanks is due to the 1661 persons living with HIV who have participated in the CHAIN Project and shared their experiences with us.

Contact: aaa1@columbia.edu