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Soc Sci Med. 2018 Oct;214:70-82. doi: 10.1016/j.socscimed.2018.07.051. Epub 2018 Aug 13.

The effect of unstable housing on HIV treatment biomarkers: An instrumental variables approach.

Author information

1
Brown University, School of Public Health, 121 S. Main St., Providence, RI 02912, USA. Electronic address: omar_galarraga@brown.edu.
2
University of Alabama at Birmingham, School of Medicine, 1720 2nd Ave. South, Birmingham, AL 35294, USA. Electronic address: rana@uab.edu.
3
Brown University, School of Public Health, 121 S. Main St., Providence, RI 02912, USA. Electronic address: momotazur_rahman@brown.edu.
4
Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA. Electronic address: mardge.cohen@gmail.com.
5
University of North Carolina at Chapel Hill, Institute for Global Health and Infectious Diseases, 130 Mason Farm Rd., Chapel Hill, NC 27599, USA. Electronic address: adimora@med.unc.edu.
6
Montefiore Medical Center, 3311 Bainbridge Ave., Bronx, NY, 10467, USA. Electronic address: ksosanya@montefiore.org.
7
SUNY Downstate Medical Center, 450 Clarkson Ave., Brooklyn, NY 11203, USA. Electronic address: susan.holman@downstate.edu.
8
Georgetown University, Department of Medicine, 3800 Reservoir Rd., NW, Washington, DC 20007, USA. Electronic address: sgk23@georgetown.edu.
9
University of Southern California, Institute for Health Promotion & Disease Prevention Research, 2001 N. Soto St., Los Angeles, CA 90032, USA. Electronic address: joel.milam@med.usc.edu.
10
University of California at San Francisco, School of Pharmacy, 1515 Scott St., San Francisco, CA 94115, USA. Electronic address: jennifer.cohen@ucsf.edu.
11
Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA. Electronic address: egolub@jhu.edu.
12
Columbia University, Mailman School of Public Health, 722 W. 168th St., New York, NY 10032, USA. Electronic address: lm2892@columbia.edu.
13
University of Alabama at Birmingham, School of Nursing, 1720 2nd Ave. South, Birmingham, AL 35294, USA. Electronic address: mkempf@uab.edu.

Abstract

Unstable housing, including homelessness, is a public policy concern for all populations, and more critically for people with a serious health condition such as HIV. We measure the effect of unstable housing on HIV treatment biomarkers: viral suppression (viral load < 200 HIV RNA copies per ml) and adequate CD4+ T-cell count (CD4>350 cells per μl). We use panel data (1995-2015) from 3082 participants of the Women's Interagency HIV Study (WIHS) sites in Bronx and Brooklyn (NY), Chicago (IL), Los Angeles and San Francisco (CA), and Washington (DC). The instrumental variable (IV) measures allocations for the Housing Opportunities for People with AIDS (HOPWA) per person newly infected with HIV, and it represents actual availability of housing assistance for HIV-positive persons at the metropolitan area level. Using an extended probit model with the IV, we find that unstable housing reduces the likelihood of viral suppression by 51 percentage points, and decreases the probability of having adequate CD4 cell count by 53 percentage points. The endogeneity-corrected results are larger than naïve probits, which show decreases of 8.1 and 7.8 percentage points, respectively. The hypothesized pathways for the effect are: decreased use of mental healthcare/counseling, any healthcare, and less continuity of care. Increasing efforts to improve housing assistance, including HOPWA, and other interventions to make housing more affordable for low-income populations, and HIV-positive populations in particular, may be warranted not only for the benefits of stable housing, but also to improve HIV-related biomarkers.

KEYWORDS:

CD4 cell count; HIV/AIDS; Housing assistance; Instrumental variables; Unstable housing; Viral suppression

PMID:
30153546
PMCID:
PMC6171130
[Available on 2019-10-01]
DOI:
10.1016/j.socscimed.2018.07.051
[Indexed for MEDLINE]

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