Promoting HAART Adherence Among the Homeless: Housing as a Structural Intervention for People Living with HIV/AIDS

Background & Significance: People living with HIV/AIDS (PLWHA) on highly active antiretroviral therapy (HAART) need to be highly adherent to their medication regimen in order to keep healthy (Bangsberg et al., 2000). Homelessness contributes to non-adherence to HAART (Wolitski et al., 2007). The structural hurdles of lack of housing, exposure to street violence and barriers to service utilization undermine the effectiveness of HIV treatment programs for homeless PLWHA (Aidala & Sumartojo, 2000). Homelessness is also associated with several risk factors for non-adherence: the homeless are more likely to suffer from mental health problems, become victims of sexual and other violence, and abuse substances (Bassuk et al., 1998, Johnson et al., 2003). While research has demonstrated the healthy outcomes of housing, few studies have examined the actual mechanism through which it influences health choices. This study examines the effectiveness of a housing-first program (where housing is not contingent on sobriety) in promoting HAART adherence for a sample of previously homeless PLWHA, and the pathway through which housing influences adherence. Methods: A mixed methods approach was used to study all 80 chronically homeless PLWHA placed in a congregate housing program (i.e. residents staying in one housing facility) in New York. Guided by recent scholarship, we used viral loads as a measure of adherence (Gross et al., 2006). Viral loads were measured at baseline (when subjects entered housing) and 6 months after baseline. In addition, 30 semi-structured qualitative interviews were conducted with subjects in housing. SAS and QSR N6 were used to analyze the data.

Results: 80% of subjects were active substance users, while 81% reported a history of incarceration. After controlling for possible correlates, subjects were almost three times more likely to have an undetectable viral load (less than 400 copies/ml) at the six month follow-up, compared to their viral load at the time of intake (OR=2.89, 95% CI=5.87, 1.42). Results of the qualitative interviews indicated that housing's effect on adherence is mediated by material and subjective improvements in the lives of previously homeless PLWHA. Housing's materiality effect is produced by: a) reducing exposure to risk environments, b) reducing chaos in living conditions, and c) increasing access to psychosocial and support services. Housing's subjective effect is realized by a) changing medication-related attitudes among housing residents, b) establishing health-seeking collective norms, and c) improving medication-related self-efficacy.

Implications: The results indicate that housing should be conceptualized as an effective treatment for homeless PLWHA. Moreover, the results suggest that when housed, mandatory abstinence may not be required for PLWHA to be adherent to their medication. The materiality effects of housing underline the manner in which housing operates as a structural intervention that changes the risk environment for homeless PLWHA. Elements of the subjective pathway are embedded in the theory of planned behavior (Fishbein & Azjen, 1975) and illustrate the manner in which congregate housing acts as a catalyst for these cognitive processes. The identification of a conceptual model for housing's influence builds on previous scholarship and needs to be tested in future research.