Enhanced Housing Placement Assistance (EHPA): Baseline Characteristics of Homeless PLWHA in New York City Rachel Johnson, MPH John Rojas, MPA NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE North American Housing and HIV/AIDS Research Summit Montréal, Québec September 26, 2013
Homelessness in New York City (NYC) 104,754¹ unduplicated number of individuals accessing homeless shelter system in 2012 3,262² estimate of street homeless in 2012 886³ PLWHA residing in emergency Single Room Occupancy (SRO) hotels in July 2013 3,108⁴ PLWHA who utilized the homeless shelter system at least once between 2001-2003 1. NYC Department of Homeless Services. (2012). Total DHS Services Fiscal Year 2012. 2. NYC Department of Homeless Services. (2012). Homeless Outreach Population Estimate Results, 2012. 3. NYC Human Resources Administration. (2013). HASA Facts (July 2013). 4. NYC Department of Health and Mental Hygiene & NYC Department of Homeless Services. (2005). The Health of Homeless Adults in New York City.
HIV in New York City, 2011¹ 113,319 people living with HIV/AIDS (PLWHA) in NYC 3,404 new HIV diagnoses NYC represents 10% of the national HIV prevalence Blacks and Hispanics are disproportionately affected 77% of PLWHA in NYC are Black and/or Hispanic 1. New York City HIV/AIDS Annual Surveillance Statistics. New York: New York City Department of Health and Mental Hygiene, 2011. Updated December 18, 2012.
Housing Assistance for Low-Income PLWHA The HIV/AIDS Services Administration (HASA), administered through the Human Resources Administration (HRA), provides public assistance to symptomatic, low-income PLWHA There are currently 32,510 PLWHA enrolled in HASA¹ Nearly 85% of all HASA clients receive enhanced rental assistance² Emergency housing placements for homeless PLWHA enrolled in HASA are made to Single Room Occupancy (SRO) hotels Placements are intended to be temporary, no more than 90 days 800-900 PLWHA daily; ~2,500 PLWHA annually 1. NYC Human Resources Administration. (2013). HASA Facts (July 2013). 2. NYC Human Resources Administration. (2013). HASA Facts (July 2013).
What is EHPA? A pilot housing program, administered by the NYC Department of Health and Mental Hygiene (DOHMH) Enhanced version of traditional Housing Placement Assistance (HPA) programs (i.e., housing specialist assists client to prepare for and find independent housing) Target population is chronically homeless PLWHA living in emergency SROs in NYC Short term Standard HPA Referral and connection to services made as needed Clients closed postplacement (a few months) Long term Enhanced HPA Support services provided weekly and then monthly, for up to 1 year Clients remain open for 1 year post-placement
Evaluation of EHPA Recruitment directly from emergency SROs in NYC Random assignment to either EHPA or Usual Care (referral to traditional HPA program) Baseline, six, and twelve month interviews Program evaluation data is linked to other available data sources at DOHMH: HIV/AIDS Surveillance Registry, housing data, service utilization data Mitigates some issues with loss to follow-up
Primary Longitudinal Outcomes Housing stability HIV health care Risk behaviors Placement No. and % of months spent in stable housing 6- and 12- month housing retention No. of moves Gaps in stable housing Engagement and retention in care Sustained viral suppression Stable/improved CD4 counts Antiretroviral therapy (ART) adherence Decreased substance use or increased harm reduction techniques Decreased risky sex behaviors
Evaluation Timeline Apr 2012 Apr 2013 Informed consent Random assignment Baseline interview Oct 2012 Oct 2013 6- month interview Apr 2013 Apr 2014 12- month interview Qualitative portion Recruitment 6 months 12 months
Recruitment for EHPA Randomized list of NYC emergency SROs and visited each in order Approached rooms in ascending order Continued to return to each SRO to try and get response from rooms that had not previously answered doors Obtained informed consent from eligible participants Provided emergency food vouchers as incentive
SRO Eligibility/Recruitment Individuals were eligible if they reported: Symptomatic HIV/CDC-defined AIDS diagnosis Current residence in emergency SRO Ability to live independently without home health aide Recruited clients from 18 SROs in NYC 236 clients eligible and enrolled (from April 2012 to April 2013) 119 in EHPA 117 in HPC
Baseline Survey Survey took 60-90 minutes Conducted in participants room or other private, comfortable space in emergency SRO Collected data on: Basic demographics Housing/homelessness history History of incarceration Sexual behaviors Drug and alcohol use Antiretroviral therapy (ART) use and adherence Social service history Social network history
PROGRAM PARTICIPANT DEMOGRAPHICS
Demographics of program participants vs. all SRO residents¹ GENDER AGE RACE 80% 45% 60% 70% 60% 40% 35% 50% 50% 30% 40% 40% 30% 20% 10% 25% 20% 15% 10% 5% 30% 20% 10% 0% Male Female Transgender 0% <18 18-40 41-50 51+ 0% Black Hispanic White Other N=236 N=2,623 Study sample was reflective of the general homeless population: primarily male, over the age of 40 and Black or Hispanic. 1. All HASA clients spending any time in SRO in 2011
Snapshot of Program Participants 94% of clients make less than $15,000 per year 94% are disabled for work or unemployed 53% are never married 22% are married or living together as married 99% have health insurance (Medicaid/Medicare/ADAP) 52% receive Social Security benefits (SSI/SSDI)
EXPERIENCE IN SROS
History of Homelessness, Past Three Years 19% 16% 65% Total program (N = 236) Inability to maintain permanent housing 73% were stably housed (either supportive housing or independent rental apartment) before regressing to emergency housing Chronic homelessness Episodic, non-chronic First time (in 3 years) The majority of participants cycled between stable housing and homelessness, indicating inability to maintain independent living.
Top 8 Most Important Reasons for Moving into Current SRO Recently discharged from facility/institution Safety became an issue in prior housing Could not afford to pay rent at last place 10% 11% 17% Temporarily staying with friends or relatives Substance abuse issues 8% 8% Prior housing not meant to be permanent 8% Falling out with people living there 7% Evicted/going to be evicted 7% 1. Jail/prison/substance abuse treatment, psychiatric facility, nursing home 0% 5% 10% 15% 20%
History of Incarceration 100% 90% 80% Total N = 236 78% Don't Know 1% 70% 60% 50% 40% Not Recent 66% Recent* 33% 30% 20% 10% 22% * Recent = past two years 0% No Yes The vast majority of participants have a history of incarceration, one-third of whom had been incarcerated in the past two years.
SUBSTANCE USE
Substance Use, Past 12 Months 90% 80% 82% Total N = 236 70% 60% 64% 61% 50% 40% 30% 20% 10% 10% 0% Any Substance Use Drank Alcohol Non-injection Drugs Injected Drugs Participants reported high levels of substance use with almost two-thirds reporting non-injection drug use in the past 12 months.
Non-Injection Drug Use, Past 12 Months Marijuana 74% Crack 52% Cocaine 25% Total Program (N=236) No, 38% Yes, 61% Pain Killers 19% Downers 14% Crystal Meth 10% Ecstasy 6% MULTIPLE SUBSTANCES 59% 0% 20% 40% 60% 80% Of those who had used non-injection drugs in the past year, over half used crack. This is the most commonly reported drug, other than marijuana.
Injection Drug Use Shared Needles 8% Yes, past 12 mos. 10% Shared Works 21% Total Program (N = 236) Yes, ever 27% Never 62% 0% 10% 20% 30% 40% 50% 60% 70% Of those injecting drugs in the past year, most participants are using clean needles and not sharing works.
Injection Drug Use Yes, past 12 mos. 10% Heroin Alone 58% Heroin and Cocaine together 38% Powdered Cocaine 38% Meth 17% Crack 13% Hormones 4% Total Program (N = 236) Yes, ever 27% MULTIPLE SUBSTANCES 38% Never 62% 0% 10% 20% 30% 40% 50% 60% 70% Of those injecting drugs in the past year, most are injecting heroin or heroin and cocaine together.
SEX RISK BEHAVIORS
45% Sex Partners, Past 12 Months Opposite Sex Partners (N=212) Same Sex Partners (N=57) 40% 40% 37% 35% 32% 30% 25% 25% 25% 18% 20% 16% 15% 10% 5% 0% 6% None 1 partner 2-4 partners > 5 partners 29% of all participants reported two or more sexual partners.
Sex Behaviors, Past 12 Months Sex Without Condom (N= 161) Sex with Negative/Unknown HIV Status Partner (N= 161) No 47% Yes 53% No 33% Yes 67% Of those who had sex in the past year, more than half had sex without a condom.
MENTAL HEALTH
Mental Health Mental Health Diagnosis, Ever 60% Type of Diagnosis 50% 48% Total N = 236 No 40% Yes 60% 40% 30% 20% 24% 10% 5% 9% 0% Anxiety Disorder Mood Disorder Personality Disorder Psychotic Disorder The majority of participants have been diagnosed with a mental health disorder, with almost half diagnosed with a mood disorder.
CLINICAL INDICATORS
HIV Care Outcomes 100% 90% 93% Total N = 236 80% 70% 60% 50% 40% 30% 24% 41% 51% * 20% 10% 0% HIV care visit, past 6 mos Perfect ART adherence, past 3 days Viral suppression at baseline CD4 >350 cells/µl The vast majority of participants are engaged in care, but only 41% are virally suppressed.
Conclusions EHPA participants have experienced high levels of instability including homelessness and histories of incarceration Most participants have histories of chronic homelessness punctuated by short episodes of stable housing, indicating that individuals can secure permanent housing but are unable to maintain it Despite consistent engagement in HIV primary care, homeless PLWHA have poor health outcomes the majority are not virally suppressed and have a mental health disorder There are high self-reported rates of drug usage among homeless PLWHA Homeless PLWHA are using harm reduction practices (i.e., using clean needles and not sharing works) and most report zero or only one sexual partner
Discussion This data reflects the complex needs of this chronically homeless population and the need to further assess existing service delivery models to better serve this population While access to and retention in HIV primary care is high, homeless clients struggle with viral suppression and chronic mental illness, indicating the need for interventions beyond primary medical care The pattern of cycling between independent housing and homelessness indicates that independent living may not be a sustainable housing option for all chronically homeless PLWHA Need to preserve and increase supportive housing Need to develop strategies to better engage chronically homeless PLWHA and directly connect them to permanent supportive housing
Acknowledgements EHPA program participants Laura McAllister-Hollod, MPH, Evaluation Specialist DOHMH EHPA Outreach Coordinator, Sandy Guillaume, MPA and the Mailman School of Public Health evaluation intern teams NYC DOHMH Bureau of HIV/AIDS Prevention & Control Robert Cordero and the staff from BOOM!Health (formerly CitiWide Harm Reduction)