Trends in cardiac CT utilization for patients with pediatric and congenital heart disease: A multicenter survey study.

BACKGROUND: The use of cardiac CT (CCT) has increased dramatically in recent years among patients with pediatric and congenital heart disease (CHD), but little is known about trends and practice pattern variation in CCT utilization for this population among centers. METHODS: A 21-item survey was created to assess CCT utilization in the pediatric/CHD population in calendar years 2011 and 2021. The survey was sent to all non-invasive cardiac imaging directors of pediatric cardiology centers in North America in September 2022. RESULTS: Forty-one centers completed the survey. In 2021, 98% of centers performed CCT in pediatric and CHD patients (vs. 73% in 2011), and 61% of centers performed >100 CCTs annually (vs. 5% in 2011). While 62% of centers in 2021 utilized dual-source technology for high-pitch helical acquisition, 15% of centers reported primarily performing CCT on a 64-slice scanner. Anesthesia utilization, use of medications for heart rate control, and type of subspecialty training for physicians interpreting CCT varied widely among centers. 50% of centers reported barriers to CCT performance, with the most commonly cited concerns being radiation exposure, the need for anesthesia, and limited CT scan staffing or machine access. 37% (11/30) of centers with a pediatric cardiology fellowship program offer no clinical or didactic CCT training for categorical fellows. CONCLUSION: While CCT usage in the CHD/pediatric population has risen significantly in the past decade, there is broad center variability in CCT acquisition techniques, staffing, workflow, and utilization. Potential areas for improvement include expanding CT scanner access and staffing, formal CCT education for pediatric cardiology fellows, and increasing utilization of existing technological advances.

Examining Concordance Between Self-Report and Biomedical HIV Viral Load Data: A Scoping Review.

Assessment of HIV viral load based on laboratory results is the gold standard in HIV care and research. However, blood assay or accessing medical records is not always possible due to research or service contexts and constraints. Self-report of viral load test results expands data resources, is a convenient method of collecting data in both research and service settings, and is useful for HIV surveillance. The purpose of this scoping review was to identify existing literature on the validity of self-reported viral load data compared to blood assay or medical record review. We found that the existing literature is limited, with varied data collection methods, self-report measures, and study designs, as well as predictors of accuracy. Concordance between self-reported viral load and biomedical data varied across studies but appeared to be more consistent among samples recruited from clinical populations that reported engagement in HIV care. While it is difficult to draw definitive conclusions about the validity of self-reported viral load across existing studies, there is a need for a standardized measure and method of collection that can be utilized across diverse populations living with HIV.

RESUMEN: La evaluación de la carga viral del VIH basada en resultados de laboratorio es el patrón-oro en la atención e investigación del VIH. Sin embargo, el análisis de sangre o el acceso a los registros médicos no siempre es posible debido a los contextos y limitaciones de la investigación o los servicios. El autoinforme de los resultados de las pruebas de carga viral aumenta los recursos de datos, es un método conveniente de recopilación de datos tanto en contextos de investigación como de servicios, y es útil para la vigilancia de VIH. El propósito de esta revisión de alcance fue identificar la literatura existente sobre la validez de los datos de carga viral autoinformados en comparación con análisis de sangre o revisión de registros médicos. Encontramos que la literatura existente es limitada, con variados métodos de recopilación de datos, medidas de autoinforme y diseños de estudio, así como predictores de exactitud. La concordancia entre la carga viral autoinformada y los datos biomédicos varió entre los estudios, pero pareció ser más consistente entre las muestras reclutadas de poblaciones clínicas que indicaron participación en la atención del VIH. Aunque es difícil extraer conclusiones definitivas sobre la validez de la carga viral autoinformada en los estudios existentes, existe la necesidad de una medida y un método de recopilación estandarizados que puedan utilizarse en diversas poblaciones que viven con el VIH.

Medical, Mental Health, and Social Service Linkage Predicts Better HIV Outcomes: A Network Analytic Approach.

This study presents a conceptual and quantitative approach to assess service linkages among people living with HIV (PLWH). We use network analytic techniques to document linkages among service providers based on client reports of service utilization. Data are provided by a cohort study of 1012 PLWH in New York City interviewed up to 8 times from 2002 to 2015. Participants in each interview reported service needs, services received, and location of services for primary care, behavior health, case management, and housing, food, or other social services. Each reported clinic or agency was linked to entries in a database of medical and social service providers, which included details on organizational characteristics. Based on connections indicated by clients' reported referrals, service co-location within a single agency, or service site part of a larger parent organization, we constructed networks of linkages operationally defining which service areas were linked with others. Case management and primary care were services most commonly linked with other services. The most common pairing was case management and housing services. Individuals with more linkages in their care networks, as measured by average number of connections per provider, were associated with greater odds of adherence to antiretroviral medication and suppressed viral load. Further, higher levels of service linkage were associated with reduced emergency department visits and hospital admission rates. This study offers an innovative approach to analyzing linkages and outcomes from the perspective of service users in terms of their care experiences and provides insights into patient self-management of what are often multiple medical and support service needs. Study limitations include the use of data from a single urban setting and gaps in service reports.

Syndemic factors associated with adherence to antiretroviral therapy among HIV-positive adult heterosexual men.

BACKGROUND: Suboptimal adherence to HIV antiretroviral therapy (ART) and concomitant lack of viral control can have severe consequences for health and onward transmission among persons living with HIV. Little is known about the barriers and facilitators of optimal ART adherence among heterosexual HIV-positive men. METHODS: Structural equation modeling (SEM) was performed to test a theory-derived model of ART adherence using data from a cross-sectional sample of 317 HIV-positive self-identified heterosexual men residing in New York City. We assessed a conceptual model in which mental health (depression, anxiety) and substance use dependence mediated the effects of socio-structural factors (HIV-related stigma, social support) on ART adherence, and subsequently, undetectable viral load. RESULTS: Structural equation modeling analyses indicated that men who reported higher levels of HIV-related stigma tended to experience higher levels of general anxiety, which in turn was associated with reduced probability of optimal ART adherence. Moreover, men who reported higher levels of social support tended to exhibit less dependence on illicit substance use, which in turn was associated with increased probability of optimal ART adherence. African-American men reported lower ART adherence compared to other racial/ethnic groups. CONCLUSIONS: Our findings support the hypothesis that substance use dependence and mental health problems, particularly anxiety, may be primary drivers of suboptimal ART adherence among heterosexual men, and that socio-structural factors such as HIV-related stigma and social support are potential modifiable antecedents of these drivers.

Strategies and Tools for Public Health Workforce Training Needs Assessments in Diverse and Changing Population Health Contexts.

CONTEXT: A key component of the improvement of public health infrastructure in the United States revolves around public health workforce development and training. Workforce challenges faced by the public health system have long been recognized, but there are additional challenges facing any region-wide or cross-jurisdictional effort to accurately assess priority workforce training needs and develop training resources to address those needs. These challenges include structural variability of public health organizations; diverse population health contexts; capturing both topic-specific skill sets and foundational competencies among public health workers; and reaching/representing the target population despite suspicion, disinterest, and/or assessment "fatigue" among employees asked to participate in workforce development surveys. OBJECTIVE: The purpose of this article is to describe the challenges, strategies to meet those challenges, and lessons learned conducting public health workforce training needs assessments by academic and practice partners of the Region 2 Public Health Training Center (R2/PHTC). SETTING AND PARTICIPANTS: The R2/PHTC is hosted by the Mailman School of Public Health at Columbia University and serves New York, New Jersey, Puerto Rico, and the US Virgin Islands within its jurisdiction. RESULTS: Strategies for responding to diverse organizational structures and population health contexts across the region; defining training priorities that address both foundational competencies for public health professionals and content-specific training to address local public health needs; reaching/representing target populations of public health workers; and analysis and report writing to encourage rapid response to identified needs and comprehensive workforce development planning are discussed. Lessons learned are likely instructive to other workforce training needs assessments in complex and ever-changing public health environments.

Effects of Discrimination on HIV-Related Symptoms in Heterosexual Men of Color.

HIV-related symptoms have a deleterious effect on quality of life. One determinant of HIV symptom burden among individuals of color may be discrimination. The aim of this study was to explore whether multiple lifetime discrimination events are associated with a greater number of HIV-related symptoms among heterosexual HIV-positive men of color and to examine the influence of anxiety and social support on this relationship. Data for this study were drawn from a cross-sectional survey of 307 heterosexual HIV-positive men recruited from health and social service agencies in New York City (NYC). This study indicated that the number of discrimination events experienced in one's lifetime was positively associated with the number of HIV-related symptoms experienced in the past month. Moreover, the direct effect of discrimination on HIV symptoms remained significant after anxiety was included as a mediator in the model, and there was a significant indirect effect of discrimination on HIV symptoms through anxiety. Evidence supported a potential moderated mediation effect involving social support: As social support increased, the indirect effect of discrimination on HIV symptoms through anxiety decreased. The results of this study suggest an association between discrimination and HIV-related symptom burden. Furthermore, the relationship between number of major discrimination experiences and HIV symptom burden was partially mediated by anxiety. Future research should consider how lifetime discrimination might be associated with negative health outcomes among HIV-positive individuals of color.

Validation of the Client Diagnostic Questionnaire to Assess Mental Health in South African Caregivers of Children.

BACKGROUND: Given the high prevalence of mental health (MH) and substance abuse problems in low-to-middle income countries, the scarcity of MH professionals and the negative impact of psychiatric disorders on caregivers of young children, there is significant need for brief evidence-based screening tools for lay counselors to assist with MH assessment. This study aimed to validate a brief screening tool to assess psychiatric and substance use disorders, the Client Diagnostic Questionnaire (CDQ), in South Africa (SA). METHODS: Data are from a longitudinal study of health and psychosocial needs in preschool children in SA. Participants included 322 Zulu-speaking, female caregivers. Following procedures of the US CDQ validation study, lay counselors interviewed participants using the translated Zulu CDQ. Subsequently a psychologist conducted a full psychiatric assessment guided by the CDQ questions. Analyses examined sensitivity, specificity and overall accuracy, comparing lay counselor and psychologist assessment. RESULTS: Sensitivity (73%), specificity (81%) and overall accuracy (79%) were good for the variable indicating presence of 'any diagnosis.' Among those cases identified by the psychologist as having any psychiatric diagnosis, over 70% were correctly identified by lay counselors using the CDQ (i.e., positive predictive value was greater than 70%). The false positive rate was relatively low (19%). Specificity for 'any disorder' (including substance use) and 'any psychiatric disorder' were 81% and 79%. CONCLUSIONS: The isiZulu CDQ is a sensitive and valid MH diagnostic screener that can be used by lay counselors with limited MH training to identify those in need of treatment and target extremely scarce MH professionals. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: South Africa (SA), a country heavily impacted by poverty, HIV and the legacy of Apartheid, has a high prevalence of mental health (MH) and substance abuse problems. In SA and other low-and-middle-income-countries (LMIC) there is a dearth of MH professionals. This study examined use and validity of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic MH screening tool designed for use by lay counselors in HIV-affected populations. Comparing lay counsellor diagnoses on the CDQ to clinician assessment, sensitivity, specificity and overall accuracy were good at the level of 'any diagnosis.' The CDQ can be used effectively in SA and other LMIC with limited MH services to enable appropriate and efficient referral of individuals in primary care settings, supporting caregivers and the children in their care.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review.

BACKGROUND: Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. OBJECTIVES: We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. SEARCH METHODS: We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. SELECTION CRITERIA: We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. DATA COLLECTION AND ANALYSIS: Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. RESULTS: Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. CONCLUSIONS: Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Determinants of physical and global functioning in adult HIV-positive heterosexual men.

Little is known about the psychosocial factors that might impact the functioning ability of heterosexual men living with HIV. We examined positive and negative coping, social support, and HIV stigma as predictors of physical and global functioning in a cross-sectional sample of 317 HIV-infected adult heterosexual male patients recruited from clinical and social service agencies in New York City. Study participants were primarily minority and low income. Sixty-four percent were African-American, 55% were single, and 90% were 40 years of age or older. The majority had long-term HIV (LTHIV), with an average duration of 15 years since diagnosis. After controlling for participant characteristics, structural equation modeling analyses revealed that positive coping and social support had a significant positive direct effect on global functioning, while stigma had a significant negative direct effect on global functioning. The physical functioning model revealed that negative coping and HIV stigma had significant negative direct effects, whereas social support had a significant positive indirect effect. Age and duration of HIV diagnosis were not associated with physical and global functioning. In conclusion, we found that heterosexual men living with LTHIV who have ineffective coping, less social support, and greater stigma have reduced functioning ability. Study findings have implications for developing interventions aimed at increasing and retaining functioning ability with the end goal of improving successful aging in this population.

Implementation of a Multimodal Mobile System for Point-of-Sale Surveillance: Lessons Learned From Case Studies in Washington, DC, and New York City.

BACKGROUND: In tobacco control and other fields, point-of-sale surveillance of the retail environment is critical for understanding industry marketing of products and informing public health practice. Innovations in mobile technology can improve existing, paper-based surveillance methods, yet few studies describe in detail how to operationalize the use of technology in public health surveillance. OBJECTIVE: The aims of this paper are to share implementation strategies and lessons learned from 2 tobacco, point-of-sale surveillance projects to inform and prepare public health researchers and practitioners to implement new mobile technologies in retail point-of-sale surveillance systems. METHODS: From 2011 to 2013, 2 point-of-sale surveillance pilot projects were conducted in Washington, DC, and New York, New York, to capture information about the tobacco retail environment and test the feasibility of a multimodal mobile data collection system, which included capabilities for audio or video recording data, electronic photographs, electronic location data, and a centralized back-end server and dashboard. We established a preimplementation field testing process for both projects, which involved a series of rapid and iterative tests to inform decisions and establish protocols around key components of the project. RESULTS: Important components of field testing included choosing a mobile phone that met project criteria, establishing an efficient workflow and accessible user interfaces for each component of the system, training and providing technical support to fieldworkers, and developing processes to integrate data from multiple sources into back-end systems that can be utilized in real-time. CONCLUSIONS: A well-planned implementation process is critical for successful use and performance of multimodal mobile surveillance systems. Guidelines for implementation include (1) the need to establish and allow time for an iterative testing framework for resolving technical and logistical challenges; (2) developing a streamlined workflow and user-friendly interfaces for data collection; (3) allowing for ongoing communication, feedback, and technology-related skill-building among all staff; and (4) supporting infrastructure for back-end data systems. Although mobile technologies are evolving rapidly, lessons learned from these case studies are essential for ensuring that the many benefits of new mobile systems for rapid point-of-sale surveillance are fully realized.

Prevalence, incidence, and persistence of psychiatric and substance use disorders among mothers living with HIV.

OBJECTIVE: To evaluate prevalence, incidence, remission, and persistence of psychiatric and substance use disorders among HIV-infected mothers and identify biopsychosocial correlates. METHODS: HIV-infected mothers (n = 1223) of HIV-exposed uninfected children enrolled in a prospective cohort study; HIV-uninfected mothers (n = 128) served as a comparison group. Mothers provided sociodemographic and health information and completed the Client Diagnostic Questionnaire (CDQ). Prevalence of any psychiatric or substance use disorder at initial evaluation was compared between the 2 groups. Incident, remitting, and persisting disorders were identified for 689 mothers with HIV who completed follow-up CDQs. We used logistic regression to evaluate adjusted associations of biopsychosocial characteristics with presence, incidence, remission, and persistence of disorders. RESULTS: Thirty-five percent of mothers screened positive for any psychiatric or substance use disorder at initial evaluation, with no difference by maternal HIV status (P = 1.00). Among HIV-infected mothers, presence of any disorder was associated with younger age [adjusted odds ratio (aOR): 1.39; 95% CI: 1.09 to 1.75], single parenthood (aOR: 1.35; 95% CI: 1.08 to 1.68), and functional limitations (aOR: 2.29; 95% CI: 1.81 to 2.90). Incident disorders were associated with functional limitations (aOR: 1.92; 95% CI: 1.10 to 3.30). Among HIV-infected mothers with a disorder at initial evaluation (n = 238), 61% had persistent disorders. Persistent disorders were associated with lower income (aOR: 2.44; 95% CI: 1.33 to 4.76) and functional limitations (aOR: 3.19; 95% CI: 1.87 to 5.48). Receipt of treatment for any disorder was limited: 4.5% at study entry, 7% at follow-up, 5.5% at both entry and follow-up. CONCLUSIONS: Psychiatric and substance use disorders remain significant comorbid conditions among HIV-infected mothers and require accessible evidence-informed treatment.

An Ecological View of Internet Health Information Seeking Behavior Predictors: Findings from the CHAIN Study.

OBJECTIVE: The purpose of the study was to further elucidate proximal and distal demographic and social predictors of Internet Health Information Seeking Behavior (IHISB) among a cohort of HIV+ individuals through an ecological framework. METHODS: The Community Health Advisory & Information Network (CHAIN) project is an ongoing prospective study of a representative sample of persons living with HIV/AIDS in New York City and the Tri-County region. The study sample was drawn from a two-stage randomized technique with the clients of 43 medical and social service organizations with 693 HIV+ participants. Bivariate correlations were computed between IHISB and independent demographic variables in ecological blocks. Multivariate hierarchical logistic regression was used to test association between blocks of variables and IHISB. RESULTS: Among the surveyed respondents (n=645) 50.3% indicated that they used the Internet. Being above the poverty line, having less than a high school education, and having fewer neighbors were statistically significant predictors of IHISB related to HIV. CONCLUSIONS: The benefits of accessing the Internet may influence health behavior and may be considered a target for interventions that aim to increase access to health related information online. Coupled with increased access, is the need for increased patient education interventions, and creative managed care approaches to ensure that information gleaned from online sources is interpretable and accurate in order to benefit the lives of those living with HIV/AIDS.

Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV.

We present a cost-utility analysis based on data from the Housing and Health (H&H) Study of rental assistance for homeless and unstably housed persons living with HIV in Baltimore, Chicago and Los Angeles. As-treated analyses found favorable associations of housing with HIV viral load, emergency room use, and perceived stress (an outcome that can be quantitatively linked to quality of life). We combined these outcome data with information on intervention costs to estimate the cost-per-quality-adjusted-life-year (QALY) saved. We estimate that the cost-per-QALY-saved by the HIV-related housing services is $62,493. These services compare favorably (in terms of cost-effectiveness) to other well-accepted medical and public health services.

Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV.

Homelessness affects HIV risk and health, but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS. Homeless/unstably housed people living with HIV/AIDS (N = 630) were randomly assigned to immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance or customary care. Self-reported data, CD4, and HIV viral load were collected at baseline, 6, 12, and 18 months. Results showed that housing status improved in both groups, with greater improvement occurring in the treatment group. At 18 months, 51% of the comparison group had their own housing, limiting statistical power. Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health; significant differential change benefiting the treatment group was observed for depression and perceived stress. Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization, mental health, and physical health. HOPWA rental assistance improves housing status and, in some cases, health outcomes of homeless and unstably housed people living with HIV/AIDS.

Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV.

Prior research suggests that the interconnections between substance use, HIV risk and lack of adherence to HIV medications are especially strong among homeless individuals. Thus, study of these interconnections warrants public health attention. The objectives of this paper are to describe patterns of alcohol and drug use, associations between substance use and participation in high-risk sex, and associations between substance use and adherence to HIV treatment regimens among a sample of 602 homeless or unstably housed HIV-seropositive individuals who are part of a housing-based intervention--the Housing and Health Study. Participants experienced high levels of substance use. Significant associations were found between substance use and adherence to HIV treatment medications, and between substance use and high-risk sexual practices within the entire group. Group analyses by sexual orientation/gender show that the association between substance use and treatment adherence is found primarily among heterosexual males whereas the relationship between several drugs and high-risk sexual practices is strongest among gay and bisexual men. Health professionals working with HIV-seropositive individuals should routinely ascertain housing status and screen for substance use and risky sex.

Factors associated with adherence to highly active antiretroviral therapy in homeless or unstably housed adults living with HIV.

The aim of this study is to investigate adherence to highly active antiretroviral therapy (HAART) in persons living with HIV/AIDS (PLWHA) who are homeless or unstably housed. We evaluated homeless or unstably housed PLWHA (n=644) in three US cities were enrolled in the Housing and Health Study. Using baseline data and controlling for gender, race, age, and education, we examined associations between self-reported two- and Seven-day adherence and access to healthcare, mental health, substance use, and attitudes toward HIV medical therapy. Of the 644 participants, 358 (55%) were currently on HAART. For two-day adherence, 280 (78%) reported missing no prescribed doses (100% adherence), and for seven-day adherence, 291 (81%) reported > or =90% adherence. Logistic regression analyses indicated being younger, not having health insurance, and drug use were associated with missing > or =1 dose over the past two days. Scoring lower on SF-36 mental component summary scale and having greater risk of depression (CES-D) and stress (Perceived Stress Scale) were associated with poorer adherence for both two- and seven-day outcomes. Negative attitudes toward HIV treatment were also associated with lower adherence. Adherence to HIV medications in this population is similar to other groups. Coexisting problems of access to healthcare, higher risk of mental health problems, along with poorer attitudes toward treatment are associated with increased likelihood of missing doses. Comprehensive models of HIV care that include a continuum of medical and social services are essential for treating this population.

Housing need, housing assistance, and connection to HIV medical care.

HIV infection has become a chronic condition that for most persons can be effectively managed with regular monitoring and appropriate medical care. However, many HIV positive persons remain unconnected to medical care or have less optimal patterns of health care utilization than recommended by good clinical practice standards. This paper investigates housing status as a contextual factor affecting access and maintenance in appropriate HIV medical care. Data provided from 5,881 interviews conducted from 1994 to 2006 with a representative sample of 1,661 persons living with HIV/AIDS in New York City demonstrated a strong and consistent relationship between housing need and remaining outside of or marginal to HIV medical care. In contrast, housing assistance increased access and retention in medical care and appropriate treatment. The relationship between housing and medical care outcomes remain controlling for client demographics, health status, insurance coverage, co-occurring mental illness, and problem drug use and the receipt of supportive services to address co-occurring conditions. Findings provide strong evidence that housing needs are a significant barrier to consistent, appropriate HIV medical care, and that receipt of housing assistance has an independent, direct impact on improved medical care outcomes.

Why housing?

Housing/lack of housing and HIV are powerfully linked. Housing occupies an important place in the causal chains linking poverty and inequality, and HIV risk and outcomes of infection. The articles in this Special Supplement of AIDS and Behavior confirm the impact of homelessness, and poor or unstable housing, on HIV/AIDS, and challenge scientists to test and policy makers to implement the promise of housing as an innovative response to the epidemic. In order to influence the development of policies on housing to benefit at-risk or HIV-infected persons, however, proponents must justify why this association exists, and how housing can help end the epidemic as well as improve the care and health of persons living with HIV/AIDS. We introduce this supplement with a discussion of the "why" question.

Cost and threshold analysis of housing as an HIV prevention intervention.

The Housing and Health study examines the effects of permanent supportive housing for homeless and unstably housed persons living with HIV. While promising as an HIV prevention intervention, providing housing may be more expensive to deliver than some other HIV prevention services. Economic evaluation is needed to determine if investment in permanent supportive housing would be cost-saving or cost-effective. Here we ask -- what is the per client cost of delivering the intervention, and how many HIV transmissions have to be averted in order to exceed the threshold needed to claim cost-savings or cost-effectiveness to society? Standard methods of cost and threshold analysis were employed. Payor perspective costs range from $9,256 to $11,651 per client per year; societal perspective costs range from $10,048 to $14,032 per client per year. Considering that averting a new case of HIV saves an estimated $221,365 in treatment costs, the average cost-saving threshold across the three study cities is 0.0555. Expressed another way, if just one out of every 19 Housing & Health intervention clients avoided HIV transmission to an HIV seronegative partner the intervention would be cost-saving. The intervention would be cost-effective if it prevented just one HIV transmission for every 64 clients served.