The Impact of Housing and HIV Treatment on Health-Related Quality of Life Among People With HIV Experiencing Homelessness or Unstable Housing

摘要

Objectives. To determine the impact of improvements in housing and HIV clinical parameters on health-related quality of life (HRQOL) in persons with HIV infection experiencing homelessness. Methods. This prospective cohort study took place in 9 US sites. Local efforts sought to improve HIV and housing status. Longitudinal data analyses determined the impact of changes in housing status, HIV suppression, and CD4 cell counts on HRQOL at 12 months, measured as mental and physical component summary scores. Results. Among 909 participants enrolled from 2013 to 2016, 75.1% were homeless, 51.6% did not have HIV suppression, and 23.6% had a CD4 count less than 200 cells per cubic millimeter. Median mental and physical component summary scores were 35.4 and 38.9, respectively. These 5 parameters all improved by 6 months. In multivariate modeling, maintaining or achieving stable housing predicted higher PCS at 12 months, but CD4 count and HIV suppression improvements did not. Improvements in housing, CD4 count, and HIV suppression did not predict mental component score at 12 months. Conclusions. Housing and HIV treatment are necessary but not sufficient to improve HRQOL in this challenging population. The high prevalence of socioeconomic and mental health needs we found support the call for patient-centered comprehensive care. The National HIV/AIDS Strategy seeks to end the HIV epidemic and reduce health disparities by improving treatment of HIV in vulnerable populations. It also seeks to promote the provision of “comprehensive, coordinated patient-centered care for people living with HIV, including addressing HIV-related co-occurring conditions and challenges in meeting basic needs, such as housing.” 1 Health-related quality of life (HRQOL) is a validated measure of well-being and function, typically divided into physical component summary (PCS) and mental component summary (MCS) scores. 2 Interventions to address the many comorbidities and unmet housing needs of people with HIV experiencing homelessness could improve HRQOL. For example, in persons with serious mental illness, improving adherence to antiretroviral therapy (ART) and to medications to treat psychiatric conditions led to improved quality of life. 3 However, providing immediate housing to people with HIV experiencing homelessness did not improve HRQOL more than providing standard housing assistance in a randomized trial; nor did it improve clinical indicators of health. Even in an “as-treated” analysis of the study, MCS but not PCS improved with housing. 4 In a population without HIV infection, immediate supportive housing versus a wait-list control also did not improve most study outcomes, including HRQOL. 5 In both of these studies, the ability to detect differences was limited by improved housing status in participants in the control arms. Nonetheless, the impact of housing on HRQOL in persons with HIV experiencing homelessness is not clear. Effective ART reduces HIV morbidity and mortality by suppressing HIV replication as measured by viral load. The relationships among HIV, its treatment, and HRQOL are not completely understood. Participants in the landmark Strategic Timing of Antiretroviral Treatment (START) trial, which only included persons with high CD4 cell counts not yet on ART, reported HRQOL that was not lower than population averages, and immediate ART improved HRQOL compared with deferred ART. 6 However, in studies of persons with a broader range of HIV disease status, lower HRQOL than population averages have been found even in persons with HIV suppression, which may at least partly be attributable to comorbid conditions. 7,8 The available data suggest that, although ART consistently leads to improved HRQOL, it is not enough to normalize HRQOL, especially in persons with advanced HIV disease and other comorbidities. We conducted a large, multisite study of persons with HIV who were experiencing homelessness or unstable housing. All participants were provided assistance in achieving housing, as well as navigation services to support care for HIV and to address other unmet medical and subsistence needs. We measured HRQOL at baseline, 6 months, and 12 months, along with housing status and indicators of HIV disease and treatment, including ART use, viral load, and CD4 cell count. We sought to understand how HRQOL changes over time in this cohort, especially how changes in HIV disease status and housing impact HRQOL.