Effect of supportive housing on CD4-cell count among homeless adults in supportive housing

INTRO: The San Francisco Department of Public Health funds 1710 permanent supportive units in 43 buildings. Our permanent supportive housing consists of on-site case management & property management, and on-site nursing care in 10 of these buildings, which all target chronically homeless adults. While homelessness alone results in higher rates of mortality and morbidity, the combination of HIV infection and homelessness further increases mortality. In previous studies, we have shown that homeless people with AIDS have an 80% higher mortality rate than housed people with AIDS and have also shown that this disparity is eliminated by moving homeless people into supportive housing.  In this study, we report on the impact of housing on CD4-cell counts among homeless people with HIV who have moved into supportive housing. 

METHODS: We used a nest case-cohort design to examine CD4-cell results for HIV positive adults who were placed in housing between 2007-2013. Triple-diagnosis was defined as an HIV diagnosis and co-occurring axis-1 mental health diagnosis and substance abuse or dependence.  All those in the study received their diagnosis of HIV/AIDS before the DAH housing referral was made. 

RESULTS: 15.4% of the individuals housed had HIV (n=243). 64% of HIV+ individuals had mental-health diagnoses; 74% had a substance abuse disorder and 49% had triple diagnoses.  The average CD4 cell count one year before housing was 340 (SD: 234); after six months in housing the CD4 count was 371 (SD: 231), after twelve months it was 407 (SD: 209).  Among triply diagnosed individuals placed in units with on-site nursing the mean CD4-cell count increased 53%. 

DISCUSSION/CONCLUSION:   It’s critical to acknowledge the difficulties that HIV-positive homeless patients with co-occurring illnesses face in getting and retaining care. Supportive housing should be prioritized towards homeless people with HIV to improve mortality and immune functioning.  Placing triply diagnosed individuals in buildings with on-site nursing has a significant impact on CD4-cell count, presumably through improved adherence to anti-retroviral medication.