Homeless
people with HIV who are provided with rapid rehousing and intensive,
tailored case management are placed in stable housing more quickly and are
twice as likely to be virally suppressed when compared to
individuals receiving standard homelessness support, according to research
conducted in New York City and published in AIDS and Behavior.

The rapid
rehousing intervention involved intensive case management and support to
overcome potential obstacles to stable housing and viral suppression, such as
mental health problems and substance abuse. Support was temporary, lasting
12 months.

“Results from this
trial suggest that how a rapid re-housing program is implemented can
potentially impact housing and health outcomes among homeless populations,”
comment the authors. “The overall importance of placing participants as quickly
as possible in housing was captured in this study.”

Homelessness is a
widespread problem in the US, especially for people with HIV. Lack of stable,
secure or adequate housing has been associated with poorer HIV-related, overall
health and social outcomes.

Housing in New York City (NYC) is
among the most expensive in the US, and people with HIV often face multiple
barriers to finding affordable, secure and appropriate housing, such as stigma,
mental and physical health problems, substance abuse, a history of imprisonment
and institutional racism.

A team of
investigators therefore wanted to see if a rapid rehousing initiative involving
short-term intensive case management had a positive impact on both housing
outcomes and viral suppression.

They designed a
study involving 236 homeless adults living with HIV in NYC. Recruited from HIV
homelessness shelters across the city between 2012 and 2013, participants were
randomised to receive the rapid rehousing or standard homelessness support.

Individuals in the
rapid rehousing group were immediately assigned a case manager. The case
manager worked to quickly identify affordable and appropriate housing,
travelled with participants to housing appointments and viewings, ensured that
individuals received assistance with moving and rent, and delivered intensive
housing stabilisation services (for example substance abuse, mental illness,
financial management) for up to a year post enrolment.

Individuals in the
standard-of-care group received referral to an organisation engaged by NYC
authorities to find housing for individuals with HIV. Housing stabilisation
services were provided as needed and usually ended within three months of
enrolment. Individuals assigned to the
standard-of-care arm had to travel to housing programme offices to access
services.

Participants were
followed for 12 months post-enrolment. Outcomes were speed and rate of
placement in stable housing and the rate of viral load suppression, data which
were accessed through registries.

Ten people died
during the study and one individual could not be matched to HIV registry
databases, leaving a final study population of 225 people.

The majority were
male, black or Hispanic, aged 40 years and older, medically unfit for work, and
in chronic housing need. Over three-quarters had a history of incarceration,
over half had a mental health diagnosis and over 80% reported substance abuse
in the year prior to enrolment. Almost all were enrolled in HIV care, but just
40% were virally suppressed and the majority had a CD4 cell count below 350
cells/mm3.

Individuals
assigned to the rapid rehousing initiate were significantly more likely to have
been placed in stable housing within 12 months compared to those who
received the standard of care (45% vs 32%, p = 0.02). It took 150 days to
place a quarter of people in the rapid rehousing group into stable housing.
It took almost 100 days longer (243) to achieve the same outcome for a quarter of
individuals in the standard-of-care group.

Provision of rapid rehousing support was associated with an 80% higher rate of
housing placement (aHR = 1.8; 95% CI, 1.1-2.8).

As regards
HIV-related outcomes, 97% of people in both study groups were in HIV care at
the 12-month follow-up point.

A significant
improvement in the proportion of people with viral suppression was observed
among those assigned to rapid rehousing, from 28% at baseline to 47% at the
end of follow-up (p 0.01). The rate of viral suppression in the standard-of-care group increased modestly from 52% to 57%. (One limitation of the study is that the two study groups were unbalanced in their baseline viral suppression, despite randomisation.)

The rate of
improvement in viral suppression was twice as high in the rapid rehousing group
(aOR = 2.1; 95% CI, 1.1-4.1).

The authors
conclude that their study showed that, compared with usual housing services for
people with HIV, immediate case management lasting up to a year is associated
with higher rates of housing placement and a greater rate of improvement in
viral suppression.