San Francisco Homeless Have 27-Fold Greater Risk of Dying Following HIV Diagnosis

Individuals in San Francisco experiencing homelessness at the time of HIV diagnosis are 27 times more likely to die, according to a new study evaluating the impact of potentially intervenable factors on mortality for people living with HIV (PLWH).

Driven by the “Getting to Zero SF” (GTZ-SF) coalition’s goal of reducing preventable deaths among PLWH, investigators with the University of California, San Francisco, and the San Francisco Department of Public Health sought to assess why the age-adjusted mortality rate among PLWH in San Francisco has not decreased since 2013 despite a 44% reduction in new HIV diagnoses. Their findings were published in the journal AIDS.

“The goal of this investigation was to identify factors associated with death among [PLWH] using an incidence-density case-control study, to inform programs designed to meet the GTZ-SF goal of reducing preventable deaths among [PLWH],” the research team wrote. “We hypothesized that substance use, housing status, and mental health would contribute to increased odds of HIV mortality.”

Using data on PLWH pulled from the SF Department of Public Health surveillance registry, investigators randomly selected 50 of 171 decedents for enhanced mortality review and matched them with living controls based on age +/- 3 years and date of diagnosis +/- 6 months. The research team extracted demographic, transmission group, housing status at diagnosis, CD4 counts, and HIV viral load data from the registry, and performed unadjusted and adjusted conditional logistic regression in order to assess risk factors for mortality. In total, data from 156 individuals, 48 decedents, and 108 matched controls were included.

“As clinicians, we know that HIV viral load and CD4 count are important prognostic factors, and we know that housing is also important. However, I was surprised by the extent of the impact of housing status on mortality,” Matthew Spinelli, MD, with the Division of HIV, ID, and Global Medicine at the University of California, San Francisco, and lead author of the study, told Contagion®. “Our findings were a stark reminder that housing status may be as important and perhaps more important than traditional markers of disease control that I follow closely among my patients.”

In the adjusted analysis, factors associated with death among PLWH in San Francisco included: homelessness at diagnosis [adjusted odds ratio (AOR)=27.4; 95% CI=3.0-552.1], injection drug-use in the past year (AOR=10.2; 95% CI=1.7-128.5), tobacco use in the past year (AOR=7.2; 95% CI=1.7-46.9), not using antiretroviral therapy (ART) at any point in the prior year (AOR=6.8; 95% CI=1.1-71.4), and being unpartnered/living alone vs. married/partnered (AOR=4.7; 95% CI=1.3-22.0).

Spinelli further explained what clinicians can take away from the study results.

“Housing is a key vital sign for our patients. I would recommend working closely with social workers and case managers to help your patients access additional services that may be available, including housing,” he said. “Unfortunately, the housing supply is not currently sufficient to meet the need. We need to continue to advocate that policy makers increase the supply of supportive housing in San Francisco and elsewhere and ensure there are protections for those who are at risk of losing their housing, such as legal aid and rental subsidies.”

Carlos del Rio, MD, FIDA, co-director of the Emory Center for AIDS Research and Contagion® Editorial Advisory Board member who was not involved in the study, also weighed in on the significance of the findings.

“Causes of death included an HIV-associated condition in about a third, non-AIDS cancer and overdose in 15% each, and in 10% cardiovascular disease,” he said. “Substance use, mental illness, and housing status were the major contributors to mortality and suggests that mental health care, treatment of drug use, and housing should be considered lifesaving interventions necessary to end the HIV epidemic in the US.”

Future research should focus around exploring innovative care delivery models that integrate substance use treatment, housing support, and case management with medical care, Spinelli said.

“We need to develop new strategies, as well as scale up strategies that we know save lives, such as supportive housing, to prevent deaths among PLWH,” he concluded. “Developing evidence that shows the impact of these strategies will be key for advocating for wider adoption from policy makers. The clinic where I work (Ward 86) has recently developed the Positive-Health Onsite Program for Unstably-Housed Populations (POP-UP), which seeks to provide low-barrier care, incentives, and enhanced outreach to try to improve outcomes for our unstably housed patients.”