Abstract
BackgroundSan Francisco has implemented several programs addressing the needs of two large vulnerable populations: people living with HIV and those who are homeless. Assessment of these programs on health outcomes is paramount for reducing preventable deaths.MethodsIndividuals diagnosed with HIV/AIDS and reported to the San Francisco Department of Public Health HIV surveillance registry, ages 13 years or older, who resided in San Francisco at the time of diagnosis, and who died between January 1, 2002, and December 31, 2016 were included in this longitudinal study. The primary independent variable was housing status, dichotomized as ever homeless since diagnosed with HIV, and the dependent variables were disease-specific causes of death, as noted on the death certificate. The Cochran-Armitage test measured changes in the mortality rates over time and unadjusted and adjusted Poisson regression models measured prevalence ratios (PR) and 95% confidence intervals (CI) for causes of death.ResultsA total of 4158 deceased individuals were included in the analyses: the majority were male (87%), ages 40–59 years old at the time of death (64%), non-Hispanic White (60%), men who have sex with men (54%), had an AIDS diagnosis prior to death (87%), and San Francisco residents at the time of death (63%). Compared to those who were housed, those who were homeless were more likely to be younger at time of death, African American, have a history of injecting drugs, female or transgender, and were living below the poverty level (all p values < 0.0001). Among decedents who were SF residents at the time of death, there were declines in the proportion of deaths due to AIDS-defining conditions (p < 0.05) and increases in accidents, cardiomyopathy, heart disease, ischemic disease, non-AIDS cancers, and drug overdoses (p < 0.05). After adjustment, deaths due to mental disorders (aPR = 1.63, 95% CI 1.24, 2.14) were more likely and deaths due to non-AIDS cancers (aPR = 0.63, 95% CI 0.44, 0.89) were less likely among those experiencing homelessness.ConclusionsAdditional efforts are needed to improve mental health services to homeless people with HIV and prevent mental-health related mortality.
Highlights
San Francisco has implemented several programs addressing the needs of two large vulnerable populations: people living with Human immunodeficiency virus (HIV) and those who are homeless
Given that San Francisco has provided many housing programs and supportive services to reduce the number of people who are unsheltered and that San Francisco was an early adopter of better clinical care programs for people living with HIV, we aimed to identify differences in causes of death between people with HIV who were housed and those who were homeless to help understand the impact of these programs on fatal health outcomes
Study sample characteristics A total of 4158 deceased individuals were included in the analyses: the majority were male (87%), ages 40–59 years old at the time of death (64%), non-Hispanic White (60%), men who have sex with men (MSM) (54%), had an Acquired immunodeficiency syndrome (AIDS) diagnosis prior to death (87%), and San Francisco residents at the time of death (63%; Table 1)
Summary
San Francisco has implemented several programs addressing the needs of two large vulnerable populations: people living with HIV and those who are homeless. Assessment of these programs on health outcomes is paramount for reducing preventable deaths. Adoption of ART has led to a change in the causes of death among PLWH This change is evident in San Francisco where the proportion of deaths among PLWH in which HIV was listed as a cause of death declined from 69.8% in the years 2006–2009 to 59.0% in 2014–2017 [1]. A city-wide point-in-time count in 2017 estimated that 4353 people, regardless of HIV status, were unsheltered in San Francisco and another 2505 individuals were marginally sheltered [2]. Carrying the additional burden of living with HIV puts people living with homelessness in a more vulnerable state
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