Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review
Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review
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DOI：
10.2105/ajph.2015.302905
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发表时间：
2016-01-01
影响因子：
12.7
通讯作者：
Rourke, Sean B.
中科院分区：
文献类型：
--
作者：
Aidala, Angela A.;Wilson, Michael G.;Rourke, Sean B.
背景越来越多的证据表明，应对艾滋病毒的措施应将联合收割机个人层面的干预措施与处理影响感染风险和健康结果的结构性或背景因素的干预措施相结合。住房就是这样一个因素。住房作为一个中间结构因素占据着战略地位，它将“上游”经济、社会和文化决定因素与日常生活所处的更直接的物质和社会环境联系起来。住房状况对艾滋病毒预防和护理的重要性已得到承认，但这种关注主要集中在作为特殊风险群体的无家可归者身上。分析很少将社区住房的可得性和条件作为影响人口健康的因素，或将不稳定、不适当或负担不起的住房作为一种情况或临时状态。关注与字面无家可归相关的个人层面特征掩盖了社会，经济和政策驱动因素在很大程度上超出了任何特定个人的控制范围，影响住房和居住环境以及此类环境提供的健康资源或风险暴露。我们研究了现有的经验证据之间的关联住房状况（广义），医疗保健，艾滋病毒感染者的健康结果和分析结果，为未来的研究，项目开发和政策实施提供信息。我们检索了1996年1月1日至2014年3月31日期间的8个电子健康和社会科学数据库，使用与住房、居住和生活安排以及艾滋病毒和艾滋病相关的检索词。我们联系了专家获取更多的文献。选择标准。我们选择的文章，如果它们是以英语，法语或西班牙语发表的定量分析，其中包括至少1个住房状况作为自变量，以及至少1个高收入国家艾滋病毒感染者的健康状况，医疗保健，治疗依从性或风险行为结果。我们将住房状况定义为包括考虑住房充足性、稳定性和保有权保障的物质或社会层面。两名独立的审查员进行数据提取和质量评价。我们使用科克伦偏倚风险工具进行随机对照试验，使用改良版的纽卡斯尔渥太华质量评估工具进行非干预性研究。在我们的质量评估中，我们关注观察性研究的质量问题：确定暴露和测量结果的适当方法以及控制混淆的方法。研究共获得5528篇参考文献，其中包括152项研究，代表139757名HIV阳性参与者。大多数研究在美国和加拿大进行。研究审查了艾滋病毒医疗保健的获得和利用、抗逆转录病毒药物的坚持、艾滋病毒临床结果、其他健康结果、急诊室和住院病人的利用以及性和药物风险行为。在所有领域的研究中，除了极少数例外，更差的住房状况与更差的结局独立相关，控制了一系列个体患者和护理系统特征。缺乏稳定、安全、适足的住房是持续和适当的艾滋病毒医疗护理、获得和坚持抗逆转录病毒药物、持续抑制病毒以及存在向前传播风险的一个重大障碍。在结果评估前几年检查无家可归或有问题的住房历史的研究最不可能发现负面结果，无家可归是一个潜在的可改变的背景因素。随机对照试验和观察性研究表明，住房援助对改善以前无家可归或住房不足的艾滋病毒感染者的结果具有独立影响。住房挑战是个人脆弱性与更广泛的经济、政治和法律的结构性健康决定因素之间复杂的相互作用的结果。维持社会排斥和不平等的广泛结构性进程似乎超出了艾滋病毒干预措施的直接范围，但改变住房和居住环境是可能的，也是有希望的。
Background. Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.Objectives. We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.Search methods. We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.Selection criteria. We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.Data collection and analysis. Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.Results. Searches yielded 5528 references from which we included 152 studies, representing 139 757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.Conclusions. Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.