Pacific AIDS Network
General Assembly
October 17, 2007
Moving Research into Action:
Housing Status and Health Outcomes for
People Living with HIV in Ontario
Ruthann Tucker
Co-Principal Investigator, PSHP
Expert Advisor CBR Initiatives, OHTN
(Former Executive Director, Fife House)
Sean B. Rourke, Ph.D.
Scientific and Executive Director, OHTN
Associate Professor, University of Toronto
Research Scientist, Centre for Research on Inner City Health
Ontario HIV Treatment
Network (OHTN)
Mission
• To optimize the quality of life of people living with HIV in Ontario and
to promote excellence and innovation in treatment, research,
education and prevention through a collaborative network of
excellence representing consumers, providers, researchers and
other stakeholders.
Goals
• Promote the Ontario HIV Treatment Network (OHTN) as a leader for
stakeholder collaboration and development of policy on issues
related to excellence in health care and the optimal care of people
living with HIV in Ontario.
• Achieve positive change by making effective and timely
recommendations and continuing to build an effective
recommendation process.
• Build an evaluative component to the activities of the Network.
Ontario HIV Treatment
Network (OHTN) 2
Goals Con’t
• Foster and sustain excellence in HIV research and evaluation in
Ontario.
• Integrate information technology and database management of
providers and consumers to facilitate HIV treatment.
• Facilitate the effective utilization of health resources in the treatment
and management of HIV in Ontario.
Values Statement
• Caring, Respect, Compassion and Responsibility
(for and towards people with HIV/AIDS)
• Support and Sustain Excellence and Innovation
(in HIV research, care and treatment)
• Foster Leadership and build Integrity and Accountability
(as an organization)
PSHP Community-Academic
Investigator Team
Principal Investigators
Ruthann Tucker, Expert Advisor, CBR Initiatives, OHTN (Former Executive Director, Fife House)
Dr. Saara Greene, Director Research and Evaluation Fife House, Adjunct Professor York
University, School of Social Work
Dr. Dale Guenter, McMaster University
Co-Investigators
Michael Sobota, Executive Director, AIDS Thunder Bay
Jay Koornstra, Executive Director, Bruce House
Steve Byers, Executive Director, AIDS Niagara
Lea Narciso (On Leave), Ontario AIDS Network
LaVerne Monette, Executive Director, Ontario Aboriginal AIDS Strategy
Dr. Steven Hwang, Centre for Research on Inner City Health (CRICH), University of Toronto
Dr. James Dunn, CRICH, University of Toronto
Dr. Sean B. Rourke, OHTN, University of Toronto, CRICH
Project Coordinator
Dr. Amrita Ahluwalia
Peer Research Assistants
D. Hintzen, J.Watson, Jim Truax, Michael Hamilton, Pius J. White, Marie Kayitesi
Funders
Canadian Institutes of Health Research (CIHR)
- $300,000
Ontario HIV Treatment Network (OHTN) $170,000 + in-kind (office space,
teleconference calls etc)
Ontario Ministry of Health and Long-term Care,
AIDS Bureau - $35,000
Wellesley Institute - $18,750
Ontario AIDS Network (OAN) - $6,600
Total = $530,350 over 3 years
Partners
Community-Based
AIDS Service
Organizations
AIDS Niagara AIDS Thunder Bay Bruce House
Fife House
Universities
Hospitals &
Research
Centres
Clear Unit
Ontario AIDS
Network
McMaster
University
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Ontario Aboriginal
HIV/AIDS Strategy
School of Social Work,
York University
University
of Toronto
Context
• In 2002, at the Ontario AIDS Network (OAN) annual
retreat for Executive Directors of AIDS Service
Organizations participants overwhelmingly identified
“housing issues” as a significant problem for PHAs across
the province.
• OAN receives Canadian Institutes of Health Research
(CIHR) funding for a Research Technical Assistant
• Proposed Strategy to Address HIV/AIDS in Ontario to
2008 identifies “housing as a key unmet need of PHAs”
• Fife House develops new strategic plan, 2003+ , that
identifies community-based research as a priority for the
agency to work on;
Context
• Key literature reviews indicate no information
regarding this issue within the Canadian context.
• Housing Connections, the agency that maintains
the central wait list for social housing in Toronto,
depriorizes HIV from the medical priority list.
• People with HIV must now get a Doctor to check a box
that states the person has less than 2 years to live.
• A small baseline study “Assessing the Housing
Needs of PHAs Now and Into the Future” is
funded by the OHTN.
• The OHTN offers to assist study group to develop
a proposal for submission to the CIHR for a grant
to expand study to a more comprehensive 3 year
study which includes both quantitative and
qualitative methodologies.
Context
• CIHR funds 3 year study – “A prospective study
to explore the impact of housing support and
homelessness on health outcomes of PHAs”
• Positive Spaces. Healthy Places. is created
through the amalgamation of Assessing the
Need and Exploring the Outcomes.
PSHP Study Objectives
1. Establish a baseline of the housing status of
PHAs in Ontario.
2. Identify the range of housing and supportive
housing options currently available to PHAs
in Ontario, including those provided by ASOs,
community-based health and social service
organizations and other housing and/or
homelessness agencies.
3. Identify the characteristics of appropriate
housing and supportive environments for
PHAs applicable at various stages of the
disease course.
PSHP Study Objectives (2)
4. Determine the kind of housing options desired or
required by PHAs that will ensure access to health
care, treatment and social services.
5. Identify the factors that affect the housing status and
stability of PHAs; and to understand how such factors
may impact the physical and mental health of PHAs
and their access and utilization of health care,
treatment and social services.
6. Determine possible variations in the housing and/or
homelessness experiences of PHAs from specific
communities: aboriginal communities, ethnocultural
communities, women, families, sexual identities, youth
and ex-prisoners.
Expected Outcomes
Specific outcomes that this CBR initiative
aims to achieve include:
• The positioning of PHAs in housing situations
that improve access to health care, treatment
and social services.
• Safe and stable housing situations for PHAs in
communities across Ontario.
• The development of effective and appropriate
housing policies and supportive care models
that support PHAs throughout their life course.
Project Overview (1)
600 face-to-face quantitative interviews with
PHAs from across Ontario.
• Participants will complete two face-to-face
interviews across the study period, one at
baseline and one at 12 months; and a short
telephone survey at six months.
• 50 of whom will participate in a qualitative substudy aimed at enhancing our understanding of
the housing experiences of PHAs.
Project Overview (2)
4 Regions across the province:
1. Northern (Algoma, Muskoka, Sudbury, North Bay. Northwestern, Porcupine,
Thunder Bay, Timiskaming); 1 Peer Research Assistant working out of
AIDS Thunder Bay
2. Eastern (Ottawa, Hastings-Prince Edward, Kingston-Frontenac, LeedsGrenville, Renfrew); 1 Peer Research Assistant working out of Bruce
House in Ottawa
3. Central West and South West (Niagara Region, St. Catherine's, Niagaraon-the-Lake, Niagara Falls, Hamilton-Wentworth, Middlesex-London, Halton,
Waterloo, Wellington-Dufferin, Haldimand, Brant, Bruce Grey-Owen Sound, Elgin-St
Thomas, Huron, Kent Chatham, Lambton, Oxford, Perth, Windsor-Essex); 2 Peer
Research Assistants (1 French Speaking) working out of AIDS
Niagara
4. Central East and GTA (Toronto, Durham, Haliburton, Peel, Peterborough,
Simcoe, York Region); 3 Peer Research Assistants working out of Fife
House in Toronto
PSHP Study Demographics
Ontario Sites
Age (in yrs)
Gender
Male / Female /
Transgender
Sexual
Orientation
Greater
Toronto
(n=377)
Eastern
Ontario
(n=94)
Central &
Southwest
(n=94)
Northern
Ontario
(n=40)
(N=605)
43 (8)
43 (8)
45 (8)
46 (8)
43 (8)
(range 21-70)
(range 25-65)
(range 26-70)
(range 20-55)
(range 20-70)
289 / 83 / 5
70 / 23 / 1
70 / 23 / 1
27 / 13 / 0
456 / 142 / 7
36% Gay**
10% Bisexual
53% Heterosex
51% Gay
09% Bisexual
36% Heterosex
23% Gay**
08% Bisexual
68% Heterosex
62% Gay
08% Bisexual
29% Heterosex
Total
54% Gay
08% Bisexual
36% Heterosex
*Member of
Aboriginal Grp
11%
(28 / 10 / 0)
21%
(10 / 7/ 3)
7%
(2 / 4 / 0)
31%***
(10 / 2 / 0)
13%
(N=80)
Speak English
at Home
92%
92%
96%
98%
93%
Education
Less than HS: 18%
Finished HS: 21%
Some College: 22%
College degree: 32%
* First Nations / Mètis / Inuit; *** p < 0.001
Less than HS: 36%
Finished HS: 19%
Some College: 21%
College degree: 21%
Less than HS: 20%
Finished HS: 25%
Some College: 25%
College degree: 29%
Less than HS: 45%**
Finished HS: 23%
Some College: 18%
College degree: 10%
Less than HS: 22%
Finished HS: 22%
Some College: 23%
College degree: 28%
Income, Expenses and Housing Risk
Ontario Sites
Greater
Toronto
(n=377)
Eastern
Ontario
(n=94)
Central &
Southwest
(n=94)
Northern
Ontario
(n=40)
(N=605)
$ 1,559
$ 1,300
$ 1,535
$ 1,202
$ 1,489
(0 - 17,500)*
(300 - 4,000)
(100 - 9,000)
(350 - 3,800)
(0 - 17,500)**
$ 462
$ 483
$ 503
$ 479
$ 473
Live in RGI Unit
48%
43%
39%
11%***
43%
Currently working
for pay
21%
15%
23%
15%
20%
Face difficulty
buying food
56%
65%
55%
55%
57%
Face difficulty
buying clothes
51%
57%
55%
65%
54%
Housing at risk^
(mo. rent/income)
29%
40%
33%
23%
31%
Gross monthly
income (median)
Monthly amount
for rent /mortgage
Total
* 72% had income < $ 1,500/month; 90% had income < $ 2,500/month; income > $ 5,000/month (n=10); **75 % had income < $ 1,500/month
*** p < 0.01;
^ excluding those with RGI unit
Medical Status and Substance Use
Ontario Sites
Greater
Toronto
(n=374)
Eastern
Ontario
(n=94)
Central &
Southwest
(n=94)
Northern
Ontario
(n=40)
(N=605)
Time HIV+ (yrs)
% since 2000
11 (6)
11 (6)
13 (6)
10 (6)
11 (6)
Length on
ARVs (in yrs)
7 (5)
8 (6)
9 (6)
8 (5)
8 (5)
186 (173)*
253 (297)
234 (222)
290 (282)
209 (282)
History of AIDS
defining Dx
49%
49%
48%
58%
49%
AUDIT score /
% harmful use
6.6 (6.9)
29%
9.7 (8.5)*
42%
4.3 (4.8)
17%
5.4 (4.6)
24%
6.6 (6.9)
29%
DAST-20 score
7.3 (4.7)
9.9 (5.1)*
7.3 (4.7)
9.7 (5.6)*
8.0 (5.0)
22%
54%*
32%
70%*
32%
NADIR CD4
Ever been in
jail or prison
* p < 0.01
Total
PSHP Study Demographics
Housing Groups
Age (in yrs)
Gender (% Male)
Sexual
Orientation
Housed with
Support
Services (n=87)
Housed without
Support Services
(n=484)
Unstable
Housing (n=34)
P Value
45 (8)
43 (8)
39 (8)*
0.001
76%
76%
53%*
0.02
70% Gay/Bisexual
30% Heterosexual
64% Gay/Bisexual
36% Heterosexual
30% Gay/Bisexual
65% Heterosexual*
0.001
Member of
Aboriginal Group
21%
12%
18%
0.054
% with AIDS Dx
60%
48%
38%
0.18
Gross Monthly
Income
$ 1,309
$ 1,542
$ 957
0.08
AUDIT score
6.4 (5.3)
6.3 (6.7)
11.3 (9.3)*
0.003
DAST-20 score
9.5 (5.3)
7.5 (4.7)
12.3 (5.2)*
0.001
37%
30%
41%
0.06
Ever been in jail or
in prison
Note: Means and (standard deviation) or % as noted; * Significant p < 0.05
Housing Status for Participants Across Ontario
Housing Status for People with HIV by Ontario Region
Location of support services: Hamilton = 29%; Ottawa = 15%; Toronto = 15%;
GTA = 16%; All others < 10%
350
300
52
250
200
150
100
13
5
50
10
4
1
1
1
0
Toronto
(n=342)
Ottawa
& Area
(n=88)
Southwest Hamilton GTA (n=25) Thunder North Bay Kingston
region
& Niagara
Bay & Area
& Area
& Area
(n=57)
(n=35)
(n=23)
(n=18)
(n=17)
Housed with support services (n=87; 14% of sample)
Housed without support services (n=484; 80% of sample)
Those with unstable housing (n=34; 6% of sample)
P = 0.05 (marginal differences in proportions across geographical areas)
Geographical Differences in RGI
60
Overall 43% of sample receiving RGI
% Receiving Rent Geared to Income (RGI)
53
50
45
44
40
32
30
20
14
11
10
10
8
0
Toronto
Hamilton &
Niagara
Ottawa &
Area
Southwest Kingston & North Bay
Thunder
region
Area
& Area
Bay & Area
P < 0.001 (Significant differences across regions)
GTA
290 People Face Anxiety Regarding Living Situation
% Endorsing worry about being forced to move out
Overall: 52% of sample worry about being forced to move out
60
53
50
40
51
50
36
34
32
32
30
22
20
10
0
North Bay Hamilton & Kingston & Southwest
& Area
Niagara Area (n=8)*
(n=20)*
(n=9)*
(n=18)*
Toronto
(n=102)*
Ottawa &
Area
(n=27)*
GTA (n=8)*
P = 0.48 (similar proportions across regions); * Number in each area
Thunder
Bay & Area
(n=5)*
120 People Housed at Risk of Losing Homes and Where
“Housing Risk”: Defined as spending > 50% of income per month on rent
% Housed at significant risk of losing their home
45
40
35
Overall 21% in sample at risk of losing their home
39
36
35
28
30
24
25
20
17
16
13
15
10
5
0
North Bay GTA (n=9)* Kingston &
& Area
Area (n=6)*
(n=7)*
Ottawa &
Area
(n=24)*
Hamilton &
Niagara
(n=8)*
Toronto
(n=54)*
Southwest Thunder
region
Bay & Area
(n=9)*
(n=3)*
P < 0.05 (significant differences across areas); * Number of People at Risk
Considering your income, how difficult is it to
meet monthly housing costs: HRQOL Impact
0.6
42% of sample find it difficult to meet housing costs
0.4
0.2
0
-0.2
-0.4
-0.6
Not all
difficult
(n=167)
A little
difficult
(n=160)
Fairly
difficult
(n=108)
Very
difficult
(n=128)
Overall Mental Health (p < 0.005)
Overall Physical Health (p < 0.005)
132 People Housed Moved Once or More in Past Year
Number of People Who Moved in Past Year
Overall 23% of sample housed in Ontario moved in past year
60
50
40
30
12
17
20
10
11
11
20
12
0
Toronto
(n=49)*
Ottawa &
Area
(n=34)*
4
6
5
3
4
5
0
2
5
1
3
2
1
0
5
0
3
Southwest Thunder Kingston & North Bay Hamilton & GTA (n=3)*
region
Bay & Area Area (n=7)*
& Area
Niagara
(n=15)*
(n=12)*
(n=6)*
(n=6)*
Moved 3 or more times in past year (24%)
Moved 2 times in past year (33%)
Moved 1 time in past year (43%)
P ns (similar proportions across geographical areas); * Number moved in each area
Impact of moving since HIV diagnosis on
health-related quality of life
0.6
47% reduction in
overall physical health
0.4
0.2
0
-0.2
-0.4
-0.6
Moved once or
less (n=123)
Overall Mental Health
Moved 2-5 times Moved 6 or more
(n=266)
times (n=169)
Overall Physical Health (p < 0.001)
Number of times moved in past year:
Impact on health-related quality of life
0.6
0.4
Reductions in HRQOL with moving
MH
40 %
PH
36 %
59 %
54 %
0.2
0
-0.2
-0.4
-0.6
Move once
(n=57)
Moved 2 times
(n=41)
Moved 3 times
or more (n=32)
Overall Mental Health - MH (p < 0.05)
Overall Physical Health - PH (p < 0.05)
Prevalence of depression across regions
% Experiencing significant depression / distress
Overall 54% of sample depressed (290 individuals affected)
80
70
60
67
64
61
60
59
56
50
50
42
40
30
20
10
0
Kingston & Thunder
North Bay Southwest
Area
Bay & Area
& Area
(n=31)*
(n=10)*
(n=14)*
(n=11)*
Ottawa &
Area
(n=59)*
Hamilton &
Niagara
(n=19)*
Toronto
(n=148)*
P = 0.42 (similar proportions across regions); * Number in each area
GTA
(n=10)*
Prevalence of substance use by region
Overall Harmful Use of Drugs (27%) and Alcohol (19%)
% Experiencing harmful drug or alcohol use
50
47
45
42
40
35
32
33
32
29
30
25
22
20
16
18
22 21
20
20
16
15
10
6
6
5
0
Thunder
Bay & Area
Ottawa &
Area
North Bay Southwest Kingston & Hamilton &
& Area
Area
Niagara
Harmful drug use (n=162; p = 0.41)
Toronto
GTA
Harmful alcohol use (n=125; p < 0.05)
Satisfaction with Access to Health/Social Agencies
110 people in study (20%) are dissatisfied with access to services
45
42
38
% Experiencing dissatisfaction
40
36
35
29
30
23
25
23
21
20
14
15
10
5
0
GTA
(n=10)*
Kingston & Thunder
North Bay Hamilton & Southwest
Area (n=6)* Bay & Area
& Area
Niagara
(n=12)*
(n=8)*
(n=5)*
(n=8)*
Ottawa
(n=18)*
P = 0.01 (significant differences in access across province); * Number in each area
Toronto
(n=43)*
% of People with HIV who did not access Family MD services
100 People with HIV Did Not Access MD in Past 3 Months
Overall 17% of sample in Ontario did not access Family MD
45
40
39
35
30
25
30
25
23
20
20
17
15
12
12
10
5
0
Thunder Southwest Kingston & Hamilton &
Bay & Area
region
Area (n=4)* Niagara
(n=9)*
(n=17)*
(n=8)*
Ottawa &
Area
(n=17)*
North Bay GTA (n=3)*
& Area
(n=3)*
P < 0.005 (significant differences across areas); * Number of People at Risk
Toronto
(n=39)*
Key Findings and Main Messages
Housing Elements and Supports:
• Only 15% of sample with housing had support services, which when
available, are generally accessible only in GTA, Ottawa and Hamilton
• Rent geared to income available to only 43% of those sampled;
lowest rates in northern regions, Kingston and the GTA
• 42% of sample have significant difficulty meeting monthly housingrelated costs and these individuals have significantly lower healthrelated quality of life relative to those who can make ends meet
Housing Vulnerability and Risk
• 21% of sample are at significant financial risk for losing their housing;
these rates vary significantly across the province with those in North
Bay, Kingston, GTA and Ottawa regions being at the highest risk
• 52% of sample face significant anxiety and worry about being forced
out of their homes and this is seen at similar rates across province
• 35% of sample experienced discrimination when trying to get housing
• 1 out of 4 people with HIV do not feel that they belong in their
neighbourhood; only 20% feel that their home provides a good place
for them to live
Key Findings and Main Messages
Housing Instability:
• Overall 23% of sample moved in the past year; 57% moved twice or
more
• Moving since HIV diagnosis has dramatic effect on physical healthrelated quality of life
• Moving in past year has significant effect (and stepwise increases
with more moves) on both physical and mental health-related quality
of life; both effects are likely pronounced because of symptomatic HIV
disease of sample
Social Determinants of Health Putting People with HIV More at Risk
• 75% of sample report income less than $ 1,500 per month
• Overall 54% of sample exceeds screening threshold for depression
• Harmful drug and alcohol use is seen in 27% and 19% of sample
• Over 20% of sample is dissastisfed with access to health and social
services (highest rate seen northern, GTA and Kingston areas)
• There are significant differences in the rate of persons in study who
accessed a family MD in the past 3 months (e.g., 3-4 out of 10 in
Thunder Bay and in the Southwest regions did not access an MD)
Factors Associated with Housing Risk
At 6 Months: “What has happened that put your housing at risk”
30
27
25
25
20
% Reporting
20
15
12
10
10
6
5
0
Financial
Issues
External
Factors (often
interpersonal)
Mental Health
and Addiction
Issues
Housing
Conditions
Interpersonal
Issues
Health
Concerns
Housing Risk by Geography
“Has anything happened that has put your housing at risk”
100
80
%
60
40
20
0
North Bay
& Area
(n=18)
Toronto
(n=342)
Hamilton GTA (n=25) Southwest
& Niagara
region
(n=35)
(n=57)
No
P < 0.001
Lost
Yes
Ottawa
& Area
(n=88)
Kingston
& Area
(n=17)
Thunder
Bay & Area
(n=23)
Housing Risk at 6-months by Ethnoracial Status
“Has anything happened that has put your housing at risk”
100
95
92
93
90
85
83
%
80
75
69
70
65
60
55
50
Caucasian (n=399)
P < 0.01
Aboriginal (n=70)
From Africa or
Carribean (n=64)
Asian / Pacific Island
(n=14)
Impact of Mental Health and Addiction at Baseline
At 6 Months: “Has anything happened that has put your housing at risk”
40
35
30
%
25
23
23
1 condition (Depression or
Substance Use) n=50
2 or more Conditions (n=30)
20
15
10
8
5
0
No Depression / Substance Use
(n=16)
P < 0.001
Changes in Health from Baseline to 6-Month Follow-up
Participants rated their physical / emotional condition at 6 mos compared to baseline
% Reporting change compared to 6 months ago
100
90
14
27
29
80
70
32
18
60
28
50
40
30
54
55
43
20
10
0
Housed with support services
(n=81)
Housed without support
services (n=443)
About the same
P = 0.04
Better
Those with unstable housing
(n=22)
Worse
Changes in Health Over 6 Months by Geography
Participants rated their physical / emotional condition at 6 mos compared to baseline
% Reporting change compared to 6 months ago
100
90
21
32
80
70
34
37
28
60
22
50
24
37
40
30
51
20
46
39
29
10
0
GTA
P = 0.003
Eastern Ontario
Central/ Southwest
About the same
Better
Worse
Northern Ontario
Relationship of Housing Risk to Overall Health
80
22% Reported that Their Housing is at Risk
70
% Reporting
60
50
40
30
20
10
0
Excellent / Very
Good / Good
Fair
Housing not at risk (n=450)
P < 0.0001
Poor
Housing is at risk (n=95)
6-Month Key Findings and Main Messages
Links Between Housing Risk and Health:
• Increased housing risk is affected by key social determinants of health (ie,
particularly income, housing conditions and proximal environmental factors,
mental health and addiction issues)
• People living with HIV from Aboriginal communities are the most vulnerable
and have highest level of housing risk
• People with HIV who also have depression or substance use issues at study
enrollment are 2-3 times more likely to be reporting that there housing is at
risk at 6 months
• Changes in health over the first 6 months of the study are related to
geography (where you live - people living in Thunder Bay, Kingston and
Ottawa at highest risk) and housing situation (1 out of 6 with housing and
support services had a worsening in their health compared to about 30% in
those housed without support services or those with unstable housing)
• People living with HIV who in a situation where their housing at risk have
significantly lower ratings of overall health
Contact Information
• Positive Spaces. Healthy Places.
www.healthyhousing.ca
• Ruthann Tucker
ruthann.tucker@shaw.ca
• Sean Rourke, OHTN
ed@ohtn.ca