Research Article: Influence of Jail Incarceration and Homelessness Patterns on Engagement in HIV Care and HIV Viral Suppression among New York City Adults Living with HIV/AIDS

Date Published: November 23, 2015

Publisher: Public Library of Science

Author(s): Sungwoo Lim, Denis Nash, Laura Hollod, Tiffany G. Harris, Mary Clare Lennon, Lorna E. Thorpe, Viviane D. Lima.


Both homelessness and incarceration are associated with housing instability, which in turn can disrupt continuity of HIV medical care. Yet, their impacts have not been systematically assessed among people living with HIV/AIDS (PLWHA).

We studied a retrospective cohort of 1,698 New York City PLWHA with both jail incarceration and homelessness during 2001–05 to evaluate whether frequent transitions between jail incarceration and homelessness were associated with a lower likelihood of continuity of HIV care during a subsequent one-year follow-up period. Using matched jail, single-adult homeless shelter, and HIV registry data, we performed sequence analysis to identify trajectories of these events and assessed their influence on engagement in HIV care and HIV viral suppression via marginal structural modeling.

Sequence analysis identified four trajectories; 72% of the cohort had sporadic experiences of both brief incarceration and homelessness, whereas others experienced more consistent incarceration or homelessness during early or late months. Trajectories were not associated with differential engagement in HIV care during follow-up. However, compared with PLWHA experiencing early bouts of homelessness and later minimal incarceration/homelessness events, we observed a lower prevalence of viral suppression among PLWHA with two other trajectories: those with sporadic, brief occurrences of incarceration/homelessness (0.67, 95% CI = 0.50,0.90) and those with extensive incarceration experiences (0.62, 95% CI = 0.43,0.88).

Housing instability due to frequent jail incarceration and homelessness or extensive incarceration may exert negative influences on viral suppression. Policies and services that support housing stability should be strengthened among incarcerated and sheltered PLWHA to reduce risk of adverse health conditions.

Partial Text

Maintaining continuous engagement in HIV medical care is critical for HIV disease management for people living with HIV/AIDS (PLWHA) [1, 2]. Housing stability is considered to be an important determinant of retention in HIV medical care and for achieving and sustaining viral suppression because it helps enable PLWHA to attend regular medical visits and adhere to antiretroviral medications [3]. Housing stability may also provide other less quantifiable benefits such as stronger social networks and a sense of identity, which some researchers have postulated may motivate individuals to avoid risk behaviors and to maintain health [3]. Empirical evidence to support this relationship has been documented among PLWHA with histories of homelessness. For example, according to longitudinal data from a representative sample of New York City (NYC) PLWHA, self-reported receipt of assistance for housing problems was positively associated with appropriate HIV medical care [4]. Similarly, several studies have reported higher likelihoods of adherence to antiretroviral treatment among stably-housed PLWHA versus their homeless or unstably housed counterparts [5–7]. Along with homelessness, incarceration disrupts individuals’ housing stability and contributes to housing instability after release from incarceration. However, the association between housing stability and HIV care has rarely been described among formerly incarcerated PLWHA; current evidence is mainly concentrated on disrupted HIV care post release [8–10]. Because both events affect housing stability and incarceration is strongly correlated with homelessness, it is important to take into account dynamic aspects of incarceration events along with homelessness to more accurately characterize the impact of housing instability on continuity of HIV care. The purpose of this paper was to examine whether and how different patterns of jail incarceration and homelessness influence continuity of HIV care and HIV viral suppression among NYC PLWHA with recent experiences of both jail incarceration and homelessness, using a measure that captures sequencing and duration of jail incarceration and homelessness. Specifically, the study tested the hypothesis that frequent transitions between jail incarceration and homelessness are associated with lower likelihood of subsequent engagement in HIV care and viral suppression, plausibly due to the greater housing instability of PLWHA with this pattern.

A total of 1,698 individuals living with HIV/AIDS had at least one jail incarceration event in a NYC jail and spent at least one night at a NYC single adult shelter during January 2001–May 2005. Compared with NYC PLWHA who did not experience jail incarceration or homelessness during the study period (N = 84,659), this study population was disproportionately male (84% vs. 69%) and non-Hispanic black (65% vs. 45%), and the percent of non-Hispanic whites (4% vs. 21%) and residents living in medium poverty neighborhoods (14% vs. 29%) was much smaller (Table 1). In contrast, the age distribution and stage of HIV infection were similar between the two groups.

In this study, almost half of NYC adults living with HIV/AIDS who were sheltered and incarcerated from January 2001–May 2005 experienced inadequate engagement in HIV care during the one-year follow-up period. This percentage was similar between the study cohort and non-incarcerated/non-sheltered NYC PLWHA who were diagnosed and alive prior to 2005. Unlike with measures of HIV care engagement, however, overall prevalence of viral suppression was much lower among the study cohort relative to non-incarcerated/non-sheltered NYC PLWHA, suggesting that treatment initiation and/or adherence to treatment might be more difficult among PLWHA with exposure to jail incarceration and homelessness.