Basic subsistence needs and overall health among human immunodeficiency virus-infected homeless and unstably housed women

Abstract

Some gender differences in the progression of human immunodeficiency virus (HIV) infection have been attributed to delayed treatment among women and the social context of poverty. Recent economic difficulties have led to multiple service cuts, highlighting the need to identify factors with the most influence on health in order to prioritize scarce resources. The aim of this study was to empirically rank factors that longitudinally impact the health status of HIV-infected homeless and unstably housed women. Study participants were recruited between 2002 and 2008 from community-based venues in San Francisco, California, and followed over time; marginal structural models and targeted variable importance were used to rank factors by their influence. In adjusted analysis, the factor with the strongest effect on overall mental health was unmet subsistence needs (i.e., food, hygiene, and shelter needs), followed by poor adherence to antiretroviral therapy, not having a close friend, and the use of crack cocaine. Factors with the strongest effects on physical health and gynecologic symptoms followed similar patterns. Within this population, an inability to meet basic subsistence needs has at least as much of an effect on overall health as adherence to antiretroviral therapy, suggesting that advances in HIV medicine will not fully benefit indigent women until their subsistence needs are met.

Figure 1.

Causal diagram for the effect of competing social needs on the health status of human immunodeficiency virus-positive, unstably housed women living in San Francisco, California, 2002–2008. A₀ and A₁ represent measurements of a single exposure variable at 2 consecutive timepoints (t₁ and t₂). L₀ and L₁ denote measured confounders that are associated with both A₀ and A₁ and, therefore, are included in the treatment model. Y₁ and Y₂ represent the health status at 2 consecutive timepoints (t₂ and t₃). It is important to note that marginal structural models account for changes in confounding over time and account for the fact that the outcome can influence the exposure.