title: The population impact of eliminating homelessness on HIV viral suppression among people who use drugs.
abstract: OBJECTIVE
  We sought to estimate the change in viral suppression prevalence if homelessness were eliminated from a population of HIV-infected people who use drugs.
  
  
  METHODS
  Community-recruited prospective cohort of HIV-infected people who use drugs in Vancouver, Canada. Behavioural information was collected at baseline and linked to a province-wide HIV/AIDS treatment database. The primary outcome was viral suppression (<50 copies/ml) measured during subsequent routine clinical care.
  
  
  METHODS
  We employed an imputation-based marginal modelling approach. First, we used modified Poisson regression to estimate the relationship between homelessness and viral suppression (adjusting for sociodemographics, substance use, addiction treatment, and other confounders). Then, we imputed an outcome probability for each individual while manipulating the exposure (homelessness). Population viral suppression prevalence under realized and 'housed' scenarios were obtained by averaging these probabilities across the study population. Bootstrapping was conducted to calculate 95% confidence limits.
  
  
  RESULTS
  Of 706 individuals interviewed between January 2005 and December 2013, the majority were men (66.0%), of white race/ethnicity (55.1%), and had a history of injection drug use (93.6%). At first study visit, 223 (31.6%) reported recent homelessness, and 37.8% were subsequently identified as virally suppressed. Adjusted marginal models estimated a 15.1% relative increase [95% confidence interval (CI) 9.0-21.7%) in viral suppression in the entire population - to 43.5% (95% CI 39.4-48.2%) - if all homeless individuals were housed. Among those homeless, eliminating this exposure would increase viral suppression from 22.0 to 40.1% (95% CI 35.1-46.1%), an 82.3% relative increase.
  
  
  CONCLUSIONS
  Interventions to house homeless, HIV-positive individuals who use drugs could significantly increase population viral suppression. Such interventions should be implemented as a part of renewed HIV/AIDS prevention and treatment efforts.
authors.affiliation: aDepartment of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA bUrban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver cFaculty of Health Sciences, Simon Fraser University, Burnaby dDepartment of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Brandon D L
authors.initials: BD
authors.lastname: Marshall
authors.forename: Beth
authors.initials: B
authors.lastname: Elston
authors.forename: Sabina
authors.initials: S
authors.lastname: Dobrer
authors.forename: Surita
authors.initials: S
authors.lastname: Parashar
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hogg
authors.forename: Julio S G
authors.initials: JS
authors.lastname: Montaner
authors.forename: Thomas
authors.initials: T
authors.lastname: Kerr
authors.forename: Evan
authors.initials: E
authors.lastname: Wood
authors.forename: M-J
authors.initials: MJ
authors.lastname: Milloy
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D002170:Canada; D055030:Drug Users; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011446:Prospective Studies; D015819:Substance Abuse, Intravenous / Q000150:complications* / Q000523:psychology*; D016896:Treatment Outcome; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents