Unmet basic subsistence needs is the most important factor affecting health of poor HIV-positive men

An inability to provide for the most basic needs of life is the biggest predictor of poor physical and mental health for homeless and marginally housed HIV-positive men, according to a study conducted in San Francisco and published in the open-access journal PLoS One.

“While ART [antiretroviral therapy] adherence and viral load were among the most important predictors of overall health, unmet subsistence needs and social support had even larger influences,” comment the investigators. “Results presented here suggest that addressing subsistence needs first (i.e., ensuring access to housing, food, clothing and hygiene needs) will have the most impact on the health of HIV-positive unstably housed persons.”

It is well known that social, economic and behavioural factors affect the health of HIV-positive people. For instance, a study conducted by investigators in San Francisco showed that unmet subsistence needs were the single biggest factor affecting the health of homeless and marginally housed HIV-positive women. With the findings of this research in mind, the same team of investigators wished to see which factors had the biggest impact on the physical and mental health of HIV-positive men in the city who were either homeless or had unstable housing.

The longitudinal study lasted between 2000 and 2008. The population comprised 288 homeless and marginally housed HIV-positive men who were followed on a quarterly basis. Their CD4 cell count and viral load were monitored every three months and they completed a questionnaire to assess factors that might influence physical and mental health.

These factors included socioeconomic variables, including homelessness, unmet subsistence needs (difficulties obtaining housing, clothing, food or meeting basic hygiene needs); social support; drug and alcohol use; CD4 cell count and viral load; and the use of HIV therapy if eligible (a CD4 cell count below 350 cells/mm³). The patients’ physical and mental health were scored by the investigators on a scale from 0 to 100.

Almost of a quarter of patients (23%) were users of crack cocaine, 40% were white, and their median age at baseline was 41 years.

Median CD4 cell count on entry to the study was 349 cells/mm³ and median viral load was 7200 copies/ml. Only 18% of patients with a CD4 cell count below 350 cells/mm³ were taking antiretroviral therapy. Overall, the median score for physical health, rated according to answers to standardised questionnaires on physical functioning and mental health, was 43 out of 100.

After adjusting for potential confounders, the three factors with the biggest impact on physical health were unmet subsistence needs (-4.33 physical health score), white race (-3.71) and no source of social support (-1.56). The fourth most important factor was a higher viral load.

There was a high prevalence of mental health problems in the cohort. Over a third of patients (35%) had a history of major depression, 22% had experienced manic problems, and 16% had post-traumatic stress disorder. The overall median mental health score was 46.

Unmet subsistence needs were identified as the most important factor leading to poorer mental health. Overall mental health scores were 3.5% lower for men reporting unmet subsistence needs than for those who did not. Scores were an average of 3% lower for drug users than non-drug users, 2% lower for individuals who did have a source of social support, and 1.7% lower for individuals with poor adherence to HIV therapy.

“Results presented here expand implications from a recent CDC report showing that poverty is the single most important demographic factor associated with HIV infection among inner-city heterosexuals living in the United States,” write the authors. “Taken together, these observations indicate that unmet subsistence needs are having critical influences on the health of impoverished persons both with and at risk for HIV/AIDS.”

They conclude: “Advances in HIV medicine will not be fully realised by unstably housed persons until opportunity and choice limited by social and structural barriers are overcome.”