BACKGROUND
Homelessness and housing instability, which are on the rise nationally, are considered
important social determinants of health. Among nonpregnant adults living with HIV,
both have been associated with decreased linkage to medical care and virologic nonsuppression.
This association may be particularly concerning in pregnancy, because virologic control
is the primary determinant of HIV perinatal transmission. In addition, housing instability
in pregnancy may be an independent risk factor for adverse perinatal outcomes, further
amplifying perinatal risks in pregnant individuals living with HIV. However, the role
of housing as a social determinant of health among such individuals is largely unstudied.
OBJECTIVE
The objective was to examine the association between housing instability and virologic
control among pregnant individuals living with HIV.
STUDY DESIGN
This was a retrospective cohort study of pregnant individuals seeking perinatal care
in a specialty HIV clinic from 2007 to 2018. Markers of virologic control, including
time from antiretroviral therapy initiation to virologic suppression, antiretroviral
therapy adherence, and viral load at 36 weeks and at delivery, were assessed. All
patients underwent assessment of housing status with a licensed clinical social worker
and were classified as experiencing housing instability (ie, staying with family or
friends, transitional housing, treatment program, shelter, outdoors or vehicle, hotel,
or incarcerated) vs not experiencing instability (renting or owning). Multivariable
regression models assessed the associations of housing instability with virologic
control.
RESULTS
Of 232 pregnant patients living with HIV with documented housing status, 41.4% (n=96)
experienced housing instability. Patients with housing instability were younger and
more likely to self-identify as non-Hispanic Black, have public or no insurance, and
have a mental health or substance use disorder. They were less likely to be married,
be employed, or have greater than a high school education. There were no differences
in parity, number of prenatal visits, or timing of HIV diagnosis between groups. On
adjusted analyses, patients with housing instability required an adjusted 2.45 weeks
(95% confidence interval, 0.16–4.74) longer to achieve initial viral suppression and
had greater odds of missing 5 or more doses of antiretroviral medications (adjusted
odds ratio, 2.09; 95% confidence interval, 1.07–4.09) and having a detectable viral
load at delivery (adjusted odds ratio, 2.13; 95% confidence interval, 1.02–4.47).
CONCLUSION
Housing instability among pregnant individuals living with HIV is common and is associated
with decreased virologic control during pregnancy. Given the association between virologic
control and perinatal transmission, housing instability may be an important social
determinant of HIV-related perinatal outcomes. Addressing housing instability during
pregnancy may be a critical avenue to improve maternal and neonatal health and reduce
the risk of perinatal transmission.
Key words
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Article info
Publication history
Published online: May 28, 2021
Accepted:
May 25,
2021
Received in revised form:
May 12,
2021
Received:
February 25,
2021
Footnotes
The authors report no conflict of interest.
L.M.Y. was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development grant K12 HD050121-11 at the time of the study.
The conclusions and opinions expressed in this article are those of the authors and do not necessarily reflect the views of the National Institutes of Health.
These study findings were presented in the form of a poster at the 40th annual pregnancy meeting of the Society for Maternal-Fetal Medicine, Grapevine, TX, February 3–8, 2020.
Cite this article as: Cassimatis IR, Miller ES, Benes L, et al. Housing instability is associated with failure to achieve virologic control among pregnant individuals with HIV. Am J Obstet Gynecol MFM 2021;XX:x.ex–x.ex.
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