DDRESSING THE HEALTH NEEDSof the homeless population is a challenge to physicians, health institutions, and federal, state, and local governments. Homelessness is pervasive in the United States, and an estimated 3.5 million individuals are likely to experience homelessness in a given year. 1 To address this problem, 860 cities and counties have enacted 10-year plans to end homelessness, and 49 states have created Interagency Councils on Homelessness. 2 Rates of chronic medical illness are high among homeless adults. With the exception of obesity, stroke, and cancer, homeless adults are far more likely to have a chronic medical illness such as human immunodeficiency virus (HIV), hypertension, and diabetes mellitus and more likely to experience a complication from the illness because they lack adequate housing and regular, uninterrupted treatment. [3][4][5][6] Homeless adults are frequent users of costly emergency department and hospital services, largely paid for by public dollars. [7][8][9][10][11][12][13][14] The combination of chronic medical illnesses and poor access to primary health care has substantial health and economic consequences.Prior intervention research has focused on subgroups of the homeless For editorial comment see p 1822. Context Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. Objective To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. Design, Setting, and Participants Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat.Intervention Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered onsite at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers.Main Outcome Measures Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. ResultsThe analytic sample (n=405 [n=201 for the intervention group, n=204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the inter...
Serum RPR titer helps predict the likelihood of neurosyphilis. HIV-induced immune impairment may increase the risk of neurosyphilis.
The purpose of this study was to examine the attitudes about hypothetical human papillomavirus (HPV) vaccines in two groups of women in clinical settings. Twenty adolescent women attending an urban community adolescent health clinic and 20 adult women attending a city health department sexually transmitted disease (STD) clinic were recruited to participate in individual interviews. Adolescents were 14-18 years of age (mean 15.6), 75% nonHispanic white, and 75% sexually experienced. Adults were 20-50 years of age (mean 33.6), 95% African American, and all were sexually experienced. As part of the interview, participants ranked nine hypothetical HPV vaccines in order of acceptability. Each vaccine was uniquely defined as a function of cost ($150, $50, or free), efficacy (50% or 90%), disease targeted (genital warts, cervical cancer, or both), and physician recommendation (not mentioned by a physician or specifically recommended). Rankings by adolescents and adults were highly concordant (Spearman rho = 0.9). Efficacy, physician's recommendation, and cost influenced rankings most strongly. Ranking decisions were often based on complex decision making, in which all characteristics were considered simultaneously. These findings suggest that certain features of an HPV vaccine might significantly affect vaccine acceptability. Vaccine efficacy, physician endorsement, and cost were particularly salient issues.
To identify factors that affect normalization of laboratory measures after treatment for neurosyphilis, 59 subjects with neurosyphilis underwent repeated lumbar punctures and venipunctures after completion of therapy. The median duration of follow-up was 6.9 months. Stepwise Cox regression models were used to determine the influence of clinical and laboratory features on normalization of cerebrospinal fluid (CSF), white blood cells (WBCs), CSF protein concentration, CSF Venereal Disease Research Laboratory (VDRL) reactivity, and serum rapid plasma reagin (RPR) titer. Human immunodeficiency virus (HIV)-infected subjects were 2.5 times less likely to normalize CSF-VDRL reactivity than were HIV-uninfected subjects. HIV-infected subjects with peripheral blood CD4+ T cell counts of < or =200 cells/ mu L were 3.7 times less likely to normalize CSF-VDRL reactivity than were those with CD4+ T cell counts of >200 cells/ mu L. CSF WBC count and serum RPR reactivity were more likely to normalize but CSF-VDRL reactivity was less likely to normalize with higher baseline values. Future studies should address whether more intensive therapy for neurosyphilis is warranted in HIV-infected individuals.
Objectives. We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV. Methods. HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count ≥ 200 and viral load < 100 000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts. Results. Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts. Conclusions. Homelessness is a strong predictor of poor health outcomes and complicates the medical management of HIV. This housing intervention improved the health of HIV-positive homeless people.
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