Impact of unstable housing on all-cause mortality among persons who inject drugs

Abstract

BackgroundIllicit drug injecting is a well-established risk factor for morbidity and mortality. However, a limited number of prospective studies have examined the independent effect of unstable housing on mortality among persons who inject drugs (PWIDs). In this study we sought to identify if a relationship exists between unstable housing and all-cause mortality among PWIDs living in Vancouver, Canada.MethodsPWIDs participating in two prospective cohort studies in Vancouver, Canada were followed between May 1996 and December 2012. Cohort data were linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariate Cox proportional hazards regression to determine factors associated with all-cause mortality and to investigate the independent relationship between unstable housing and time to all-cause mortality.ResultsDuring the study period, 2453 individuals were followed for a median of 69 months (Inter-quartile range [IQR]: 34 – 113). In total, there were 515 (21.0%) deaths for an incidence density of 3.1 (95% Confidence Interval [CI]: 2.8 – 3.4) deaths per 100 person years. In multivariate analyses, after adjusting for potential confounders including HIV infection and drug use patterns, unstable housing remained independently associated with all-cause mortality (adjusted hazard ratio [AHR] = 1.30, 95% CI: 1.08 – 1.56).ConclusionsThese findings demonstrate that unstable housing is an important risk factor for mortality independent of known risk factors including HIV infection and patterns of drug use. This study highlights the urgent need to provide supportive housing interventions to address elevated levels of preventable mortality among this population.

Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs

“…Additionally, PWID systemically experience disproportionate levels of homelessness [9,25*,29], untreated mental health comorbidities [37], polysubstance use [32] (including alcohol use [33]), and lower levels of healthcare engagement [9], all of which shape access and adherence to ART, as well as progression to AIDS and death. Additionally, incarceration [1**,43] and personal violence [3**,7,10*] remain persistent issues among HIV-positive PWID, with research demonstrating increased rates of suicides [7,44] being independently associated with a history of IDU (adjusted hazard ratio: 3.95; confidence interval: 1.99 – 7.86) [44].…”

“…However, Joseph and colleagues [45] demonstrated that even in a setting with free access to HIV care, becoming non-adherent was associated with periods of homelessness, active IDU, and incarceration. In the same setting, Zivanovic and colleagues [25*] found that after adjusting for confounders such as HIV infection and drug use patterns, housing instability was independently associated with all-cause mortality in a cohort of PWID. This research highlights the need to consider contextual factors in the design of HIV care and treatment to PWID beyond treatment access, extending to the provision of basic subsistence needs, including supportive housing.…”

“…As the estimates of lower life expectancy among PWID are frequently grounded in individual-level analyses, most research cites IDU as a risk factor for premature mortality because of higher levels of various health and social harms (e.g., higher prevalence of comorbidities [24*] and injection-related illnesses, greater socioeconomic disadvantage [25*], inferior contact with the healthcare system [9,11,26]). However, the influence of sociostructural factors on mortality of PWID in the era of modern ART remains relatively under-researched.…”

A Hazard Analysis of Risk Factors of Mortality in Individuals Who Inject Drugs in Denver CO

“…While acute-toxicity is common, other causes of premature death are prevalent among PWID as well, including but not limited to accidents [5], suicide [8, 9], and HIV-related mortality [10, 11]. Research has also identified important predictors of all-cause and acute-toxicity mortality relevant to PWID, such as sex work [12], unstable housing and/or homelessness [13], polydrug use [14, 15], bisexual orientation [16], and exiting methadone or other drug replacement treatment modalities [17, 18]. PWID also experience increased risk of acute-toxicity mortality after release from incarceration [19, 20] and male gender is commonly identified as a mortality risk factor [21].…”

Eviction and loss of income assistance among street-involved youth in Canada

“…18 Similarly, unstable housing is a well-documented independent risk factor for mortality in adult populations. 16, 19–21 Some of us found unstable housing to be an independent risk factor for initiation into injection drug use among street-involved youth in Vancouver. 22 This highlights the importance of ensuring youth have economic security and stable housing.…”