Dissertations, Theses, and Capstone Projects

Date of Degree

6-2014

Document Type

Dissertation

Degree Name

D.P.H.

Program

Public Health

Advisor

Lorna E. Thorpe

Advisor

Denis Nash

Subject Categories

Epidemiology

Keywords

causality, HIV, Homelessness, Incarceration, Mortality

Abstract

Objectives

The purpose of this dissertation study was to identify timing and sequencing of jail incarceration and homelessness by utilizing sequence analysis and to test whether a particular trajectory contributes to mortality risk and discontinuity of HIV care.

Methods

The main data source was an existing matched dataset, constructed using administrative data from the New York City (NYC) Departments of Health and Mental Hygiene, Correction, and Homeless Services. The study cohort consisted of 15,620 NYC adults with recent histories of both jail incarceration and homelessness. Monthly experiences of jail incarceration, homelessness, and community-dwelling in 2001-03 were summarized into trajectory groups using sequence analysis. Then, the study examined associations between trajectory groups and all-cause, drug-related, and HIV mortality risk during the subsequent two years using Standardized Mortality Ratio (SMR) and marginal structural modeling. The study further focused on the sub-set of the cohort living with HIV/AIDS, and tested whether trajectory groups were associated with retention in HIV care and viral suppression.

Results

Sequence analysis identified six trajectory groups of incarceration/homelessness. A majority of the study cohort had sporadic experiences of brief incarceration and shelter stays (Temporary pattern), whereas the others had mixed experiences in various lengths and frequencies. The SMR analysis found that all-cause, drug-related, and HIV mortality risk among individuals with the Temporary pattern was significantly higher than that of non-incarcerated/non-sheltered NYC adults of the same age, sex, race/ethnicity, and neighborhood poverty. Similarly, after accounting for confounding in marginal structural modeling, the elevated mortality risk was associated with the Temporary versus persistent shelter stay patterns (Continuously homeless pattern). Of 1,173 individuals living with HIV/AIDS, the Temporary pattern was independent of retention in HIV care, but significantly associated with lower prevalence of viral suppression, compared with a pattern of prolonged shelter-free and jail-free period (Decreasingly homeless pattern).

Conclusions

Sporadic experiences of brief jail incarceration and homelessness among NYC incarcerated/sheltered adults were associated with excess risk of mortality and low prevalence of viral suppression. The study highlights the importance of public health efforts to modify patterns of incarceration/homelessness experiences, along with behavioral interventions, in order to reduce risk of adverse health conditions.

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