HIV / STI
Experiences of housing instability, HIV, and mortality among transgender women in the United States: a multistate analysis of prospective cohort data from the LITE study Dorothy Apedaile* Dorothy Apedaile Sari L Reisner Erin Cooney Tonia Poteat Susan Bondy Amaya Perez-Brumer Andrea L Wirtz on behalf of the American Cohort to Study HIV Acquisition Among Transgender Women (LITE) Study Group
Housing insecurity among transgender women can be highly dynamic, with individuals moving between housing stability and instability. Unstable housing can lead to serious health issues, including HIV acquisition and mortality. This analysis uses multistate modelling to estimate the probability of transitions between states of stable housing, unstable housing, and HIV seroconversion or death among transgender women in the United States. A total of 725 HIV-negative transgender women were enrolled in a prospective cohort study from March 2018 to May 2020 in 6 cities across the eastern and southern United States. Participants completed surveys and HIV testing every 3 months for up to 2 years, contributing 1078 person-years of follow up time. Participants were censored at death or HIV seroconversion. Housing instability was defined as experiencing homelessness in the past 3 months. Multi-state models under a time-homogenous Markov assumption were used to estimate the probability of transition between states, presented over 6-month periods. Confidence intervals were estimated using 1000 bootstrap replications. At enrollment, the median age of participants was 29 (IQR: 24-37), 45% had experienced lifetime homelessness, and 11% were currently experiencing housing instability. Over follow up, 6 participants died, 7 acquired HIV, and 169 (23%) experienced housing instability at least once. Participants who were unstably housed had a 57.2% (95% CI: 50.2%-63.7%) probability of being housed at the end of 6 months and a 2.1% (95% CI: 0.3%-4.3%) probability of dying or acquiring HIV while participants who were stably housed had only a 0.4% (95% CI: 0.2%-0.8%) probability of death or HIV seroconversion after 6 months. These results demonstrate housing instability is highly dynamic among transgender women and multistate modelling can be used to better understand changes in housing status. Furthermore, interventions to improve housing stability are needed to prevent HIV and mortality.
