· Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The number of street dwelling homeless have increased over the past decade, and recent ballot supported initiatives have made it illegal to have long-term encampments in public spaces. These encampments are subject to clearing by the Department of Public Works leading to disposal of personal property of those sleeping on the streets. Moreover, street dwelling people, as a result, are more likely to come in to contact with law enforcement, likely leading to arrest and incarceration. Combined, these two outcomes have the potential to negative impact virologic suppression in patients with HIV due to loss of medications, multiple transitions in-and-out of prisons/jails, both of which have been shown to negatively impact adherence, and increased health care utilization due to destabilizing events.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
This policy has unintended consequences on the health of people living with HIV. Housing instability, including transitions out of prison/jail, can represent a major challenge in long-term suppression of serum HIV viral load which when uncontrolled can lead to increased forward transmission of HIV. An evaluation could provide crucial information on the mediating impact of destabilizing events on poor clinical outcomes in people living with HIV who are living on the streets, including, incarceration, virologic suppression and use of medical care in people living on the streets.
· Specify the outcomes and populations you think most affected or least affected by the policy.
Three specific outcomes of interest would be incarceration rates, health care utilization and virologic suppression in patients living with HIV. Health care utilization would include primary care visits, social work visits and acute care visits, such as urgent care visits, emergency department visits and hospitalizations.
· Propose a study design to evaluate the policy.
One could evaluate at the odds of virologic non-suppression, acute care visit and incarceration in the one year prior to the policy change compared to one year after the policy change for people reporting having lived on the streets.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
There are substantial secular trends not related to the exposure of interest that may confound the relationship between the exposure and the outcome. For instance, San Francisco has adopted a much more aggressive test-and-treat strategy of HIV care, peer navigation and case management to support patients that are in HIV care that are prone to poor retention in care. These efforts to improve adherence and reduce acute care utilization may disproportionately impact those with unstable housing while simultaneously improving the outcomes of interest (eg virologic non-suppression and acute care utilization).