Associations between alcohol use and homelessness with healthcare utilization among human immunodeficiency virus-infected veterans

Background: Alcohol use is a frequent root cause of homelessness, and both homelessness and alcohol use influence the quality and quantity of interactions with health care providers. Objective: The objectives of this study are to compare rates of homelessness and alcohol use in a cohort of human immunodeficiency virus (HIV)-infected persons and to evaluate the influence of homelessness and alcohol use on utilization of health services. Research Design and Measures: Data were obtained from the Veterans Aging Cohort 3-Site Study, a cohort study of 881 HIV-infected veterans at 3 VA hospitals. In a baseline survey, we assessed current and past history of homelessness and levels of alcohol consumption. Health care service utilization (ambulatory visits, emergency room visits, and hospital admissions) for the preceding 6 months was determined by self-report and VA administrative records. Logistic regression was used to assess whether homelessness and drinking variables were associated with health care visits in the past 6 months. Results: Among HIV-infected veterans with complete data (n = 839), 62 (7%) were currently homeless, and 212 (25.3%) had a past, but not current, history of homelessness. Among the currently homeless, 36% reported alcohol consumption, 34% were hazardous drinkers, 46% were binge drinkers, and 26% had a diagnosis of alcohol abuse. When adjusting for age, severity of HIV disease, and use of illicit drugs, hazardous drinking (adjusted odds ratio [AOR] 0.68, 95% confidence interval [CI] 0.49-0.93) and current homelessness (AOR 0.56, 95% CI 0.32-0.97) were associated with less than 2 outpatient clinic visits. HIV-infected veterans who were homeless in the past were more likely to be hospitalized in the prior 6 months than those never homeless (AOR 1.51, 95% CI 1.07-2.11). Conclusions: Although homeless HIV-infected veterans tend to use inpatient services more than nonhomeless HIV infected veterans, they were less likely to achieve optimum outpatient care. Alcohol use complicates the effect of homelessness on adherence to outpatient care and is associated with increased inpatient utilization among HIV-infected veterans.