Evidence Into Action: Housing Is HIV Prevention and Care
Policy Paper From the North American Housing and HIV/AIDS Research Summit Series 2011
Table of Contents
To prevent and treat HIV/AIDS in North America, we must end homelessness and housing instability for people living with and at risk of HIV infection. Prevention and care efforts that focus on changing individual behaviors are doomed to fail for persons who lack access to a proven, cost effective health intervention -- a safe secure place to live.
Combination antiretroviral therapy (ART) can effectively manage HIV disease and dramatically reduce ongoing HIV transmission -- yet in North America where ART is relatively easy to access, the ongoing 30-year AIDS crisis is marked by stalled prevention efforts and worsening HIV health disparities. These health inequities are driven by poverty, place, and other structural factors that "shape and constrain" individual behaviors.
According to a large and growing body of research, housing status has a direct, independent, and powerful impact on HIV incidence and on the health of people living with HIV/AIDS. Homelessness and unstable housing are consistently linked to greater HIV risk, inadequate HIV health care, poor health outcomes and early death. In fact, housing status is a stronger predictor of HIV health outcomes than demographics, mental health, substance use, or use of other services. Whatever factor makes someone vulnerable to HIV infection -- homelessness magnifies the risk. Whatever factors lead to disparities in care -- for women, for youth, for sexual minorities, for people of color, for those who experience mental illness, addiction, violence, abuse or incarceration -- housing instability amplifies these disparities in tragic and avoidable ways.
Housing instability is a significant social driver of HIV health inequities in North America that can be addressed by investing in housing interventions. Housing supports create stability and help connect people to care -- improving health, reducing behaviors that lead to HIV transmission, and sharply cutting the cost of avoidable emergency room visits and inpatient care. Innovative "low-threshold" housing models achieve these results regardless of all other co-occurring behavioral issues. Health care savings realized by preventing HIV infections and reducing use of crisis care can offset all or part of the cost of housing, making housing assistance a cost-effective HIV prevention and care intervention. In fact, public action to address the unmet housing needs of persons living with HIV/AIDS costs far less than inaction.
The published evidence on the effectiveness of housing assistance as HIV health care is more substantial than the evidence for many widely accepted health care interventions.2 Yet housing supports are still considered an "ancillary" HIV service rather than a core prevention and health care intervention. Given what we know about the impact of housing on HIV prevention and care, providing stable housing for people with or at high risk of HIV is a moral/human rights issue, a public health issue, and an issue of fiscal responsibility. We need a new policy and practice paradigm: one that recognizes housing interventions as a core HIV health activity, and builds a strong bridge between the housing and health sectors. The housing sector must be a key partner in any serious effort to reduce health inequities, and the health sector must invest in housing as a cost-effective, evidence-based HIV prevention and care strategy.
Following the Evidence: The Housing and HIV/AIDS Research Summit Series
Summit VI -- Eliminating HIV Health Disparities -- focused on the potential of housing interventions as a strategy to reduce inequities in HIV transmission and health outcomes. Participants shared new findings and worked across disciplines to translate the evolving evidence on housing and health into concrete action strategies to inform policy, practice and ongoing research.7 This paper summarizes the key research findings and their policy implications.
The North American HIV epidemic is increasingly concentrated in low income and marginalized communities. (ONAP 2010; PHAC 2010) Members of racial, ethnic and sexual minorities account for the majority of people living with HIV/AIDS, new HIV infections, new AIDS diagnoses, and AIDS deaths. (Prejean, et al. 2011; PHAC 2010) In Canada, Aboriginal people and people from HIV-endemic countries are disproportionately represented in the HIV epidemic. (PHAC, 2010) In the U.S., Blacks account for only 14% of the population but 44% of new HIV infections, and the HIV infection rate among Black women is 15 times the rate of infection among White women. (CDC, 2011) In the U.S., young people (ages 13 to 29) are at particular risk where they accounted for 39% of new infections in 2009. (Prejean, et al. 2011) In Mexico and the Caribbean, mobile populations and persons displaced by economic conditions or natural disasters are often excluded from care, and experience high rates of HIV infection, morbidity and mortality. (Boucicaut & Ghose, 2011; Infante, 2011)
Recent U.S. research points to poverty -- not race -- as the most significant factor contributing to HIV health inequities. According to U.S. Centers for Disease Control and Prevention (CDC) surveillance data, heterosexual men and women in 23 major U.S. cities living below the poverty line are twice as likely to have HIV infection (2.4%) as those living above it (1.2%), and other social determinants of health -- including homelessness, unemployment, and low education level -- are also independently associated with HIV infection. (Denning & Dinenno, 2010)
Housing Is the Greatest Unmet Need of People With HIV
Housing instability is a key marker of extreme poverty, and is both a cause and an effect of the ongoing AIDS crisis in North America. Rates of HIV infection among homeless persons are as much as 16 times higher than in the general population (Denning & Dinenno, 2010; Kerker, 2005; Roberson, 2004; Culhane, 2001), and at least half of all persons living with HIV report experiencing homelessness or housing instability following diagnosis. (Aidala, et al., 2007; Bacon, et al., 2010)
Housing is consistently cited as the greatest unmet need of North Americans living with and at high risk of HIV. (NAHC, 2011; Bacon, et al., 2010) In the U.S., at least 140,000 households living with HIV have a current unmet housing need . (NAHC 2009) For example, 38 % of people living with HIV/AIDS surveyed for an Alabama statewide needs assessment reported being unstably housed after diagnosis, and almost 30% of Black males and 20% of Black females living with HIV in Alabama had experienced chronic homelessness in the last three years. (Bennett & Hiers, 2011) Almost half (42%) of a large cohort of persons living with HIV in Ontario have difficulty meeting housing costs, and one in three are at risk of losing their housing. (Bacon, et al., 2010)
Housing Instability = Greater HIV Risk and Poor Health Outcomes
Housing status is also a key determinant of worsening HIV health disparities. Among persons at greatest risk of HIV infection (e.g., men who have sex with men, persons of color, homeless youth, people who inject drugs, and impoverished women), those who lack stable housing are significantly more likely to acquire HIV over time. (Marshall, 2009; Denning & DiNenno, 2010; Marshall, 2011) Even in communities of concentrated poverty, the rate of new HIV infections is almost twice as high (1.8 times) for persons with a recent experience of homelessness, compared to those with stable housing. (Denning & Dinenno, 2010)
For people living with HIV, homelessness and unstable housing are strongly associated with inadequate HIV health care, poor health outcomes and early death. (Wolitski, et al., 2007) Compared to their peers who are stably housed, persons living with HIV who lack stable housing: are more likely to delay HIV care; have poorer access to regular care; are less likely to receive optimal antiretroviral therapy; and are less likely to adhere to therapy (Kidder, et al., 2007; Aidala, et al., 2007; Leaver, et al., 2007). Homeless people with HIV experience worse overall physical and mental health than their housed counterparts, have lower CD4 counts and higher viral loads, and are more likely to be hospitalized and use emergency rooms. (Kidder, et al, 2007) Homelessness is independently associated with HCV/HIV co-infection (Rourke, et al. 2011), and the death rate due to HIV/AIDS is seven to nine times higher among homeless persons than in the general population. (Kerker, 2005; Walley, et al, 2008; Schwarcz, et al., 2009)
Why is housing so critical? Because having a safe secure place to live is fundamental to the basic activities of daily living. When one is homeless or facing housing instability, immediate survival takes priority over other activities and choices. The stresses of the environment are relentless. Violence is ubiquitous, and stable intimate relationships are all but impossible. Homelessness degrades one's very identity.
The Most Vulnerable Persons Also Face the Greatest Risk
People living with HIV who are members of marginalized groups and those with co-occurring needs are most heavily affected by both housing loss and HIV health disparities. Aboriginal people living with HIV/AIDS in Ontario are three times more likely than their Caucasian counterparts to have experienced homelessness, and are only half as likely to be on anti-retroviral therapy. (Monette, et al. 2011) More than half of HIV-positive inmates released and then re-incarcerated in the San Francisco jail system in a 12-month period were homeless in the month preceding re-incarceration, and 59% of those with a history of antiretroviral use were not taking HAART. (Clements-Nolle, et al., 2008) Among people who inject drugs in a Canadian setting where HIV care is free, only homelessness and frequent heroin use were significantly negatively associated with ART adherence after adjusting for sociodemographics, drug use, and clinical variables. (Palepu, et al. 2011) An ongoing study of U.S. veterans living with HIV shows that 42% have experienced homelessness, 11% are currently homeless (compared to fewer than 1% for veterans in general), and (controlling for other factors) HIV-positive veterans who have experienced homelessness are significantly less likely to adhere to HAART and are more likely to be hospitalized than housed veterans living with HIV. (Ghose, et al., 2011; Gordon, et al., 2007) A large multisite study of people receiving HIV care in eight U.S. urban centers found that 43% of persons triply diagnosed with HIV, substance use and mental health issues currently lacked stable housing. (Conover, et al. 2009)
To Stop HIV, We Must Address Structural Barriers to Prevention and Care
We have the tools to end AIDS in North America. HIV infection can be effectively managed with combination antiretroviral therapy, and exciting new research shows that successful therapy also dramatically reduces ongoing HIV transmission. ((NIAID, 2011) Yet in the U.S. and Canada there has been no significant decline in the number of new HIV infections and large numbers of HIV positive persons remain outside of care. In the U.S., over 20% of HIV-positive persons are unaware they are infected, nearly half of all persons who have tested positive for HIV are not engaged in regular care, and only 19% of Americans living with HIV have a viral load that has been driven to undetectable levels by combination therapy. (Gardner, et al. 2011) In Canada, where people with HIV have access to publicly funded health care including HIV medications, there has still been no appreciable effect on the number of new diagnoses each year, and a significant proportion of people with HIV are not in care. (PHAC, 2010)
These facts highlight the limited success of conventional HIV interventions that seek to influence knowledge, attitudes and behaviors, and underscore the need to intervene to influence social or "structural" determinants of health that perpetuate inequities. (CDC, 2010) Progress in reducing HIV-related morbidity and mortality will require structural approaches -- policies or programs that aim to change the conditions in which people live -- applied in combination with individual behavioral or medical interventions. As Dr. Kevin Fenton of the CDC recently observed, "We need to address larger environmental issues, such as poverty, homelessness and substance abuse, which are well beyond the traditional scope of HIV intervention. Addressing those is as essential to HIV prevention as providing condoms." (LA Times, 2010)
Housing status is a key social determinant of HIV health outcomes, and one that is amenable to intervention. (Auerbach, 2010; Gupta, et al., 2008) A substantial body of research supports the need for urgent action to address the unmet housing needs of North Americans living with HIV and those most at risk for acquiring HIV infection. "Structural factors can be influenced but until they are, individuals in many settings will find it difficult to reduce their risk and vulnerability." (Gupta, et al., 2008)
This article was provided by National AIDS Housing Coalition. Visit NAHC's website to find out more about their activities and publications.
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