HIV prevention isn't just about condoms and clean syringes. In order for these prevention tools to work, we must look at the ways that people are forced into high-risk environments. One of the most glaring reasons for the expanding HIV epidemic -- despite decades of prevention messages -- is what happens to people when they don't have stable housing.

Housing is one of our most basic needs. Unfortunately, housing is not treated as a human right. As a result, in New York City, there are significant numbers of homeless people moving day-to-day, bed-to-bed. This forum examined the connections between homelessness and HIV risk, demonstrating why HIV prevention doesn't work in a vacuum, and helped us understand why societal injustices must be addressed if we are to see an end to the AIDS epidemic.

6:30 - 8:30 PM, The LGBT Community Center, New York City

Speakers:
Chloe Tribich, Youth Organizer, Housing Here & Now!
Angela Aidala, Ph.D., Associate Research Scientist, Mailman School of Public Health, Columbia University
David Golden, New York City AIDS Housing Network
Moderated by: Kristin Goodwin, Gay Men's Health Crisis (GMHC)

Co-sponsors:
African Services Committee
Community HIV/AIDS Mobilization Project (CHAMP)
Gay Men's Health Crisis (GMHC)
Harm Reduction Coalition
Housing Here & Now!
Housing Works
The LGBT Community Center
New York City AIDS Housing Network (NYCAHN)
Queers for Economic Justice
Women's Initiative to Stop HIV in New York (WISH-NY) - Legal Action Center

Summary of Discussion

Chloe Tribich, Youth Organizer, Housing Here & Now!

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In February 2005, community groups, churches and synagogues united to form Housing Here & Now!. Since then, Housing Here & Now! has worked on housing conditions, targeted bad landlords, targeted banks lending money to bad landlords and campaigned for affordable rent -- the New York is Our Home Campaign.

A brief timeline of rent regulation in New York City:

• 1974: Emergency Tenant Protection Act extends Rent Stabilization
• 1993: Decontrol of vacant apartments allowed when rent reaches threshold
• 1997: Landlords can raise rents by 20% when apartments are vacant
• 2003: Landlords increase rents from preferential to legal on lease renewal

Between 1975 and 2005, New Yorkers have lost 354,028 regulated apartments in all of the boroughs combined. Additionally, New Yorkers are paying more for rent now than what they were in the 1970's.

In response to these housing issues, Housing Here & Now! launched the New York Is Our Home: Affordable Rent Campaign. This campaign is working to:

• Preserve Rent Regulated Units: Eliminate the rent threshold that allows owners to exempt units from regulation upon vacancy and eliminate unfair rent increases and tenant harassment by strengthening enforcement and reforming the NYS Division of Housing and Community Renewal (DHCR).
• Preserve Mitchell-Lama and Section 8 Housing: Extend rent regulation to all Mitchell-Lama and Section 8 units and provide other protections to maintain affordability.
• Preserve State, City and Federally Built Public Housing: Respective levels of government must fund full operating costs of their own developments.
• Implement Fairness in Rental Payments for New Yorkers Living With AIDS: State must cap all rental payments to 30% of a tenant's income. The current State assistance program requires some tenants living with AIDS to pay all but $330 of income toward rent.

Angela Aidala, Ph.D., Associate Research Scientist, Mailman School of Public Health, Columbia University

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There is an increasing awareness of the association between housing and HIV infection -- usually discussed in terms of "the homeless" as a "special population." It's important that we look for the "upstream" cause of problems in contextual or environmental factors that influence risky behavior or use/non-use of medical services rather than focus exclusively on the characteristics of individuals who engage in risky behaviors or don't utilize medical services. In that sense, housing is a structural factor.

Two recent studies -- one national and one in New York City -- looked at people living with HIV/AIDS, housing and risk behaviors. The New York City HIV Health and Human Services Planning Council recently conducted the NYC Community Health Advisory & Information Network (CHAIN) Study. This study included a multi-stage probability sampling, representative of the larger population of persons living with HIV/AIDS in the city. The HRSA SPNS/HUD HOPWA Multiple Diagnoses Initiative conducted the national evaluation, targeting "hard to reach" marginalized populations that aren't often included in conventional clinical studies.

When measuring housing status, three options were defined: homeless, unstably housed, and stably housed.

Homeless

• homeless
• sleeping in the street, park, abandoned building
• in a public place (e.g. subway) not intended for sleeping
• in a shelter for homeless persons
• in a limited stay SRO or welfare hotel
• in jail with no other address

Unstably Housed

• in transitional housing, resident treatment, halfway house
• doubled up with other people

Stably Housed

• own, secure housing in regular apartment or house

Examining the housing need among New York City and national study participants, over 60% of participants experienced unstable housing or homelessness at least once over the course of their illness. In New York City, approximately 50% were homeless or unstably housed during the year they were diagnosed with HIV. In the national study, over 40% of clients at general medical or social service agencies were homeless or unstably housed at program enrollment. The rate of housing need in New York City has remained consistently high over time; as some PLWHA's housing needs are met, others develop housing problems.

Regarding housing and HIV risk, the two studies addressed these questions:

1. What is the association between homelessness/unstable housing and drug and sexual risk behaviors among HIV positive people
2. Does housing status significantly predict drug and sexual risk behaviors for HIV?
3. Is the impact of housing on HIV risk behaviors mediated by the concurrent receipt of medical care or other health or social services?

In both studies, significant differences in drug and sexual risk behaviors are associated with a person's current housing status. Those unstably housed are at a greater risk than those stably housed, and the homeless are at a greater risk than those who are unstably housed.

Regarding housing and HIV medical care, the two studies addressed these questions:

1. What is the relationship between unstable housing and access and engagement with medical care and treatment?
2. Does housing need predict receipt of medical care that meets good clinical practice standards?
3. What is the relationship between the receipt of housing assistance and entry and maintenance in appropriate HIV medical care?

Considerable research has shown that HIV positive persons who are in care and receiving services are less likely to continue high-risk behaviors. Also, when not receiving comprehensive care and when not on antiretroviral medications, viral load increased, so that there was both more risk behavior and greater infectivity. Each experience of unprotected sex or needle sharing increases the risk of HIV transmission. Effective treatment with antiretroviral medications reduces the infectivity of persons living with HIV.

In both studies, unstable housing was found to lead to delayed entry into care, discontinuous care, recent breaks in care, dropping in and out of care, and/or changing providers often. Also, homeless or unstably housed individuals are less likely than other PLWHAs to be receiving medical care that meets minimum clinical practice guidelines. Additionally, homelessness/unstable housing is one of the most important barriers limiting the use of antiretroviral therapy. Finally, high viral load, recent opportunistic infection, and hospitalization for HIV-related disease are associated with homelessness/unstable housing.

An important question when considering these findings is: Does housing status influence individual risk behaviors and medical care outcomes, or are the findings evidence of self-selection of "risky persons" into conditions of homelessness?

To answer this question, one most begin with the "risky person" model, which essentially argues against an independent causal role for housing as it affects risk for HIV infection. One might argue that the above findings are evidence of the self-selection of "risky persons" into conditions of both homelessness and HIV infection. That is, an individual's personality dispositions or character "traits" may lead them to drug use, risky sex and illegal activities which would have consequences on both health (increased risk for HIV infection) and housing (limited economic resources to purchase conventional housing).

There is an opposing model: "structural contexts of risk." In this model, housing is seen as "vector" -- an intermediary by which the pathogenic inequality that inheres in broader economic and political structures is carried to a susceptible host. Lack of housing makes it hard to move out of risky situations or to use risk-reducing tools and institutions.

Housing has many effects on people, both direct and indirect. Housing has meaning as well as materials dimensions that affect health and well-being. While a home and neighborhood are, for most people, a source of identity and belonging, for those without, being "homeless" is a mark of failure at the most basic level of adult role functioning. Internalized shame and lack of self-esteem may further contribute to risky behaviors.

Neighborhoods of substandard housing, abandoned buildings, and warehouses are not high on "social capital" resources that might mediate the effects of strain and stressful events in the lives of the urban poor.

The homeless tend to be socially isolated or involved in social ties and networks that support risky behaviors (substance use, sex exchanges).

Another causal dynamic to consider is the role of housing as it structures the private sphere. The lack of housing, transient living conditions, and the communal sleeping arrangements in most homeless shelters pose a formidable barrier to forming stable intimate relationships. The lack of a stable "home" and community ties is associated with multiple sexual partners, casual liaisons, sex exchanges, and low rates of marriage or stable partner relationships.

The pressure of daily survival needs -- accessing medical care, adhering to treatment -- is not high on the list of priorities. Even if the motivation is high, structural barriers exist to service use, such as waiting to see a doctor in a public clinic or being assured of a meal at soup kitchen.

The "risky person" model assumes that behavior follows a person -- the formerly homeless person who receives housing will continue to engage in risky behavior and remain marginal to systems of care. To test this, the change in risk behaviors associated with change in housing status was examined. The odds of risk behavior associated with change in housing status were compared to no change in housing status.

In the national sample, improved housing meant that the person went from being homeless to unstable or stably housing, or went from unstable or temporary housing to stable or permanent housing.

The analysis shows that improved housing situations are associated with reduction in risk behaviors and positive change in medical care outcomes.

In summary, HIV positive persons with housing problems are more likely to engage in sex and drug risk behaviors and are less likely to be engaged in appropriate medical care. Overtime analyses show that improvement in housing situation is associated with a reduction in risk behaviors and positive change in medical care outcomes. Additionally, the study data show strong and consistent relationships between housing and risk and medical care outcomes, regardless of other client characteristics, health status or service use variables. These findings suggest that the condition of homelessness, and not simple traits of homeless individuals, influence risk behaviors and service utilization.

Angela suggested the National AIDS Housing Coalition's Policy Tool Kit as a valuable resource -- Housing is HIV Prevention and Health Care: Talking Points On Frequently Asked Questions.

David Golden, New York City AIDS Housing Network (NYCAHN)

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NYCAHN is a membership-led organization bringing together homeless and formerly homeless people living with HIV/AIDS, AIDS service organizations and nonprofit housing providers. They believe housing is a human right. Their mission is to empower low-income people living with HIV/AIDS to organize communities to advocate for more and better housing for all New Yorkers living with HIV/AIDS.

Low-income New Yorkers who test positive for HIV are in need of rental assistance in order to keep them from becoming homeless. But unless they have an AIDS diagnosis, they only qualify for standard public assistance benefits -- not enough to pay the rent. They are forced to wait until they get "sick enough" to qualify for HASA.

AIDS is the number one killer of women struggling to survive the Department of Homeless Services shelter system. It is the 2nd killer of men.

ALL poor HIV positive New Yorkers should receive enhanced rental assistance and increased food and nutrition benefits from the NYC HIV/AIDS Services Administration (HASA). Providing full HASA benefits to low-income people with HIV is cheaper than a shelter bed.

NYCAHN is working with Housing Works and GMHC to push forward legislation in the New York City Council and in Albany.