Life is good now for Alejandro Rodríguez. You may remember when TheBody interviewed him three years ago, in his drag persona as Lady Quesa’Dilla. Diagnosed with HIV in 2015, this Latinx, El Paso–born New Yorker is the career advancement coach at The Door, a longtime New York City youth-services agency—and he still performs regularly as the big-wigged, ruffle-gowned Lady Q! Plus, he’s got a cute studio apartment in Brooklyn’s Flatbush neighborhood.
“I’m able to keep it all together!” says this irrepressible queen, who has been known to make guacamole onstage in order to “feed the children” (read: her audience).
But it wasn’t always like that. A few years after his HIV diagnosis, personal struggles led to Rodríguez losing his share in an apartment and becoming essentially homeless, couch-surfing. So he went to New York City’s HIV/AIDS Services Administration (HASA) office, which then hooked him to the Brooklyn social-services agency CAMBA, which found him that cute studio. Under New York law, he was not only guaranteed housing as a low-income person with HIV, he also did not have to pay more than a third of his income toward rent. So now, he has affordable housing—and CAMBA, as the “tenant” on the apartment (he’s CAMBA’s subtenant), pays the rest with funds from HASA.
“I’m so thankful,” he says. “Being stably housed has given me the ability to be good in my job and provide for myself.”
Had he lived in San Francisco, his story might have played out differently—which brings us to our story. In recent years, both New York City and San Francisco—the two cities where AIDS hit earliest and hardest—have proudly announced data suggesting that, after nearly 40 often nightmarish years, they are close to ending their respective HIV epidemics. Last year, San Francisco revealed that its HIV diagnoses for the prior year, 2018, were below 200—a record low. Also last year, New York City reported that, in addition to record low numbers of new HIV diagnoses, it had also not only met but exceeded those key “90-90-90” targets now touted worldwide as crucial to ending HIV epidemics: At least 90% of those with HIV aware of their status, at least 90% of those retained in care and on treatment, and at least 90% of those with undetectable (hence untransmittable) virus in their blood.
But as the two cities race to see who can reach the end first, they both continue to struggle with high rates of homelessness—and multiple studies have found that stable housing is essential for people to not only prevent getting HIV, but to take one’s HIV meds consistently in order to stay both healthy and uninfectious once diagnosed with HIV.
Moreover, sharp contrasts exist in the two cities’ efforts to house low-income people living with HIV/AIDS, especially at a time when the tech boom and gentrification have driven rents sky-high in both places. One such difference lies in the numbers: In New York, about 78,000 people are deemed homeless in a city of about 8.6 million, while in San Francisco, nearly 10,000 people are considered homeless in a city of about 880,000. For both cities, that’s a homelessness rate of around 1%.
However, in San Francisco, in part because of its milder weather as well as its compact size compared to New York, the population of people living on the streets (as opposed to the so-called “unstably housed,” who often live intermittently with friends or family) often feels larger and more visible. “The amount of homelessness we have in SF is unbelievable,” says Elise Riley, Ph.D., a University of California, San Francisco epidemiology professor who works with homeless people, some living with HIV. “It’s almost unfair to compare the two cities. There are tent encampments over most of SF, which is not true in NYC.” (It is often noted in New York that much of its unstably housed population is not visible, such as families who work and have kids in school but nonetheless live in shelters.)
New York: Guaranteed Protections
In addition to scale differences, New York sharply differs from San Francisco in that, in 2016, after a years-long battle on the part of activists, it became the first jurisdiction in the world to guarantee housing—as a form of HIV care, starting the day it’s requested—to all income-eligible homeless or unstably housed residents living with HIV. Also, by law, the city requires that those who are permanently disabled by HIV/AIDS pay no more than 30% of their income toward rent.
“The whole reason that NYC is doing better than SF on the 90-90-90 goals is because we have this massive, guaranteed housing program,” says Charles King, the cofounder and longtime CEO of Housing Works, the large HIV nonprofit that, with other groups such as VOCAL-NY, pushed so hard for those protections—and is currently trying to get them extended to the whole state of New York.
And, says Ginny Shubert, an attorney and longtime New York City HIV housing expert who currently consults for Housing Works and the city health department on Ending the Epidemic efforts, “I’d be shocked if anyone in SF would maintain that their system was better. The NYC system provides ongoing rental assistance for almost 30,000 households, which is an enormous amount of money.” (For context, it’s estimated that more than 125,000 New York City residents are living with HIV/AIDS.)
She continues: “In recent years, NYC has done a terrific job of providing immediate housing assistance to any low-income person with HIV who’s homeless or faces housing instability.” The program, she notes, allows people to make a certain amount of income on the books—including a so-called “income disregard” in which, for up to five years after someone returns to work, half of their income is not factored into their rental assistance eligibility. “It’s a bridge” back to self-sufficiency, says Shubert.
San Francisco: Making New Efforts
In San Francisco, it appears that advocates and officials aren’t disputing that New York’s guaranteed-housing law gives it an advantage in terms of keeping poor folks with HIV stably housed.
“It’s great that that’s the law in NYC,” says Manuel Vasquez, who manages the HIV housing programs in the San Francisco mayor’s office of housing and community development. Says openly HIV-positive Brian Basinger, cofounder and executive director of the San Francisco HIV housing nonprofit Q Foundation, “It’s absolutely true” that New York’s law gives it the edge. “We’ve long held up the accomplishments in NYC as a model to organize around.” In California, he adds, there is finally a bill that would guarantee a right to shelter—although it recently stalled out in the state legislature.
Short of that, San Francisco—with its very wealthy tax base—has a large fund of its own for housing assistance (in addition to federal funds via the Housing Opportunities for Persons With AIDS program), which flows down through Vasquez’s office to a handful of nonprofits, including the Q Foundation (QF).
And Basinger, who proudly calls himself “one of the few disabled people with AIDS in the nation who runs a large organization,” is confident that he’s going to help close the HIV housing gap in San Francisco as $1 million of those funds flow into QF’s new program. In his words, it’s the “first rental subsidy program specifically targeting people with HIV and AIDS—120 new subsidy slots, and the first rental subsidy expansion in SF in 12 years.”
He says that the new QF system is designed to stop evictions—a major source of homelessness—in real time. “We offer subsidies on demand when people actually need them to stop an eviction in its tracks. Every Wednesday here in SF, people are getting evicted at the courthouse for nonpayment of rent, because someone’s spouse has died or someone has become disabled. We’re losing more people through eviction than we’re getting housed post-homelessness.
“So,” he continues, “I put all my resources online and shared them with every agency in SF. We work with every legal-services provider in the city. I’ve had attorneys call me on their cell in front of a judge and I’ve approved the subsidy on the spot for as high as $26,000 in back-rent.” (For context, the average market-rate one-bedroom in San Francisco proper now rents for about $3,500.)
The QF platform also ensures, says Basinger, that people have the necessary up-front money on hand when they win the affordable-housing-unit lottery, for which they’ve often spent years on a waitlist. “We have relationships with the affordable housing unit providers, and it’s our highest priority that our clients get those units when they become eligible,” he says. “So now the providers, instead of turning people down, have accounts with us, so we can tailor our subsidy amount to meet their needs” for a new tenant.
It’s still early days for the QF program, but Basinger says that the platform is engineered to help 10,000 people a month, at an average monthly subsidy of $670. He even says that he wants to replicate his on-demand subsidy model in other cities, using their public and private funding. “We’ve built the engine, and they just need to put in the fuel,” he says.
The QF approach to HIV housing is “an opportunity for us to see if it works,” says Vasquez. Whereas in New York, HIV housing subsidies come directly via the city’s HASA office, with nonprofits often hand-holding clients through the process, in San Francisco, it’s somewhat the reverse, with the funding flowing down through the city to nonprofits, such as QF, that administer the subsidies.
That model, says Vasquez, “gives nonprofits the opportunity to try to drive new ideas and have their needs heard. SF has specific housing funding buckets for different communities”—such as people with HIV, transgender people, seniors, and disabled people—“and this lets each nonprofit shine and show how their community is or isn’t being served, and how they can do it better.”
And while San Francisco currently doesn’t have recent data, as New York City does, showing a close correlation between expansion of housing opportunities with 90-90-90 rates, Basinger says that HIV transmission rates there started dropping after 2004, the year that he and others got the city to pass a law that slowed evictions.
“There’s no other new thing that happened that could account for this drop,” he says. (But it should be noted that San Francisco HIV rates dropped most dramatically after 2012, the year that the FDA approved pre-exposure prophylaxis [PrEP] for HIV prevention—and San Francisco promoted uptake of the pill faster than any other U.S. city.)
Housing Is Healthcare
There’s one thing nobody on either coast will dispute: Stable housing usually means virally suppressed HIV, and well-managed HIV is a key part of bringing new HIV rates to zero, regardless of where. Riley says that a study she and colleagues recently published shows that stably housed people with HIV had higher chances of viral suppression than those living in shelters, and those living in shelters had higher chances of suppression than those living on the streets.
And if you want proof on an individual level of how stable housing helps folks with HIV to thrive, just look at Alejandro Rodríguez. “Having my own apartment has given me the ability to get my health stable and my life back on track,” he says.
It’s also helped him keep Lady Quesa’Dilla alive and well. “I just did a performance at the Whitney Museum last week,” he reports. “She’s upgraded to the art-world, darling!”