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"Housing is the Foundation of HIV Prevention and Treatment,"

by Virginia Shubert & Hilary Botein July/August 2006 issue of Poverty & Race

Compelling new research findings demonstrate the critical significance of housing as an intervention to address both public and individual health priorities, including disease prevention, health care access and effectiveness, and cost containment. This is especially true of HIV and related conditions, where recent studies show strong correlations between improved housing status and reduced HIV risk, improved access to HIV medical care, and better health outcomes.

This growing body of evidence refutes the predominant “risky person” model for understanding the co-occurrence of homelessness, HIV infection and poor health outcomes among persons living with HIV/AIDS who lack stable housing. The “risky person” model assumes that behavior follows the person. This research shows instead that housing status has an independent effect on risk behaviors and treatment access, after controlling for a range of individual characteristics like histories of prior homelessness, drug use and mental illness. It is not the homeless or unstably housed person who is risky but the person’s situation.

In June 2005, public health and housing experts gathered for the first time to share research findings on the relationship between housing status and HIV prevention and care. The first National Housing and HIV/AIDS Research Summit was sponsored by the National AIDS Housing Coalition (NAHC) and hosted by the Emory Center for AIDS Research (CFAR). Leading researchers in the field of HIV care, homelessness and heath care economics convened Summit I, and working sessions included researchers who have conducted important recent work in each of these areas, as well as experts on housing policy and health care access. Participants presented and discussed findings, shared information and strategies regarding ongoing and planned research projects, considered policy and program implications of rigorous research, and examined disparities in access to care and health outcomes.

Examples of key findings from the Summit are summarized below. A complete discussion, with supporting citations, is available from NAHC in its policy paper Housing is the Foundation of HIV Prevention and Treatment: Results of the National Housing and HIV/AIDS Research Summit, which can be found at www.nationalaidshousing.org.

Homelessness is a major risk factor for HIV, and HIV is a major risk factor for homelessness. Homelessness or unstable housing is directly related to greater HIV risk among vulnerable persons. The prevalence of HIV infection is three to nine times higher among persons who are homeless or unstably housed, compared to similar persons with stable and adequate housing. Indeed, overall rates of HIV infection among homeless populations range from 3-10% or higher—ten times the rate of infection in the general population. Homelessness and unstable housing are likewise common and recurring issues among persons living with HIV/AIDS. As many as 60% of all persons living with HIV/AIDS have experienced homelessness since becoming HIV positive; at any given time, up to 16% of all persons with HIV in some communities are homeless—sleeping in shelters, on the street or in cars.

Housing is HIV prevention. A growing body of research suggests that unstable housing is more strongly associated with increased HIV risk behaviors than individual characteristics of homeless and unstably housed individuals, highlighting the potential of housing as an independent structural intervention to reduce the spread of HIV. Persons who were homeless or unstably housed were two to six times more likely to have recently used hard drugs, shared needles, or exchanged sex than persons with stable housing, controlling for demographics, economic resources, health and mental health status, and service utilization. Persons whose housing status improved during the course of research were half as likely to use hard drugs, use needles, share needles or have unprotected sex as were individuals whose housing status did not change. Those whose housing status worsened over time were four times more likely than others to have recently exchanged sex. Indeed, research indicates that appropriate housing protects very-low-income individuals from “exposure” to a range of individual and public health threats, including HIV, violence, harmful drug use and incarceration. Housing protects and stabilizes not only individuals, but also their families and communities.

Housing is HIV health care. Housing is a matter of life or death for persons with HIV/AIDS. The all-cause death rate among homeless persons with HIV/AIDS is five times the rate of death among housed persons with HIV/AIDS. Lack of stable housing is a barrier to starting HIV health care, staying in care, and access to antiretroviral therapy (ART). Improved housing status is directly related to improved access to health care, higher levels of ART adherence, lowered viral loads, and reduced mortality. After controlling for variables including outpatient use at baseline, demographics, health status and receipt of case management, persons who improved their housing were almost five times more likely to report a recent outpatient visit for HIV care than persons who remained homeless or unstably housed. Homeless or unstably housed persons who improved their housing between baseline and follow-up were over six times as likely as persons who did not change their housing situation to be receiving antiretroviral medications at follow-up.

Housing is a cost-effective prevention and treatment intervention. The provision of housing for persons with HIV and persons at high risk of HIV due to homelessness may be not only lifesaving, but cost-effective as well. The economic costs of ongoing HIV transmissions and HIV treatment failure within this population are enormous. The estimated lifetime medical treatment cost of each new infection is $155,000-$195,000; the annual cost of providing supportive housing is approximately $14,000. Cost analyses of behavioral prevention interventions have demonstrated that their costs are more than offset by the savings associated with prevented HIV infections. Likewise, research has shown that the cost to the public of providing supportive housing is offset by reduced use of more expensive public services such as acute health care, mental health inpatient care, emergency shelters, and prisons and jails. The effectiveness and cost implications of housing as an HIV prevention and treatment intervention are currently the subject of a national research project conducted by the U.S. Department of Housing and Urban Development and the Centers for Disease Control and Prevention.

This growing body of knowledge supports a public health response to housing need. Models of care that include housing as a key component offer great power, enabling new and more effective approaches to HIV prevention and treatment. Four public policy imperatives emerged from the research presentations and policy discussions at the first National Housing and HIV/AIDS Research Summit:
  • Make subsidized, affordable housing (including supportive housing for those who need it) available to all persons with HIV;
  • Make housing homeless persons a top prevention priority, since housing is a powerful HIV prevention strategy;
  • Incorporate housing as a critical element of HIV health care; and
  • Continue to collect and analyze data to assess the impact and effectiveness of various models of housing as an independent structural HIV prevention and health care intervention.

Summit II: Transforming fact into strategy. The National AIDS Housing Coalition will convene the second National Housing and HIV/AIDS Research Summit on October 20-21, 2006, in Baltimore, Maryland, in collaboration with the Department of Health, Behavior and Society of the Johns Hopkins Bloomberg School of Public Health. Summit II will build on the momentum and results of the first Research Summit—providing a unique forum for continuing to gather and communicate what we know and what we need to know about HIV, housing, and individual and community health; and offering a first-of-its-kind opportunity for participants to transform research findings into concrete strategies for change.

Notes:

Virginia Shubert and Hilary Botein are the principals of Shubert Botein Policy Associates (www.shubertbotein.com). The National AIDS Housing Coalition (www.nationalaidshousing.org) retains SBPA to help plan, coordinate and document the National Housing and HIV/AIDS Research Summit Series.

For the Summit II schedule and registration information, contact NAHC at 1518 K St. NW, #410, Washington, DC 20005, 202/347-0333, nahc@nationalaidshousing.org. Early registration ends September 15.


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