Part of the HIV PJA Social Driver Issue Brief Series “HIV/AIDS is more than just a disease, its proof positive of injustice.”
Housing, HIV and Social Justice There are many interlocking social drivers of the HIV/AIDS epidemic and many structural barriers to effective prevention, accessible care and elimination of disparities.i In this issue brief, we focus on housing, which cuts across virtually all populations and regions affected by HIV/AIDS. Furthermore, a growing consensus of research proves that housing can be key in helping individuals achieve stability and independence while lowering the risk of HIV transmission. Homelessness and inadequate or unstable housing cannot
Key Recommendations •
Expand and Prioritize Overall Federal Housing Assistance Increase Funding for Housing Opportunities for Persons with AIDS (HOPWA) Eliminate Program Restrictions Encourage Research, Evaluation, and Coordination
Learn more about the HIV PJA at preventionjustice.org be solved without simultaneously confronting related social drivers of the epidemic. HIV funding and the “AIDS sector” alone cannot overcome these barriers, so we must pursue a broad based social justice approach to HIV prevention. While this issue brief will describe the role housing plays as a social driver of the HIV epidemic, it is important to keep in mind that the individuals most at risk for HIV infection often find themselves subject to multiple structural barriers (e.g. homophobia, racism, poverty, mass incarceration, lack of housing opportunities) and experiencing multiple interrelated health problems (e.g. substance poor mental health, physical or sexual violence). However, ‘ignoring complexity and context doesn’t make it go away.’ii It is up to us as prevention justice advocates to begin to unpack these constructs in order to shape better policies.
The HIV Prevention Justice Alliance (HIV PJA) issue briefs are intended to serve as outreach and teaching tools to engage advocates and the general public in developing a deeper understanding of the social drivers of HIV and how they are connected to the underlying social justice issues fueling the HIV epidemic in the U.S.
HIV PJA Issue Brief: Housing, HIV, and Social Justice The work of carrying out and compiling evidence on housing as a social driver of HIV benefited from expertise in the field, particularly the National AIDS Housing Coalition (NAHC) and its partners, as well as the experts that informed the Findings and Recommendations from the Office of National AIDS Policy Consultation on Housing and HIV Prevention and Care. However, drawing on these resources, we hope to help prevention justice advocates from outside the housing sector make the connections between housing as a social driver of HIV, their own work, and the larger prevention justice movement.
housing as a human right as it relates to the right all persons have to an adequate standard of living. Unfortunately, the devaluing of marginalized communities and lack of political will on the part of policy makers stands in the way of assuring many human rights in practice. As such, a prevention justice policy framework, while founded on the bedrock of human rights, must also be based on research and evidence in support of goals that policy makers have already accepted, like reducing HIV incidence and ensuring access to care for all living with HIV/AIDS.
Housing is a Human Right
Housing as a Social Driver of HIV
The lack of stable housing is not only a key social driver of HIV, but is also an issue of fundamental human rights. Indeed, the Universal Declaration of Human Rights as adopted by the General Assembly of the United Nations in 1948 explicitly lists
What are Social Drivers? Social drivers are factors outside of an individual person that directly or indirectly influence: 1) an individual’s risk of being exposed to HIV and/ or 2) the health outcomes of those people already living with HIV/AIDS. These forces are often applied at a community level and pushed by structural factors (such as funding, zoning, regulation, infrastructure) meaning that interventions must occur at the community and structural levels to impact individuals in the population.
A strong and consistent body of research shows that housing status has an independent, direct impact on HIV risk, access to care, and HIV medical outcomes, regardless of demographics, drug use, health and mental health status, or receipt of other services, and that receipt of housing assistance is associated over time with reduced HIV risk behaviors and improved health care outcomes.iii Housing Influences HIV Risk Behavior The chaotic lifestyle that accompanies being homeless or unstably housed often results in chronic stress and a lack of stable relationships, both of which may influence patterns of drug use and sexual activity.iv As Aidala and Sumarjoto observe, addressing awareness of risk, motivation and intention goes only so far when persons are faced with the myriad challenges associated with the lack of stable, secure housing. Housing status is thus a significant structural or “environmental” risk factor that itself affects the ability of individuals to avoid risky situations or effectively use risk reduction resources.v Studies have demonstrated that homeless and unstably housed HIV-positive individuals are more likely to engage in sex exchange, have unprotected sex, use hard drugs, and share syringes.vi This independent effect of housing status on HIV risk behavior has been shown to impact populations
Learn more about the HIV PJA at preventionjustice.org
HIV PJA Issue Brief: Housing, HIV, and Social Justice already bearing the brunt of the epidemic â€“ gay men and other men who have sex with men, persons of color, women, and injection drug users.vii Housing Improves Health Outcomes: Treatment as Prevention Access to treatment and adherence to regimens lower viral load and reduce the likelihood of HIV transmission.viii However, homeless individuals are less likely than the general population to have stable access to health care, often relying on a patchwork system of public health care services and hospital emergency departments for life saving treatment. High rates of mental illness, substance abuse, and poverty can further complicate health problems. A lack of transportation, limited financial resources or things as simple as home phones for making appointments or a refrigerator for storing medications combine to create a tidal wave of challenges for HIV-positive homeless individuals needing to acquire and maintain HIV-related medical care.ix
Recommendations for Policy Makers Expand and Prioritize Overall Federal Housing Assistance Any programs aimed at keeping people stably housed or finding housing for those that are homeless will impact the HIV epidemic by improving health and reducing new infections. The U.S. Department of Housing and Urban Development (HUD) should receive funding at a level that sufficiently addresses the scope of the problem of homelessness and housing instability. This funding should also be prioritized for the most vulnerable individuals, including those living with or at risk for HIV. Increase Funding for Housing Opportunities for Persons with AIDS (HOPWA) HOPWA funded housing assistance currently only reaches approximately 56,600 households annually
Improving the housing status of unstably housed or homeless HIV-positive individuals is a structural intervention that simultaneously helps improve health outcomes and prevents new HIV infections from occurring.
Why Prevention Justice Advocates Should Prioritize Housing: 1)People at risk for HIV experience high rates of homelessness and unstable housing status. 2) Homeless and unstably housed individuals often are subject to other health problems related to increased HIV risk (substance use, physical or sexual violence, mental illness). 3) For those already living with HIV/AIDS, s table housing reduces the likelihood of transmitting the virus to others by decreasing risky behaviors, like sharing syringes, and lowering viral load, via increased access and adherence to HIV treatment.
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HIV PJA Issue Brief: Housing, HIV, and Social Justice – far less than estimated need. HIV-targeted housing assistance is cost-effectivex and represents a miniscule portion of the federal budget. The HOPWA program must be fully funded and new resources must be apportioned based on a living HIV/AIDS formula and consistent with the Ryan White funding formula. Housing for people living with HIV improves their health outcomes and reduces the risk of transmitting the virus. Eliminate Program Restrictions Many current housing assistance programs exclude individuals that are actively using drugs, have a history of incarceration or are in the process of re-entering society after time in an institution. These restrictions unjustly deny housing assistance to the most vulnerable populations, including people living with or at risk for HIV. Restrictions on HIV-targeted housing based on disease state or drug use should also be eliminated. ‘Housing first’ and harm reduction models must be integrated as key programmatic elements across the board. Encourage Research, Evaluation, and Coordination Recent research has begun to develop the connection between housing status, HIV risk, and health outcomes. However, much more work remains to be done in order to fully grasp the complexity inherent in these kinds of relationships. Program evaluation tools have helped to generate data that researchers can evaluate, feeding insights back into the policy making process. Funding agencies, such as the Health Resources Services Administration or the Department of Housing and Urban Development, should refine program evaluation tools in coordination with one another and the research community in order to ensure the most efficient and effective use of tax payer dollars.
Community Action Items Make sure the new National HIV/AIDS Strategy and CDC HIV/AIDS Strategic Plan prioritize housing
and result in expanded housing services These important new documents being developed in 2010 will help frame and shape the response to the HIV/AIDS epidemic over the next five years. It is critical that activists and advocates watch carefully and weigh in when drafts of these documents are made available for comment. After final versions are published, it is likewise critical that communities and national networks assess how the new priorities on social divers and structural interventions in general and housing in particular can be used as fulcrums for change on the ground. Establish links and coalitions with housing action groups and campaigns outside the HIV/AIDS arena Housing is a an unmet social need that affects far more than HIV/AIDS, and the cost of providing stable housing to all will require resources of the larger society, both governmental and private sectors. To leverage such unprecedented action will require wider and more powerful coalitions to build social and political will. We need to build bridges at the local, state and national levels with other housing action forces … sharing information, explaining if necessary the particular housing needs of people living with or at risk for HIV, and most of all, joining larger efforts or planning unified campaigns and strategies. Consider specific action campaign that highlights a particular HIV prevention justice goal While supporting national campaigns to eliminate federal restrictions on access to public housing (such as for those convicted of drug-related offenses), assess state and local barriers to accessing public housing or various housing assistance, particularly those related to other social drivers of HIV, like a history of incarceration or active substance use or mental illnesses. Choose one or two specific policy-change objectives that are both important in themselves and will help mobilize your community. Even some of the federally-imposed barriers allow room for local modifications if there is the will to use that freedom.
Learn more about the HIV PJA at preventionjustice.org
HIV PJA Issue Brief: Housing, HIV, and Social Justice F. (2007). “HIV, homelessness, and public health: Critical Issues and a call for increased action.” AIDS & Behavior, 11(6)/Supp 2: S167-S171.
Further Reading: National AIDS Housing Coalition nationalaidshousing.org
Aidala et al., “Housing status and HIV risk behaviors.”
Housing Works housingworks.org
Aidala & Sumartojo, 2007.
Aidala et al., “Housing status and HIV risk behaviors”; D. German, M. A Davey, and C. A Latkin, “Residential transience and HIV risk behaviors among injection drug users,” AIDS and Behavior 11 (2007): 21–30; D. P Kidder et al., “Housing Status and HIV Risk Behaviors Among Homeless and Housed Persons With HIV,” JAIDS Journal of Acquired Immune Deficiency Syndromes 49, no. 4 (2008): 451.
AIDS Foundation of Chicago aidschicago.org HIV Prevention Justice Alliance preventionjustice.org
About the HIV PJA
The HIV Prevention Justice Alliance (HIV PJA) is a coalition of organizations led by CHAMP in collaboration with AIDS Foundation of Chicago and Sister Love, Inc that mobilizes advocates in order to bring about more just and effective HIV prevention policy in the U.S. The prevention justice framework is built upon three elements: the need for a paradigm shift away from focusing solely on individual risk in HIV prevention to a model that also addresses structural factors and social justice issues, the method of community based research as a means of framing and answering questions in overlooked populations, and the strategy of inter-governmental collaboration and national planning in order to coordinate federal, state, and local efforts to prevent HIV.
See e.g. J. Auerbach, “Transforming Social Structures And Environments To Help In HIV Prevention,” Health Affairs 28, no. 6 (2009): 1655; G.R. Gupta et al., “Structural approaches to HIV prevention,” Lancet 372 (2008): 764–75; D. W Purcell and D. H McCree, “Recommendations From a Research Consultation to Address Intervention Strategies for HIV/AIDS Prevention Focused on African Americans,” American Journal of Public Health (2009). ii
J Auerbach et al., “Addressing Social Drivers of HIV/AIDS: Some Conceptual, Methodological, and Evidentiary Considerations” (aids2031, September 3, 2009).
Aidala, A. & Sumartojo, E. (2007). Why housing? AIDS & Behavior, 11(6)/Supp 2: S1-S6; Wolitski, R., Kidder, D. & Fenton,
B. D.L Marshall et al., “Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth,” Health and Place 15, no. 3 (2009): 753– 760; Wenzel et al., “Sexual risk among impoverished women”; R. J Wolitski, D. P Kidder, and K. A Fenton, “HIV, homelessness, and public health: Critical issues and a call for increased action,” AIDS and Behavior 11 (2007): 167–171.
Wolitski, Kidder, and Fenton, “HIV, homelessness, and public health”; D. R Holtgrave and J. W Curran, “What Works, and What Remains to Be Done, in HIV Prevention in the United States” (2006).
D. P Kidder et al., “Access to housing as a structural intervention for homeless and unstably housed people living with HIV: Rationale, methods, and implementation of the housing and health study,” AIDS and Behavior 11 (2007): 149–161.
See e.g., Sadowski, L., Kee, R., VanderWeele, T., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial, JAMA-Journal of the American Medical Association, 301(17), 1771; Buchanan, D.R. MD, Kee, R. MD, MPH, Sadowski, L.S. MD, MPH, and Garcia, D. MPH (2009). The Health Impact of Supportive Housing for HIVPositive Homeless Patients: A Randomized Controlled Trial, American Journal of Public Health, 99:6; AIDS Foundation of Chicago (AFC) (2009). Studies on Supportive Housing Yield Promising Results for Health of Homeless. Fact sheet prepared by the AIDS Foundation of Chicago, September 2009.
Learn more about the HIV PJA at preventionjustice.org