The Role of Housing in Ending the HIV Epidemic
By Sophia Goetz with art by Sana Ikramuddin
Where someone lives—both in terms of the stability, affordability, and quality of housing, and the characteristics of their neighborhood—can have a profound impact on their health and wellbeing. Social determinants of health are the conditions in which people are born, grow, work, live, and age, and the broader set of forces and systems that shape conditions of daily life. Housing acts as a social determinant of health; research tells us that where someone lives influences their health and wellbeing, and that stable housing is associated with better health outcomes. Powerful HIV prevention and treatment tools help keep people healthy and prevent HIV transmission, but nonmedical factors can certainly also influence HIV-related health outcomes. In contrast to many other illnesses, HIV is unique. When one gets tested for other conditions, especially other communicable diseases, these complicated physical, emotional, social, and economic considerations do not surface. Although improvements in treatment have significantly improved the lives of many persons with HIV, knowledge and acceptability within American society have not changed as significantly. About 30 years after the HIV epidemic began, HIV stigma and prejudice still exist and have a significant negative impact on those who are affected by the virus. Today, in the United States, people with HIV are still denied employment, fi red from their homes, told to limit contact with family, and subjected to numerous other forms of discrimination. Perhaps most disturbingly, health care staff have been known to stigmatize individuals with HIV, in some cases refusing to treat them or delivering subpar care. Frequently, individuals fi nd that even family and friends behave differently around and toward them after learning they have the virus. And while this stigma currently exists against those who are affected by the virus, systemic prejudices toward underrepresented communities–such as indigenous people, people of color, LGBTQIA+ people, and the homeless– inform a lack of access to care.
How do HIV and Homelessness Inform One Another?
HIV and homelessness are intricately related. The costs of health care and medications for people living with HIV are often too high for people to keep up with. In addition, affected individuals are in danger of losing their jobs due to discrimination or as a result of frequent health-related absences. And as we live in a nation where the majority of working-class Americans are less than a couple of missed paychecks from abject poverty, it is no wonder that nearly half of all people affected by HIV in the United States stand at risk of becoming homeless. In terms of its effects on mental and physical health, homelessness already has dire consequences. The long term consequences are grave, with higher incidence and severity of illness and injury among people experiencing homelessness. According to a 2021 study done by the National Healthcare for the Homeless Council, chronic conditions, such as diabetes, hypertension, and heart attacks are almost twice as prevalent among people experiencing homelessness than in the general population; substance use disorders are three times as prevalent; and depression and hepatitis C are more than six times as prevalent. Homelessness also has serious developmental effects on children, and children experiencing homelessness have higher rates of mental distress, physical illness, and dental problems. Lacking stable housing makes treating every condition more diffcult and further damages health. People who die on the streets on average live roughly 30 fewer years than the US life expectancy, and the age-adjusted death rate of the homeless population is at least twice that of the general population. So how do HIV and homelessness in the United States inform one another? Stable housing is closely linked to successful HIV-related health outcomes. People experiencing homelessness or housing instability have higher rates of HIV than people with stable housing. Additionally, those experiencing homelessness or housing instability are also more likely to engage in activities associated with increased chances of HIV acquisition or transmission, including substance use, and injection drug use —factors that can also contribute to higher rates of sexually transmitted infections (STIs) and hepatitis. Individuals who have been diagnosed with HIV also experience greater risk for inadequate care and treatment due to unstable housing and housing loss. According to CDC data, in 2020, 17% of people with diagnosed HIV experienced homelessness or other forms of unstable housing.
What the Data Tells Us
Research shows that housing instability is a significant barrier to HIV care and is associated with higher rates of behaviors that may increase the chance of getting or transmitting HIV, such as substance use and condomless sex. According to a study done by AIDS Education Prevention in 2007, people with HIV experiencing homelessness are also more likely to delay entering HIV care, have reduced access to regular HIV care, and poorer adherence to antiretroviral treatment. In terms of access to testing for HIV, data shows that people experiencing homelessness or housing instability are less likely to report having tested for HIV in the past year or ever, compared to people with stable housing. One study found that gay and bisexual men experiencing homelessness are over fifteen times more likely to delay HIV testing than those with stable housing. Having access to general medical services is associated with higher likelihood of HIV testing, and recent access to any medical or dental services increases the likelihood of HIV testing among people experiencing homelessness. Meeting people where they are with the services they need can help overcome barriers posed by unstable housing and homelessness and support people to access and stay engaged in care. Some populations are disproportionately affected by both housing instability and HIV, highlighting persistent disparities in access to critical health and social services by race, ethnicity, age, and gender identity. Black people make up over 40% of the population experiencing homelessness in the United States, and 42% of new HIV diagnoses, despite making up only 14% of the population. Due to historical racial discrimination and residential segregation, some Black people live in communities with the highest social vulnerability, in which a number of factors, including poverty, lack of transportation access, and crowded housing, increase vulnerability to negative health outcomes and make it harder to obtain HIV care services. In 2019, 11% of Black people with HIV reported homelessness in the past year. Black adults who live in communities with high social vulnerability have increased chances of receiving an HIV diagnosis compared with Black adults in communities with the lowest social vulnerability. Transgender and gender non-conforming people are also more likely to experience housing instability or homelessness than cisgender people. From 2016 to 2019, the number of adult transgender people experiencing homelessness in the United States increased 88%. One analysis of studies conducted between 2006 and 2017 found that 30% of transgender people reported unstable housing or homelessness. Transgender people are also affected by HIV: in 2019, transgender people accounted for 2% of new HIV diagnoses in the United States and dependent areas, and HIV diagnoses among transgender people increased 7% between 2015 and 2019. Transgender women are disproportionately affected by HIV, with prevalence estimated at 14%. Ending the HIV epidemic in the United States requires implementing integrated solutions that address the comprehensive health, social services, and housing needs of people with HIV. And while the CDC is actively working with other federal agencies, people with HIV, and other community leaders to implement strategies that increase access to affordable, high-quality housing and support national HIV prevention goals, policy changes cannot ultimately end stigmatization.