Housing and HIV/AIDS: A Public Health Opportunity
By Christy Hudson, Annick Benson-Scott
Ten years ago, an article in the American Journal of Public Health reminded the public health community of the intersection between housing and health, emphasizing the role of racial and socioeconomic disparities in both areas. In the article, James Krieger and Donna L. Higgins reminded readers of the progressive history of the public health profession and a continued responsibility to address housing as an important social determinant of health.
Like millions who live with chronic disease, persons living with HIV/AIDS are often low income and may also experience physical disabilities, mental illness, and substance use disorders. These conditions can present barriers to accessing health care and housing. To address these barriers, federally funded HIV programs, such as the Ryan White
HIV/AIDS Treatment Extension Act and the Housing Opportunities for Persons with AIDS program, provide support services, such as housing, as a health intervention.
The Case for Housing
To be effective, HIV medications need to be taken as prescribed 95 percent of the time. Proper adherence to HIV medications decreases concentrations of the virus in the blood, reduces the risk of transmission, and improves health outcomes. Numerous studies demonstrate that access to safe, secure, and stable housing provides a foundation for treatment adherence to HIV medications.
Research by David Buchanan and others, published in 2009, shared the results of a randomized controlled trial conducted with 105 HIV-positive participants who were being discharged from a Chicago hospital. The study found that participants in scattered-site permanent supportive housing were significantly more likely to have intact immunity (defined as alive with CD4 > 200 and viral load < 100,000) and undetectable viral loads (p=.04 and p=.051 respectively) at 12-month follow-up as compared to participants who received discharge planning as usual.
Housing also decreases the risk of transmission because people who are stably housed are less likely to engage in risky activities of survival. A multi-site behavioral survey, conducted by Daniel P. Kidder and others with 8,705 HIV-positive respondents, found that although housed individuals were more likely to be sexually active, housing instability was significantly predictive of multiple sex partners, sex exchange for housing or money, and unprotected sex, even when controlling for substance use.
Admittedly, the provision of housing is a resource-intensive undertaking. To look at the cost effectiveness of housing as an intervention, a study among 315 persons served with permanent supportive housing conducted by David L. Holtgrave and others showed that preventing as few as five transmissions to HIV seronegative partners made the intervention cost-effective.
Policies and Programs
In 2011, after 30 years of a national HIV epidemic, the Obama administration released the first National HIV/AIDS Strategy. The administration’s policy recommendations specifically included the need to address housing stability as an important health intervention. This recognition supports the perspective that meeting the basic needs of persons living with HIV/AIDS is as important as the medications and treatments they require to stay alive.
A regional example of the use of housing to improve health outcomes is the Oregon Housing Opportunities in Partnership Program, a permanent supportive housing program for people living with HIV. Begun in 2001 and currently administered by the Public Health Division of the Oregon Health Authority, the program serves about 160 households annually. The mission of the program is to help HIV-positive individuals and their families obtain and maintain housing stability to ensure access and retention in care and treatment.
The program provides rental assistance, and in partnership with local health departments and non-profit organizations, delivers case management and supportive services aimed to address barriers to housing stability and treatment adherence. Although there is no maximum on the amount of housing assistance an individual could receive, the average stay in program-supported housing is 37 months with the majority of individuals transitioning to permanent stable housing.
The program has successful outcomes. In 2012, 93 percent of clients maintained permanent stable housing, and 95 percent had regular contact with an HIV medical provider. This rate of contact for persons living with HIV is higher than the statewide rate of approximately 75 percent. The program leverages multiple Department of Housing and Urban Development funding streams and works closely with local housing partners to develop referral networks and partnerships. The formation of these relationships has provided an opportunity to participate as an active partner in the fight against homelessness and to advocate for a vulnerable population that still experiences significant stigma and discrimination.
Housing and Reform
The current era of health reform is a promising one for establishing housing as a public health intervention, not only for HIV-infected individuals but for those with tuberculosis infection, viral hepatitis, or obesity. As the health care system prepares for the implementation of the Affordable Care Act, the United States Department of Housing and Urban Development is also experiencing considerable change with the implementation of the Homeless Emergency Assistance and Rapid Transition to Housing Act. This legislation has the potential to create opportunities for innovative housing programs. With mechanisms like these, the public health community is well positioned to play a role in promoting housing as a cost-effective intervention for improving the health of vulnerable populations.
Christy Hudson, MSW, is currently the Grants and Capacity Building Coordinator for the HIV Care and Treatment Program of the Oregon Health Authority.
Annick Benson-Scott is the HIV Community Services Manager for the Oregon Health Authority.
- Aidala A, Cross JE, Stall R, Harre D, Sumartojo E. Housing status and HIV risk behaviors: implications for prevention and policy. AIDS Behav. 2005 9(3): 251-265.
- Buchanan DB, Kee R, Sadowski LS, Garcia D. The health impact of a supportive housing for HIV-positive homeless patients: A randomized controlled trial. Am J Public Health. 2009 99, S3, S675-S680.
- Oregon Balance of State HIV/AIDS & Service Systems Integration Plan: http://public.health.oregon.gov/DiseasesConditions/HIVSTDViralHepatitis/HIVCareTreatment/Documents/OregonPlanFinal08.pdf
- The positive impacts of affordable housing on health: A research summary. Center for Housing Policy & Enterprise Community Partners: http://chispahousing.org/docs/The%20Positive%20Impacts%20of%20Affordable%20Housing%20on%20Health.pdf
- Holtgrave DR, et al. Cost and threshold analysis of housing as an HIV prevention intervention. AIDS Behav 2007 11, S162-S166.
- Kidder DP, et al. Housing status and HIV risk behaviors among homeless and housed persons with HIV. Journal of Acquired Immune Deficiency Syndrome. 2008 00(0) : 1-5.
- Krieger J, Higgins DL. Housing and health: time again for public health action. AM J Public Health,2002 92, 758-768.