Housing is the Foundation of HIV Prevention and Treatment
Compelling new research findings demonstrate the significance of housing as an intervention to address 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.
Models of care that include housing status as a key component offer great power, enabling new and more effective approaches to HIV prevention and treatment.
Recent studies that examine the relationship of housing status to HIV prevention and care show strong correlations between improved housing status and reduced HIV risk, improved access to medical care, and better health outcomes. Homelessness or unstable housing is directly related to greater HIV risk among vulnerable persons. For persons with HIV, being homeless is a barrier to starting outpatient care, staying in care and starting antiretroviral therapy (ART). For those engaged in HIV care, improved housing status is directly related to higher levels of ART adherence, lowered viral loads, and reduced mortality. Indeed, appropriate housing protects 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.
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.
There is also evidence that housing is a cost-effective prevention and treatment intervention.
Research involving behavioral HIV prevention interventions has shown that the costs of the interventions is dwarfed by the substantial 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 United States Department of Housing and Urban Development (HUD) and the Centers for Disease Control and Prevention (CDC).
These powerful findings provide the basis for a sound, data-driven public health response to housing needs of persons living with HIV/AIDS, and of persons whose homelessness places them at heightened risk of HIV infection – a response based on facts rather than assumptions, on research rather than opinion. On June 11 and 12, 2005, the National AIDS Housing Coalition (NAHC) convened a small group of leading health, housing, and social service researchers and policy makers to discuss and document existing and proposed research regarding the relationship between housing status and HIV prevention and care. The National Housing and HIV/AIDS Summit provided an unprecedented opportunity for national research and policy experts to share existing data regarding the role of housing as a public health intervention, and to identify gaps in current knowledge and questions for ongoing examination.
The research findings presented and discussed at the Summit support the development of new housing policies and practices based upon the proven effectiveness of and primary importance of housing as a structural HIV prevention and treatment intervention. This paper summarizes those findings, framed in terms of four public policy imperatives that are dictated by our current understanding of the critical relationship of housing and health:
First Imperative: Make subsidized, affordable housing (including supportive housing for those who need it) available to all low-income people living with HIV/AIDS;
Second Imperative: Make housing homeless persons a top prevention priority, since housing is a powerful HIV prevention strategy;
Third Imperative: Incorporate housing interventions as a critical element of HIV health care; and
Fourth Imperative: Continue to collect and analyze data to assess the impact and effectiveness of various models of housing as an independent structural HIV prevention and healthcare intervention.
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