National Housing and HIV/AIDS Research Summit Sponsored by the National AIDS Housing Coalition Housing is the Foundation of HIV/AIDS Prevention and Care

Acknowledgements  The National Housing & HIV/AIDS Research Summit is a project of the Visioning Committee of the National AIDS Housing Coalition.  The summit was hosted by the Emory Center for AIDS Research ( and supported by the efforts of Center Director Dr. David Holtgrave and Arnel Montenegro.  NAHC engaged Hilary Botein and Ginny Shubert from Shubert Botein Policy Associates ( to help plan and document the summit.  NAHC thanks the Emory University African American Alumni Association for providing meeting facilities at the Emory University Miller-Ward Alumni House.  NAHC gratefully acknowledges the financial support of the MAC AIDS Fund; Housing Works, Inc.; Broadway Cares; the Southern AIDS Coalition; the Corporation for Supportive Housing; the National Alliance to End Homelessness; the AIDS Foundation of Chicago; Gilead Pharmaceuticals; Bailey House, Inc.; Del Norte Neighborhood Development Corporation; AIDS Services of Dallas; CARES, Inc.; SAVE, Inc.; Gina Quattrochi in honor of Keith Cylar; Doorways Interfaith AIDS Residence; and Cassandra Ackerman.

Summit Background  First of its kind examination of the relationship of housing status to HIV prevention & treatment  Held June 11th & 12 th, 2005 at Emory University in Atlanta, Georgia  Working session of a core group of homelessness & HIV/AIDS researchers and advocates to discuss policy implications of existing & proposed research  Community discussion among advocates, providers & consumers from across the country of the importance of policy that is informed by rigorous research

Participating Researchers  Convening Researchers: Angela Aidala, Ph. D., of the Center for Applied Public Health at Columbia University & the Department of Sociomedical Sciences Dennis Culhane, Ph. D., of the Leonard Davis Institute of Health Economics & the Cartographic Modeling Lab at the University of Pennsylvania School of Social Work David Holtgrave, Ph. D., of the Rollins School of Public Health at Emory University  Participating Researchers: Martha Burt, Ph.D., of the Urban Institute’s Center on Labor, Human Services & Population Carlos del Rio, M.D., of the Emory University School of Medicine Ernest Drucker, Ph.D., of Montefiore Medical Center/Albert Einstein College of Medicine Elise Riley, Ph.D., M.P.H., of the University of California, San Francisco/San Francisco General Hospital Suzanne Wenzel, Ph.D, of the Rand Corporation

Summit Result: A Re-Visioned HIV/AIDS Housing Policy & Advocacy Agenda  Make subsidized, affordable housing (including supportive housing for those who need it) available to all low-income people living with HIV/AIDS.  Make housing homeless persons a top prevention priority, since housing is a proven HIV prevention strategy.  Establish a national commitment to decent, safe, affordable and adequate housing as a right of every American.

Homelessness & HIV Inextricably Linked  Homelessness is a major risk factor for HIV, and HIV is a major risk factor for homelessness  Studies have shown that from 3% to 10% of homeless persons are HIV+ (10 times the rate among general population)  40% to 60% of all PLWHA have lifetime experience of homelessness or housing instability  Research refutes the “risky person model” by showing that unstable housing is more strongly associated with greater HIV risk than individual characteristics

Research shows that housing works to:  Reduce HIV/AIDS transmission  Facilitate access to medical care  Improve health outcomes  Reduce harmful drug use, violence, incarceration and other public and private harm  Save taxpayer dollars  Protect and stabilize individuals, families and communities

Housing is HIV/AIDS Prevention  Recent research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues Recent hard drug use was 4 times higher among homeless persons Sex exchange was 4 times higher among homeless persons Homeless persons were 6 times more likely to engage in high risk sex  Reduction in risk with improved housing status; increase in risk when housing status worsened  Research involving indigent women suggests that housing may be protective against HIV, violence and other public health problems

Housing is HIV/AIDS Prevention  Access to housing increases access to antiretrovirals, which lowers viral load and may reduce the risk of transmission  Analyses have demonstrated the cost-effectiveness of behavioral prevention interventions; the cost of interventions is dwarfed by the savings realized through prevented infections  Estimated lifetime medical treatment cost of each new infection is $155,000 to $195,000  25% of persons with HIV/AIDS who do not know they are infected: Are transmitting at a 8.5% to 11% rate per year - compared to 1.7% to 2.5% for persons who are aware of their status

Housing is Health Care  Provision of housing is an important structural intervention to improve access to care, ongoing engagement in care, and treatment success  Being homeless is a barrier to starting outpatient care, staying in care and starting ART  Persons who are HIV+ and outside of any medical care are 4 times more likely to enter into health care if they have housing

Housing is Health Care  The all-cause death rate among homeless HIV+ persons is deaths per 100 person years compared to 1-2 for HIV+ persons who are housed  There is accumulating evidence that improved housing is associated with improved medical outcomes for formerly homeless persons with HIV: Lower viral loads Reduced mortality Improved health and social functioning

Access to ART by Homeless Persons  Recent research among homeless persons has found no evidence to support withholding antiretroviral treatment based on housing status Even a low level of adherence results in prolonged life, without increasing the risk of resistant strains Importantly, however: improved housing status improves adherence, and improved adherence is associated with improved health outcomes (including lowered viral load)

Research Gaps: Evidence We Need  Standardized definitions across fields to facilitate data collection and analyses Housing status Treatment access Health care outcomes  Demonstration of the cost effectiveness of housing as a structural intervention (comparing the cost of housing with the cost savings from improved outcomes) Housing as prevention Housing as a component of primary care and HIV drug therapy

Research Gaps: Evidence We Need  Mandatory collection of data on housing status in all funded research regarding HIV prevention and treatment and in all funded prevention and service interventions  Measures of the impact of housing on individual and community quality of life

Ongoing Challenges: Effectively “Framing” (presenting) the Evidence  Housing provides protection from “exposure” to a range of individual and public health threats, including HIV, violence, harmful drug use, incarceration  Housing is a key component of re-entry from prison or jail  Housing research refutes the “risky person” model  Housing active users is critical & effective (“low demand” housing models; “housing first” models; “harm reduction” housing)

Ongoing Challenges: Key Policy Issues  HIV/AIDS exceptionalism - the need for HIV-specific resources  Competition for limited funding - on every level of government  Refuting the predominate “risky person” model  Documenting the cost-effectiveness of housing as a structural intervention  Showing the impact of homelessness on the life of communities  Establishing & communicating the independent “effect” or significance of housing as a structural intervention necessary to address existing priorities: Disease prevention Health care treatment access and good outcomes Reduction of harm associated with drug use Successful re-entry following incarceration

Stay Tuned!  The National AIDS Housing Coalition will release a report of the results of the National Housing and HIV/AIDS Research Summit later this summer  To read more about the Summit, make sure you get a copy of the summit report, and to find out how to get and stay involved in advocacy efforts Go to NAHC at