1. Housing Is Healthcare SHNNY Conference: June 9, 2011 New York, NY Virginia Shubert, Shubert Botein Policy Associates Kenneth Robinson, Vice President for Housing Operations, Housing Works, Inc.

2. Housing Works, Inc. Founded in 1990 – spun off of ACT-UP – now the US’s largest minority controlled provider of housing & supportive services for homeless people living with HIV/AIDS. Four Adult Day Healthcare Centers, including four complete medical clinics. Community-based (COBRA) case management programs in all five boroughs of NYC; the largest in NY State. Advocacy offices in NYC, Albany, Washington & Mississippi Job Training Program Social Enterprise: 12 Thrift Stores; Used Book Cafe; The Works Catering; Gotham Property Management 170 units of housing Housing Works: A Brief Overview

3. Women’s Housing Program Transgender Housing Program Staten Island Housing Program Stand-Up Harlem House Jefferson Ave (in dvlpmt) Keith D. Cylar House East New York House Housing at Housing Works

4. Housing Works, Inc. Homelessness and unstable housing are linked to greater HIV risk, inadequate care, poor health outcomes & early death Studies also show strong & consistent correlations between improved housing status and… – Reduction in HIV/AIDS risk behaviors – Access to medical care – Improved health outcomes – Savings in taxpayer dollars Recent research shows that that housing is both effective and cost saving as a health care intervention for homeless/unstably housed persons with HIV & other chronic conditions Summary of Key Findings on Housing & HIV:

5. Housing Works, Inc. “Sustained progress in HIV prevention requires structural approaches rather than continuing to address individual-level factors. Structural factors can be influenced but until they are, individuals in many settings will find it difficult to reduce their risk and vulnerability.” The Lancet, 2008. “providing stable housing to people living with or most vulnerable to HIV infection is an effective strategy to prevent and mitigate HIV and AIDS.” Health Affairs, 2009 “We need to address larger environmental issues, such as poverty, homelessness and substance abuse, which are well beyond the traditional scope of HIV intervention. Addressing those is as essential to HIV prevention as providing condoms.” LA Times, 2010, quoting Dr. Kevin Fenton of the CDC Structural Determinants of HIV Risk: A Growing Consensus

6. Housing Works, Inc. CDC analysis of National HIV Behavioral Surveillance among heterosexuals in 25 cities Men and women in 23 major U.S. cities living below the poverty line were twice as likely to have HIV infection (2.4%) as those living above it (1.2%) Homelessness, unemployment, low education level—all independently associated with HIV infection Homeless in last 6 months doubled risk of HIV diagnosis In NYC, respondent driven sample from 30 poor neighborhoods – 39% currently homeless 9.2% of women tested HIV positive – 96% did not know status “Individual risk behaviors do not appear to explain the high prevalence of HIV” Poverty (not race) predicts HIV

7. Housing Works, Inc. Rates of HIV infection are 3 times to 16 times higher among persons who are homeless or unstably housed, compared to similar persons with stable housing Over time studies show that among persons at high risk for HIV infection due to injection drug use or risky sex, those without a stable home are more likely than others to become infected HIV is also a major risk factor for homelessness: up to 70% of all PLWHA report a lifetime experience of homelessness or housing instability Currently, over 142,000 PLWHA in the US are homeless or unstably housed Homelessness & HIV – Bidirectional Risk:

8. Housing Works, Inc. Research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues Homeless or unstably housed persons were 2 to 6 times more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal and service use characteristics Homeless women were 2 to 4 times as likely to have multiple sex partners as housing indigent women – in part due to the effects of physical violence Housing Status Predicts HIV Risk Behaviors:

9. Housing Works, Inc. Overtime studies show a strong association between change in housing status and risk behavior change Over time, persons who improved housing status reduced risk behaviors by half; while persons whose housing status worsened over time were 4 times as likely to exchange sex Access to housing also increases access to appropriate care and antiretroviral medications which lower viral load, reducing the risk of transmission Improved Housing Reduces HIV Risk Behaviors:

10. Housing Works, Inc. Data from the CDC SHAS project: homeless PLWHA compared to stably housed: – More likely to delay entry into care and to remain outside or marginal to HIV medical care – Worse mental, physical & overall health – More likely to be uninsured, hospitalized & use ER – Lower CD4 counts & less likely to have undetectable viral load – Fewer ever on ART, and fewer on ART currently – Self-reported ART adherence lower Housing status found more significant than individual characteristics as a predictor of health care access & outcomes Lack of Stable Housing = Lack of Treatment Success:

11. Housing Works, Inc. Homeless/unstably housed PLWHA whose housing status improves over time are: –More likely to report HIV primary care visits, continuous care & care that meets clinical practice standards –More likely to return to care after drop out –More likely to be receiving HAART Increased housing stability is positively associated with: –Effective HAART (viral suppression) –Better HIV related health status ( as indicated by viral load, CD4 count, lack of co-infection with HCV or TB) Placement is supportive housing has been found to reduce mortality among homeless PLWHA by as much as 80% over time Housing is Healthcare – Stable Housing Improves Health Outcomes:

12. Housing Works, Inc. The Housing & Health (H&H) Study, a 3-city randomized controlled trial (RTC) examining the impact of HOPWA vouchers, found that 84% of voucher recipients remained stably housed at 18 months, and that Increased housing resulted in a 35% reduction in ER visits and 57% reduction in hospitalization But H&H participants who remained homeless were 2.5 times more likely to use an ER, 2.8 times more likely to have a detectible viral load, and more likely to report unprotected sex and perceived stress Likewise, the CHHP Study, a Chicago-based RTC of supportive housing for chronically ill homeless persons, showed that PLWHA who received a housing placement were twice as likely at 12 months to have an undetectable viral load as those who did not receive housing Housing Interventions = Stability & Better Health:

13. Housing Works, Inc. Community based participatory research (CBPR) partnership with the University of Pennsylvania School of Social Policy & Practice – Collaborative agenda setting – Advocacy-based research agenda Agency-wide standardized assessment process/tools – Incorporating validated measures – Staff training & mentorship Examining the effectiveness of a housing-first program in promoting HAART adherence for a sample of previously homeless PLWHA – Initial findings: residents 3x more likely to have undetectable viral load at follow up – Exploring the pathways through which housing influences medication adherence Practice-based evidence at Housing Works:

14. Housing Works, Inc. CHHP, H&H and other research studies show that investments in supportive housing reduce emergency and inpatient health services, criminal justice involvement, and other crisis costs A SF Dept of Public Health study found that low-threshold supportive housing reduced health care costs by 55% for HIV+ residents, generating savings that fully offset the cost of the housing intervention Where We Sleep, a large-scale study using administrative records in Los Angeles, found 19-79% reductions in average monthly public costs when homeless individuals obtained housing, with the largest cost savings among PLWHA But Can We Afford It? Improved Outcomes & Reduced Public Costs:

15. Housing Works, Inc. The U.S. National HIV/AIDS Strategy, released July 2010: – Recognizes that housing is healthcare for PLWHA – Calls for increased housing resources for households living with HIV – “Federal agencies should consider additional efforts to support housing assistance and other services that enable people living with HIV to obtain and adhere to HIV treatment.” Opening Doors: Federal Strategic Plan to Prevent and End Homelessness, released June 2010: – Recognizes housing as an evidence-based HIV prevention and health care intervention for homeless/unstably housed persons – “Housing assistance coupled with health care has been shown to decrease overall public expense and make better use of limited public resources” Evidence-Based Action: Informing Policy

16. Housing Works, Inc. Aug. 3-8;19 staff and clients from Housing Works attended Primary goal was to promote the need for adequate housing as a vital structural intervention in the global fight against HIV/AIDS. On Sunday, August 3, 2008, we convened the first-ever IAC session addressing homelessness and AIDS: The International Summit on Poverty, Homelessness & HIV/AIDS At the end of the session we presented an International Declaration demanding that governments and policymakers address the lack of adequate housing for homeless people living with HIV/AIDS IAC 2008: Mexico City, Mexico

17. Housing Works, Inc. Whereas adequate and secure housing has long been recognized as a basic human right, Whereas growing empirical evidence shows that the socioeconomic circumstances of individuals and groups are equal or even more important to health status than medical care and personal health behaviors, Whereas in the case of HIV/AIDS, the link between poverty and disparities in HIV risk and health outcomes is well established, and new research findings demonstrate the direct relationship between inadequate housing and greater risk of HIV infection, poor health outcomes and early death, Whereas poor living conditions, including overcrowding and in extreme cases, homelessness, undermine safety, privacy and efforts to promote self-respect, human dignity and the attendant responsible sexual behavior, Whereas the lack of stable housing directly impacts the ability of people living in poverty to reduce HIV risk behaviors and homeless and unstably housed persons are two to six times more likely to use hard drugs, share needles or exchange sex than similar persons with stable housing, Whereas, in spite of the evidence indicating that adequate housing has a direct positive effect on HIV prevention, treatment and health outcomes, the lack of adequate housing resources has been largely ignored in conferences and policy discussions at the international level, and Whereas the United Nations, in both its 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS, embraced the goal of universal access to comprehensive prevention programs, treatment, care and support by 2010. The International Declaration On Poverty, Housing Instability, and HIV/AIDS

18. Housing Works, Inc. Therefore, we hereby demand that policy makers address the lack of adequate housing as a barrier to effective HIV prevention, treatment and care; and we further demand that all governments fund and develop housing as a response to the AIDS pandemic. The International Declaration On Poverty, Housing Instability, and HIV/AIDS

19. Housing Works, Inc. July 18-23; 23 clients and staff from Housing Works attended On July 18, Housing Works convened a satellite session, “Housing & HIV/AIDS: Bridging the Gap” It was a week jam-packed with both intense advocacy & activism initiatives, all to bring attention to the need for adequate housing as a vital structural intervention in the global fight against HIV/AIDS and the plight of AIDS services in Haiti, which had become virtually non-existent after the earthquake IAC 2010: Vienna, Austria

20. Housing Works, Inc. June 8-10, 2011 UN Declaration on HIV/AIDS includes housing as part of an “effective global response to HIV.” This groundbreaking step would boost activists’ efforts to convince world governments to provide housing to the poor as part of a comprehensive strategy to prevent and treat HIV/AIDS. The declaration will be released at the June 8 th UN High Level Meeting on AIDS.June 8 United Nations High Level Meeting on HIV/AIDS

21. Housing Works, Inc. The return of the International AIDS Conference to the United States in July 2012 represents a significant victory for public health and human rights The selection of Washington, DC as the site for the XIX International AIDS Conference (AIDS 2012) is the result of years of dedicated advocacy to end the nation’s misguided entry restrictions on people living with HIV – restrictions that were based on fear, rather than science The National AIDS Housing Coalition, Housing Works & other partners will hold a pre-conference on Housing & HIV/AIDS We are working to have a plenary session, as part of the official program. IAC 2012: Washington, D.C. July 22-27

22. Housing Works, Inc. Attend the Housing & HIV/AIDS Research Summit VI in New Orleans, Sept. 21-28, 2011, as convened by the National AIDS Housing Coalition (NAHC) and the Ontario HIV Treatment Network. Stay in touch for news and materials on the Summit Series website: www.hivhousingsummit.orgwww.hivhousingsummit.org Join the International AIDS Housing Roundtable: http://groups.yahoo.com/group/iahr/ http://groups.yahoo.com/group/iahr/ Endorse the International Declaration on Poverty, Housing Instability and HIV: - http://nationalaidshousing.org/2008/07/endorseconference/ http://nationalaidshousing.org/2008/07/endorseconference/ Use the NAHC Policy Tool Kit to inform local policy & funding decisions: http://www.nationalaidshousing.org/policytoolkit.htm http://www.nationalaidshousing.org/policytoolkit.htm Share your successes – let NAHC know how you use research findings to inform practice and policy: nahc@nationalaidshousing.orgnahc@nationalaidshousing.org Get Involved!