1. Shelter, Health care, And Drug use associations with Overall health, especially among Women (SHADOW) The SHADOW Qualitative Study Kelly Knight, Jennifer Cohen, Andrea Scott, and Elise Riley CAPS Conference April, 2006

2. Thinking across the behavioral-social-structural divides HIV is and has been embedded in multiple forms of oppression, such as social exclusion, racism and sexism, since the beginning of the epidemic. HIV is and has been embedded in multiple forms of oppression, such as social exclusion, racism and sexism, since the beginning of the epidemic. The ongoing challenge to HIV programs and research is in responding effectively to overlapping social vulnerabilities which play out on the individual and social levels as the HIV risk behaviors of individuals or groups. The ongoing challenge to HIV programs and research is in responding effectively to overlapping social vulnerabilities which play out on the individual and social levels as the HIV risk behaviors of individuals or groups. Qualitative methods provide both researchers and providers with keen insights into the complexity of social vulnerability and HIV risk that are useful to the development of prevention theory, research and practice because they can elucidate the social history and context of an individual and bring their HIV risk environments “to life”. Qualitative methods provide both researchers and providers with keen insights into the complexity of social vulnerability and HIV risk that are useful to the development of prevention theory, research and practice because they can elucidate the social history and context of an individual and bring their HIV risk environments “to life”.

3. Structural/environmental Social/interpersonal Personal/individual

4. The case study of HIV, homelessness and victimization The SHADOW qualitative investigation demonstrates how qualitative methods can be used to investigate the interplay between personal, social, and structural vulnerabilities. Personal/IndividualSocial/interpersonalStructural/environmental Drug use Sexual behavior Mental health Family/children Peer groups Intimate relationships Housing status HIV status Drug-sex economy

5. Research Questions How do HIV+ women navigate housing instability? How do HIV+ women navigate housing instability? What are the unique vulnerabilities that HIV+ women face when they are unstably housed? What are the unique vulnerabilities that HIV+ women face when they are unstably housed?

6. Qualitative Methods Qualitative Methods 20 women recruited from the REACH cohort 20 women recruited from the REACH cohort Interviewed for 60-90 minutes Interviewed for 60-90 minutes Topics: background, social and sexual relationships, current housing, recent housing mobility, safety and housing, financial support, social service utilization, and drug use Topics: background, social and sexual relationships, current housing, recent housing mobility, safety and housing, financial support, social service utilization, and drug use

7. Data Analysis Interviews were transcribed verbatim Interviews were transcribed verbatim Participant summaries were created from the interview topic areas Participant summaries were created from the interview topic areas Group analysis meetings discussed individual summaries and cross-participant emergent themes Group analysis meetings discussed individual summaries and cross-participant emergent themes

8. Preliminary findings Housing instability and HIV infection were highly linked to intimate partner violence (IPV). Housing instability and HIV infection were highly linked to intimate partner violence (IPV). Lifetime histories of housing instability and childhood physical and sexual victimization were common. Lifetime histories of housing instability and childhood physical and sexual victimization were common. Women described socially isolating from peers to control drug use and reduce (stranger/peer) victimization, but unsuccessfully shifting IPV relationships. Women described socially isolating from peers to control drug use and reduce (stranger/peer) victimization, but unsuccessfully shifting IPV relationships. HIV entitlements for housing and cash benefits were not adequately protecting women from housing instability and victimization. HIV entitlements for housing and cash benefits were not adequately protecting women from housing instability and victimization.

9. Homelessness is different for men and women

10. HIV Infection: Intimate partner violence (IPV) and housing instability

11. HIV infection: Sex work in the drug sex-economy

12. Why are HIV+ women at risk for housing instability? Gender roles and partner dependency

13. Legacy of IPV: On-going housing instability

14. Directions for Prevention: individual/clinical HIV+ women may still have housing instability HIV+ women may still have housing instability Homelessness and victimization are relational and historic Homelessness and victimization are relational and historic Focus on HIV negative unstably housed women to prevent future HIV infections Focus on HIV negative unstably housed women to prevent future HIV infections Explore social isolation as a survival skill (resilience) and weigh cost for the individual woman Explore social isolation as a survival skill (resilience) and weigh cost for the individual woman

15. Directions for Prevention: social/community Build community advocacy opportunities for marginally housed women within agencies (i.e. volunteer programs) Build community advocacy opportunities for marginally housed women within agencies (i.e. volunteer programs) Explore how build safe and supportive peer support for homeless women Explore how build safe and supportive peer support for homeless women Address IPV, and the psycho-social legacy of trauma and victimization, directly in HIV prevention programs Address IPV, and the psycho-social legacy of trauma and victimization, directly in HIV prevention programs

16. Directions for Prevention: Structure and Policy Analyze and amend laws that evict women who are victims of IPV Analyze and amend laws that evict women who are victims of IPV Provide couples access to housing with conflict resolution training and accountability for violent behavior Provide couples access to housing with conflict resolution training and accountability for violent behavior Improve health/social services oversight in access to transitional and permanent housing Improve health/social services oversight in access to transitional and permanent housing

17. Last words : “ I don’t want to die in a 1-room SRO!”

18. Contact information Kelly Knight CAPS-UCSF415.597.4651 kelly.knight@ucsf.edu Generation Five: http://www.generationfive.org http://www.generationfive.org Looking to End Abuse Permanently: http://www.leapsf.org/ http://www.leapsf.org/