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.
Housing Works:
A BriefWorks,
Overview Inc.
Housing
• 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 at Housing Works
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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
Summary of
Key Findings
on Housing
Housing
Works,
Inc.& HIV:
• 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
Housing Works, Inc.
Structural Determinants of HIV Risk: A Growing Consensus
•
“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
Poverty (notHousing
race) predicts
HIV
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”
Housing
Inc.
Homelessness
& HIV – Works,
Bidirectional
Risk:
• 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
Housing Status
PredictsWorks,
HIV Risk Behaviors:
Housing
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
Improved Housing
Reduces
HIV Risk
Housing
Works,
Inc.Behaviors:
• 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
Housing
Works,
Inc.Success:
Lack of Stable
Housing = Lack
of Treatment
• 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
Housing is Healthcare
–
Stable
Housing
Improves
Housing Works, Inc.
Health Outcomes:
• 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
Works,
Inc.
Housing Interventions = Stability & Better Health:
• 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
Works,
Inc.
Practice-based evidence at Housing Works:
• 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
But Can We
Afford It?Inc.
Housing
Works,
Improved Outcomes & Reduced Public Costs:
• 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
HousingAction:
Works,
Inc. Policy
Evidence-Based
Informing
• 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”
Housing
Works,
Inc.
IAC
2008: Mexico
City, Mexico
• 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
The International
Declaration
Housing
Works,
Inc.
On Poverty, Housing Instability, and HIV/AIDS
•
•
•
•
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,
•
•
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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
Housing
Works, Inc.
On Poverty, Housing Instability, and HIV/AIDS
• 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.
Housing
Works,
Inc.
IAC 2010: Vienna,
Austria
• 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
Housing
Works,
Inc.
United Nations
High Level
Meeting
on HIV/AIDS
• 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 8th UN High Level Meeting on
AIDS.
Housing
Works, Inc.
IAC
2012: Washington,
D.C.
July 22-27
• 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.
Housing
Works, Inc.
Get Involved!
•
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.org
•
Join the International AIDS Housing Roundtable:
http://groups.yahoo.com/group/iahr/
•
Endorse the International Declaration on Poverty, Housing Instability and HIV: http://nationalaidshousing.org/2008/07/endorseconference/
•
Use the NAHC Policy Tool Kit to inform local policy & funding decisions:
http://www.nationalaidshousing.org/policytoolkit.htm
•
Share your successes – let NAHC know how you use research findings to inform
practice and policy: nahc@nationalaidshousing.org