34th PCB Thematic – second moderated panel discussion
By NGO Delegate Charles King, North America
“Low-Threshold Harm Reduction Housing for Active Substance Users Living with HIV who are Experiencing Homelessness or Housing Insecurity”
I used to walk the streets of New York City and see people sitting on the sidewalk holding signs that read “Homeless with AIDS – Please help me!” and I used to think to myself, how could this possibly be happening in the wealthiest city, in the wealthiest country in the world. That question led me to join a small group of people who formed the Housing Committee of ACT-UP New York to agitate about homelessness.
As it turns out, homeless people with HIV and AIDS in NYC tend to come from certain specific groups – many use injection drugs or smoke crack; many are mentally ill; many are gay, bisexual, transgender or lesbian, and had their first taste of homelessness as abused or cast-away adolescents or teenagers; many are former prisoners, usually convicted of crimes associated with addiction or poverty. And of course, all of these cohorts overlap enormously.
In other words, the reason NYC had an estimated 12,000 homeless people with AIDS living on its streets in 1989 was because these were people we would just as soon throw away. But of course, the excuses always give for not doing anything was that “drug addicts can’t be housed.” So we founded Housing Works to prove that this wasn’t true.
(After all, most people who are addicted to drugs or alcohol are not only stably housed, they go to work every day … and if you don’t believe that, you don’t know your neighbors very well!)
Our approach is pretty simple. We provide people – single adults, couples, and families with children with safe decent housing and wrap support services around it. What does safe and decent mean? Well, I have lived in one of our community housing facilities now for over 15 years – so it has to be good enough to where I would want to live there. What kind of services? It depends. For some it is a home visit by a care manager at least once a week, every day when there is a crisis. For others, in congregate units, we have trained staff on site 24 hours a day. What you do in the privacy of your apartment is your business, but we are always ready to listen and help out if you have a problem.
So what is the result? Well, the overwhelming magnitude of our folk do quite well, with many moving to our more independent housing settings after a year or two in a supportive environment. All in all, about 95% of the people we house come in with long histories of addiction. And generally, we see the same pattern in our facilities. Over time, about 1/3 of people stop using drugs all together, 1/3 reduce or change their use so that they can successfully manage all of their other activities of daily living, including employment. And 1/3 continue to live reasonably chaotic lives but are having their health needs met.
Even before we started “the Undetectables,” over 70% of people living in our housing were completely virally suppressed. And that isn’t unusual. Studies show that housing stability is a much bigger predictor of viral suppression than factors such as mental illness or drug use. And just to show you why housing is so important, people who are housed after being homeless are four times less likely to engage in high risk behavior such as sharing syringes or transactional sex. When you look at data like that, you quickly see that housing is an effective healthcare intervention for people living HIV, both for its prevention benefits and for the direct health outcomes.
But housing is just the first step. If you offer other services on top of housing, like voluntary harm reduction therapy, mental health services and education, job vocational training and work opportunities, such as we have at Housing Works, you achieve even bigger success. What kind of success? Well, over 25% of Housing Works’ 600 fulltime employees, including a number of managers and program directors, came through our doors as homeless people living with AIDS.
What is the causal link between homelessness and HIV?
There have been a number of studies that show that homeless people are up to seven times more likely to become HIV positive than other people, even controlling for other risk factors such as injection drug use and sex work. For homeless people, it’s not about risk behaviors – it’s more about a high-risk context that involves chaos, violence, particularly for homeless women and gay men, lack of privacy, and pressure to engage in high-risk sex for survival.
In fact, we are seeing a case study of these unfold before our eyes in Greece, where the economic crisis has forced more people who use drugs into homelessness, resulting in huge upsurge of new HIV infections.
Why is housing so important?
Safe, stable housing is the threshold to everything else, including reducing risk, increasing access to care and maintenance of treatment, and the ability to make positive and healthy choices and changes in behavior. Study after study shows that:
- Housing reduces behaviors that can transmit HIV
- Increases rates of engagement in primary care
- Increases use of ARVs
- Increases adherence to treatment
- Increases viral suppressing
- Reduces avoidable emergency room and in-patient care
- And uses less public resources even taking into account housing supports… unless of course, you count on people dying earlier for lack of a place to live.
What are appropriate up-steam interventions?
The first thing we need to do is just start tracking the housing status of the people we serve – it costs almost nothing but that isn’t done in most places and if we tracked it – the implications would jump out at us.
The second thing is to start seriously experimenting with housing interventions, from rent subsidies to supportive congregate housing, in low and middle income countries to prove the viability and cost-effectiveness of the intervention in those settings – it’s pretty shocking that the only body of research on housing and HIV is in North America.
The third is to scale up using both HIV specific and cross-sectorial HIV-sensitive approaches. For example, housing program targeting key homeless populations with HIV aren’t that expensive. Meanwhile, if a LIC or MIC is using World Bank money to develop housing, why not prioritize housing homeless people with HIV an those most at risk of infection?
Sitting here in front of representative of nation states, large and small, rich and poor, I ask you to imagine what it would be like if you were a homeless person with HIV or AIDS. Where would you sleep? What would you eat? How would you bath or take your ARVs? And how would you feel when people look the other way as they pass you by on the streets as if you were nothing more than unsightly rubbish?
Then imagine if that person you just conjured up were your brother or your sisters, your son or your daughter. And when you go home to the country from which you have come, or to the next meet with the leadership of a country to which you give aid, consider a program that treats every homeless person with HIV as if he or she is that person. If you do that, we will know the real meaning of solidarity in a world living with AIDS.