Housing Protects and Improves Health Outcomes for People Living With HIV/AIDS

December 1^st is World AIDS Day, whose theme this year is "End inequalities. End AIDS. End pandemics". Despite the availability of prevention and treatment measures shown to be highly effective against HIV, the world is still a long way from reaching the UNAIDS target of ending AIDS by 2030. Vast economic, social, cultural and legal inequalities are the main obstacles that prevent drugs, information and preventive tools from reaching the people who need them the most. We will not be able to end the HIV epidemic if we continue to exclude marginalised populations, such as people affected by housing exclusion.

We will not be able to end the HIV epidemic if we continue to exclude marginalised populations, such as people affected by housing exclusion

Housing—adequate housing—is a fundamental right. However, since the financial crisis of 2008, housing exclusion—a concept that refers to situations rather than people, and which includes the categories of rooflessness, communal accommodation in temporary shelters, and unsafe or unfit housing—has been increasing at an alarming rate throughout Europe: more than 91 million people across the continent are now at risk of poverty or social exclusion and 700,000 sleep on the street every night. In Spain, it is estimated that more than 33,000 people are affected by housing exclusion and this figure is expected to increase. In Barcelona, there are currently at least 4,845 people in this situation, an increase of over 100% since 2008.

People experiencing housing exclusion have difficulty accessing the health system. According to Spain’s National Statistics Institute, 24% of Spanish people facing this situation and up to 76% of people of other nationalities do not have a health card. Specific measures such as Royal Decree-Law 16/2012 prevent people in an irregular situation from accessing primary care services. As a result, most people affected by housing exclusion do not use primary care; instead, they seek emergency care only when they find themselves in a serious or extreme situation.

The Impact of Housing on HIV/AIDS

Consequently, according to Spain’s 2015-2020 Comprehensive National Strategy for Homeless People, people affected by housing exclusion are at higher risk of infectious diseases such as tuberculosis and HIV, chronic diseases such as diabetes, substance use disorders and mental health disorders, while also have a reduced life expectancy of 30 years compared with the general population.

Housing has a direct and independent impact on the spread of HIV and the health of people living with HIV/AIDS. Housing exclusion is associated with a higher risk of HIV infection (due to the greater likelihood of certain risky behaviours such as condomless sex and needle sharing), inadequate medical care, poor adherence to treatment, poor health outcomes and premature death.

Housing has a direct and independent impact on the spread of HIV and the health of people living with HIV/AIDS

In fact, housing status is a stronger predictor of HIV health outcomes and poor adherence to treatment than sociodemographic factors, mental health or drug use. Whatever risk factors make a person vulnerable to HIV infection, homelessness increases that risk even further. Regardless of the factors that cause inequalities in medical care, housing instability exacerbates these inequalities in tragic and avoidable ways.

To improve care and treatment adherence for people living with HIV in a situation of housing exclusion, the recommended approach is individualised, patient-centred (i.e. taking patient preferences into account), flexible (i.e. allowing for drop-in visits), multidisciplinary (i.e. including psychological and addiction treatments) and integrated with housing facilities. Moreover, HIV treatments often involve taking several pills several times a day. Therefore, in order to improve the treatment adherence of unstably housed people, once-daily single-pill regimens should be prioritised.

Housing status is a stronger predictor of HIV health outcomes and poor adherence to treatment than sociodemographic factors, mental health or drug use

Peer Support

One intervention that has been shown to be effective is the “peer navigator” strategy, in which patients living with HIV help facilitate interaction with the health system for other people living with HIV and experiencing housing exclusion, guiding them throughout the process. In a US peer-support study that looked at a population of 700 unstably housed people with substance use and psychiatric disorders, 85% of newly diagnosed and out-of-care patients were linked to the health system, 83% were retained in HIV care and 80% were on treatment.

Despite the availability of effective interventions that improve the health of people living with HIV in situations of housing exclusion, the priority must be to ensure that no one is living on the streets. The implementation of specific housing programmes that guarantee stable housing for people living with HIV will implicitly help to manage their infection, while at the same time will help to prevent the spread of the disease, thereby furthering the goal of ending AIDS by 2030.