HIV, Homelessness, and Public Health: Critical Issues and a Call
for Increased Action
Richard J. Wolitski Æ Daniel P. Kidder Æ
Kevin A. Fenton
Published online: 4 August 2007
? Springer Science+Business Media, LLC 2007
nificant public health issues that increase the risks of HIV
acquisition and transmission and adversely affect the health
of people living with HIV. This article highlights the
contributions of selected papers in this special issue of
AIDS and Behavior and considers them within the broader
context of prior research on the associations between
housing status and HIV risk, use of HIV medical care,
adherence to HIV treatment, and the physical health of
HIV-seropositive persons. Special recognition is given to
the roles of interrelated health problems, such as substance
abuse, poor mental health, and physical and sexual abuse,
that often co-occur and exacerbate the challenges faced by
those who are homeless or unstably housed. Taken as a
whole, the findings indicate a critical need for public health
programs to develop strategies that address the funda-
mental causes of HIV risk among homeless and unstably
housed persons and, for those living with HIV, contribute
to their risk of disease progression. Such strategies should
include ‘‘mid-stream’’ and ‘‘upstream’’ approaches that
address the underlying causes of these risks. The successful
Homelessness and housing instability are sig-
implementation of these strategies will require leadership
and the formation of new partnerships on the part of public
health agencies. Such efforts, however, may have signifi-
cant effects on the individuals and communities most af-
fected by HIV/AIDS.
Unsafe sex ? Health services utilization ? Public policy
Homeless persons ? Housing ? HIV infections ?
The articles in this special issue of AIDS and Behavior add
further evidence that homelessness should be treated as a
major public health problem confronting the United States.
Prior research has repeatedly shown that homelessness is
associated with a wide range of chronic health problems
(including substance abuse and mental illness), physical
and sexual violence, and infectious diseases such as
tuberculosis and HIV infection (Aidala and Sumartojo
2007; Institute of Medicine 1988; Krieger and Higgins
2002; O’Toole et al. 2004; Zolopa et al. 1994). This special
issue represents a major contribution to existing knowledge
and highlights two key public health threats: (1) the asso-
ciations between homelessness and behaviors that increase
individuals’ risk of acquiring HIV or transmitting it to
others, and (2) the links between housing status and the
health and well-being of persons living with HIV.
The conditions that lead to homelessness for some
individuals, coupled with the numerous challenges of being
homeless, result in a substantially higher risk of HIV
acquisition. Persons who are homeless or unstably housed
have HIV/AIDS infection rates that are three to nine times
higher than stably housed persons (Allen et al. 1994;
Culhane et al. 2001; Estebanez et al. 2000; Zolopa et al.
1994). These elevated infection rates are attributable to a
range of behaviors that are associated with HIV risk
Disclaimer: The findings and conclusions in this report are those of
the authors and do not necessarily represent the views of the Centers
for Disease Control and Prevention
R. J. Wolitski (&) ? D. P. Kidder
Division of HIV/AIDS Prevention, National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention,
1600 Clifton RD NE (E-37), Atlanta, GA 30333, USA
K. A. Fenton
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, Centers for Disease Control and Prevention,
1600 Clifton RD NE (E-07), Atlanta, GA 30333, USA
AIDS Behav (2007) 11:S167–S171
including substance use, injection drug use, multiple sex
partners, and unprotected sex with casual partners (Aidala
et al. 2005; Allen et al. 1994; Burt et al. 2001; Culhane
et al. 2001; O’Toole et al. 2004). For example, in this is-
sue, Wenzel et al. (2007) found that African American and
Hispanic women who were homeless were much more
likely to have had multiple sex partners in the prior
6 months than were housed women, in part because of the
effects of physical violence and substance abuse.
Similarly, other studies in the special issue (Coady et al.
2007; Eastwood and Birnbaum 2007; DesJarlais et al. 2007;
German et al. 2007; Henny et al. 2007; Salazar et al. 2007)
illustrate how lack of housing operates as a contextual or
environmental influence that interacts with other risk fac-
tors such as substance use, risky sexual and injection
practices, sexual abuse, physical violence, poor mental
health, and sex work. Not only does homelessness con-
tribute to existing levels of risk, the longitudinal data
reported by Elifson et al. (2007) show that persons who are
unstably housed are less likely than their housed peers to
reduce their HIV risk. This finding has important implica-
tions for HIV prevention efforts as it shows, as many have
believed for some time, that it is more difficult to motivate
behavior change in people who are struggling with the
myriad of challenges associated with being homeless or
unstably housed. This does not mean, however, that persons
who are unstably housed cannot change their risk behavior.
As discussed below, research has shown that behavioral
interventions can significantly reduce risk behavior in this
Studies in this special issue and elsewhere also provide
important insights into the especially difficult circum-
stances faced by homeless persons living with HIV that
affect their risk behaviors and ability to maintain good
health over time. The higher levels of HIV observed in the
blood of unstably housed persons living with HIV com-
pared to those who are stably housed (Kidder et al., in
press; Knowlton et al. 2006) has ominous implications for
the health of unstably housed people living with HIV and
increases their biological potential to transmit HIV to
others. High viral load may indicate advanced HIV disease,
and persons with higher viral loads are more likely than
those with low or undetectable viral loads to efficiently
transmit HIV during risky sexual or drug injection behav-
iors (Montaner et al. 2006).
Access to regular medical care, use of effective anti-
retroviral medications, and high rates of antiretroviral
adherence are all important for reducing HIV viral load.
Unfortunately, homeless persons living with HIV are: (1)
more likely to delay entering HIV care, (2) more likely to
have poorer access to regular HIV care, (3) less likely
to receive optimal antiretroviral therapy, and (4) less likely
to adhere to therapy than stably housed persons (Aidala
et al. 2007; Kidder et al., in press; Leaver et al. 2007;
Smith et al. 2000). Many of these differences likely result
from the competing needs faced by homeless persons,
poverty, and the instability that being without permanent
housing causes in people’s lives. Some physicians may also
contribute to the poor health status of homeless persons
living with HIV by prescribing suboptimal antiretroviral
regimens or withholding antiretroviral treatment because
they are concerned that homeless persons cannot ade-
quately adhere to medical appointments and medication
dosing schedules (Kidder et al. 2006; Loughlin et al.
Even though homeless patients may be at greater risk of
poor adherence, many can achieve levels of adherence that
are comparable to housed populations (Bangsberg et al.
2000; Royal et al. 2006; Moss et al. 2004). Homeless and
unstably housed persons living with HIV have been shown
to significantly benefit from HIV treatment, even when
adherence is less than perfect (Bangsberg 2006; Bangsberg
et al. 2000; Kidder et al. 2006), and health care providers
should not deprive these patients access to this life-saving
treatment (Bangsberg and Moss 1999). This perspective is
consistent with public health guidelines that specifically
state that ‘‘no patient should automatically be excluded
from antiretroviral therapy simply because he or she
exhibits a behavior or characteristic judged by the clinician
to indicate a likelihood of nonadherence’’ (CDC 2002,
p. 7). As they would with other patients, health care pro-
viders should routinely assess and encourage adherence in
homeless and unstably housed persons living with HIV and
actively work with them to develop strategies for achieving
and maintaining high levels of adherence.
Taken as a whole, the available research makes it readily
apparent that access to adequate housing profoundly affects
the health of Americans who are at-risk for or living with
HIV. Sadly, much of the public health community has been
slow to recognize this fact and take action to address it
(Breakey 1997; Krieger and Higgins 2002). It is likely that
there are numerous reasons for this inaction, including a
failure to recognize the powerful connection between
homelessness and multiple health threats, a tendency for
public health programs to have a single focus rather than an
integrated approach to addressing closely related health
problems, a disconnect between housing and public health
efforts that is inherent in the separate funding streams and
organizational structures that typically support these activ-
ities, and a sense that homelessness is too big of a problem
for public health programs with limited budgets to take on.
Although it is true that there are many complex challenges
to improving public health’s response to homelessness, the
articles in this special issue provide a great deal of hope that
these challenges can be overcome and provide much needed
direction for moving the field forward.
S168AIDS Behav (2007) 11:S167–S171
A critical step that public health programs should take is
to expand their HIV prevention efforts to intervene with,
and provide services to, persons who are homeless or
unstably housed. As the studies in this issue demonstrate,
homeless persons living with HIV are at considerable risk
for multiple health threats that negatively affect their health
and increase the risk of HIV transmission to others. These
multiple risks make this population an especially important
one for intervention efforts. Prior research has shown that
providing risk reduction interventions in shelters serving
homeless and runaway youth can lead to reductions in
substance use and risky sex (Rotheram-Borus et al. 1991).
Several other interventions have been shown to signifi-
cantly reduce risk behavior among people living with HIV
(Lyles et al. 2007), and it is likely that these can be suc-
cessfully adapted for those who are inadequately housed.
In addition to interventions that reduce risk behavior,
public health programs should also ensure that people
living with HIV are linked to adequate medical care. Case
management is one strategy that can facilitate access to and
maintenance in care (Gardner et al. 2005) and has been
shown to improve antiretroviral adherence and immune
function (Kushel et al. 2006). Integrated models of health
care and service provision, in which a range of infectious
diseases, chronic illnesses, and mental health and social
service needs are addressed, can play an especially
important role in engaging and maintaining homeless and
unstably housed persons in care (Douaihy et al. 2005;
Nyamathi et al. 2005). Various models for creating inte-
grated systems of care already exist and may guide local
communities in the planning and implementation of their
own integrated systems of care (e.g., Gordon et al. 2007;
Nyamathi et al. 2005; O’Connell et al. 2005).
Reaching those who are homeless or unstably housed is
complicated by the fact that homelessness is often a tran-
sitory state. Furthermore, housing is multidimensional and
many individuals experience different forms of housing
instability that increase their risk for multiple health threats
(Scott et al. 2007; Weir et al. 2007). Many at-risk members
of this population may not be reached through programs
that only provide shelter or other forms of assistance to
those who are currently living on the street. Even when
they are reached, many homeless and unstably housed
persons may not be recognized as such in HIV prevention
programs, research, and disease or behavioral surveillance
systems. Including a brief assessment of housing status as
part of screenings conducted in public health programs and
clinics may be useful for identifying homeless and unstably
housed individuals who are at increased risk for multiple
health threats. Collecting data about housing status in on-
going research and surveillance efforts represents a low-
cost strategy that also has the potential to yield significant
benefits by expanding the existing research literature.
Interventions that motivate individuals to eliminate
HIV-risk behaviors, remain connected to care, and adhere
to treatment regimens face an uphill battle as long as
participants or clients remain homeless or unstably housed.
Ultimately, such efforts may be more successful if they are
based on ‘‘mid-stream’’ and ‘‘upstream’’ approaches (Sat-
cher 2006) that address community-level influences and
policies that negatively affect the ability of at-risk indi-
viduals to obtain safe and healthy housing. These influ-
ences include the cost and limited availability of prevention
and medical services, poverty, racism, and other forms of
discrimination. Much remains to be learned about the most
efficient ways to influence these factors, but it is clear that
we must address these factors that perpetuate risk and ill
health among the homeless and other disenfranchised
Funding and implementing programs that assist indi-
viduals with obtaining permanent housing and maintaining
them in housing represent specific structural interventions
that may yield substantial benefits (Fenton and Imrie 2005;
Sumartojo 2000). The results of Project Independence
(Dasinger and Speiglman 2007) demonstrate that even
modest amounts of rental assistance can make it possible
for HIV-seropositive people who were at risk of becoming
homeless to remain in their homes. The impressive finding
that 96% of participants in Project Independence were still
housed 2 years later, compared to 10% of persons not en-
rolled in the project, is a powerful illustration that even a
relatively small investment has the potential for a very
substantial public health benefit.
The ability of modest and more ambitious investments
in housing to improve the health of persons living with
HIV and prevent transmission to others is a critical issue
for public health. Cross-sectional studies and longitudinal
observations of persons living with HIV have shown that
moving into stable housing is associated with engagement
in medical care, positive health outcomes, and reduced risk
behavior (Aidala et al. 2005; Leaver et al. 2007). These
studies do not, however, provide definitive proof of the
effectiveness of housing as a public health intervention
because of possible biases associated with the receipt of
housing services. Many housing programs require that
individuals be drug-free in order to obtain and keep
housing benefits, which may bias comparisons of health
status and risk behavior. The ability to obtain housing may
also be differentially determined by client need or by the
skill, persistence, or other characteristics of persons seek-
ing housing services. The results of the Housing and Health
Study (Kidder et al. 2007) should provide data that address
at least some of these limitations. Although outcome data
are not yet available, it is reassuring to see the high follow-
up rates (85% at 18 months) achieved in this study. It is
even more exciting to see the cost analysis presented by
AIDS Behav (2007) 11:S167–S171 S169
Holtgrave et al. (2007), showing that this approach has the
very real potential to be cost effective or even cost saving.
Obtaining the data to support the cost effectiveness of
housing as a public health intervention has the potential to
play a major role in shaping not only the future public
health response to the HIV epidemic but could also have a
substantial impact on housing policy in the United States
As important as data showing the cost effectiveness of
housing as an HIV intervention would be, it is essential that
we not lose sight of the fact that housing is a fundamental
human right (Thiele 2002) and that housing plays a major
role in a wide range of health problems. Public health
agencies have an important role to play in ensuring that
vulnerable populations have access to the basic essentials
of healthy living including access to good nutrition, clean
air and water, and adequate housing. Ensuring equitable
access to these essential building blocks of good health will
require leadership and sustained effort from public health
agencies, housing providers, homeless and unstably housed
persons, and their advocates. In order to effectively bring
about change at the local, state, and national levels, agen-
cies and organizations will have to expand existing coali-
tions and reach out to new partners with whom they may
not have worked with closely in the past. By forging new
partnerships, new opportunities can be created to ensure
that basic human rights and public health needs are both
satisfied. We expect that the data in this special issue will
be an important catalyst for forming new partnerships,
shaping the goals and activities of these partnerships, and
strengthening the empirical basis of efforts to improve the
health of homeless and unstably housed persons in the
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