From the chilly houses in New Zealand’s south to the single-room-occupancy units of Vancouver’s downtown eastside, housing is making big a difference for community health ― including for people living with, or affected by, HIV/AIDS. As we gear up for PAN’s Positive Living, Positive Homes research project, here is a summary of recent research that brings insights on the importance of housing for health.
It is well known that poor housing contributes to a variety of health conditions. Research is increasingly showing how poverty often involves living with housing deficiencies that can create serious health risks relating to factors like mold, dust mites, dampness and lead pipes.6 Researchers refer to this situation as a housing exposure chamber, in which people are exposed to ongoing health threats and toxins that make houses into hazards rather than healthy homes.
For instance, improper insulation and fuel poverty have come to be pressing issues in countries such as New Zealand, with about a quarter of the population unable to afford heating costs, leading to a higher rates of excess winter mortality.9 In impoverished housing in Canada and the United States, inadequate ventilation and moisture management have been found to contribute significantly to mold-induced illnesses, carbon monoxide poisoning, and other injuries.10
Undeniably, being homeless or marginally housed may have an even greater negative impact on heath.3 For example, crowded shelter conditions can expose individuals to health issues such as tuberculosis, and long periods of standing in the cold can lead to such issues as venous stasis and fungal infections.4 Without doubt, homelessness and housing insecurities pose enormous risks to population health, and no country is immune to this concern.11
The link between housing and health is particularly strong in relation to HIV/AIDS, aggravated by the fact that people living with HIV/AIDS may be ten times more likely to be homeless than the general population.13 People living with HIV/AIDS experience housing insecurity due to a variety of factors, including (but not limited to) social stigma, poverty, and the impacts of other concurrent conditions such as hepatitis C co-infection and mental health issues. The new “State of Homeless in Canada 2013 Report” estimates that each year 200,000 Canadians experience homelessness.5 Studies from across North America have shown how homelessness housing insecurity have contributed to HIV transmission and infection rates.12 Housing instability also negatively impacts the ability of people living with HIV/AIDS to access medications, compromises treatment outcomes,14, 15 and increases use of hospital emergency services.17
Research conducted in Vancouver has shown that in single-room-occupancy units in that city’s downtown eastside (representing basic shelter for low-income individuals in generally under-maintained buildings), residents living with HIV/AIDS have often struggled to maintain proper health while coping with inadequate sanitation and facilities.16, 22 These studies highlight the urgent need to address homelessness and housing conditions that compromise health strategies for people living with HIV/AIDS.
While homelessness and housing insecurity have created hardships, it is important to remember that people living with HIV/AIDS have also demonstrated resilience, determination and strong community involvement. People living with HIV/AIDS have also played active roles in research demonstrating the benefits of housing for health and advocating for important program and policy changes.
In particular, recent qualitative research shows how housing has mental, social and physical benefits for people living with HIV/AIDS. Above all, the issue of control over housing has emerged as a crucial factor in determining the health of people living with HIV/AIDS.2 For example, a Vancouver study found that HIV positive women with housing stability and control were better able to manage their space and time to accommodate their health and medical needs.19
Results of the Positive Spaces, Healthy Places study from Ontario also suggest that issues of control and neighborhood belonging are significant in determining the health-related quality of life for people living with HIV/AIDS over time.20 Access to and control over housing are important for improving self-esteem, pride and community belonging ― all vital elements of health.
This research points to the need for increased supportive housing, particularly for people living with HIV/AIDS facing situations of homeless and/or housing insecurity. The provision of supportive housing for people living with HIV/AIDS has been shown to not only be feasible and to improve access to care, but to also contributes significantly to reduced vital loads, decreasing risks of HIV morbidity, mortality, and transmission.7 Examples of these types of services in British Columbia include those of the Dr. Peter Centre, and McLaren Housing Society, both of which are currently being evaluated through CIHR-funded research projects.
In addition to the overall health benefits, research evidence is emerging that demonstrates the significant economic benefits of providing housing services for people living with HIV/AIDS. A recent study provided a cost-utility analysis of rental assistance for homeless people living with HIV/AIDS in the United States, and estimated that the cost-per-quality-adjusted life-year saved by the HIV-related housing is $62,493,8 meaning that it is more cost-effective for a society to provide rental assistance than to keep individuals homeless. Research from Canada demonstrates similar findings, noting that homelessness costs the Canadian economy $7 billion annually,5 and that providing more supportive housing and/or rental assistance would save tax payers significantly.17, 18
Above all, access to suitable, safe and culturally appropriate housing is a right. Shelter is a safeguard, and the social and community benefits of housing are immeasurable.
Over the next three years, the Positive Living, Positive Homes research project will be investigating the crucial relationship between housing services, housing and health for people living with HIV/AIDS in British Columbia. It is hoped and anticipated that this study will impact housing programs and policies in BC, promoting greater access to suitable, affordable and culturally appropriate housing services.
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2 Julia Dickson-Gomez, Helena Hilario, Mark Convey, A Michelle Corbett, Margaret Weeks, and Maria Martinez, ‘The Relationship between Housing Status and Hiv Risk among Active Drug Users: A Qualitative Analysis’, Substance Use & Misuse, 44 (2009), 139-62.
3 Donna Fitzpatrick-Lewis, Rebecca Ganann, Shari Krishnaratne, Donna Ciliska, Fiona Kouyoumdjian, and Stephen Hwang, ‘Effectiveness of Interventions to Improve the Health and Housing Status of Homeless People: A Rapid Systematic Review’, BMC Public Health, 11 (2011), 638.
4 C JAMES Frankish, STEPHEN W Hwang, and DARRYL Quantz, ‘The Relationship between Homelessness and Health: An Overview of Research in Canada’, Finding home: Policy options for addressing homelessness in Canada (2009), 1-21.
5 Stephen Gaetz, Jesse Donaldson, Tim Richter, and Tanya Gulliver, ‘The State of Homelessness in Canada 2013′, Retrieved on June, 23 (2013), 2013.
6 Marcia Gibson, Mark Petticrew, Clare Bambra, Amanda J Sowden, Kath E Wright, and Margaret Whitehead, ‘Housing and Health Inequalities: A Synthesis of Systematic Reviews of Interventions Aimed at Different Pathways Linking Housing and Health’, Health & place, 17 (2011), 175-84.
7 Mary Hawk, and Dana Davis, ‘The Effects of a Harm Reduction Housing Program on the Viral Loads of Homeless Individuals Living with Hiv/Aids’, AIDS care, 24 (2012), 577-82.
8 David R Holtgrave, Richard J Wolitski, Sherri L Pals, Angela Aidala, Daniel P Kidder, David Vos, Scott Royal, Nkemdiri Iruka, Kate Briddell, and Ron Stall, ‘Cost-Utility Analysis of the Housing and Health Intervention for Homeless and Unstably Housed Persons Living with Hiv’, AIDS and Behavior (2012), 1-6.
9 Philippa Howden-Chapman, Helen Viggers, Ralph Chapman, Kimberley O’Sullivan, Lucy Telfar Barnard, and Bob Lloyd, ‘Tackling Cold Housing and Fuel Poverty in New Zealand: A Review of Policies, Research, and Health Impacts’, Energy Policy, 49 (2012), 134-42.
10 David E Jacobs, Tom Kelly, and John Sobolewski, ‘Linking Public Health, Housing, and Indoor Environmental Policy: Successes and Challenges at Local and Federal Agencies in the United States’, Environmental Health Perspectives, 115 (2007), 976.
11 Michael Marmot, and R Bell, ‘Fair Society, Healthy Lives’, Public health (2012).
12 Brandon DL Marshall, Thomas Kerr, Jean A Shoveller, Thomas L Patterson, Jane A Buxton, and Evan Wood, ‘Homelessness and Unstable Housing Associated with an Increased Risk of Hiv and Sti Transmission among Street-Involved Youth’, Health & place, 15 (2009), 783-90.
13 Gregorio A Millett, Jeffrey S Crowley, Howard Koh, Ronald O Valdiserri, Thomas Frieden, Carl W Dieffenbach, Kevin A Fenton, Regina Benjamin, Jack Whitescarver, and Jonathan Mermin, ‘A Way Forward: The National Hiv/Aids Strategy and Reducing Hiv Incidence in the United States’, JAIDS Journal of Acquired Immune Deficiency Syndromes, 55 (2010), S144-S47.
14 M-J Milloy, Thomas Kerr, David R Bangsberg, Jane Buxton, Surita Parashar, Silvia Guillemi, Julio Montaner, and Evan Wood, ‘Homelessness as a Structural Barrier to Effective Antiretroviral Therapy among Hiv-Seropositive Illicit Drug Users in a Canadian Setting’, AIDS Patient Care and STDs, 26 (2012), 60-67.
15 M-J Milloy, Brandon DL Marshall, Julio Montaner, and Evan Wood, ‘Housing Status and the Health of People Living with Hiv/Aids’, Current HIV/AIDS Reports, 9 (2012), 364-74.
16 Surita Parashar, Keith Chan, David Milan, Eric Grafstein, Alexis K Palmer, Chelsey Rhodes, Julio SG Montaner, and Robert S Hogg, ‘The Impact of Unstable Housing on Emergency Department Use in a Cohort of Hiv-Positive People in a Canadian Setting’, AIDS care (2013), 1-12.
17 David Patterson, ‘Comparative Costs and Benefits of Permanent Supportive Housing before and after Chronic Homelessness’, in 141st APHA Annual Meeting (November 2-November 6, 2013) (APHA, 2013).
18 Michelle Patterson, Julian Somers, Karen McIntosh, Alan Shiell, and Charles James Frankish, ‘Housing and Support for Adults with Severe Addictions and/or Mental Illness in British Columbia’, (2008).
19 Leslie Robertson, ‘Taming Space: Drug Use, HIV, and Homemaking in Downtown Eastside Vancouver’, Gender, Place and Culture, 14 (2007), 527-49.
20 Sean B Rourke, Tsegaye Bekele, Ruthann Tucker, Saara Greene, Michael Sobota, Jay Koornstra, LaVerne Monette, Jean Bacon, Shafi Bhuiyan, and Sergio Rueda, ‘Housing Characteristics and Their Influence on Health-Related Quality of Life in Persons Living with Hiv in Ontario, Canada: Results from the Positive Spaces, Healthy Places Study’, AIDS and Behavior, 16 (2012), 2361-73.
About the author: Christina Bielek is the Coordinator of the Positive Living, Positive Homes (PLPH) community-based research project. PLPH is funded by the Canadian Institutes of Health Research. Questions? Comments? Email:
This article previously appeared on the website of the Pacific AIDS Network here.