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HOPWA In Focus: Structural Intervention

December 08, 2016 Print ShareThis

Greetings HOPWA Grantees, Project Sponsors, and Friends,

As we commemorated World AIDS Day last week, the Office of HIV/AIDS Housing (OHH) took that opportunity to not only remember those we have lost to the HIV/AIDS epidemic, but also show support for people living with HIV, and renew our united fight against HIV. This past week also marked my one-year anniversary as the Director of OHH, a role I have been honored to serve in. As I reflect on the progress this office has made and evaluate the work that needs to continue in the fight against HIV, one thing is apparent – Housing Matters. This is why OHH has established the vision to “Elevate housing as a structural intervention in ending the AIDS epidemic in the United States”.

Housing as a structural intervention to improve health outcomes for PLWHA

The United States has more than 1.2 million people living with HIV or AIDS (PLWHA). Of these Americans, about half, or 600,000, will face a housing crisis in their lifetime. In fact, between 3% and 10% of all homeless individuals are living with HIV/AIDS as of 2015. This demonstrates a need for HIV/AIDS housing, since PLWHA are more vulnerable to homelessness. However, housing is not just a way to reduce homelessness. Housing should be used as a structural intervention to improve health outcomes for PLWHA and ultimately as a vital tool in bringing an end to the HIV/AIDS epidemic.

To address housing needs of PLWHA, the U.S. Department of Housing and Urban Development (HUD) administers the Housing Opportunities for Persons With AIDS (HOPWA) Program. HOPWA is the only federal program dedicated to the housing needs of people living with HIV/AIDS. Under the HOPWA Program, HUD makes grants to local communities, States, and nonprofit organizations for projects that benefit low-income persons living with HIV/AIDS and their families.

HIV Care Continuum

Because there is no cure for HIV, achieving viral suppression is the ultimate goal for PLWHA in beating the disease. This means that the presence of HIV in blood is so low that it is almost undetectable. Viral suppression allows PLWHA to stay healthy, live longer, and reduces the chance of HIV being passed on by about 96%. With the goal of viral suppression in mind, the White House has developed the HIV Care Continuum. The HIV Care Continuum is a tool used to identify engagement in five sequential stages of HIV medical care. OHH has also created an initiative using the HIV Care Continuum to demonstrate the proportion of HOPWA beneficiaries that are engaged at each stage of HIV care at the community level. Additional information on the HIV Housing Care Continuum Initiative can be accessed on the HUD Exchange. The stages are diagnosis of HIV infection, linkage to care, retention in care, receipt of antiretroviral therapy, and achievement of viral suppression.

  • Diagnosis of HIV Infection
    Housing instability is linked to delayed HIV diagnosis and to increased risks of acquiring and transmitting HIV infection. Undiagnosed PLWHA are not accessing the care they need to stay healthy and can unknowingly pass the virus on to others. In fact, about 1 out of 8 PLWHA are not aware that they are HIV positive. Partnerships between HUD's housing programs and other service organizations present important opportunities for HIV education and testing to support HIV prevention, timely HIV diagnosis, and linkage to ongoing medical care for both HIV positive and HIV negative persons.
  • Linkage to Care
    Just as someone experiencing housing instability is less likely to have access to an HIV test, individuals facing a housing crisis are less likely to be connected to an HIV healthcare provider who can provide treatment and counseling to promote health and reduce the risk of ongoing HIV transmission. Stable housing provides a foundation for a person to take control of their health and reduces the likelihood of engaging in risky behaviors that may include sex in exchange for shelter or limited condom usage.
  • Retention in Care
    Once an individual is diagnosed with HIV and linked to care, it is essential that they remain in care. Individuals facing a housing crisis are less likely to be able to regularly connect with a healthcare professional. Homeless PLWHA also face additional health issues. People without stable housing are often subject to a poor diet, exposure to harsh weather conditions, and overcrowding in emergency shelters. An HIV diagnosis compounds the negative effects of these conditions, since the virus attacks the immune system. This shows the connection between housing and health care. Individuals without stable housing are less likely to have access to health care, and at the same time are more vulnerable to negative health outcomes.
  • Receipt of Antiretroviral Therapy
    Antiretroviral therapy (ART) is a combination of prescription drugs that help prevent the virus from multiplying in the body and attacking the immune system. People without stable housing are less likely to have access to a healthcare provider to prescribe ART, and are less likely to be able to afford the drug. In many cases, PLWHA are force to choose between paying for their medications and paying rent. This shows that housing is an important tool for helping PLWHA achieve viral suppression, because providing support for housing prevents HIV positive individuals from having to make that choice between health and shelter.
  • Achievement of Viral Suppression
    With strict adherence to ART, it is possible for PLWHA to live long and healthy lives with a significantly reduced risk of transmitting the virus. Because there is no cure for HIV, PLWHA must manage the virus through medication for the rest of their lives. Stable housing is crucial to managing HIV. Without stable housing, individuals may not be able to get into a routine of taking daily medication, may not have a place to store their medication, or may have their prescriptions lost or stolen. For this reason and so many others, housing is a necessary structural intervention to help PLWHA achieve viral suppression and end the HIV/AIDS epidemic.

Housing assistance for PLWHA is not just about putting a roof over people’s heads. It’s about creating a more stable environment that makes it easier to take daily medications and remain engaged in care. It’s about lowering the risk of HIV transmission by reducing the viral load of PLWHA and reducing risky behaviors that go along with living on the street. Housing is an important tool in eradicating HIV/AIDS. Housing is healthcare.


Rita Flegel
Director, Office of HIV/AIDS Housing

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