Last week our HIV post looked at the theoretical link between HIV and homelessness (ponder the adapted version of Maslow’s Hierarchy).  We wondered about policy and implementation implications for homelessness, as the global HIV epidemic refocuses its lens on key populations, who are among the world’s most vulnerable to homelessness and housing instability.

So today we’ll take a quick look at exactly what we know about the link between homelessness and HIV (and some other health issues), where the US government’s policy currently stands, and how that policy might be changed or improved for the future.

What we know…

Aside from  housing being a basic human right that is provided for in the Universal Declaration of Human Rights‘ Article #25, we know that there are two ways that homelessness interacts with HIV (and, indeed, many other health conditions).

1. Homelessness –> HIV: as Maslow’s taught us, individuals who are experiencing more pressing crises may not focus on long-term health consequences.  The urgency of procuring food, shelter or safety to survive the day may lead to risk-taking behavior, including transactional or commercial sex work, or involvement with (including using and selling) illicit drugs.  In addition, individuals experiencing traumatic circumstances, such as the violence associated with homelessness and untreated mental health conditions, may self-medicate with injected narcotics.

Health risks don’t stop at HIV, either.  Homeless individuals are more at risk for other infections, including TB and HCV, as well as exacerbation of non-communicable conditions, including hypertension, diabetes, and mental health issues – and, of course, are more at risk for injury from violence.

2. HIV –> Homelessness: whether it’s a low-income country or a high-income country, individuals with HIV are more likely to experience homelessness due to stigma and discrimination.  Landlords may evict tenants whose HIV status becomes known, and employers may dismiss HIV-positive employees, often regardless of laws to protect against these violations; furthermore, people living with HIV may have reduced social networks due to stigma, meaning that the normal safety nets of family and friends are absent or reduced.  In this situation, individuals who become housing unstable may have a more difficult time adhering to treatment, and may de-prioritize treatment adherence and medical care in exchange for the more basic needs on in Maslow’s pyramid.

Current Policies

As noted last week, PEPFAR has been outspoken about, and recently reaffirmed, the importance of housing stability for orphans and vulnerable children (OVCs) – particularly for programming in sub-Saharan Africa, where OVC issues loom large after decades of parental loss to HIV.  But what about for adults?  Particularly adults who have ‘undesirable’ risk behaviors, like selling sex, or injecting illegal drugs?  While some PEPFAR documentation makes references to preventing homelessness for women and girls, nowhere is there a mention of engaging with those who are already homeless.  In fact, a search of the new PEPFAR Blueprint yields exactly zero results for the words: homeless, homelessness, and housing.

This might seem particularly strange because the US government seems to acknowledge housing as an issue critical to its own domestic HIV/AIDS strategy.  What’s going on here?  With such a growing focus on key populations, why so little movement on addressing a major issue like housing stability?

Policy Future

In this blogger’s mind, this leads us to two options for US government programming to better address the dramatic health issues that accompany homelessness:

1. Create a separate initiative to address homelessness, potentially lodging it under the Global Health Initiative, and devoting special focus to homeless women, who are often face additional barriers to accessing housing services.  A myriad of existing USG programming to fight malaria, TB, food insecurity, and a host of other issues could leverage and link seamlessly with efforts to alleviate housing instability.

2. If adding more programming specifically for the homeless sounds like too controversial an issue for a government grappling with a shrinking aid budget and facing rising rates of poverty at home, make it a priority to target homeless individuals within existing PEPFAR programming for key populations.

While homeless individuals are not explicitly excluded from interventions in current programming, in my experience even the harm reduction NGOs reaching vulnerable populations often consider chronically homeless individuals to be ‘too difficult’ to work with; as a result, the absolute most vulnerable individuals are left uncovered, never even reached by the possibility of HIV prevention, diagnosis or treatment.  Worse yet, there are poor linkages between the limited local groups and resources that serve the homeless, and those that conduct HIV prevention and other harm reduction activities for key populations.

If PEPFAR can’t step forward as a leader on true harm reduction issues by procuring needles and syringes, or seriously addressing ineffective policies that criminalize sex work, why can’t it be a leader on a ‘softer’ issue like linking HIV services with other broader-based services to address homelessness?

*Check back next Friday for Part III of this series, looking at successful models and approaches that have been used to address homelessness alongside health, and how we might scale them up globally.*