Mapping Injustice: Redlining's Legacy in HIV Treatment Delays

A new study from Tulane University reveals how discriminatory housing policies from decades ago continue to shape HIV care outcomes today. Published in JAMA Internal Medicine, the research shows that people living with HIV (PLWH) in historically redlined neighborhoods face 15% longer delays in achieving viral suppression compared to counterparts in non-redlined areas—193 days versus 164 days. These delays impact both patient health outcomes and broader public health efforts to prevent HIV transmission.

The Lasting Legacy of Redlining

Redlining—the practice where mortgage lenders marked certain areas with red lines to deny loans based on race or ethnicity—was officially abolished in 1968. Yet its consequences persist in the built environment, healthcare infrastructure, and social conditions that determine health outcomes.

The Tulane study analyzed 1,132 newly diagnosed patients in New Orleans between 2011 and 2019. Of these patients, 62% resided in formerly redlined neighborhoods. Most were men between ages 25-44 years, and despite New Orleans having a majority Black population, the study found a higher concentration of Black residents in redlined areas than in non-redlined ones.

The findings validate what many healthcare advocates have long observed: geography profoundly influences health. As senior author Scott Batey noted, "The association between redlining and health outcomes is not a new concept, but applying this lens specifically to HIV was novel." Even where gentrification has occurred, treatment delays remain—indicating that historical marginalization creates barriers that investment alone cannot remove.

Interconnected Barriers to HIV Care

What explains these persistent treatment delays? The answer lies in multiple overlapping structural barriers that create a healthcare access quagmire for PLWH in redlined communities.

Pharmacy Deserts

One-third of neighborhoods in major U.S. cities qualify as pharmacy deserts, with predominantly Black and Latino neighborhoods disproportionately affected. In Los Angeles, for example, one-third of all Black and Latino neighborhoods were pharmacy deserts, particularly concentrated in South Central LA neighborhoods.

For PLWH, this means not just longer travel times for medication but reduced access to HIV prevention resources and testing services. Pharmacies serve as crucial health access points—they provide HIV prevention tools like PrEP, conduct HIV testing, and offer medication counseling essential for treatment adherence. When pharmacies close or never open in certain neighborhoods, these services disappear too.

Medicare Part D and Medicaid plans often exclude independent pharmacies serving these communities, forcing PLWH to travel even farther for care. These policies function as a form of structural racism that requires historically marginalized populations to overcome additional barriers to access life-saving medications.

Provider Network Inadequacy

Healthcare provider shortages plague formerly redlined areas. Current federal network adequacy standards fail to ensure sufficient HIV care providers in these communities. Provider directories frequently overstate physician availability, and narrow insurance networks often include less than one-fourth of available providers.

Studies show that adults with Medicaid or Marketplace coverage are more likely than those with Medicare or employer-sponsored insurance to report network problems. This is especially concerning as approximately 40% of people living with HIV (PLWH) rely on Medicaid for their healthcare coverage. For PLWH, this translates to longer wait times, fewer options for culturally competent care, and reduced provider continuity—all factors that influence treatment adherence and viral suppression rates.

Time/distance standards for network adequacy ignore the reality that residents often rely on limited public transportation, making even "acceptable" distances functionally unreachable. A mile can feel like thirty when bus service is limited, transfers are required, or service ends before evening clinic hours conclude.

Hospital Consolidation

The acceleration of hospital consolidation has further eroded healthcare infrastructure in vulnerable communities. When acquiring systems take over local hospitals, they frequently close specialized services, forcing patients to travel further for care.

"The unfortunate reality is that more than 25 years of market-driven health facility consolidation has really left too many communities across the U.S. without timely access to needed care," experts note. This especially impacts residents of redlined neighborhoods, who often must navigate complex transportation systems to reach consolidated healthcare facilities.

Research shows hospitals without nearby competitors charge prices 12.5% higher than those in competitive markets—a financial burden that falls heavily on communities already struggling with economic disadvantage. As of 2017, 19% of markets—representing 11.2 million U.S. residents—were served by only one hospital system, creating healthcare monopolies that exacerbate access disparities.

Political Context: New Threats to Health Equity Research

Political attacks on health equity initiatives now compound these structural barriers. Recent executive orders targeting Diversity, Equity, and Inclusion (DEI) programs across federal agencies threaten vital HIV research and services.

The U.S Department of Health and Human Services (HHS) faces proposed budget cuts from $121 billion to $80 billion in discretionary funding, cutting precisely the prevention-focused health initiatives designed to address disparities. Healthcare researchers report increasing censorship pressures around health disparity research, particularly when using terminology associated with equity.

One cancer researcher noted the chilling effect: "We aren't sure what we can say in our grants. I very freely — before — wrote about disparities and equity in my grants." This uncertainty threatens the very research needed to understand and address HIV treatment delays in historically redlined communities.

Federal agencies have removed HIV-related content from websites, especially materials serving transgender populations. Reports indicate hundreds of HIV-related web pages were removed following executive orders targeting "gender ideology" and "DEI." When pages were restored, they often lacked reference to transgender people, creating significant gaps in data and care recommendations for key populations.

The threat extends to global HIV prevention efforts, with pauses on foreign aid affecting PEPFAR implementation and leaving vital medication and services in limbo. These disruptions threaten to reverse hard-won progress in controlling the HIV epidemic both domestically and globally.

From Analysis to Action

Understanding redlining's impact on HIV treatment access demands more than recognition—it requires targeted policy responses:

1. Strengthen pharmacy access in underserved areas by incentivizing pharmacy establishment and requiring Medicaid and Medicare Part D plans to include independent pharmacies serving marginalized communities. State pharmacy boards should consider pharmacy access when reviewing new applications and closures.

2. Reform PBM practices to eliminate patient steering by prohibiting PBM-owned specialty pharmacies from exclusively dispensing HIV medications. Research shows that patient steering to mail-order or specific chain pharmacies disrupts established care relationships and reduces medication adherence, particularly affecting PLWH in historically redlined areas who rely on community pharmacies for wrap-around services.

3. Reform network adequacy standards to ensure sufficient culturally-competent providers in historically redlined neighborhoods. Standards must account for transportation realities and penalize narrow networks that exclude critical HIV care providers. Secret shopper surveys should validate actual appointment availability beyond paper compliance.

4. Mandate PBM transparency and fair reimbursement to prevent discriminatory practices forcing community pharmacies in redlined neighborhoods to close. State legislation should require PBMs to disclose all revenue streams, prohibit retroactive fee clawbacks, and establish minimum reimbursement rates based on acquisition cost plus a fair dispensing fee.

5. Enhance antitrust enforcement to prevent further hospital consolidation, reducing access points in vulnerable communities. When mergers occur, mandate maintenance of essential services in historically underserved areas and require community benefits agreements that address historical inequities.

6. Protect and expand community-based HIV programs that provide testing, prevention education, and linkage to care services directly within affected neighborhoods. This includes mobile testing units, community health worker programs, and faith-based outreach initiatives.

7. Prioritize long-acting injectable antiretrovirals as a solution for areas with limited pharmacy access, reducing adherence challenges for people facing transportation barriers. Delivery models should include provision through mobile clinics and community-based organizations.

8. Defend health equity research funding against political attacks that threaten to undermine our understanding of how structural racism impacts health outcomes. Ensure that Institutional Review Boards (IRBs) and research institutions protect researchers examining health disparities.

Moving Forward

The link between historical redlining and HIV treatment delays reveals how structural inequities become embodied in health outcomes. This connection demands that policymakers, healthcare systems, and advocates recognize that achieving HIV treatment equity requires addressing the legacy of discriminatory housing policies.

As Dr. Batey notes, "If we can make services more accessible and get people virally suppressed sooner, the impact on the HIV epidemic can be quite significant." This requires defending existing health equity initiatives and developing new approaches that confront the structural barriers in historically redlined communities.

The one-month treatment delay identified in the Tulane study translates to real health consequences for PLWH and increased transmission risk within communities. Moving from awareness to action means investing in healthcare infrastructure that overcomes geography as destiny, creating systems where treatment access doesn't depend on neighborhood history.

In an era of political attacks on health equity initiatives, this research underscores why structural analysis matters. Without understanding how policies like redlining continue to shape healthcare access, we risk addressing symptoms while ignoring causes. Achieving HIV treatment equity demands both acknowledging historical injustice and implementing structural change—starting with the communities where barriers remain highest.

Beyond Medicine: Medicaid's Role in Bridging Healthcare and Housing

The evolving landscape of healthcare now acknowledges housing as a crucial element of well-being, marking a significant shift in public health recognizing certain goals advocates have trumpeted for decades - housing can be healthcare. Highlighted by a California Healthline article, this shift challenges old paradigms by recognizing stable, affordable housing as essential for optimal health outcomes. With states like California, Oregon, and New York at the forefront and thanks to a slew of waiver opportunitjes offered from the Biden Administration, some Medicaid programs are increasingly integrating housing services, reflecting a broader understanding that health is inextricably linked to our living conditions.

The Case for Housing as Healthcare: A Closer Look at the Evidence

The role of housing as a fundamental component of healthcare is being increasingly recognized among policymakers and supported by a growing body of evidence that underscores the critical impact of stable living conditions on health outcomes. The American Medical Association (AMA) has highlighted the essential nature of stable housing, pointing out that its absence significantly elevates the risk of various health issues, including severe infections that may necessitate amputation, and an increased likelihood of experiencing violent trauma.

Research featured in Health Affairs strengthens this viewpoint by establishing a clear link between housing stability and better health outcomes, emphasizing housing's non-negotiable position within a comprehensive healthcare framework. The benefits of stable housing can extend beyond physical health, with some studies showing significant mental health improvements through housing stability interventions, such as rental and foreclosure assistance.

The AMA further notes that people with access to stable housing are less prone to the stressors that lead to physical and mental health issues. Such environments reduce the risk of infectious diseases by providing a clean and secure living space conducive to health, facilitating easier access to medical care. Moreover, stable housing is linked to better chronic condition management, as it encourages an environment in which people can adhere to treatment plans and maintain regular contact with healthcare providers and is often accompanied with other medication necessities, such as food security and potable water.

Cost Savings and Healthcare Efficiency Through Housing

Integrating housing services into healthcare significantly enhances health outcomes and generates notable cost savings. By transitioning towards stable housing, reliance on high-cost healthcare services, such as emergency visits and hospital admissions, markedly decreases. A compelling study in Oregon demonstrated that providing affordable housing to nearly 10,000 individuals with unstable living situations resulted in a 12% reduction in Medicaid expenditures. Furthermore, this initiative increased outpatient primary care utilization by 20% and reduced emergency department visits by 18%, highlighting a shift towards preventive care.

This approach not only improves the health of Medicaid beneficiaries but also leads to more judicious healthcare spending. Allocating resources to housing services supports preventive care and vital services, amplifying the impact of stable housing on individual health and the overall healthcare system. Medicaid's strategic involvement in providing housing may prove a crucial tool for achieving better health outcomes and optimizing healthcare expenditure.

Medicaid Waivers and Housing Initiatives: Navigating New Pathways

The integration of housing services within Medicaid, facilitated by Section 1115 waivers and the innovative In Lieu of Services (ILOS) guidelines, represents a transformative approach to healthcare. These policy mechanisms are enabling states to address housing as a fundamental social determinant of health, acknowledging its critical impact on health outcomes.

Section 1115 Waivers: Expanding Medicaid's Reach

Section 1115 waivers grant states the flexibility to use Medicaid funds in novel ways that can include addressing housing instability, a key factor affecting health. The Kaiser Family Foundation reports on various state initiatives that leverage these waivers to directly tackle the housing needs of Medicaid enrollees. For example, some states have received approval to use Medicaid dollars for supportive housing services, such as helping people find and maintain stable housing. The programs with the best outcomes not o ly provide a method of entry but also work to ensure continuing housing stability. These waivers are instrumental in demonstrating how targeted housing support can lead to better health outcomes and reduced healthcare costs by minimizing the need for emergency care and hospital readmissions.

ILOS: Streamlining Support for Housing Needs

The Centers for Medicare & Medicaid’s (CMS) recent guidance on ILOS marks a significant policy shift, allowing Medicaid programs to offer housing-related services as enhancements to traditional medical interventions. This guidance enables states to provide a range of housing supports, including housing navigation assistance and one-time financial aid for security deposits or first month's rent. Importantly, while ILOS does not cover ongoing housing costs, it addresses critical barriers to stable housing for Medicaid enrollees, emphasizing the role of housing stability in achieving health equity.

State-Led Innovations in Housing and Health

States are at the forefront of integrating housing solutions within Medicaid, driven by the opportunities presented by Section 1115 waivers and ILOS guidelines. Shelterforce highlights innovative state programs that are setting precedents for how Medicaid can be utilized to support housing needs. For instance, initiatives that fund temporary housing for individuals transitioning out of hospital care not only provide immediate shelter but also contribute to better health outcomes and lower the likelihood of readmission. These programs exemplify the potential of Medicaid to address the holistic needs of its enrollees, underscoring the necessity of stable housing for overall health and well-being.

Through the strategic use of Section 1115 waivers and ILOS, Medicaid is evolving to meet the complex health and social needs of its enrollees. By recognizing housing as a critical component of healthcare, these policy innovations are paving the way for more integrated and effective approaches to improving health outcomes and advancing health equity. The success of state-led initiatives in leveraging these tools to address housing instability highlights the significant role of Medicaid in not only providing medical care but also in addressing the broader determinants of health.

Applying a Harm Reduction Perspective to Housing

Harm reduction in housing services adopts a compassionate approach, recognizing the varied challenges and needs of those facing housing instability. It emphasizes meeting people "where they are," providing flexible support without coercion, and respecting each person's autonomy and circumstances. This strategy is crucial for addressing the spectrum of housing stability, which ranges from homelessness to permanent, secure living situations. Each stage has unique health implications, with instability often worsening health conditions and hindering access to consistent healthcare.

Harm reduction aims to alleviate these health impacts by offering immediate, sometimes temporary, support to navigate towards more stable housing. This approach is vital for those with chronic health issues, mental health concerns, or substance use disorders, where a stable home can significantly influence health outcomes and quality of life. By tailoring services to meet personal needs—including healthcare access, mental health support, and substance use treatment—harm reduction in housing can effectively reduce the harms of instability and facilitate a path to stable living conditions.

Navigating Oversight in Medicaid's Housing Initiatives

The expansion of Medicaid to include housing services, aimed at addressing social determinants of health, introduces significant management and oversight challenges. A key concern is the potential for program exploitation, where resources meant for the most vulnerable are diverted or misused. The AIDS Healthcare Foundation (AHF) case, reported by the Los Angeles Times, exemplifies such risks, highlighting the need for stringent oversight to prevent organizations from prioritizing performance over patient care, qualityof life, and more permanent outcomes for program participants.

Ensuring Transparency and Accountability:

To counteract exploitation risks and guarantee the effective delivery of housing services, a strong emphasis on transparency, accountability, and comprehensive oversight is essential. The Center on Budget and Policy Priorities (CBPP) provides strategies for overseeing housing initiatives, stressing the importance of clear objectives, performance metrics, and consistent audits. These measures are vital for tracking service implementation, assessing health outcome impacts, and promoting ethical, efficient fund use.

Developing Robust Oversight Frameworks:

Implementing effective oversight requires layered scrutiny, including internal audits, external reviews, regular site audits, and autonomous, third-party feedback mechanisms for beneficiaries. Building partnerships across Medicaid programs, housing providers, healthcare entities, and community organizations can enrich oversight through varied insights and expertise. Such collaborative oversight efforts are pivotal in identifying and disseminating best practices, learning from experiences, and crafting innovative solutions to the intricate challenges of merging housing with healthcare services.

As Medicaid ventures into housing services, its success in enhancing health outcomes for vulnerable groups hinges on overcoming oversight hurdles. Committing to transparency, accountability, and strong oversight will protect against misuse, optimize resource allocation, and ensure housing's role as an integral part of comprehensive healthcare.

The Path Forward: Enhancing Medicaid's Role in Housing and Health Integration

As Medicaid evolves to more fully recognize housing as a crucial component of healthcare, a strategic and multifaceted approach is essential to ensure the effective integration of housing services. This approach should leverage the insights from recent policy developments and successful state initiatives, focusing on policy adjustments, increased funding, cross-sector collaboration, and robust oversight mechanisms.

Policy Adjustments and Increased Funding: A Foundation for Success

1. Policy Adjustments: Recent guidance on In Lieu of Services (ILOS) and the innovative use of Section 1115 waivers illustrate the potential for Medicaid to directly address housing instability. States should be encouraged to explore these and other policy tools to expand Medicaid's capacity to fund housing-related services, thereby acknowledging the profound impact of stable housing on health outcomes. Legislative and regulatory frameworks must evolve to support these changes, ensuring Medicaid can effectively contribute to housing stability for its enrollees.

2. Increased Funding: The expansion of housing initiatives within Medicaid necessitates substantial investment. This includes not only funding for direct housing assistance but also for the development of infrastructure that facilitates the delivery and coordination of services. Advocacy efforts are crucial to secure increased federal and state funding, aiming to bolster Medicaid's ability to meet the housing and health needs of its beneficiaries comprehensively.

Cross-Sector Collaboration: Building Bridges for Better Health

The success of housing initiatives within Medicaid is significantly enhanced by cross-sector collaboration. Partnerships among Medicaid agencies, housing authorities, healthcare providers, and community organizations are vital. These collaborations can draw on the strengths and resources of each sector to address the multifaceted challenges at the nexus of health and housing, creating integrated solutions that improve outcomes for individuals and communities alike.

Implementing Comprehensive Oversight and Adaptive Management

1. Comprehensive Oversight: To safeguard the integrity of housing initiatives and ensure resources are used effectively, a framework for comprehensive oversight is imperative. This framework should include clear implementation guidelines, success metrics, and regular evaluations to monitor impact and guide continuous improvement.

2. Adaptive Management: Effective management strategies are critical to navigate the complexities of integrating housing services within Medicaid. This includes ongoing training for program administrators and service providers, as well as the development of care models that seamlessly coordinate healthcare and housing services, ensuring that Medicaid enrollees receive the support they need to achieve and maintain stable housing.

The path forward for Medicaid's integration of housing services presents a unique opportunity to significantly improve health outcomes and advance health equity. By adopting a strategic approach that includes policy innovation, increased funding, cross-sector collaboration, and rigorous oversight, Medicaid can play a pivotal role in addressing the housing needs of its enrollees. This comprehensive strategy not only meets immediate housing challenges but also lays the groundwork for a healthier, more equitable future.

A Call to Action for Housing as Healthcare

The journey towards integrating housing into healthcare through Medicaid is not just a policy shift; it's a moral imperative. As we've seen, stable housing is not merely a foundation for individual well-being; it's a cornerstone of public health. The evidence is clear: when people have access to safe, stable housing, their health improves, healthcare costs go down, and communities thrive.

The Time Has Come to Centralize HIV Services in West Virginia

My name is Marcus J. Hopkins, and I have been living with HIV since 2005. While I’m not considered a “long-term survivor” of HIV—a term deservedly ascribed to People Living with HIV/AIDS (PLWHA) since the 1980s or 1990s—my experiences receiving treatment for HIV through the Ryan White HIV/AIDS Program (RWHAP) and AIDS Drug Assistance Program (ADAP) have run an interesting gamut across five states: Georgia, Florida, Tennessee, California, and West Virginia. Across those five states, I have experienced a wide variety of HIV services provision over the course of being in HIV treatment since 2007, and can truly attest to the adage, “When you’ve seen one ADAP, you’ve seen one ADAP.”

Over the course of sixteen years of receiving services through the RWHAP and ADAP programs, several things have changed:

• Providers no longer wait until a patient receives an AIDS diagnosis to initiate HIV Antiretroviral Therapy (ART)

• Treatment regimens have largely transformed from multi-pill regimens to single-pill regimens and even long-term injections requiring once monthly or every other month injections

• The emergence of Pre-Exposure Prophylaxis (PrEP)—a once-daily pill or once-monthly or every other month injection to prevent the transmission of HIV between serodiscordant sex partners—means that the possibility of no new diagnoses is a distinct possibility within our lifetimes

• The threat of waiting lists to receive treatment and services is largely a thing of the past

• The passage of the Affordable Care Act (ACA, or “Obamacare”) allowed state ADAP programs to pay the premiums and co-pays for private insurance for eligible clients

• The passage of the ACA also allowed states to expand Medicaid in such a way that PLWHA are now automatically covered by state Medicaid programs, rather than ADAP. To date, 39 states have expanded their Medicaid programs (Kaiser Family Foundation, 2022)

And yet, despite all of these advancements, issues remain, particularly in rural parts of the country where even basic medical services are limited, much less HIV-specific services. Such is the case for my home state of West Virginia.

Since returning to West Virginia from Los Angeles in 2013, my experience with this state’s HIV services has been…fraught, at best. I can’t complain about the quality of care I’ve received, here; I can say that qualifying and recertifying for the various RWHAP parts is made extremely cumbersome.

You see, in the state of West Virginia, there is one organization that handles Ryan White Part B (basically, the ADAP program) for the entirety of the state. This entity is separate from the clinics that provide Part C and Part D services (outpatient care and the provision of medical care and support services for low-income women, children, and youths with HIV and their families, respectively). And THOSE entities are entirely separate from the Part F services, which cover education, HIV treatment projects, dental programs, and the Minority AIDS Initiative. And even THOSE entities are entirely separate from the ones that provide services for the Housing Opportunities for People with AIDS (HOPWA) program that provides various housing and utility assistance services for PLWHA.

So, let’s do a quick recap: in order to receive the full breadth of services to which most PLWHA are eligible in the state of West Virginia, one must engage with at least four separate entities. This doesn’t even address nutrition assistance, non-emergency medical transportation for visits, and other supportive services.

This is a problem.

It is a problem for patients; it a problem for providers; it is a problem for the HIV Care Continuum (United States Department of Health and Human Services, 2021); it is a problem for HIV surveillance and prevention.

As far as I can tell, this problem seems kind of unique to West Virginia. West Virginia never saw the proliferation of AIDS Service Organizations (ASOs) that most of the rest of the country saw during the 1990s and early-2000s. While the rest of the country and especially surrounding states saw an influx of new 501(c)(3) non-profit organizations and clinics step in to provide the wide swath of HIV case management, clinical, behavioral health, and supportive services, West Virginia’s services developed in inefficient siloes that left patients scrambling to figure out the veritable pantheon of providers necessary to get the services for which they are eligible.

By comparison, in the northeastern region of the state of Tennessee (still deep in Appalachia), Ryan White caseworkers went out of their way to assist with every aspect of HIV care, from enrollment in the program to clinical services to mental health services to dental services to HOPWA services to enrolling in nutrition assistance programs—they did it all. The same was true of my experiences in California and Florida.

In West Virginia, however, every aspect of seeking and qualifying for HIV services requires patients to perform an intricate and ever-changing ballet, the steps for which they are never taught. Because there are so few providers of these services, when patients experience issues, there aren’t really any other avenues to turn to for assistance.

This has become the case with one of West Virginia’s terribly mismanaged HOPWA grantees.

Again, unlike virtually every other state in the U.S., HOPWA services in West Virginia are not seated within the HIV treatment and services infrastructure, insufficient as it is, but within various organizations dealing with homelessness, such as Covenant House and the West Virginia Coalition to End Homelessness. Comparatively, in other states, referral to and enrollment in the HOPWA program is handled by ASOs, who work in concert with state housing agencies to assist with housing issues.

Over the course of the past few years, when one of West Virginia’s HOPWA service providers stopped paying housing and utility payments in a timely manner, patients had nowhere to turn without having to go through multiple channels to resolve their issues…but not even really resolve them; just lodge a complaint. Those HOPWA clients would have had to complain, first, to the very agency that failed to return their panicked calls, as they lost their housing or their electricity was cut off; instead, they had to jump through several different hoops just to find out where to go to complain—the regional office in Pittsburgh, PA, which initiated an investigation which, frankly, doesn’t do anything for those who are trying to get their rent paid or their electricity reconnected.

The time has come for the formation of not one, but several ASOs in the state of West Virginia to centralize these services. It is unconscionable that a state with a burgeoning HIV infection rate should have such a disorganized and disjointed service provision landscape. The time has come to centralize services at these ASOs, lest we continue to beat numerous dead horses and fail to serve those living with HIV.

Sources:

• Kaiser Family Foundation. (2022, April 26). Status of State Medicaid Expansion Decisions: Interactive Map. Washington, DC: Kaiser Family Foundation: Medicaid. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

• United States Department of Health and Human Services. (2021, June 21). What Is the HIV Care Continuum? Washington, DC: United States Department of Health and Human Services: HIV [dot] gov: Federal Response: Policies & Issues. https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum

The Most Meaningful Public Health Intervention: Housing

A note on the language used in this article: Some housing advocates reference a difference between “homelessness” and “houselessness” with exceptional, nuanced conversations on individual experiences with housing instability, connection to community, and personal autonomy. While some advocates may opt to consider a frame of “home is where the heart is” as an issue of empowerment, I, as an author and advocate, use these distinctions because of well-established links between housing instability and uncertainty in situations of domestic violence. A roof does not necessarily a “home” make. For the stakeholder targets of this blog, the link between intimate partner violence/domestic violence and HIV is so notable, the Department of Housing and Urban Development has recently announced funding opportunities for joint demonstration projects between HOPWA and VAWA (Housing Opportunities for People with AIDS and the Violence Against Women Act, respectively).

For 30 years, people living with HIV have advocated “housing is health (care)” religiously. A drumbeat of nearly every action, the inevitable topic of any roundtable or meeting, even if housing isn’t an agenda item – or especially if housing isn’t an agenda item. Arguably, when it comes to issues of “social” Justice and policies impacting the notion of equity, outpacing even health care is housing. Housing is the lone sustainable investment any person or family in the United States can make and, generally, expect to last well beyond their own time. Housing is the basis of both defeating and maintaining systems of inequity and oppression. Housing is such a significant factor in individual and collective outcomes it had its own carve out, separate and apart from the Ryan White Care Act, via the program known as Housing Opportunities for People with AIDS.

Indeed, the housing’s impact on health care is so exceptional, in 2019, the American Medical Association built upon limited calls to improve identification access for people experiencing houselessness and expanded their policy position for more comprehensive and collaborative resources aimed to bring care to this population and called for decriminalizing houselessness. In the same year, the Department of Housing and Urban Development’s annual “point in time” data estimated about 568,000 people were experiencing houselessness on any given night in the United States, a near 10% increase of “unsheltered persons” from the prior year.

Late last month, the University of Bristol published in The Lancet a systemic review and meta-analysis of housing instability and houselessness finding among people who inject drugs (PWID), recent houselessness and housing instability were associated with a 55% and 65% increase in HIV and HCV acquisition, respectively. Additional findings include of the global 15.6 million PWID, over 1 in 6 have acquired HIV and over half have acquired HCV at some point and an astounding estimation that half of PWID in North America actively experiencing houselessness or housing instability.

None of the studies included data collect prior to the start of the COVID-19 pandemic. While several states near immediately began introducing short-term eviction moratoriums and the CARES Act provided for federally backed mortgage holders to seek forbearance or deferment, these protections were short-lived, with many states looking toward the federal government for guidance. As with many issues, the summer of 2020 brought the country little comfort due to a lack of cohesive and coordinated public health response to the emergency. A paper published by housing heavy-weight, Emily Benfer, and HIV champion, Gregg Gonsalves, among others, found this failure to uphold and maintain meaningful and enforceable state-based eviction moratoriums contributed to racial health inequity and cited research finding that lifting moratoriums prematurely, triggering displacement, is associated with an additional 10,700 preventable COVID-19 deaths and 433,700 excess cases. In fact, an organization Benfer serves with, Eviction Lab, rates nearly every state in the country as “one star” in terms of housing protections for renters.

Under this frame, tens of millions of people in the United States are at extraordinary risk of contracting COVID-19. Which is part of why the Centers of Disease Control attempted to flex some public health muscle by issuing an eviction moratorium for public health purposes in October, 2020. Like with other investments made in the fight against COVID, the move was bittersweet for public health advocates at the intersection of housing and HIV, HCV, and SUD syndemics – where was this before now?

“Among the Biden administration’s first priorities is the advancement of racial equity and support for underserved communities,” Benfer said. “This requires redress of the structural and systemic discrimination in housing. As an immediate measure, the federal government should bolster the nationwide moratorium on evictions to apply to all stages of eviction, all forms of eviction, and all renters who face housing instability. At the same time, to prevent an avalanche of evictions and protect small property owners from harm once moratoria lapse, policy makers must provide the rental assistance necessary to address the accumulating back rent and sustain renters, state and local governments, and the housing market—and direct it to the communities at the greatest risk of housing instability.”

“Preventing COVID-19 eviction alone could save the U.S. upwards of $129 billion in social and health care costs associated with homelessness,” Benfer added.

However, the CDC’s moratorium is on shaky ground and implementation/access is not automatic – those seeking to use this protection most pro-actively notify their landlords and express intent to seek cover of the moratorium in eviction court. Several states and localities have not evenly implemented the moratorium or setting up “eviction kiosks” to expedite the process, because so many cases were in que, and some going so far as to list children as defendants in eviction actions. Which, according to Benfer, is not an uncommon occurrence. And due to the lack of protections for tenants and outdated credit reporting associated with eviction judgements, these legal actions can and often do follow people for at least a decade, compounding barriers to housing and drastically increasing the risk of houselessness. Because state-based protections have ended, Texas is allowing evictions to resume and the 6th Circuit Court of Appeals has recently allowed a challenge to the authority expressed by the CDC for the moratorium to move forward, even as some landlords are openly exploiting loopholes in the moratorium.

Landlords aren’t the only abusive persons seeking to take advantage of weaknesses in our housing protections. An unfortunate side-effect of the moratorium actions and our lack of investment in ensuring adequate resources for people experiencing intimate partner violence is perpetrators exploited stay-at-home orders and survivors, who are already at exceptional risk of housing instability, with an estimated 26% increase in domestic violence abuse calls made in some cities across the US during the strictest of those orders.

Additionally, with more people facing a lack of houselessness, even more are now at risk for “mobile homelessness” – or a lack of car to sleep in – an issue which may be masking just how many people are experiencing houselessness and housing instability, due to the design of some point in time surveys are conducted. And with an estimated 49% increase in chronic homelessness expected as a result of COVID-19 over the next 4 years, the potential exacerbation of the existing housing crisis in the US may well likely become an even larger, permanent feature without extraordinary action from all levels of government and, or even especially, private stakeholders. To put this figure into context, this would twice as much homelessness as was caused by the 2008 housing recession.

In The American Eviction Crisis, Explained, Benfer suggests there’s some basic policy moves to be made for longer-term successes:

“In the long term, federal, state, and local policymakers must reform the housing market in a way that provides equal access to housing, thriving communities, and areas of opportunity. Rental subsidies, new construction or rehabilitation, home ownership, and investment in long ignored communities would increase long-term affordable housing. Government-Sponsored Enterprises (GSEs) must remedy the current market conditions that can be traced to racially discriminatory lending policies. This means GSEs must address disparities in asset accumulation and the persistence of discrimination in mortgage lending and the siting of homes.

Where eviction is absolutely necessary, the eviction system itself must be reformed. Evidence-based interventions, such as providing a right to counsel, diversion programs, ‘just cause’ and ‘clean hands’ policies, as well as altering the eviction process, and sealing or redacting identifying information from eviction records, can prevent or mitigate the harm of eviction.”

That long-term investment is well past-due in addressing the needs of people living with and affected by HIV, HCV, and substance use disorder.

Benfer added, “Eviction prevention and the right to safe and decent housing must be the priority. As President Biden said while signing executive orders directed at ending housing discrimination: ‘Housing is a right in America, and homeownership is an essential tool to wealth creation and to be passed down to generations.’ It’s time the U.S. fulfilled the promises of the 1944 Economic Bill of Rights, which includes a right to a decent home, and the 1949 Housing Act that set the national housing goal: ‘the realization as soon as feasible of the goal of a decent home and a suitable living environment for every American family.’ Ultimately, our policies and budgets reflect our humanity and morality as a nation, and nothing could justify the continued denial of basic human needs and access to opportunity. If we are ever to call our society humane or just, we must finally redress housing disparities and discrimination and secure every American’s right to a safe and decent home.”

For far too long, housing as been placed on a shelf as an “unreachable” necessity in actionable advocacy. We cannot afford to “kick this can down the road” any longer. We’ve long known housing is one of the most effective interventions in prevention and in patient care. The oft-touted “it’s too expensive” excuse has manifested a broken dam with lives sifting through the cracks. We already pay for housing for PWID, it’s just most often manifested in the form of imprisonment. A far more meaningful investment in a person’s recovery and success, regardless of recovery, and in community health and in Ending the HIV Epidemic and in ending violence against women and interrupting cycles of generational poverty and answering our most sacred, moral promise and…and…and… would be to address the issue squarely: it’s time to invest in housing.