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Positive Reentry
Housing is a fundamental necessity for all people, one that increases exponentially when a person is living with HIV/AIDS (PLWHA). For PLWHA who have also experienced incarceration, the need to provide immediate and stable housing becomes even more imperative, as justice involvement, poor HIV health, and housing insecurity work to exacerbate one another.
Sustained housing support for justice-involved PLWHA not only provides shelter, but also the foundation by which an individual can address basic needs, avoid choices that carry risk, attain treatment adherence and viral suppression, and avoid future justice involvement.
5X rate of HIV among incarcerated populations, compared to general population.
10X rate of HIV is among those experiencing homelessness, compared to general population.
Housing as HIV Treatment and Prevention for Justice-Involved People
Akin to proper nutrition and antiretroviral therapy, housing is a core component to HIV care; recent studies have highlighted that PLWHA who are experiencing homelessness and housing insecurity are less likely to be taking medication or following treatment recommendations, are less likely to have achieved viral suppression, and are significantly less likely to have an HIV care provider. Recent or frequent incarceration can be highly disruptive for individuals who are trying to engage in and adhere to treatment, and challenging for a person’s ability to maintain housing. By providing stable and supportive housing to justice-involved PLWHA, individuals can more easily adhere to treatment, avoid incarceration, and sustain housing.
Housing has also been identified as an effective HIV prevention tool. A study published in 2018 showed lower incidence of HIV infection among those who received more than 7 days of housing placement compared to the control. HIV prevention is particularly important for people who have experienced incarceration. Release from a prison or jail facility often coincides with an uptake in choices that carry risk of HIV transmission, such as injection substance use, and participation in survival or commercial sex work. These behaviors are all propelled by lack of stable housing. Providing stable and supportive housing to recently released people is essential to individual HIV prevention, and also to community-level epidemiology; jails have been shown to drive community-level epidemiology of communicable diseases in areas where rates of incarceration are higher.
3 in 5 of PLWHA have experienced homelessness.
Unstable housing reduces likelihood of viral suppression by 51%.
Interwoven Identities
The cyclical nature of housing insecurity, poor HIV health, and incarceration, is explicitly illustrated through data collection and analysis. Roughly 60% of PLWHA have experienced homelessness at some point; concurrently, previous justice involvement among people experiencing homelessness has been measured as high as 68%. Separate examination of justice-involved people and people experiencing homelessness show both groups have heightened rates of HIV infection, five times higher among incarcerated people when compared to the United States average, even higher among frequently incarcerated people, and up to ten times higher than average among people experiencing homelessness. To break this cycle, formerly incarcerated PLWHA need specific support in accessing and maintaining housing, as higher prevalence of mental illness, substance use, and lack of continuity of care due to frequent incarceration all hinder a person’s ability to access and adhere to treatment. One study conducted in 2017 revealed that need for mental health, substance use, and case management services was coupled with housing need in 80% of cases.
What is Needed?
Academic literature enthusiastically affirms supportive housing models as a vital component of provision of care to justice-involved PLWHA. There are a variety of supportive housing models, all intended to provide stable housing while also engaging the client in case management, mental health, substance use, and other supportive services. Rates of substance use and overdose are heightened among recently released individuals, and substance use is a known risk-factor for unstable housing and homelessness. Housing First, provision housing paired with on-site supportive services without the requirement of sobriety, is one supportive housing model that speaks directly to the intricacies of serving PLWHA who have also experienced incarceration. When stable housing is provided alongside on-site medical care management, psychosocial services, and a harm reduction ideology, a more holistic and sustainable approach to treating justice-involved PLWHA is achieved.
In spite of the strides made by the HIV/AIDS Service Administration (HASA), there are still significant barriers to providing adequate housing for formerly incarcerated PLWHA. The paired stigma of incarceration and HIV/AIDS, lack of legislative protections specific to criminal justice involvement and HIV status, landlord non-compliance with the Fair Housing Act, and the overall scarcity of affordable housing, all work to create substantial barriers to stable housing access for formerly incarcerated PLWHA. Housing policies that speak to specific needs of PLWHA with justice involvement are vital in ensuring that the population can not only access housing in theory, but also in practice.
To date, research conducted to examine the causal relationship between stable housing and health care outcomes has not recognized incarceration as a central contributing factor, and interventions meant to impact homelessness, justice-involvement, and/or HIV/AIDS health outcomes, have not adequately addressed the multiple interwoven identities that justice-involved PLWHA connect with. More robust study of housing interventions directed at improving HIV treatment and prevention outcomes for justice-involved PLWHA is needed, and housing interventions that speak to the overlapping identities of this population are essential to the simultaneous address of health and housing needs for justice involved people living with HIV/AIDS.
Next Steps: Policy Considerations
Make HASA for All a state-wide policy.
Specific housing vouchers pertaining to justice involvement; Innovations in housing subsidies should be geared toward, not disallow for, justice-involved PLWHA.
For people accessing housing vouchers ensure that the subsidy amount provided is sufficient to meet the increased market rate rent demands, on an annual basis.
Care Coordination and Transitional Care Planning should include housing planning.
Make housing assistance a top HIV prevention priority.
Continue to collect and analyze data to assess housing as an independent structural HIV prevention and healthcare intervention, and how justice involvement further effects that relationship.
