Inadequate housing is a tremendous barrier to achieving good health—especially when dealing with a chronic illness. A team of researchers is examining largely rural counties in West Alabama to assess the impact of stable housing on the well-being of people living with HIV/AIDS.
We know that where we live, work, learn, and play greatly impacts our health. Especially important among these, and too often overlooked, is the impact of where we live. Housing is tied to health in powerful and inextricable ways. Think about the steps you take each morning to care for yourself, or each evening when you go to sleep. What would happen if you didn’t know where you would sleep that night, or weren’t sure how long you had until you were forced to find new shelter? Would you still take the time to go through your routines, if there was nothing routine about them? Would you set up relationships with health providers if you might not live in the same community next month—or even next week?
I faced homelessness twice and they were the most stressful experiences in my life. Lack of access to stable housing can feel like an insurmountable barrier to achieving good health and well-being—even more so when one is dealing with a chronic illness or other health challenges.
These experiences have given me unique perspective as I now work with a team to evaluate how housing impacts people living with HIV/AIDS in Alabama. My team includes Billy Kirkpatrick, PhD, Executive Director of Five Horizons Health Services, Inc. (formerly West Alabama AIDS Outreach) and George Mugoya, PhD, Associate Professor in the Department of Educational Studies in Psychology, Research Methodology and Counseling in the College of Education at the University of Alabama.
Our work is funded by the Interdisciplinary Research Leaders Program, a Robert Wood Johnson Foundation-supported leadership development program. The Interdisciplinary Research Leaders program supports teams of researchers and community leaders to use the power of action oriented research—that is research that is designed and done directly with the community, in order to drive change to create healthier, more equitable communities.
Research shows that homelessness and unstable housing contribute to poor health in people living with HIV/AIDS. In addition, being unstably housed contributes to high-risk behaviors. In fact, one-third of people living with HIV/AIDS are marginally housed across the country and many have a history of trading sex for money, drugs, or a place to stay.
We need to change this paradigm and begin to put housing at the core of health.
As my teammate Dr. George Mugoya notes, “It’s actually quite simple; if you don’t have housing, how can you take care of yourself? But if you do have stable housing, you will also have the ability to care for yourself, access health care services, and also reduce the transmission of the disease.”
Our research extends across 10 counties in West Alabama, nine of which are in rural communities. We are assessing the health impact of affordable housing programs, and identifying promising strategies for effective case management of people living with HIV/AIDS. Statewide we are evaluating community and policy advocacy programs and interviewing elected officials to gain a better understanding of the policy environment.
The 2011 Tuscaloosa–Birmingham tornado wiped away much of the affordable housing, and new housing being built is predominantly for the high-priced student market. As a result, there are fewer slots available for affordable housing, with waiting lists of up to two years in some cases. There is a long history of underinvesting in affordable housing in Alabama, which disproportionately impacts people living with HIV/AIDS.
While our research project is ongoing, we would like to share some preliminary lessons from our work to help inform the efforts of others who are striving to build healthier communities for all.
Housing Instability Disrupts Consistent Care
Moving from place to place often entails losing the connection to health services that are critical for treating a chronic disease. It is not unusual for case managers to get a new phone number for a client at the beginning of the week, and then not be able to reach them at the same number by the end of the week.
Identifying practices to better manage the transitory nature of people living with HIV/AIDS or reducing that instability through provision of stable housing, is critical.There are a few, limited opportunities to assist people living with HIV/AIDS in transition regarding living arrangements. Examples include a limited number of slots per state/service area from the federal program, Housing Opportunities for People Living with HIV/AIDS (HOPWA), housing vouchers and other programs from state Housing Authorities, emergency shelter options, and emergency aid from AIDS Service Organizations. It is crucial that people living with HIV/AIDS work closely with a case manager or social worker in order to get assistance with meeting their housing needs.
In a rural setting, when people are asked or forced to move, the distance can be substantial. For example in an urban setting you might have to move from one apartment to another within the same neighborhood. That’s hard enough. Yet in a rural community, losing housing often entails moving to another community—one that does not have your social support system or the same health services.
Stigma Associated With HIV Can Be Worse in Rural Areas
People living with HIV face stigma every day. They face unfounded fears from their friends, family, and community members, who may not be educated on how HIV is transmitted and ask them to do things like use plastic utensils or a different bathroom. These actions are isolating, and stem from a lack of understanding of the disease. The stigma can be worse in rural areas, where there are fewer people living with HIV and thus less familiarity with the disease. The stigma isn’t limited to the personal lives of these individuals. It finds its way into policy decisions, as well. As my colleague Billy Kirkpatrick highlights, “We also have stigma at our statehouse. It’s difficult to get policy decisions made when there are assumptions made about our clients. We need an educated populace.”
Many People Are Not Aware of How the Housing Crisis Impacts Those Living With HIV/AIDS
If you look at the statistics for homelessness, unstable housing among people living with HIV/AIDS may not be obvious. In Alabama, the rate of homelessness for people living with HIV is just 3 percent. However, when you probe deeper, you’ll find that 60 percent are not happy with their housing, a portion that represents a wide range of inadequate housing scenarios. Sometimes people feel unsafe; other times they are imminently homeless—meaning that they could soon be asked to leave the home of a friend or family member. The housing crisis among people living with HIV/AIDS is real and requires our attention and action.
Pursuing a Culture of Health means building communities where everyone has the opportunity to live a healthier life. Our team envisions an Alabama where people living with HIV/AIDS are empowered and able to thrive. This means access to stable housing, successful case management, and an educated populace who advocate for policies to support these goals.
Note: The author's teammates, Billy Kirkpatrick, PhD, and George Mugoya, PhD, contributed to this post.
As 2018 marks 50 years since the passage of the Fair Housing Act, I invite you to share your thoughts. What else should researchers, leaders, and communities consider when it comes to the intersection of housing and health?
About the Author
Safiya George, PhD, is Associate Professor and Assistant Dean for Research, Capstone College of Nursing, University of Alabama, Tuscaloosa, Alabama.