Housing needed to reduce HIV
Those infected stay in treatment when living in a stable home
Two years ago, “James” was sick, depressed and alone. At 40, he had spent almost half of his life in San Francisco, HIV positive and homeless.
“No one would rent to me,” he said. “So I stayed in the shelter or on the street.”
James was regularly in and out of the hospital. He tried to make medical appointments, but he often missed them and ended up in the emergency room. He was embarrassed to take HIV medicines in front of others, so he didn’t take them at all.
After several years on a waiting list, James accepted housing in a single-room occupancy building — his first permanent home in decades. It’s small but, for James, housing represents something big: a shot at health.
With housing, James is consistently keeping medical appointments, taking HIV medicines and receiving care for his depression. He is achieving the goal of HIV treatment, resulting in better health for him and for San Francisco.
“It’s easier now that I have a place to live,” he said.
In 2018, we can proudly say that in San Francisco, more HIV-positive persons than ever are engaged in HIV care and prevention. Like James, they are benefiting from treatments that have transformed HIV from a uniformly fatal disease to a chronic illness. Over the past five years, new HIV diagnoses in San Francisco have fallen by 52 percent, compared with an 8 percent decline nationally. In 2017, San Francisco experienced 221 new HIV infections, the fewest since the early 1980s.
Part of this success is due to “Getting to Zero San Francisco,” a multi-sector citywide consortium started in 2014 with the ambitious goal of reaching zero new HIV infections, zero AIDS-related deaths and zero HIV stigma. The program focuses on three initiatives: increasing the use of Prep (Pre-Exposure Prophylaxis), a daily pill to prevent HIV acquisition; coordinating the immediate start of treatment for new HIV diagnoses; and re-engaging those who have fallen out of HIV care.
Continued success will require more affordable housing. When housing is unstable, taking medicines and attending appointments take a backseat to immediate survival. Often, homeless individuals turn to sex work or substance use, which can increase the risk of HIV transmission and worsen mental health. Older adults living with HIV, who make up 65 percent of HIV-positive San Franciscans, are experiencing increasing housing instability due to declining incomes and skyrocketing rental costs.
Improving housing brings not only public health benefits, but also financial gains for society. The provision of housing reduces public spending on medical costs for homeless individuals, including the number and length of hospitalizations. In fact, San Francisco spends five times as much on medical costs for the sickest homeless people as for those in housing.
Despite San Francisco’s success in reducing new HIV infections, growing disparities threaten progress. A key element of HIV treatment depends on patients being able to achieve “viral suppression,” or to reduce the amount of HIV in one’s blood to an undetectable level. Virally suppressed patients can stay healthy and do not transmit HIV.
Of those living with HIV in San Francisco, the greatest disparity in viral suppression — more than race, gender, age, or mental illness — is related to homelessness. In 2017, twothirds of those housed had viral suppression compared with just a third of the homeless. Equally concerning, homeless persons accounted for 14 percent of new HIV diagnoses in 2017 despite being less than 1 percent of San Francisco’s population.
In 2018, Getting to Zero launched an initiative to coordinate with homeless service providers and advocates. As a result, in the city’s new Coordinated Entry program, people living with HIV and other chronic health conditions will be among those prioritized for housing. However, the program’s high demand highlights a desperate need for more housing. Fortunately, Proposition C will provide permanent housing for 4,500 youths, adults and families, and many others will stay housed because of increased subsidies and eviction prevention programs.
We call upon San Franciscans to hold the city accountable for promised investments in supportive housing and measures to prevent homelessness, and we challenge the private sector to embrace this opportunity for innovation.
Like the HIV epidemic, homelessness is a daunting problem fueled by stigma, shame and discrimination. We must draw on our history of activism and innovation to inspire us to join the fight for an effective and compassionate solution. San Francisco could be the first major city to end the HIV epidemic — but not without housing.