key: cord-1010965-38yh7rva
authors: Riley, Elise D; Hickey, Matthew D; Imbert, Elizabeth; Clemenzi-Allen, Angelo A; Gandhi, Monica
title: COVID-19 and HIV spotlight the U.S. imperative for permanent affordable housing
date: 2020-09-05
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1327
sha: 517eaad5aba63e711c246248b6ec6f06669f7c64
doc_id: 1010965
cord_uid: 38yh7rva

Job loss and evictions tied to the COVID-19 pandemic are expected to significantly increase homelessness in the coming months. Reciprocally, homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in U.S. shelters and other congregate living situations. Unless we intervene to address homelessness, these co-existing and synergistic situations will make the current public health crisis even worse. Preventing homelessness and providing permanent affordable housing has reduced the ravages of the HIV epidemic. We must take the lessons learned in 40 years of fighting HIV to respond effectively to the COVID-19 crisis. Housing is an investment that will curb the spread of COVID-19 and help protect all of us from future pandemics.

A c c e p t e d M a n u s c r i p t 4 Epidemics have a way of spotlighting vulnerabilities. As the U.S. struggles through the COVID-19 pandemic, tens of millions of Americans have lost jobs and experts predict that the existing affordable housing crisis is about to get substantially worse as more people have fewer resources to cover living expenses. Evictions in particular are expected to rise steeply, and the effects will be disproportionately felt by lower-wage earners. Unless we take bold action, experts predict a significant increase in the half million people who already live homeless in the United States each night. While our country debates strategies for supporting both public health and the economy, we would be wise to apply lessons from 40 years of HIV research. Like HIV, there will be no end to this latest pandemic without addressing homelessness.

Medical and public health research has illuminated how the HIV epidemic is inextricably linked with food insecurity, violence, incarceration, racism, substance use, PTSD and depression. Each of these factors significantly increases the risk of HIV infection, creates barriers to testing and health care, and makes negative health outcomes much more likely. The issue at the center of it all is homelessness, which magnifies the likelihood of every other risk factor. 1 These are the same issues fueling other recent epidemics, such as typhus outbreaks among unsheltered Americans 2 . Homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in U.S.

shelters and other congregate living situations. 3 Unless we intervene swiftly, tens of thousands of newly unemployed people are at risk for landing in these shelters, which are often densely populated and thus some of the riskiest places to be-for both residents and staff-during this pandemic.

COVID-19 may have turned a spotlight on the fault lines in our country, but these social and economic fissures go back decades. Even before the COVID-19 pandemic, holding down a job has not always guaranteed protection: the combination of higher rent and lower wages has created a growing population of working people who experience homelessness. 4 Neither is homelessness limited by educational status: A 2016 survey of California State University students found that 1 in 10 was homeless, and 1 in 5 did not have consistent access to food. 5 Like SARS-CoV-2 itself, housing insecurity has A c c e p t e d M a n u s c r i p t 5 penetrated every corner of our country: in rural areas, 4 in 10 Americans say their families had problems affording basic needs in the past several years, including housing. 6 Collectively, these situations tell us that housing instability can no longer be viewed as a rare condition occurring in exceptional circumstances. The challenge facing us now is that this problem is about to get substantially worse.

The HIV epidemic has given us 40 years of experience and insight. It is now understood that a cornerstone for ending the HIV epidemic is providing permanent affordable housing. 7 In addition to promoting independence and individual health, stable housing reduces the transmission of HIV. Why? Housed people without HIV are better equipped to take preventive measures such as pre-exposure prophylaxis (PrEP), 8 and are at lower sexual risk from situations involving coercion and assault. 9 Housed people living with HIV are also better able to store medication, take their antiretroviral therapy (ART), attend medical appointments and achieve sustained viral suppression, thus eliminating the possibility of transmitting HIV to others. 10 Innovative health care delivery that provides comprehensive services through streetbased medicine or low-threshold (e.g., no appointment) clinic-based care are helping to address the challenges faced by people experiencing homelessness or unstable housing; 11 however, these programs are only provisional, short-range stopgaps. No care model can adequately address the underlying social determinants of health that are so severely impacted by a lack of stable housing. Similarly, the reprieve from homelessness afforded by recently deployed "shelter in place hotels" and "isolation hotels" provide respite and risk reduction; however, these programs are only temporary. Unless they are used as bridges to permanent housing options, the individual and community-level risks remain.

Like HIV before it, the COVID-19 pandemic places America's vulnerabilities in stark relief. We know that living paycheck to paycheck amplifies a cascade of threats to safe, stable housing. We know that, as jobs disappear, the risk of homelessness increases 

MG reports grants from NIH, outside the submitted work. ER reports grants from California HIV/AIDS Research Program (CHRP) and National Institutes of Health, outside the submitted work. AC reports grants from NIH, outside the submitted work. All other authors have no potential conflicts to disclose.

Housing First: Unsuppressed Viral Load Among Women Living with HIV in San Francisco

Flea-borne (endemic) typhus. Los Angeles County Department of Public Health. Acute communicable disease control Web site

Coronavirus Disease 2019 (COVID-19) Outbreak in a San Francisco Homeless Shelter

Working Homeless Population Grows in Cities Across the U.S. . Parade

Serving displaced and food insecure students in the CSU

School of Public Health, the Robert Wood Johnson Foundation and National Public Radio. Rural Health and Well-Being in America: An RWJF Collection Web site

Getting to Zero San Francisco: A Collective Impact Approach

Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study

The Effects of Housing Status, Stability and the Social Contexts of Housing on Drug and Sexual Risk Behaviors

Degree of Housing Instability Shows Independent "Dose-Response" With Virologic Suppression Rates Among People Living With Human mmunodeficiency Virus

Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies

A c c e p t e d M a n u s c r i p t 7