As the Advocacy and Policy Associate for Housing Works, I had the opportunity to attend the 8th Annual North American Housing and HIV Research Summit from September 14–16 at the Omni Shoreham Hotel in Washington D.C. The summit was sponsored by organizations such as the Ontario HIV Treatment Network (OHTN), the National AIDS Housing Coalition (NAHC), Housing Works, the MAC AIDS Fund, and REACH 2.0, among others.
It was an exciting summit, where individuals from all over the United States and Canada shared research, ideas, and stories related to the social drivers that impact HIV. Plenty of evidence shows that housing is a form of HIV prevention. In fact, during the summit, we watched a video featuring the United States Secretary of Housing and Urban Development, Julián Castro, who stressed, “The first step to better health is having a roof over your head.” Having a stable place to live provides comfort, safety, and the opportunity to focus on other important health issues. But now that we know this, what’s next?
Throughout the event, I jotted down notes, trying to grasp the bigger picture and make connections between research, practice, policy, and advocacy. While there are complex layers to the AIDS epidemic, I came up with 6 takeaways and action items that I feel must be addressed in order to accomplish the goal of ending AIDS in the United States.
1. Medicaid expansion under the Affordable Care Act is crucial.
In the United States, 31 states have adopted Medicaid expansion under the Affordable Care Act (ACA), but 19 states are not adopting it at this time. The Affordable Care Act — also known as the Patient Protection and Affordable Care Act or, colloquially, “Obamacare” — was signed into law by President Barack Obama in 2010. The ACA was created to expand health insurance coverage and increase the quality of healthcare for many Americans who could not afford healthcare before. Some of its features include: coverage under a parent’s health plan for people under 26, free preventive care, protection for consumers with pre-existing conditions, access to a new healthcare marketplace where individuals can chose health plans based on level of need, and expansion of Medicaid.
Medicaid is a healthcare program in the United States for individuals and families who have disabilities or are low-income and do not have adequate resources to pay for healthcare. Each state decides the eligibility criteria for this program. Implementation of the ACA expanded Medicaid eligibility, but 19 states decided not to adopt this expansion. In the states that did expand Medicaid, more low-income individuals and families that meet the criteria have access to healthcare, which can significantly improve their quality of life.
People living with HIV/AIDS have high-cost healthcare needs but are often among the same populations that face barriers to accessing healthcare, Medicaid included. A study published in HealthAffairs found that of the 407,000 adults (ages 19–64) living with HIV and receiving care, almost 70,000 were uninsured. Consequently, a new type of “donut hole” has formed among adults who are not eligible for Medicaid in a state without Medicaid expansion, but who are too poor to receive government subsidies in the Healthcare Marketplace. Pushing states to expand Medicaid could help thousands of people living with HIV.
2. We need to address the intersection of intimate partner violence, drug use, and homelessness, particularly affecting women.
Many women living with HIV in the United States have a history of intimate partner violence (IPV) in addition to drug use, homelessness, or both. A number of published studies have shown that the rate of IPV among HIV-positive women in the U.S. was double the national rate. The research has been done and the results are in: IPV is a growing issue and is often associated with HIV transmission. At the summit, I asked the panelists presenting on this issue: “what type of interventions do you propose to address this problem?” I was met with “that’s a good question,” but not much else. Unfortunately, it’s difficult to determine the right intervention for this issue. There’s no one-size-fits-all method. Some recommend post-trauma counseling for the women. Others say focus the intervention on the perpetrator through anger management classes and educational campaigns on gender equality. Whatever the case may be, IPV, drug use, and homelessness is a reality for too many men and women living with HIV/AIDS.
3. PrEP Education can stop the spread of infection.
PrEP (Pre-exposure prophylaxis) is a pill (brand name Truvada) that HIV-negative individuals at risk of exposure can take daily to significantly minimize HIV infection. PrEP works by stopping the HIV virus from spreading in a person’s body but only works if adhered to daily. PrEP has rolled out across the United States, but education about it is severely lacking. I met many people at the summit who had never heard of PrEP but were excited to pass the information on to their respective organizations and jurisdictions. Spreading awareness about PrEP and its benefits can substantially aid in halting transmission. Unfortunately, outside of the U.S. not many countries are exploring PrEP implementation. Education is key.
4. Put more focus on interventions to reduce viral load and transmission.
I’m grateful to be working with an organization that is at the forefront of ending the HIV epidemic through relentless advocacy and continuous research and policy work. In 2014, Housing Works, in collaboration with researchers at the University of Pennsylvania, established the Undetectables Project with the goal of at least 80% of its HIV-positive+ clients having a HIV viral load <50 copies/mL (an undetectable viral load). Having a suppressed viral load makes a person less likely to transmit the virus. The project involves an intervention toolkit that includes financial incentives, behavioral health assessments, support groups, pill-boxing, and Directly Observed Therapy (DOT) if necessary. This project has been very successful for Housing Works — as of May 2015, 82% of its clients were virally suppressed, which is a big accomplishment, seeing that only 30% of HIV-infected individuals in the U.S. are virally suppressed. Scaling up the combination of viral load suppression interventions with continued infection prevention efforts will help us achieve the goal of ending the HIV epidemic.
5. The transgender community deserves more advocacy and support.
When I started my fellowship, my supervisor recommended I skim Inclusion Matters: The Foundation for Shared Prosperity, which goes into depth on how communities such as transgender individuals, men who have sex with men, minorities, homeless or displaced populations, recent immigrants, people living in poverty, and injection drug users struggle to achieve equitable healthcare due to discrimination and social exclusion. The transgender community encounters this on a daily basis. A recent study showed that transgender women are 49 times more likely to have HIV compared to all adults of reproductive age. Forty-nine. This is a huge problem that larger systemic issues only contribute to more. We absolutely need to include the transgender community in the HIV narrative and treat them as a unique population with the same rights as other adults.
6. Meet people where they are.
This was perhaps the biggest takeaway I gained. In public health, we hear this statement quite frequently, but I developed a stronger and more sincere appreciation for it during a Summit breakout session. We were on the subject of “stigma,” a concept in HIV that, as one attendee noted, “Has not changed since the 90's.” One of the most important things we can do is view individuals living with HIV as equals, to meet them where they are rather than see them as mere numbers in a monitoring and evaluation report. Listen to their stories. Let their voices be heard. Through this, we can breakdown the pervasive fear and stigma, taking us one huge step closer to ending the epidemic.
Farnaz Malik is a 2015–2016 Global Health Corps fellow at Housing Works in New York City. All GHC fellows, partners and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. Join the movement today.
