Housing Status, Medical Care, and Health Outcomes AmongPeopleLivingWithHIV/AIDS:ASystematicReview

Less often, analyses have addressed community housing availability and conditions as a factor influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state that people may experience.11 Although it is important to understand and address the needs of people who are homeless, literal homelessness is merely the most extreme among a range of unstable and inadequate living arrangements that can compromise health.12-14 People who are homeless have higher rates of HIV than do people who are stably housed,15,16 but people who are HIV positive are also at increasedriskforinadequateorunstable housing and housing loss.17-20 Poor health, loss of income, stigma, and policy restrictions on housing assistance for people with drug use or incarceration histories, as well as preexisting social disadvantage, make it difficult if not impossible for many people with HIV to secure or maintain adequate housing.10 The US Department of Housing and Urban Development Office of HIV/AIDS Housing recently reported that in the United States an estimated 145 366 people living with HIV (a number equal to 12% of all HIV-positive people in the United States) have a current unmet housing need; of these 44% needed ongoing assistance to pay rent, 36% sought a supportive housing placement, and the remainder required short-term emergency assistance to secure or maintain housing.16 A focus on individual-level characteristics associated with literal homelessness and its health correlates glosses over social, economic, and policy drivers operating largely outside any individual'scontrol that affect housing and residential environments and the health resources or risk exposures such contexts provide. Both US and Canadian housing policy now support Housing First as a best practice strategy to assist homeless persons with multiple complex needs, including people with HIV.189,190 In the United States, agencies that manage publicly funded health insurance are investing in housing as health care as part of a larger Medicaid redesign process that aims to improve care delivery and reduce costs through innovation made possible by the Affordable Care Act.191 Homelessness and housing challenges are the result of complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health.8-10 Broader structural processes sustaining social exclusion and inequality would seem beyond the immediate reach of