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Understanding the Impact of gentrification and Insecure Housing related to HIV Care Continuum in the Austin Transitional Grant Area (and other similar Urban Environments) Key: Bold = Main Point Underline = Subpoint 1) Introduction a) Defining the HIV Care Continuum b) Concern of Gentrification and insecure housing in large cities c) Literature Review Purpose i) To further explore challenges related housing and gentrification which impacts a person's ability to engage with the HIV care continuum ii) To discuss client characteristics that may make them more vulnerable to the challenges associated with insecure housing and gentrification iii) To explore how housing programs, like HOPWA, are being utilized 2) Gentrification and Insecure Housing a) Defining Gentrification i) As defined by the United States Housing and Urban Development - Office of Policy Development and Research, gentrification is a form of neighborhood change that occurs when higher-income groups move into low-income areas (HUD, 2017). This movement has the potential to alter the cultural and financial landscape of the original neighborhood. In the past decade, gentrification has been manifested into the “return to the cities” with redevelopment and investment of downtowns across the nation, including Austin, Texas (HUD, 2017). • Key Characteristics • Displacement • Rising Costs b) Defining Insecure Housing i) Explain how gentrification contributes to insecure housing in urban areas ii) It has been difficult to track housing insecurity reliably over time due to the inconsistent methods of measurement. The HUD has created a Housing Insecurity Research Module (HIRM), an opt-in, follow-on survey conducted shortly after the 2019 American Housing Survey (AHS). (HUD, 2022). Deeping the understanding of housing insecurity is an important task for researchers and policy makers as secure housing promotes positive outcomes in health, educational attainment, and employment (HUD, 2022). • In the HIRM, researchers measured the concept of housing insecurity based on three dimensions [...]: lack of affordability; lack of stable occupancy, and lack of safety and decency. Using these three dimensions, the research team developed six distinct profiles of Housing Insecurity [HI]. These six profiles represent points along the continuum of HI. At the lower and upper bounds of the continuum are households that are housing secure (very low HI) and those that are housing insecure in all dimensions (very high HI). Profiles in the middle of the continuum represent tradeoffs between these three dimensions of HI (HUD, 2022). c) How are these two concepts related • State that gentrification is not sole cause of housing instability • Impact of gentrification on housing affordability and stability d) Insecure Housing Trends for PLWH; Detail findings of Assessment of Needs and Barriers and Service Utilization data . i) Assessment of Service Needs and Barriers • In the Assessment of Service Needs and Barriers, half of total participants (51%, n=227) expressed that they are “very worried” or “moderately worried” about normal monthly bills or housing. • When asking participants to select their top 5 needs, help with housing was the 4th most needed service overall where 10% of total responses received were related to housing assistance. • When asked if participants felt that their housing situation is stable, 30% of persons asked indicated that it is not, and another 7% were not sure. • A participant’s housing situation impacted 18% of persons asked in being able to keep their medical appointments, which is approximately 1 in every 5 persons asked. Medication adherence was less impacted by a person’s housing situation as 13% of participants felt that their housing made it difficult to take medications as prescribed. • There is available service utilization data for housing services from 2017 to 2021. During those five years, the service category is consistently fully expended, if not over 100% expended. Throughout 2017-2021, housing services has averaged 14 clients served (SD=1.94), average cost per client being $10,585.58 (SD=1094.55), with an average of 623.8 units (1=day) (SD=136.28), average cost per unit was $245.40 (SD=32.91). The cost per clients and cost per unit has notably increased since 2020, which may be partially attributed to the COVID-19 pandemic. ii) Service Utilization Data 3) Impact on the HIV Care Continuum a) Black and brown communities disproportionately impacted by insecure housing (as an effect of Gentrification), displacement, and HIV in Austin Texas i) Nydegger LA, Benton EN, Hemingway B, Fung S, Yuan M, Phung C, Claborn KR. Housing Insecurity and Other Syndemic Factors Experienced by Black and Latina Cisgender Women in Austin, Texas: A Qualitative Study. International Journal of Environmental Research and Public Health. 2023; 20(24):7177. https://doi.org/10.3390/ijerph20247177 • Nydegger et al. Performed a qualitative study to explore housing experiences in-depth and across time among Black and Latina cis-gender women using interviews guided by syndemic theory between 2018 and 2019. Four housing insecurity categories emerged: (a) very unstable, (b) unstable, (c) stable substandard, and (d) stable costly. This is an analysis of a larger qualitative analysis exploring barriers to PrEP among Black and Latina cis-gender women • Very unstable and unstable housing participants compared to their more stable counterparts were more likely to report intimate partner violence, economic intimate partner violence, emotional abuse, and substance use. However, all participants, regardless of housing category, engaged in condomless sex. Over time, most participants, except those unstably housed, reported a decrease in condomless sex. Participants who were unstably housed continued to engage in condomless sex throughout the study. • The risk of acquiring HIV was measured by participant engagement in penetrative sex (anal and/or vaginal) without a condom, having multiple sex partners, or participants partners have multiple partners. All participants reported having condomless sex, regardless of housing stability. However, among those who’s housing was either very unstable or unstable, 50% of participants had multiple sex partners, and all (100%) participant’s partners had multiple sex partners. Results identified the importance of exploring housing insecurity with other syndemic factors among BLCW along with determining structural- and multi-level interventions to improve housing circumstances and other syndemic factors. Iyanda, A.E., Lu, Y. ‘Gentrification is not improving my health’: a mixed-method investigation of chronic health conditions in rapidly changing urban neighborhoods in Austin, Texas. J Hous and the Built Environ 37, 77–100 (2022). https://doi.org/10.1007/s10901-021-09847-8 In study conducted by Iyanda and Lu, Gentrification was found to be positively associated with SR-CHCs, after adjusting for socioeconomic variables • • • • This study examined the health impact of the rapidly changing physical and cultural environment using oral history interviews, electronic interviews, and a quantitative structured survey. The study draws on the social determinants of health framework to explain the self-reported chronic health conditions (SR-CHC) among 331 residents in Austin, Texas. Overall, this study investigates the perception of gentrification and health among east and southeast Austin, Texas, for policy implications toward improving resident health. • The study explains that gentrification is mainly produced from government policies (urban renewal and housing policies), globalization, urbanization, and structural inequality. Researchers detail that the Eastside of Austin is known for its historical segregationist policies, including the 1928 zoning policy, that moved people of color to the eastside via redlining policies that financially segregated minority communities across cities in the United States. As a consequence, neighborhoods in East Austin, Texas suffer longtime disinvestment and deterioration, leading to blight and decay before the recent reinvestment through a series of urban renewal programs. ii) Livelihood and health are deeply intertwined with where you live. While some argue that gentrification, seen as a rise in a neighborhood's affluence, improves overall well-being through better resources and social interaction, a critical question remains: how equitable is this process (Keels et al., 2013)? As mentioned by HUD, current gentrification measures lack consistency, and research on its connection to chronic health conditions is scarce. This study addresses this gap by exploring gentrification through the lived experiences of residents in East Austin, Texas. Many residents discuss how gentrification has increased the cost of housing, increased property taxes and longtime residents of Austin’s East side are at risk of displacement from newcomers due to the lack of affordability (creating a risk of losing support networks within the built environment). The lack of affordability impacts other needs such as foods security as well due to the need to pay high rents exacerbated by gentrification (Whittle et. Al, 2015) b) Challenges in accessing care among PLWH due to housing insecurity i) System of Care, 2022 • The research reveals a strong link between perceived gentrification and self-reported chronic health conditions (SR-CHCs). Residents experiencing gentrification reported more SR-CHCs. Qualitative interviews further highlighted how gentrification's impact on the physical and social environment can increase stress. These findings suggest gentrification may exacerbate health disparities within these communities. Furthermore, gentrification often disproportionately displaces low-income residents, particularly Black and Hispanic communities, before they can reap any benefits from neighborhood improvements (Richardson et al., 2019). This displacement likely contributes to the observed rise in chronic health conditions. • A five-month remote analysis (Oct. 2020-Feb. 2021) assessed Austin's HIV care system. It identified strengths, weaknesses, and opportunities for improvement. The system lacks a coordinated network, and services don't meet the diverse needs of PLWH, especially outside the city. Recommendations focus on improved access and coordination, including information sharing and expanded services beyond Travis County. • Unstable housing emerged as the most significant barrier to care (score: 3.66 on a 4-point scale). Analysis revealed strong agreement across respondent groups: homeless and unstably housed individuals living with HIV face the greatest challenges in accessing care and achieving viral suppression. Housing assistance topped the list of support services utilized, with an average of 54 service units per client. Women and Transgender PLWH are especially likely to be clients of housing services. • Unstable housing creates challenges in care access and achieving viral suppression for persons living with HIV. Rethinking HOPWA services and design was a listed recommendation, to explore ways to address issues like unsafe or undesirable temporary housing, need for support services along with housing, need for housing specialists to increase housing stabilities for PWH. Ryan white can never be a major source of HIV Housing due to the other demands on its resources, so HOPWA is a particularly critical resource. New procurement is necessary to implement needed change ii) Provider Capacity and Capabilities, 2021 • Issues related to unstable housing identified among a majority the service providers as a barrier to care access. Even from the provider perspective, unstable housing is an evident barrier iii) Graham G, Plankey MW. Antiretroviral Therapy Adherence Among People Living With HIV While Experiencing Homelessness. Georgetown Medical Review. 2023;7(1). doi:10.52504/001c.90758 • Unstable housing and lack of a permanent mailing address create significant barriers to accessing healthcare services, which are essential for improving overall health and HIV outcomes. Studies have shown that having health insurance is the strongest predictor of improved medication adherence among people experiencing homelessness. c) Challenges in retention/impact on medication adherence due to housing insecurity i) Angela A. Aidala, Michael G. Wilson, Virginia Shubert, David Gogolishvili, Jason Globerman, Sergio Rueda, Anne K. Bozack, Maria Caban, Sean B. Rourke, “Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review”, American Journal of Public Health 106, no. 1 (January 1, 2016): pp. e1-e23. https://doi.org/10.2105/AJPH.2015.302905 • Indicators of housing status tend to vary across studies. However, “worse” housing status is associated with less-than-optimal engagement and utilization of HIV medical care and poorer health outcomes, when controlling for a range of individual patient and care system characteristics. • There is strong evidence demonstrating that homelessness and unstable/inadequate housing are inconsistent with sound medical management of HIV. Therefore, intervention meeting the housing needs of PLWH can significantly improve their connection to care, adherence to treatment and medical outcomes. 4) The Austin Context a) Historical Significance regarding housing discrimination against PLWH in Austin i) Johnson, M. HIV/AIDS and Housing Discrimination in Austin, Texas: The Moral Majority and their Ipso-Facto Genocide. December 2021. Texas State University. Digital Library. digital.library.txst.edu/server/api/core/bitstreams/ef5c1f55-61c7-4312-89c6- 6bd8c558cdb4/content b) Recent efforts to address Housing Issues in Austin for Community and PLWH i) Supportive Housing Helps Stop the Spread of HIV in Austin, Texas ii) City Efforts to Address Displacement and Gentrification, 2018 iii) City of Austin Consolidated Housing Plan 2019-2024 • The City of Austin utilized the consolidated plan to help surrounding jurisdictions assess their affordable housing, community development needs, and market condition to make data-driven, place-based investment decision. The plan details how the Department of Housing and Urban Development entitlement grants are used to fund the Housing Opportunities for Persons with AIDS (HOPWA) program. Austin Public Health is responsible for the administration of HOPWA funding for the Austin TGA. The estimated Austin HOPWA funds are used between two subrecipients for Housing Case Management, Permanent Housing Placement, Short-term Supportive or Transitional Housing, Short Term Rent, Mortgage, Utility Assistance (STRMU), Supportive Services Tenant Based Rental Assistance (TBRA), and Administration. • The plan agrees that individuals living with HIV/AIDS often face significant challenges in accessing medical care due to income instability, which can also lead to homelessness. The plan suggests increasing access to supportive services, including temporary and emergency housing assistance, can help this vulnerable population achieve greater housing stability and reduce their risk of becoming homeless. The Austin Area HIV Planning Council was consulted for input on the plan on 02/25/2019, and the council did not provide comments. iv) Urban Institute. (2024, January). Efforts Toward Housing Availability in Austin and Travis County. [Memo] Retrieved from www.urban.org/sites/default/files/2024- 01/Memo_Summary_of_Austin_Guaranteed_Income_Pilot_Findings_and_Lesso ns_for_Policy_and_Practice.pdf • Memo addressed to Austin City Council from the Urban Institute detailed the findings of a pilot program from the City of Austin Equity Office that provided unrestricted cash-assistance to low-income families, who are experiencing housing insecurities. The Urban institute recommends using cash assistance to prevent evictions and improve Housing-choice voucher usability. Cash assistance provides flexibility and efficiency compared to other forms of assistance. v) HRSA New Policy Action to Improve Housing Access for PLWH c) Disconnect between Federal Housing Assistance funds (i.e. HOPWA) and local needs in the South i) Dasgupta, Sharodaa; Beer, Lindaa; Lu, Jen-Fengb; Weiser, Johna; Yuan, Xinb; Nair, Priyab; Banks, Laurenc; Marcus, Ruthannea. Needs for shelter or housing assistance among people with diagnosed HIV by jurisdiction: United States, 2015–2020. AIDS 37(3):p 535-540, March 1, 2023. | DOI: 10.1097/QAD.0000000000003460 • Dasgupta et al reviewed cross-sectional survey data from the CDC Medical Monitoring Project from 2015 to 2020. There is a high unmet need for shelter and housing assistance for many jurisdictions in the South, including Texas. Data showed that the distribution of federal housing assistance funds for PLWH may not be aligned according to local needs. Meeting this unmet need requires a multilevel approach, including strengthening partnerships between HIV care facilities and local housing service providers. Ensuring the alignment federal housing assistance funds and the local needs of the Austin area will be pertinent to be able to maximize the benefits of available funding. 5) Discussion and Conclusion 6) Future Research