Experiences of Homelessness and Unstable Housing Among People with HIV: Data from the CNICS Cohort

Abstract

BackgroundPeople with HIV (PWH) are disproportionately impacted by homelessness and unstable housing (HUH), which is associated with difficulties in accessing care and worse clinical outcomes. There is limited data available on how housing status for PWH varies over geographic areas in the US or changes over time. We sought to examine these trends to better understand the burden of HUH among PWH. Methods We used data from the Center for AIDS Research Network of Integrated Clinic Systems (CNICS) cohort, a clinical cohort of PWH the US. Data is collected from medical records and by digital surveys of patient reported outcomes (PROs) during routine clinic visits. We assessed the baseline housing status (stable, unstable, or homeless) using PROs. Demographic differences in housing status were assessed with chi-squared tests. We examined the prevalence of each housing over time. For participants with multiple PROs, we tracked how housing status changed between their first and most recent responses. We calculated the prevalence of homelessness at each clinic and compared it to the local prevalence of homelessness in each clinic’s county using the 2024 Annual Homelessness Assessment Report to Congress and US census data. Results There were 31,748 PROs from 10,097 participants at 10 clinic sites between 2019 and 2024. On their most recent PRO, 641 (5%) PWH were homeless and 1563 (13%) were unstably housed. PWH experiencing HUH were more likely to identify as a racial or gender minority and to have injection drug use as an HIV risk factor. They were less likely to report current antiretroviral use or to have a suppressed viral load. The prevalence of HUH was generally stable but 28% of participants experienced at least one change in housing status. In 2024, the proportion of PWH at each site experiencing homelessness ranged from 2 to 16%, resulting in a prevalence of homelessness 3 to 51 times higher than the local population. This difference was greatest in areas with a lower prevalence of homelessness. Conclusion PWH in the US experience a disproportionately high burden of HUH across locations despite varying local prevalences of homelessness. Many experience fluctuations in housing status over time. Our findings demonstrate that housing instability remains a critical barrier for many PWH who would likely benefit from additional access to resources and support to achieve stable long-term housing.