Association Between Housing Instability and HIV Care Outcomes Among People With HIV in the United States.

BACKGROUND

People with HIV (PWH) disproportionately experience homelessness and other forms of housing instability. Understanding how housing status influences HIV clinical outcomes remains limited, especially among individuals engaged in care.

METHODS

We evaluated associations between housing status and HIV care markers using clinical data and patient-reported measures from the Centers for AIDS Research Network of Integrated Clinical Systems cohort of adults receiving HIV care across the United States (US), between 2019 and 2025. We used relative risk regression and linear regression to estimate associations between self-perceived housing instability and outcomes including HIV viral suppression (<200 copies/mL), self-reported antiretroviral therapy (ART) use and adherence (visual analog scale), and CD4 cell count, adjusted for demographic characteristics, year, and site.

RESULTS

Among 6873 individuals in clinical care, nearly 10% reported some form of housing instability at their most recent visit: 4.6% "Unstable," 3.3% "Homeless," and 1.7% "Do not know." Compared with stably housed individuals, the prevalence of viral suppression was lower among those experiencing homelessness [prevalence ratios (PR) = 0.82, 95% CI: 0.77 to 0.89] and unstable housing (PR = 0.94, 95% CI: 0.90 to 0.98), as was the prevalence of ART use, mean ART adherence, and mean CD4 count. Results were similar when stratified by substance use and depression and when compared with a community-based cohort of PWH.

CONCLUSION

Housing instability is associated with a lower prevalence of HIV viral suppression even among individuals engaged in clinical care. These results highlight lack of access to stable housing as a structural barrier to successful management of HIV and to ending the HIV epidemic in the US.