1. Housing as a Structural Intervention for Transgender People living with HIV/AIDS Megan Stanton, MSW* Sambuddha Choudhuri* Samira Ali, MSW* Lynn Walker, D.Min., M.S.Ed.** Virginia Shubert, JD** Toorjo Ghose, MSW, PhD* Virginia (Ginny) Shubert – gshubert@shubertbotein.com *University of Pennsylvania School of Social Policy and Practice ** Housing Works, Inc.

2. HIV Prevalence 27.7% among transgender women (MtF) (Herbst et al., 2011) Syndemic Theory: Complex HIV Risk (Operario & Nemoto, 200?) Stigma, marginalization, and discrimination. Marginalization Risk Environment HIV Risk Behavior Existing Research: Prevalence and Complex Risk

3. Housing Works, Inc. Research has called for: multi-component interventions that can address the full constellation of service needs of TG individuals increased intervention efforts focused on structural barriers facing TG individuals, such as housing trans-compenent and trans-specific services Very little research exists examining structural intervention models responsive to the complex and unique needs of TG and GNC PLWHA. Existing Research: A Call to Action

4. Housing Works, Inc. Transgender Transitional Housing Project (TTHP) Housing first program tailored specifically for TG PLWHA Scattered-site housing in New York City Low threshold/ use tolerant model Supportive Services Case Management Groups Access to HW continuum of care Methods: Setting

5. Housing Works, Inc. Community-based participatory approach Meaningful involvement of residents and staff Quantitative 90 TTHP residents (assessed as program exit) were compared to 90 homeless HIV-positive clients on HIV medication Matched by age and race. Multiple regression to assess effect of TTHP participation on viral load suppression. Qualitative 30 semi-structured, in depth interviews with TTHP residents. Thematic analysis was utilized. Methods: Mixed Methods

6. TTHP: Quantitative Results TTHP residence was associated with viral suppression A significantly higher proportion of those who completed TTHP had suppressed viral loads compared to non-residents (67% vs 32%, p<.01).

7. TTHP: Qualitative Results Main Theme Stable housing undermined chaotic and risky physical environments and facilitated service-utilization that ultimately reduced HIV risk and improved adherence. Specifically...

8. TTHP: Risk Management 1. Risk management: – Mitigate exposure to chaos and violence in unstable housing – Avoid substance use environments – Provides environment facilitative of safe sex Reduces the need to engage in survival sex work

9. TTHP: Health Management 2. Health Management – Supported housing: connects residents to needed services – Refers to trans-competent services Critical to participant success in referred program – Protection from chaos/risk environment promotes personal health management Maintaining appointments Medication Adherence – Increased pride in living space and quality of life associated with motivation to maintain positive health practices

10. TTHP: Privacy-Establishment 3. Privacy-Establishment: – Control over living space promoted residents' sense of self- efficacy over their live and health – Negotiate societal stigma due to gender identity Develop and express gender identity on own terms

11. 4. Public Space-Taking : – Community space for TPLHA to connect and support one another Inspires engagement in gender-based advocacy activities Improves collective efficacy as transgender people – Residents claim ownership of a physical and visible location in the community Facilitates claim on public space Articulates rights as social citizens TTHP: Public Space Taking

12. 5. Resilience : – Transgender identity is not only a barrier to housing and social service access, but can also be a source of strength for TTHP Chosen gender expression encourages attaining health goals Transgender community is source of support and education Previous experience with advocacy fosters desire for continuing involvement only a source of difficulty with regards to housing and social service access, but can also be a source of strength can be not only a source of difficulty with regards to housing and social service access, but can also be a source of strength TTHP: Resilience

13. Conclusions Housing operates as both prevention and treatment for TPLHA Undermines the HIV risk environment – Interrupting the marginalization/risk environment feedback loop associated with HIV Facilitates positive health behaviors – Medication Adherence Housing promotes personal and collective efficacy of TPLHA Privacy to negotiate stigma Collectivization and command over public space

14. Conclusions The TTHP model can be used as a structural intervention for marginalized and stigmatized communities living with HIV

15. Acknowledgments Thanks to TTHP residents and staff for their support in this research. Housing Works and the University of Pennsylvania also thank the M*A*C AIDS Fund for supporting this research.