Using the CDOH, our study identified that most WLWH in our Metro Vancouver cohort had experienced unsheltered and unstable living situations in the last six months at baseline. Key social-structural factors, including living in the Downtown Eastside (DTES) neighbourhood of Metro Vancouver, hospitalization, physical and/or sexual violence in the last six months, were associated with unsheltered and unstable housing (vs. stable housing), with important implications for housing to address and prevent homelessness among WLWH.
Among WLWH in our study, 24.4% reported unsheltered housing situations and 47.3% reported unstable housing in the last six months at their baseline interview, with an overall 71.7% reported living in unsheltered and unstable housing (Table 2). We found limited studies with which to compare the prevalence of precarious housing among WLWH in other settings. One study of PLWH revealed 8.1% prevalence of homelessness and SRO residence among WLWH and 19.6% among trans PLWH [24] Further, the combined prevalence in our study sample is also higher than the prevalence of housing insecurity (measured by asking participants if they have difficulty affording housing and related costs) reported in a Canadian study with WLWH, at 51.5% [25]. The discrepancy may be due to the differences in how housing status was measured. In comparison to other definitions of homelessness, measuring housing status according to the CDOH provides a more comprehensive assessment of the housing status and offers categorizations that encompass the complexity of participants’ housing experiences.
DTES residence was associated with over five times the odds of being unsheltered and over twice the odds of unstable housing. These associations seem reasonable in the context of overlapping experiences with marginalization and poverty among WLWH. Vancouver’s DTES has been experiencing a systemic and structural housing crisis [26, 27]. The inexpensive and often precarious rental options and an accepting culture attracted many marginalized and low-income populations [26]. Widely available criminalized drugs have also contributed to exacerbating poverty and displacing people from housing intolerant of drug use [26]. With a growing number of higher-income urban developments, recent decades saw a systemic decrease in cheap rental units, further limiting the housing options [26, 27]. Low-rent SROs lack adequate living space, maintenance, and tenancy right protection [10]. While the resilient and vibrant community has been supported by grassroot organizations, interventions from provincial and municipal government are required along meaningful consultation with community members to increase the availability of affordable and humane housing options.
Recent stimulant use was associated with almost three times the odds of being unsheltered. Substance use as a coping mechanism in response to trauma [28]. Substance use is a known contributor to the loss of housing due to financial instability, social stigma and limited options for low-barrier approaches to drug use [9, 28, 29]. Meanwhile, experiencing homelessness can lead to or increase substance use for coping stress, resulting in a cycle of homelessness and substance use [28]. Further, historical and current colonial violence and trauma, including the devastatingly negative effects of residential schools, have impacted generations of Indigenous people, resulting in disproportionate prevalence of substance use and addiction [29]. The stigmatization of substance use and addiction fuels discrimination against potential tenants perceived to use drugs, which limits access to rental housing [30]. For PWUD to gain access to stable long-term housing, housing programs need to follow harm-reduction principles and provide or link to adequate, culturally safe and gender-responsive, gender-inclusive treatment programs with trauma- and violence-informed (TVI) principles.
Our study identified an association between hospitalization and homelessness. Current literature has conceptualized homelessness and unstable or precarious housing as a reason to explain increased utilization of the emergency department among PLWH in BC, whereas stable housing can encourage connection with primary care to avoid misuse [31]. Meanwhile, hospitalization could also lead to and explain homelessness or unstable housing [32]. Systemically, inadequate discharge planning could introduce someone with limited resources to homelessness [9]. On a structural level, hospitalization could limit income generation and lead to unemployment, poverty, and homelessness [9]. On the individual level, severe and debilitating illnesses could prevent securing employment and housing. Individuals with mental health conditions might experience disruption of social connections from family and others that support stable housing [32]. Homelessness and/or unstable housing has been associated with higher levels of hospitalization in other settings, with women experiencing homelessness and/or unstable housing having 3.5 times the rate of hospitalizations and 11.9 times the rate of outpatient mental health and substance use service usage events relative to the general population of women [33, 34]. WLWH in the United States had 51% higher rates of hospitalization than MLWH, while PLWH had higher likelihoods of hospitalization than the general population [35]. For trans WLWH, the lack of gender-responsive and gender-inclusive care further limited healthcare access [36]. Limited healthcare access while being homeless can exacerbate HIV and other illnesses, resulting in a cycle of worsening health and homelessness [5, 32]. Housing developments and public-funded programs with WLWH should facilitate healthcare access and provide adequate financial and personal support to prevent homelessness.
Our findings were consistent with existing literature that gender-based violence is a major cause of homelessness among women [9], and these effects may be exacerbated for racialized WLWH and WLWH with minoritized and marginalized sexual and/or gender identities. Women and children are most likely to become homeless upon leaving violent relationships or households [3, 9]. In Canada, the destructive effects of structural racism, residential schools and other colonial violence has resulted in Indigenous women experiencing high levels of interpersonal violence and homelessness [30]. In New Zealand, colonial violence has similarly driven the over-representation of Indigenous Maori women among women experiencing unstable housing, with nearly 80% of Indigenous Maori women experiencing unstable housing nationwide, 5.5 times of the general population [33, 34]. In an Ontario study of gender-diverse people, 73% ever experienced violence, and 67% reported having to move due to their gender identity and expression (35). Even at women-specific shelters, trans and two-spirit individuals are subject to structural violence, including discrimination, social exclusion, and gender policing [12]. HIV-related stigma exposes WLWH to verbal, physical, and sexual violence by any perpetrator, ranging from intimate partners to strangers [37]. Violence and trauma lead to psychological stress, damaged self-esteem, suicidality, and substance use [37], further marginalizing WLWH and contributing to housing instability. Our findings highlight the need to create safe, inclusive, and TVI housing solutions for all WLWH.
Inequities in employment and income among WLWH undermine housing opportunities. Unemployment, nonlegal employment, and sex work were prevalent among women in our study sample (Table 2). On a structural level, limited opportunities for secure income sources present barriers to accessing housing in over-inflated housing markets with high rents and low vacancies, resulting in loss of housing [9, 11, 29, 33]. One study suggested that the average income among women experiencing homelessness and unstable housing was less than one-fifth of the population average [33]. Another study observed that women experiencing heightened evictions had to spend 80–90% of income from minimum wage jobs on rent payments [11]. Lower education level not only limits the opportunities for employment and income, but also is linked to poor literacy and numeracy skills, which negatively affects securing housing [29]. Further, a racialized unemployment rate and pay gap affect income and housing status in some settings [38]. Intersectionality of race and socioeconomic status have been found to be associated with experiences of discrimination in securing housing among racialized and Indigenous Peoples [3]. Sufficient and timely income support is necessary to maintaining housing and bridge the long-standing income inequality for WLWH experiencing or at risk of homelessness. Meanwhile, additional programs should be designed with and for WLWH to introduce educational and recreational activities to build communities and encourage future engagement in the workforce.
Applying TVI approaches, gender-responsive and gender-inclusive supportive housing programs involving WLWH in design and implementation should be tailored for and with WLWH with critical housing and healthcare needs. To provide stable housing, reduce structural inequities, and support healthcare access, such programs often featured case management, peer support, cultural safety, harm reduction practices, and supports for maintaining family bonds [30, 39, 40]. Programs should be adaptable in fostering connection with cultural and traditional practices to improve WLWH’s mental and spiritual wellbeing [30]. WLWH in supportive housing programs may have increased chance of achieving viral suppression than those in conventional care [40]. The Housing First model may align with the housing needs of some WLWH by providing stable housing, harm reduction, supportive staff, privacy, and physical security [41, 42]. These features have been found to contribute positively towards the overall improvement in residents’ physical and mental health [41, 42]. Globally and in Canada, Housing First programs have provided stable housing to urban populations who experience homelessness and have mental health conditions [33, 34, 41]. Meanwhile, gaps in the Housing First model have been identified and need to be addressed to meet the needs of WLWH [43]. For example, limited recruitment of women and single-mother families has been observed in the programs [41,42,43]. Women’s lack of representation in Housing First might have resulted from a failure to consider and incorporate drivers of women’s loss of housing, including gender-based violence, the needs of larger family-size housing, and the lack of women-specific/women-only housing [43]. Additionally, Housing First programs rely on existing affordable housing, rather than creating new affordable options [42]. Therefore, housing programs must also be supported by concurrent policy to increase the number of affordable housing units and provide means (e.g., adequate income, employment opportunities) in order to address the root causes of homelessness and unstable housing among WLWH [33, 42].
Our study has several limitations and strengths. Self-reported data might introduce recall and reporting biases, but the community-based nature of SHAWA is designed to mitigate this. This study cannot infer causality; findings are likely not generalizable to all WLWH in Canada. Though longitudinal data collection increases statistical power via repeated measures, the sample size may have precluded us from detecting some associations, due to the exploratory nature of the study. There were significant differences in housing status according to gender identity in bivariate analysis, but this association was not retained in multivariable analysis. Low sample sizes among women with gender minority identities in our study may have affected our ability to detect the associations in multivariable analyses. A major strength was being the first study to reference the CDOH in defining the housing status among WLWH and categorizing 50 + types of accommodation into a four-category variable capturing complexity and diversity. By using the CDOH, our findings will be easily translatable to knowledge users in housing research and policy nationwide.
To conclude, our study highlighted the prevalent housing instability among WLWH in Metro Vancouver, Canada. Homelessness among WLWH is a complex product of systemic and structural inequities. Our results echo the need for interventions for WLWH and other marginalized populations to protect their basic right to housing. The experience, concerns, and needs of WLWH must be consulted to resolve the housing crisis. Structural inequity and marginalization experienced by a diverse WLWH population need to be addressed to achieve stable housing, as well as financial security, physical wellbeing, freedom from violence and discrimination to prevent future homelessness. Results from our study suggest that housing options for WLWH that are gender-responsive, gender-inclusive, low-barrier, and incorporate TVI, harm reduction, and cultural safety practices are critical to support women in accessing housing. An important future direction would be to examine the role of housing in the healthcare access and HIV care continuum among WLWH. Further research is needed to understand the housing needs of WLWH with marginalized and minoritized gender identities, given high levels of discrimination and violence [12, 36] that may affect their access to safe and stable housing and few gender-responsive and gender-inclusive programs developed specifically to meet their needs. With further evidence, a stronger case will be made to protect the housing rights of WLWH.
