Homelessness and HIV Treatment Among Men Who Have Sex With Men Across US Funding Contexts.

Importance: Unstable housing has been shown to undermine health and exacerbate health inequities, including by limiting access to HIV prevention and treatment services among people living with HIV (PLHIV), the majority of whom are gay, bisexual, and other men who have sex with men (GBMSM). Assessing the outcomes of housing policies can inform evidence-based housing and homelessness prevention efforts in the US. Objective: To examine the association between homelessness and antiretroviral therapy (ART) use among GBMSM in the US and whether this association is moderated by the Housing Opportunities for People Living with HIV/AIDS (HOPWA), a federal housing program for PLHIV. Design, Setting, and Participants: This study was a cross-sectional analyses of 2017 to 2023 American Men's Internet Survey (AMIS) data, a nationwide online survey. State-level HOPWA funding per person was estimated using collated secondary data. Participants were AMIS respondents who self-reported living with HIV and their treatment status. Exposure: Homelessness was self-reported as living on the street, in a shelter, in a single-room occupancy hotel, or in a car in the past 12 months. Main Outcomes and Measures: Current ART use among PLHIV was the primary outcome. Associations between homelessness and ART use were estimated using multilevel mixed-effects logistic regression, stratified by state-level HOPWA funding per person. Results: Among 58 108 AMIS respondents, 4911 (8.5%) self-reported living with HIV and were included in analyses (4709 [95.9%] were aged ≥25 years, 1339 [27.3%] were Black, 357 [7.3%] were Hispanic, and 1421 [28.9%] were White). Homelessness was associated with lower ART use (adjusted odds ratio [aOR], 0.51; 95% CI, 0.30-0.85). In states with at- or below-median HOPWA funding, homelessness was associated with decreased ART use (aOR, 0.43; 95% CI, 0.21-0.91). In higher-funded states, there was no association (aOR, 0.61; 95% CI, 0.30-1.27). Conclusions and Relevance: Homelessness is associated with reduced current ART use among GBMSM living with HIV. This association was not present in states with higher per-person HOPWA funding, suggesting that housing investments may mitigate barriers to HIV treatment. Taken together, these findings provide preliminary evidence of the positive health outcomes of HOPWA, underscoring the need for further research on how to optimize its effectiveness.