Making Housing A Priority for People with HIV/AIDS in Ontario

Transcription

Making Housing A Priority for
People with HIV/AIDS in Ontario
Health Systems Research and Consulting Unit, CAMH
June 2007
Housing Solutions: Towards A Better System
Housing Solutions for People with HIV/AIDS
Table of Contents
The Housing Solutions Project Team ................................................................... 4
Acknowledgements........................................................................................ 5
List of Acronyms ......................................................................................... 6
Main Messages ........................................................................................... 7
Executive Summary ...................................................................................... 8
I
Introduction........................................................................................11
Information Gathering Approach .............................................................................................................................12
Knowledge Exchange .....................................................................................................................................................12
II
The Policy Context ................................................................................13
III
The HIV/AIDS Population in Ontario ...........................................................15
Estimating the Need for Housing .............................................................................................................................18
IV
Conceptual Framework ............................................................................20
V
Thematic Overview ................................................................................21
VI
Methods ...........................................................................................26
Literature Scan .............................................................................................................................................................26
HIV/AIDS Provider Survey ......................................................................................................................................26
Focus Groups ..................................................................................................................................................................26
Broader Housing Sector Expert Key Informant Interviews ..........................................................................27
Expert Key Informant Interviews ..........................................................................................................................27
VII Findings ............................................................................................29
A
B
C
D
E
Literature Scan ...................................................................................................................................................29
HIV/AIDS Provider Survey ............................................................................................................................42
Provincial Focus Groups Findings....................................................................................................................52
HIV/AIDS Housing Expert Key Informant Interviews .........................................................................58
Key Informant Interviews from the Broader Housing Sector.............................................................63
2
VIII Recommendations..................................................................................71
I
II
III
IV
V
Broader Housing Sector ...................................................................................................................................72
Support Services ................................................................................................................................................80
Income Support...................................................................................................................................................82
Partnerships .........................................................................................................................................................83
Policy, Funding, Research..................................................................................................................................84
IX Appendices ...........................................................................................87
Appendix A: Housing Solutions Provincial Knowledge Exchange Group (PKEG) Membership List .......87
List of Provincial Workshop Participants ....................................................................................................88
Appendix B: Housing Survey......................................................................................................................................89
Housing Survey: List of Participating Organizations by LHIN ............................................................99
Appendix C: Focus Group Sites and Participant List ........................................................................................101
Appendix D: Expert Key Informant List .............................................................................................................103
Appendix E: Broader Housing Sector Key Informant List ............................................................................104
Appendix F: Values Framework ..............................................................................................................................106
Appendix G: Glossary of Terms..............................................................................................................................107
Appendix H: Bibliography .........................................................................................................................................109
3
The Housing Solutions Project Team
Principle Consultant
Dale Butterill, MSW, MPA, Health Systems Research and Consulting Unit, Centre for
Addiction and Mental Health
Consulting Team
Rick Kennedy, BA, Executive Director, Ontario AIDS Network
Dianne Macfarlane, MA, Health Systems Research and Consulting Unit, Centre for
Addiction and Mental Health
John Sylvestre, PhD, Centre for Research on Educational and Community Services,
University of Ottawa
Project Coordinator
Brendan Smith, MSc, Health Systems Research and Consulting Unit, Centre for Addiction
and Mental Health
4
Acknowledgements
The Housing Solutions project team would like to thank the many people who participated
in this consultation. We are indebted to the members of the Provincial Knowledge
Exchange Group, focus group participants, key informants and participants in the Provincial
Consultation. We would like to specifically acknowledge the contributions of Steve Byers,
Jay Koornstra, and Michael Sobota for their insight and support of our work.
We would especially like to thank the people who have HIV who shared their stories and
struggles with us and helped to inform our work. We would also like to thank Dr. Sean
Rourke and Dr. Robb Travers who were always available for consultation and support.
To the members of the Positive Spaces, Health Places Research Team, who generously
shared their research findings with us and to Ruthann Tucker for her guidance and
collaboration, we would like to express our gratitude.
We are also greatly appreciative of the advice and wisdom of our colleagues in the United
States who gave us the benefits of their experience. Specifically, we would like to thank
the members of the National AIDS Housing Coalition for sharing their knowledge with us.
A special thanks goes to the AIDS Bureau and the OHTN for their funding of ‘Housing
Solutions’ and to the Ontario AIDS Network who joined the project team and helped pave
the way to a successful outcome.
This project was supported by a grant from the Ontario HIV
Treatment Network
5
List of Acronyms
ACT
AIDS
ASO
CCAC
CIHR
CAMH
CPP
HAART
HIV
HOPWA
IDU
LHIN
LTC
MOHLTC
MSM
NAHC
OACHA
OAN
ODSP
OHTN
ONPHA
OW
PHA
PKEG
RGI
Assertive Community Treatment
Acquired Immune Deficiency Syndrome
AIDS Service Organization
Community Care Access Centres
Canadian Institutes of Health Research
Centre for Addiction and Mental Health
Canada Pension Plan
Highly Active Anti-retroviral Therapy
Human Immunodeficiency Virus
Housing Opportunities for Persons with AIDS
Injection Drug User
Local Health Integration Network
Long-Term Care
Ministry of Health and Long-Term Care
Men who have sex with men
National AIDS Housing Coalition
Ontario Advisory Committee on HIV/AIDS
Ontario AIDS Network
Ontario Disability Support Program
Ontario HIV Treatment Network
Ontario Non-Profit Housing Association
Ontario Works
People Living with HIV/AIDS
Provincial Knowledge Exchange Group
rent-geared-to-income
6
Main Messages
Many people living with HIV/AIDS experience the effects of a powerful intersection
of poverty, stigma and illness. Affordable, safe, stable housing can mitigate these
effects. Housing is the place where our most basic and important needs can be met. For
people with significant health needs, housing is a gateway to a range of necessary services
and supports. It provides a locus for participation in support, rehabilitation and treatment
that ultimately lead to better health outcomes and lower costs for treatment.
It is time to shift our focus to issues of “living” with HIV/AIDS. Issues of “living with
HIV/AIDS” are not secondary issues. The information that we have collected in this
report demonstrates that attending to issues of “living with HIV/AIDS” has significant
effects on both prevention and treatment. Housing = prevention and health.
Attending to the material circumstances of people’s lives is prevention because how
people live with HIV/AIDS is directly associated with the likelihood of the transmission of
HIV.
Attending to the material circumstances of people’s lives is health treatment because
how people live and are housed with HIV/AIDS leads to direct improvements in health
status, as well as adherence with treatment.
Housing and support services that help people obtain and maintain housing, work
together to support the individual through the various stages of their illness. They are in a
dynamic relationship depending on the person’s circumstances. Housing without available
support services is a partial solution and will not achieve optimal outcomes.
Safe, affordable housing is a right, not a reward. There is a role for all three levels of
government in seeing that adequate funding for housing and housing support services is
available to meet the needs of people with HIV/AIDS.
Because the broader housing sector is open to working with HIV/AIDS service
providers, Ontario can increase the range of housing options and support services through
a coordinated approach to cross-sectoral collaboration/ partnerships and
training/education initiatives.
A systems approach to housing that includes policy development, designated funding,
service planning, leadership and coordination is needed to address the pitfalls in the
current fragmented ‘non-system’.
7
Executive Summary
This project was a provincial consultation funded through the Ontario HIV Treatment
Network (OHTN) to examine the system of housing and support services in Ontario for
people with HIV/AIDS. The report includes an overview of the range of current housing
and supports, the gaps in service, barriers to access, opportunities for collaboration and a
set of recommendations. The recommendations are consistent with a Values Framework
that was developed through the project.
Housing Solutions applied many of the principles of community-based research and
knowledge exchange ‘best practices’ through the creation of the Project Provincial
Knowledge Exchange Group (PKEG)- involved with the project from the beginning- and the
Provincial Consultation held towards the end to provide feedback on the draft
recommendations. (See Appendix A for PKEG members and for Provincial Consultation
participant lists).
Much of the focus to date with respect to HIV/AIDS has been about preventing or
treating the illness. Prevalence rates continue to rise as people continue to live longer due
to improvements in treatment. It is time to shift our focus to issues of “living” with
HIV/AIDS. Issues of “living with HIV/AIDS” are not secondary issues. The information
that Housing Solutions has collected in this report demonstrates that attending to issues
of “living with HIV/AIDS” has significant effects on both prevention and treatment. First,
how people live with HIV/AIDS is directly associated with the likelihood of HIV
transmission. Attending to the material circumstances such as housing of people’s lives is
prevention. How people live with HIV/AIDS, secondly, leads to direct improvements in
health status, as well as adherence with treatment. Attending to the material
circumstances of people’s lives is health treatment.
In Ontario the cost of housing is going up, social housing wait lists are growing, and the
vacancy rate in that portion of the private rental market which could be affordable is
minimal. At the same time, many people living with HIV/AIDS report low levels of income.
Despite progress through the 1990s, HIV in Ontario continues to be a serious, unstable,
infectious, life-threatening illness. Emerging trends point to the number of new infections
increasing and perhaps up to 6000 persons who do not know they are infected. The number
of PHAs doubled between 1990 and 2000. During this period the care and treatment needs
have changed. Now the emphasis is on more support for life-long prevention, employment
and other health and social needs. This added longevity means many people are at greater
risk for poverty, losing their housing or having unstable housing. Quite simply, the need for
housing is increasing.
8
A growing body of research demonstrates that ‘poor’ housing increases vulnerability to
infection, exacerbation of the illness, and poor linkage with needed supports. The opposite
is true for ‘good’ housing as it enables treatment engagement, lowers risk and increases
healthy behaviour and good health. Studies involving the homeless population, supportive
housing and housing first programs all demonstrate the capacity of housing to positively
influence health outcomes.
The research also speaks to the need to combine supports with housing, and to tailor
these to the individual. When housing programs are well designed and placed within a
system of housing support services, the impacts on prevention of illness, improved health
and decreased service delivery costs can be substantial.
Ontario is fortunate to have several ‘mature’ targeted HIV/AIDS housing programs in
major centers, along with a network of AIDS Service Organizations (ASOs) in communities
throughout the province. These ASOs provide many of the ‘hands-on’ services that are
necessary to help people get and keep stable housing. Still today, Ontario cannot claim to
have a well-functioning ‘system’ of housing and housing supports for people with
HIV/AIDS. There are few documented connections between this sector and the broader
housing sector. In this ‘non-system’, it is difficult to pinpoint exactly how many people
need housing and housing support services as information is not being collected in a
systematic way. This is partly due to the housing area not receiving strategic advocacy
and policy attention at the provincial and federal levels until recently and the lack of
recognition of the important role of housing in prevention and health.
Helping to put the spotlight on these issues in Ontario are two recent developments. In
2005, the Canadian Institute for Health Research (CIHR), the Ontario HIV Treatment
Network, Wellesley Central Health, the AIDS Bureau and the Ontario AIDS Network
funded a major community-based research study, Positive Spaces Healthy Places, to
examine housing circumstances and the effects on PHAs in Ontario. Early results tell a
story of poverty, unstable housing, discrimination, and poor health. Concurrently, the
AIDS Bureau funded community planning initiatives in twelve communities across Ontario.
These initiatives revealed that housing was a key issue in most communities and that more
connections between HIV/AIDS organizations and the broader health and social services
sectors were needed and could be increased through joint planning.
There is an emerging international consensus among researchers, service providers,
advocates, and policy-makers that one of the key factors affecting how people live with
HIV/AIDS is housing. Reports produced by the National AIDS Housing Coalition from its
two housing research summits (NAHC: 2005, 2007) have marshalled evidence that housing
is a key factor affecting how people live with HIV/AIDS that has implications for
HIV/AIDS treatment and prevention.
Based on this perspective, we review the existing housing system in Ontario and make
specific recommendations for improving this housing system.
9
The recommendations encompass the need to:
1.
2.
3.
4.
5.
Increase the availability of housing opportunities across the full range of
housing in the broader housing sector for people with HIV/AIDS.
Increase the availability of appropriate housing supports leading to
improvements in ‘getting and keeping’ housing.
Improve the responsiveness and understanding of non-HIV/AIDS housing
service providers.
Increase collaboration and partnerships to support capacity building.
Have government, decision-makers, provincial organizations and researchers
undertake more focused housing policy development, advocacy and research
initiatives.
The goal of the recommendations is to ‘make housing a priority’ and to improve housing
stability, reduce the risks of homelessness and improve access to services and supports.
The recommendations are built on the foundation laid by organizations throughout the
province that have already established successful housing and support programs.
10
I Introduction
Increasingly, housing is being recognized as a fundamental determinant of health
(Dunn, 2002). Research in the general population has shown that good quality housing is
associated with favourable health outcomes (Evans, Wells, & Moch, 2003). People who live
in poor quality or unaffordable housing and who have meagre financial resources also tend
to have restricted access to food security, recreation and education which can result in
social exclusion and diminished health status (Bryant, 2004).
Stable, affordable housing, in conjunction with appropriate supports, for PHAs offers
access to healthcare, other important services and results in lowering risk and improving
health. We now know this from many sources. Housing also prevents illness and promotes
health and well-being. This has been well documented through research mostly originating
in the United States.
In Ontario, the need for more information about housing has been identified by several
sources. Community-based AIDS organizations have recently reported a significant
increase in the number of clients experiencing housing problems. The Ontario AIDS
Network (OAN) and the OHTN have identified housing as one of the most urgent, if not
the most urgent, current unmet need of persons with HIV/AIDS (PHAs) in Ontario
(OACHA, 2002). Most recently through the AIDS Bureau sponsored Community Planning
Initiative (2005), nine communities out of 12 reported affordable/subsidized and
supportive housing to be a major need for PHAs.
At the present time there is very little provincial or national information about housing
needs, preferences and experiences of PHAs. The jointly funded (OHTN, Wellesley
Central Health Corporation, OAN and CIHR) province-wide community- based research
initiative currently underway, Positive Spaces Healthy Places, is focusing on housing and
health outcomes and is a provincial first in this area. Led by a multi-disciplinary team of
Ontario-based investigators (Tucker et al, 2005), the study is surveying the current
housing situations, experiences and needs of a cross-section of PHAs. The Housing
Solutions’ proposal is intended to complement the housing and health outcomes study by
providing system level information and perspectives on:



The range of housing and support services currently available in Ontario and
the gaps
The barriers to access, including social exclusion , shame and discrimination,
affecting entry into and ongoing housing stability.
‘Housing solutions’---potential opportunities and mechanisms to increase the
number of appropriate housing and support services
11
Information Gathering Approach
Information gathering and analyses were designed to identify needs, resources,
barriers, gaps and opportunities for housing and housing support services for PHAs. The
information was gathered through: 1) a literature scan; 2) an electronic survey of
HIV/AIDS organizations; 3) six focus groups with service providers, decision-makers, and
policy developers; 4) eight expert key informant interviews; and, 5) nineteen broader
housing sector key informant interviews. In addition, a Values Framework was developed
through the information gathering process. The multi-dimensional approach provided the
Project Team with quantitative and qualitative information on essential dimensions of the
problem and fresh insight into how best to increase the capacity of the current system.
Please see Appendix B for the HIV/AIDS organizations electronic survey and list of
participating organizations. Appendix C provides the focus group sites and participant list.
Appendix D contains the expert key informant list, and Appendix E contains the broader
housing sector key informant list. Please see Section VI for an overview of the Values
Framework and Appendix F for the completed version.
Knowledge Exchange
A Provincial Knowledge Exchange group was struck at the outset of the project to
provide ongoing information, advice and feedback to the Project Team. Members were
drawn from various sectors, including HIV/AIDS, mental health, government, social
housing, not-for-profit housing and PHAs. The group represented different roles provider, planner, decision-maker, provincial advocacy organization and personal experience
with HIV/AIDS. This knowledgeable and diverse group met on three occasions, at the
beginning, middle and end of the project and participated as well in the Provincial
Consultation. The group’s diversity of perspectives and knowledge of the field provided an
excellent resource to the project. Member engagement had the additional benefit of
bringing the broader housing sector closer to the issues affecting PHAs and resulted in
fresh ideas and approaches to creating capacity.
Once the Project Team drafted recommendations, a Provincial Consultation was held
with leaders from the broader housing and health sectors, LHINs staff, provincial
organizations, some of whom had participated in key informant interviews and had asked to
be invited. This provided an excellent opportunity to refine the recommendations. It also
resulted in many ‘cross-sectoral’ contacts being made and a deeper understanding of the
housing and support services issues affecting PHAs by those not directly involved in the
HIV/AIDS sector. The final step in the process of formulating the recommendations was
to redraft them based on the provincial consultation feedback and to ask the PKEG
members to review them.
12
II The Policy Context
Within the provincial HIV/AIDS policy context housing has been identified by key
organizations as a major unmet need-most notably by the OHTN and OAN. The document,
“A Proposed HIV/AIDS Strategy for Ontario to 2008” (OACHA, 2002) also recommended
a new strategy to address the inequities that put people at risk and identified housing as a
key social justice issue. This strategy was based on the understanding that poverty,
marginalization and homelessness are contributing to new infections and affecting the
health status of PHAs which makes HIV more than a “health” problem. The first ever
think tank on HIV/AIDS housing was held and organized by the OHTN in 2005. Also, the
study Positive Spaces Healthy Places has created a great deal of awareness and interest in
this issue through its far-reaching community-based research process. Outside Ontario,
the two U.S. National Summits on Housing and HIV/AIDS have heightened awareness of
the research evidence on housing and HIV/AIDS (NAHC: 2005, 2007).
The timing of the Community Planning Initiative (AIDS Bureau) provides an excellent
context upon which to build and introduce the findings of this report. The Initiative was
remarkable in so far as it brought the HIV/AIDS sector together with the broader health
and social services sectors for the purpose of improving local service access and
coordination and to promote “integrated, comprehensive, effective and efficient services”
(Guidelines recommended by OACHA). The joint problem identification and planning
processes built cross-sectoral relationships and provided an emergent infrastructure that
will be critical in implementing the recommendations of this report. Importantly for this
project, nine out of twelve initiatives recommended the need for increased affordable,
subsidized, and/or supportive housing putting the issue squarely on ‘the radar screen’
across the province.
The other themes from the Community Planning Initiative that most strongly resonate
with the findings in Housing Solutions relate to the need for:





Regional cross-agency planning and network development
Increased collaboration and partnerships across HIV agencies and between HIV
agencies and other “systems”, e.g., social service, income support, mental health,
addictions
Work to address stigma, shame, exclusion and discrimination and to increase public
awareness and acceptance of people with HIV as members of their communities.
Intra-governmental advocacy (by MOHLTC and PHAC) in relation to improving
access and level of financial and housing support
Increased HIV/AIDS education to health and other social service practitioners
13
Two other areas of policy relevance are health and housing in general. The current
transformation of the healthcare system into fourteen regional LHINs has implications
for how HIV/AIDS organizations relate to the broader system. Although HIV/AIDS
organizations will continue to be funded through the AIDS Bureau most organizations
providing the housing support services that help people maintain their housing, e.g., the
CCACs, will now be funded and accountable to their local LHINs. To be effective, it will be
increasingly important for AIDS organizations to participate in the LHIN sponsored
planning processes in order to ‘get on and stay on’ the LHINs agenda.
In the area of social housing policy, in Toronto, access to social housing for PHAs was
severely affected when PHAs lost priority status in 2002. Compounding the problem is the
fact that, provincially, wait times are getting longer rather than shorter for social housing.
While Ontario is creating some additional housing through the Affordable Housing
Program there is widespread agreement that it falls short of meeting the need. The
Ontario Not for Profit Housing Association (ONPHA), in a pre-budget statement (ONPHA,
2007), strongly recommended that the provincial government use previously allocated
federal monies ($392 million) to create more permanent affordable housing and supportive
housing and that rent supplements be included. The statement also recommended an
expansion of the prioritization of new housing for the mentally ill and victims of family
violence to include a ‘broader definition of the ‘hard-to’ house’ and to extend the program
to those agencies serving them.
The recent Federal budget (March/April 2007) revealed that social housing was NOT a
priority and that Canada was likely to continue for some time to be without a national
housing policy.
In short, while there is increasing awareness of the need for housing for people with
HIV/AIDS, there is no HIV/AIDS specific housing policy in Ontario at the present time.
14
III The HIV/AIDS Population in
Ontario
“Our findings clearly indicate that the HIV epidemic in Ontario has not yet
stabilized”
Remis et al, 2006
An update on the epidemiology of HIV/AIDS in Ontario is provided annually in the Ontario
HIV/AIDS Surveillance Report. The following section is a summary of the findings in the
most recent published report by Remis, Swantee, Schiedel, Merid and Liu (2006).
HIV Prevalence
Based on their statistical modeling, Remis et al (2006) estimate that since 1985,
32,037 people have been infected with HIV in Ontario. Of these individuals, 8,267 people
have died, leaving 24, 251 persons currently living with HIV in Ontario. Overall, it is
estimated that 66% of HIV-infected persons know that they are infected. The prevalence
of HIV, or the number of persons living with HIV in the population, has increased since
1999 in Ontario, from 17,656 to 24, 251. Remis et al (2006) speculate that the increase in
HIV prevalence observed over the past five years is related to both a continued, and in
some cases an increase in HIV incidence during that time, and also a decreased mortality
due the introduction of new treatments (HAART) allowing people to live longer.
The most affected groups by exposure category are: men who have sex with men
(MSM) - (14,927), persons from countries where HIV is prevalent (3,356) and others
infected by heterosexual transmission (3,367) and 1,768 infected through injection drug
use. MSM continue to be the most disproportionately affected by the epidemic in Ontario,
constituting 62% of HIV-infected persons. In addition, there are currently 3,568 women
living with HIV in Ontario.
HIV Incidence
Based on data from 2004, 26,033 HIV infections have been diagnosed in Ontario. This
number differs slightly from the prevalence data presented above, as it is the actual
number of cases diagnosed, and does not include people who do not yet know they are
infected. Despite decreasing throughout the early and mid-1990s leading to a stabilization
from 1997 to 2000, HIV incidence, or the number of new diagnoses, started to increase
from 2000 to 2004. There were 1305 new cases of HIV diagnosed in 2004, representing a
39% increase compared to 2000. This increase in diagnoses was characterized by an
increase among several of the high-risk exposure categories for HIV infection for this
same time period, including: MSM (38%), persons from countries where HIV is prevalent
(52%) and most dramatically “low-risk heterosexuals” (114%). Further, the number of new
15
diagnoses among women increased significantly by 75% in 2004 compared to 2000. It is
important to consider that these data represent the number of cases diagnosed, and,
therefore, underestimates the actual number of new cases of HIV. For example, according
to the statistical model used by Remis et al (2006), it is estimated that 1,690 people were
infected during 2004, compared to the 1,305 that were diagnosed.
In addition, the surveillance report by Remis et al (2006) described a shift within the
proportions of HIV diagnoses by sex and high-risk exposure categories. This includes a
‘dramatically increased’ proportion of HIV diagnosis compromised of women, with an
increase from 1.8% in 1985 when testing began to 29% in 2004. Although in Ontario, MSM
have traditionally accounted for the greatest proportion of persons infected with HIV,
there has been a gradual decrease in this proportion from 1985 (89%) to 2003 (44%). The
proportion of overall diagnoses continues to increase among persons from countries where
HIV is prevalent.
AIDS Incidence
Since the beginning of the epidemic, 7,811 AIDS cases have been reported in Ontario.
The number of new AIDS diagnoses has ‘dramatically decreased’ since peaking at 715 in
1993. However, when adjusted for reporting delays, it appears AIDS incidence increased
by 124% in 2004 compared to 2000. Similarly to the decreasing trend in the proportion of
HIV diagnosis, the proportion of AIDS diagnoses among MSM is also decreasing, although
in 2004, MSM still represented 41% of diagnosed AIDS cases. Persons from countries
where HIV is prevalent, others infected by heterosexual transmission, and injection drug
users (IDU) represent significant proportions of new AIDS cases, contributing 22%, 18%
and 8% respectively, of newly acquired infections in 2004. Women also represented a high
proportion of new cases (21%) despite only representing 8% of all reported AIDS cases.
Prevalence and Incidence of HIV by Health Region in Ontario
Geographically, Toronto continues to be the centre of the epidemic in Ontario. Based
on the data from their report, Remis et al (2006) estimate that 63% of persons living with
HIV reside in Toronto, and 62% of new HIV infections in Ontario occurred in residents of
Toronto. The next highest city is Ottawa, which is home to 11% of persons living with
HIV,.14% of new HIV infections in Ontario occurred in residents of Ottawa. Together,
these two cities are home to 74% of persons living with HIV in Ontario and are where 76%
of new HIV cases are being diagnosed.
Furthermore, Remis et al (2006) also provide the distribution and breakdown by
exposure category of HIV cases by region in Ontario. The distribution of the HIV
population differs by exposure category when grouping HIV prevalence into 4 regions in
the province (Northern, Eastern, GTA and Central/Southwest). For example, the highest
proportion of HIV cases by risk factor in these regions are as follows.
16
Greater Toronto Area


MSM accounted for the highest proportion (68%).
Persons from countries were HIV is prevalent accounted for 14% of HIV cases.
Eastern Ontario


Has the highest proportion of HIV cases among persons from countries were
HIV is prevalent in Ontario (18%).
This region also has a high proportion of IDUs accounting for 19% of the total
HIV cases.
Central and Southwest Ontario


MSM represent the highest proportion (55%) of total HIV cases.
Also, there is a high proportion of heterosexual HIV infections which represent
19% of HIV cases.
Northern Ontario



Smallest proportion of total HIV cases in Ontario (2.6%).
This region is characterized by the highest proportion of HIV cases among
heterosexuals, compared to the other regions in Ontario, comprising 29% of
total HIV cases.
This region also has a very high proportion of its HIV cases among IDU,
accounting for 27% of all HIV diagnoses, which compared to the other regions
in Ontario, is the highest proportion of cases in their area.
Table 3.1: HIV Prevalence by Region and exposure category in Ontario*
MSMHIVRegion
MSM
IDU
IDU
endemic
Heterosexual
Total**
Northern Ontario
29% (180)
6% (40)
27%(170)
5% (30)
29% (180)
620
GTA
68% (11,520)
2% (370)
4% (660)
14% (2340)
12% (2040)
17,030
Eastern Ontario
43% (1,430)
4% (130)
19% (620)
18% (590)
16% (530)
3,330
Central and Southwest
55% (1,800)
3% (110)
10% (320)
12% (390)
19% (620)
3,270
* Data from Remis et al, 2006
**Cells may not add to total as Clotting factor and transfusion were not included in this table
Proportion
2.6 %
70.2 %
13.8 %
13.5 %
17
Estimating the Need for Housing
Estimating the need for housing is difficult because there are little or no data
currently being collected that can speak to the level of actual need in the province and in
various regions. Because housing is not yet connected to health and prevention, data is not
systematically collected that would enable planning. The few data sources that we were
able to identify only provide a glimpse into the scope of the problem.
HIV and Housing Difficulties
We were able to obtain the placement and waitlist data for people with HIV/AIDS for
the years 2005 and 2006 from Housing Connections1 in Toronto. This provides some
indication of the need for social housing among PHAs in Toronto. Please note that
disclosure of health status is voluntary and the actual number of PHAs in social housing or
on the waitlist is likely to be higher. The total number of people (placement and waitlist)
increased from 216 in 2005 to 287 in 2006. The percentage placed was 14%-2005 and
17%-2006. In 2005, 93% of those housed were on ODSP or OW, and in 2006 the
percentage on ODSP/OW dropped to 71% with other sources of income including CPP, longterm disability and immigration allowance making up the difference. The percentage was
the same for both years for those on the waitlist-61%.
In 2006, 10% of placements had dependents compared to 0% in 2005 and also a
greater percentage of women were housed in 2006 in 26% compared to 15% in 2005. A
similar trend was noted concerning the percentage of men to women on the waitlist with
the percentage increasing in 2006-26% for women compared to 20% women in 2005. While
we cannot assume that these data represent 63% of the need for social housing in
Ontario, it does provide some indication of the numbers involved and one would expect
them to be in proportion to the prevalence rates elsewhere.
The data from Positive Spaces Healthy Places indicate that 1/3 of those sampled (over
600 and did not include the homeless) had unstable housing. This suggests a higher number
of individuals requiring some form of housing and/or support services. There is no way of
knowing how representative this sample is of the total population.
HIV and Poverty
Also, the ODSP data show that 0.8% of recipients have HIV/AIDS or 1600 individuals.
Certainly the majority of those being placed in housing and on the waitlist for social
housing receive ODSP so to some extent there is an overlap. However, this figure is likely
larger than the waitlist/placement figures (because we can cannot state precisely based on
2
1
Personal communication: Michelle Haney-Kileeg, General Manager, Housing Connections April 20,
2007
2
Personal communication: Peter Amenta, Ministry of Community Social Services, 2007.
18
data from one municipality) and would suggest that possibly more people with HIV/AIDS
are vulnerable to unstable/poor quality housing since poverty puts people at risk.
HIV and Homelessness
Finally, although some expert key informants suggested a rate of somewhere between
3% and 10% with HIV/AIDS in the homeless population, an ongoing Toronto study3 of 600
homeless men and 300 homeless women found that 0.7% percent of men and 2.7 percent
(based on self-report) of women had HIV/AIDS, suggesting a lower rate than anticipated.
3
Personal communication Stephen Hwang, St Michael’s Hospital, May 2, 2007
19
IV Conceptual Framework
“Changes, events, and decisions at the level of programs, agencies, inter-agency
partnerships, municipal, provincial and federal governments, or in housing and
economic systems can all affect the dynamic relationship at the foundation of housing
stability: the relationships among person, place and supports.”
The Housing Solutions Conceptual Framework is informed by the research into housing
stability and the values-based approach to housing (see Section XII-a Literature Scan.
This simple framework views stable, affordable, safe housing as a vehicle for achieving
three goals: prevention of illness, health, and empowerment. The ‘mechanism’ for achieving
these goals is any action that takes place to address the dynamic relationship among the
person and their needs, preferences, and characteristics; the dwelling and its space and
social qualities; and, the supports both informal and professional. Finally, these
relationships are influenced by broader systems: inter-agency, government, housing
market.
The particular focus of this project is on the broader system taking into consideration
the needs of the individual in regards to the optimal housing and support service balance
required to achieve the goals of prevention, health and empowerment. The latter,
empowerment, draws heavily on the values-based approach to the development of housing
systems. These values situate housing as a means for achieving human dignity, quality of
life, social connection, and citizenship. For those unable to advocate for themselves or
who may be especially stigmatized, having in place a set of people-centred values is
essential.
Given the importance of values, Housing Solutions specifically sought to clarify the
values that HIV/AIDS providers and others considered essential to the provision of
housing and support services (see Appendix F). This was an iterative process involving
HIV/AIDS providers, focus group participants and key informants responding to a
question around values (see Appendix B). The result was the Housing Solutions Values
Framework which played a critical role in the appraisal and recommendation of the various
housing alternatives identified by the project resulting in some ranking more highly than
others.
Table 4.1 Housing Solutions Values Framework
Human rights and equity
Empowerment, control and choice
Human dignity and worth
Support and compassion
Confidentiality
Co-operation and collaboration
Accountability
20
V Thematic Overview
“People living with HIV/AIDS experience the effects of a powerful intersection of
poverty, stigma and illness. Affordable, safe, stable housing can mitigate these
effects. Housing is the place where our most basic and significant needs can be met.
For people with significant health needs, housing is a gateway to a range of necessary
services and supports. It provides a locus for participation in support, rehabilitation
and treatment, that ultimately lead to better health outcomes and lower costs for
treatment.”
The following overview distils the main themes that emerged from the literature scan,
HIV/AIDS provider survey, focus groups, and key informant interviews. Subsequent
sections provide the rich detail contained within each information gathering method.
The Nature of HIV/AIDS
Developing housing and supports for this population requires attention to many
dimensions, including:
 The diversity of the populations involved with respect to race, culture, language,
religion, IDU, women, MSM, aboriginal, mental health, addictions
 The range of housing needs-emergency, transitional and permanent
 The support needed to help people ‘get and keep housing’ and the need to match
housing and support with level of need
 The provincial focus that includes urban, rural and remote communities with large
variations in resources
People with HIV/AIDS have complex issues that require an understanding of a range of
health and social issues. The illness at times may be invisible even when the person is very
ill. The fluctuating nature of HIV requires a dynamic and flexible housing and support
services system. The importance of having access to high quality food is particularly
important because of the impact of diet on illness. People living with HIV/AIDS may have
difficulty seeking help because of stigma and concerns about confidentiality and
discrimination.
HIV/AIDS organizations reported that the population they are serving includes an
increasing number of people from countries where AIDS is prevalent, more women, older
people, people with complex dementias (shift from palliative), mental health and substance
use problems and chronic homelessness.
21
Looking toward the next ten years, many PHAs will be approaching their mid-fifties and
some will be nearing retirement age. An aging population will be at greater risk for
increased illness, less employment, higher poverty rates, and homelessness.
Yet, informants agreed that many issues are shared with others who have multiple
challenges, such as people with mental health and/or addictions issues, and there is
significant common ground with these other groups to enable co-operation, collaboration
and partnership.
Housing and Support Services Issues
“Housing and support services that help people to get and maintain housing, work
together to support the individual through the various stages of their illness. They
are in a dynamic relationship depending on the person’s circumstances. Housing without
available support services is a partial solution and will not achieve optimal outcomes.”
The fundamental issue is the critical shortage of safe, affordable and appropriate
housing. This is coupled with the underlying issue of poverty for many PHAs that places
them at risk for unstable housing and or homelessness. For those on income support, the
amount is inadequate to fund good quality housing, nutritious food and necessary supports.
There is also a lack of availability of necessary supports, either attached to the housing or
available to the person in the community (e.g., case management). Ontario has some
excellent but limited model housing programs in Toronto, Ottawa, St. Catharines and
London, but many urban areas lack HIV/AIDS- specific housing resulting in an insufficient
number of units to meet the current need.
This project identified and investigated three basic categories of housing- temporary,
permanent and elderly/end-of-life and found several examples of specific types within
each category within the broader housing sector. We do not mean to imply that they form
a linked continuum of housing alternatives nor that they are particularly well organized to
provide services to people with HIV/AIDS. However, in most instances housing providers
expressed their willingness to serve people with HIV/AIDS and indicated that they would
be interested in receiving HIV/AIDS training and education in order to improve their
ability to assist this population.
22
The consultation also identified the services that play an essential role in ‘getting and
keeping’ housing. Services needed to help people get housing are housing information,
assistance in obtaining housing and financial assistance-first and last months rent, rent
supplements. Services needed to help people keep housing include:
• Emergency rental assistance, utilities assistance
• Case management services
• Dedicated housing outreach services
• HIV/AIDS medical care services
• Harm reduction
• Supportive services including mental health and addictions, CCAC services
• Assistance with daily living, nutritional services
A key finding in relation to support services is the important role that training/ education
and partnerships with non-HIV/AIDS providers could play in creating more capacity.
HIV/AIDS Organizations
HIV/AIDS agencies providing services to PHAs have broad mandates including
prevention, health promotion, education, advocacy and support for inclusion in the
community. They are serving people with increasingly complex needs and are stretched to
provide this full range of services.
The majority of ASOs offer key services related to ‘getting and keeping’ housing.
However, the lack of secure funding and the multiple funding sources take up precious
resources in the ongoing pursuit of stable funding. Despite the drain on resources, these
organizations engage in a wide range of partnership activities, mainly of an informal nature.
Service Delivery Approach
Workers also identified various approaches they used that were helpful in delivering
service and engaging clients such as: 1) focusing on stabilizing clients vis-à-vis their
housing and other basic needs before addressing HIV/AIDS issues; 2) finding ways to
address the co-morbid HIV and mental health and/or substance issues of clients; 3)
engaging families and friends in helping clients to access services; and, 4) tailoring services
as much as possible to the individual.
23
Policy and Funding Issues
The main policy findings were:

The present array of housing and support services is not an organized system
resulting in barriers to access, lack of knowledge of what exists, lack of
coordination of services, and an inadequate range of appropriate support services.

The provincial housing policy framework is too underdeveloped to move the agenda
forward and does not reflect the fact that housing and health are inextricably
intertwined.

There is a need for a cross-sectoral advocacy group to make housing a priority and
put housing and support services ‘on the agendas’ of government, policy/advocacy
groups, and providers.

The elimination of the social housing priority in Toronto for people with HIV/AIDS
to a narrower definition around terminally ill had a major impact.
System Strengths
The information gathering revealed that the present ‘system’ has many strengths.
There are highly respected provincial advocacy and research organizations. The ASOs are
strongly supported by the AIDS Bureau, which is viewed by the field as a positive and
supportive partner. ASOs have formed strong partnerships with hospitals/clinics and
other service providers and the staff are viewed as being dedicated and knowledgeable.
In terms of housing, there is some availability of HIV/AIDS specific housing along with
a diversity of housing models. In fact, Ontario has several model programs and approaches
to draw upon such as: AIDS Niagara, Niagara Supportive Housing Coalition, Bruce House,
Fife House, Loft, MOHLTC Homeless Initiative and the John Gordon Home. Importantly,
the broader housing sector has indicated a willingness to partner with the HIV/AIDS
sector.
Finally, for planning purposes the province has the research base of the OHTN, access
to reliable, comprehensive provincial epidemiological data and the results of the Community
Planning Initiative.
24
Housing Framework
Based on all the information gathered about what people thought was most
important in housing for people with HIV/AIDS, there was no one single item. Instead
there were five items that were mentioned most frequently and included social justice and
health considerations. They are:
1. Safe, affordable housing is a basic human right.
2. Safe, affordable housing is a determinant of health as well as a primary and
secondary prevention strategy.
3. Accessible housing + supports are keys to maintaining housing.
4. A range of housing options/models is required to meet the needs of a
heterogeneous population.
5. A systems approach that includes policy development, designated funding,
service planning, leadership and coordination is needed to address the pitfalls
in the current ‘non-system’ and take advantage of the opportunities within the
broader housing and support services sectors.
25
VI Methods
Literature Scan
The purpose of the scan of the literature was to provide an overview of the relevant
bodies of literature that offer a perspective on how ‘good’ housing plays a role in the lives
of people living with HIV/AIDS. In order to gain a broad understanding of the significance
of housing in the lives of PHAs, we canvassed a broad range of literatures, including
literature examining social determinants of health, housing issues more broadly, housing
research related to serious mental illness and homelessness and housing research related
to people living with HIV/AIDS.
HIV/AIDS Provider Survey
The goal of the Housing Survey was to fill in important gaps in our knowledge about
housing and related support services currently available in Ontario, that are directly
targeted to PHAs or that are routinely accessed by them. Specifically, the Housing Survey
tool was designed to address three objectives: 1) to provide a description of housing and
related support services currently available in Ontario, 2) to provide a description of the
values and objectives of these services and 3) to identify housing and support system
gaps, challenges and opportunities for change.
In total, 73 provider organizations from across Ontario were identified and invited, by
way of email, to participate in the survey and the response rate was 45%. The survey was
administered online, through an easy to use format. The invitation package was sent to the
Executive Directors of the identified organizations and included a brief description of the
project, instructions on how to access and fill out the electronic survey and an
accompanying letter of endorsement from the OAN and the OHTN. In addition, common
techniques to improve electronic survey response rate were employed, including: follow up
emails and telephone calls and a presentation at the OAN’s Member’s Meeting.
Focus Groups
Five focus groups with service providers were convened across the Province: in
Thunder Bay, Toronto (2), St. Catharine’s and Ottawa. A sixth focus group, convened in
Toronto, brought together housing policy makers, researchers and decision-makers. Fortytwo individuals participated representing a variety of provider agencies including:
HIV/AIDS consumer and provider organizations, mental health and addiction provider
organizations, public health units/departments, community care access centres, community
health centres, emergency housing and hospice care services. Each focus group was
facilitated by a project team member, lasted approximately two hours, and, addressed a
26
common set of structured questions. Written summaries for each focus group’s discussion
were developed by the facilitators.
Broader Housing Sector Expert Key Informant Interviews
The broader housing sector key informant interviews encompassed providers from a
range of temporary and permanent accommodation options except private market4. The
intent was to gain insight into the larger housing system’s capacity to provide housing for
people living with HIV/AIDS in Ontario. In all, nineteen interviews were conducted. The
focus of the interviews was on: 1) the extent to which the broader housing sector is
currently serving PHAs; 2) what they identify as the barriers to housing PHAs; 3) what
would improve their ability to house this population; and 4) what they see as the needs of
PHAs who currently access their housing. This information was intended to complement
the knowledge gained through the HIV/AIDS Provider Survey and to explore the nature
of the interaction between HIV/AIDS- specific housing and support services and the
broader housing system.
The sample included representative housing and support services organizations that
regularly provide housing and/or support services to PHAs but do not exclusively focus on
this population. A list of housing and support service organizations was created through
discussion with three groups: the Ontario Non-Profit Association (ONPHA); the 47
municipal Service Managers of social housing; and, the Supportive Housing Support Unit,
Ministry of Health and Long-term Care.
From this list of housing programs, in consultation with the PKEG, a key informant list
was identified and screened according to the following criteria:
1) Area of the province; 2) Local Health Integration Network; 3) Geographic area of
clients served- urban/rural/mixed rural/urban; 4) Population served- addictions/mental
health/generic social housing; and, 5) Type of housing provided- emergency, co-operative,
shelters, scattered, congregate, transitional, permanent.
Expert Key Informant Interviews
The interviewees were eight experts from outside Ontario. They included four
providers of exemplary housing programs for PHAs located in three major U.S. cities and
one major Canadian city, two leading researchers on housing and HIV/AIDS epidemiology
in the U.S. and Canada, one leader of an HIV/AIDS housing advocacy group, and one
Canadian policy maker.
4
Background material for private market section was drawn from the ONPHA 2007 pre-budget submission
27
All interviews were conducted by phone. Detailed notes were taken during the
interviews and were transcribed into computer files. The interviews were constructed to
address the following topics:







The interviewees’ assessment of housing needs among PHAs
A housing program or system with which they were most familiar
The greatest strengths and limitations of this system
Effective strategies for improving housing for PHAs
Future directions for housing PHAs and examples of best practices
The role of government and other organizations in improving housing
The values that should inform housing solutions for PHAs
Data were summarized for each question asked in the interviews. The summaries
focused on identifying areas of agreement as well as disagreement among interviewees.
28
VII
A
Findings
Literature Scan
This section describes findings from a scan of the literature. The literature scan is
divided into five parts. The first examines more broadly conceptual issues about housing.
It describes a perspective on why housing is important, and what it means to provide good
housing. The second part describes research evidence that supports the perspective
provided in the first section. The third part provides an overview of those housing
approaches and practices that are supported by the research evidence. The fourth part
examines the characteristics of high functioning systems, systems that provide a range of
housing and support services that meet the needs of a heterogeneous population. Finally,
the last part examines the data on housing as a cost effective intervention.
1. Understanding of People, Places, and Health
Key Message
There is increasing interest in housing as a critical social determinant of health. By
improving the material quality of people’s lives, and more specifically by improving
housing, we can significantly improve health. To improve housing we need to consider
the dynamic relationships among people, their housing, and their support, and how
these relationships are affected by changes in broader social systems. More
specifically, we need to ensure that housing services are delivered to vulnerable
populations based on key person-centred values.
Most common explanations for why some people become ill, and not others, have
focused on individual level explanations such as personal vulnerabilities. These
vulnerabilities include genetic or biological factors, or faulty or inadequate personality or
health behaviours. This perspective is in line with the focus of much of our health care
spending on individual level treatments. Similarly, many preventive interventions may also
have an individual focus, aimed at altering individual biological or behavioural
vulnerabilities. In the field of HIV/AIDS, one can see a strong individual level focus in
terms of health care dollars spent on treatment or on prevention efforts aimed at
changing individual behaviours. Aidala (2005) has characterized these as “risky person”
approaches. According to these approaches, risky dispositions and personality lead
individuals to engage in risky behaviours (such as drug use and risky sex) that lead to HIV
infection as well as to marginalization and exclusion which result in homelessness.
In contrast, increasingly our attention is being drawn to the important relationship
between our health and how we live our lives. A critical perspective has been the population
health approach (Dunn, 2002). Population health approaches suggest that health disparities
29
can be explained in terms of disparities in social determinants of health (e.g., income,
housing status). From this perspective, it is suggested that improvements in health status
in a population require reductions of these disparities. It is argued, for example, that
general improvements in income, or improvements in housing status in a population, can help
to improve the overall health of the population. The significance of the determinants of
health perspective is that it draws our attention from individual level factors as the
dominant explanation for disparities in health, toward factors at broader ecological levels.
Applied to the field of HIV/AIDS, this means that improvements in health status and
in prevention can be achieved by attending to these critical health determinants. This
perspective is echoed in Aidala’s (2007) call to understand the transmission of HIV/AIDS
by focusing on “risky contexts” rather than “risky persons”. A risky contexts perspective
suggests that conditions of economic marginalization and social exclusion lead to unstable
housing. Unstable housing along with other conditions of risk that stem from
marginalization and exclusion increase the likelihood of engaging in risky behaviours that
are associated with HIV infection. Aidala identifies housing as a structural factor that is
“an environmental or contextual influence that affects an individual’s ability to avoid
exposure to HIV, or for HIV positive individuals to avoid exposing others to infection.”
Toward Stable Housing for PHAs
Key Message
In order to address health disparities, it is important to address key social
determinants of health such as housing. Inadequate housing is increasingly being
recognized as a “risky context” that leads to increased risk for exposure to, and
transmission of, the HIV virus. Housing programs can help to reduce the risky
contexts of people’s lives by promoting greater housing stability. Improving housing
stability involves promoting an optimal fit between people, their housing, and their
support, as well as by addressing forces at broader social levels that threaten the
dynamic relationship between these three factors. More specifically, greater
attention is being paid to the values that should underlie the delivery of housing
services that promote housing stability.
If housing is a critical social determinant of health, and is associated with both
exposure to HIV infection and poorer health outcomes, then it is important to consider
what it means to provide good quality stable housing. Dunn (2002) has presented a
framework for analyzing the relationship between housing and health that focuses on
three factors: materiality, meaning, and spatiality. Materiality includes the physical
integrity of the home, exposure to hazards, housing costs, etc. Meaning refers to the
meaningful dimensions of housing as “home”: privacy, control, refuge, status, pride,
socializing, continuity, stability, etc. Spatiality includes the location relative to services
and amenities, and the surrounding social environment and norms.
30
Sylvestre and colleagues (CSRU, 2001; Sylvestre, Ollenberg, & Trainor, 2006) have
developed a definition and model of housing stability from work with supportive housing
providers and tenants in Toronto, Ontario. Although developed with a focus on people with
serious mental illness, its core concepts are applicable to PHAs. At its core, this work is
based on a definition of housing stability that is in contrast to more common definitions
that focus on longer stays in a particular residence. According to this definition, housing
stability requires continuous access over the course of a person’s life to housing that
promotes health and an optimal quality of life. Housing stability is built upon a dynamic
relationship between a person, his or her housing, and the support that is available. The
relationship is dynamic in that each is continuously changing over time. Changes in one or
more domain may threaten housing stability if they significantly alter the fit between the
person and their housing and support. Maintaining stable housing requires managing the
ongoing relationship between housing and support to ensure optimal fit. As the person
changes, accommodations may be required in the domains of housing or support.
Conversely, changes in the housing and support may also require accommodations on the
part of the person, or efforts to change the housing and support altogether to restore
optimal fit.
Poor and vulnerable populations, including many PHAs, may require tailored programs
and resources to access housing situations that are a good fit for them or assistance to
manage housing situations so that the housing remains suitable for them. For example, poor
and vulnerable populations may experience difficulties making changes to their housing or
finding new housing when their housing situations change. They may have inadequate
support to help them manage their housing and the demands of their everyday lives. Poor
and vulnerable populations require flexible housing, housing programs, and housing systems
that are responsive to, and can accommodate changes in people, their housing and their
support. More broadly, the dynamic relationship between person, housing and support is
affected by factors at broader social systems. Changes, events, and decisions at the level
of programs, agencies, inter-agency partnerships, municipal, provincial and federal
governments, or in housing and economic systems can all affect this dynamic relationship
at the foundation of housing stability. These changes can also hinder or facilitate the
efforts of individuals to improve their housing stability by improving their housing or their
support.
31
Housing Options for Vulnerable Populations
Key Message
Three broad types of housing encompass the range of alternatives for
vulnerable persons: custodial, supportive and supported. Increasingly
supported housing is associated “with housing first.”
The perspective on housing stability provides an understanding of how broad social
factors can affect a dynamic, intimate relationship between a person, housing and support,
and suggests the role for programs and resources in promoting an optimal fit between each
of these three factors. A variety of housing options have been identified to help to
manage this dynamic relationship and to promote better housing stability. Parkinson,
Nelson, and Horgan (1999) have distinguished between three types of specialized housing
programs that serve people with serious mental illness, but that are also relevant to other
populations such as PHAs. The oldest, custodial housing, often features for-profit boardand-care type homes. Despite the absence of any research evidence testifying to its
effectiveness or appropriateness, it remains a major source of housing for people with
serious mental illness in Ontario. Within this approach, tenants often share rooms but have
little choice over roommates. They have limited privacy, few diversions, and are often
bound by formal rules governing their activities in the housing setting (Parkinson et al.,
1999).
The supportive housing approach typically focuses on assisting individuals to live in the
community by developing lifeskills through community-based treatment and rehabilitation
(Parkinson et al., 1999). Supportive housing can be in the form of converted houses, or in
buildings which contain a majority of apartments dedicated to people with special needs.
Residents of supportive housing typically participate in chores and responsibilities in the
housing and often share in the decision-making. A common feature of supportive housing is
that housing and support are linked. That is, staff members often work in the residences
to provide support. In Ontario many providers of supportive housing have worked to
“delink” some aspects of the support typically in the form of individualized case
management support.
Supported housing is a newer model, emerging in the 1990s. The key elements of
supported housing are: role of the tenant as a citizen, role of staff as a facilitator, an
intervention orientation focused on strengths, the potential for tenant empowerment, and
tenant control of staff support (Parkinson et al., 1999). Case management has often been
used to offer portable support for this type of housing. Typically, supported housing has
been identified with apartments, housing co-ops or other government funded social housing
for people with low incomes. Supported housing is increasingly associated with “housing
first” approaches in which people are first offered housing before they are offered other
services, and the acceptance of treatment or other supports is not required to access
32
housing (Padgett, Gulcur, & Tsemberis, 2006; Tsemberis & Eisenberg, 2000; Tsemberis,
Gulcur & Nakae, 2004).
Values-based Housing
Key Message
Values-based housing represents a shift away from housing types to a shift towards
the values inherent in promoting empowerment and citizenship.
In response to supported housing, some supportive housing providers have modified
their programs. These changes have led to consumers gaining access to independent and
individualized support and a greater measure of autonomy and control over their dwelling,
although they still live collectively (Parkinson et al., 1999). The nature and extent of these
changes remains undocumented and what currently constitutes good practice in supported
housing is unclear. Sylvestre, Nelson, Sabloff, and Peddle (in press) have advocated paying
attention to the values that underlie the delivery of housing services, in addition to the
form of the housing provided. Through an extensive review of the literature on housing for
vulnerable populations, they identified six fundamental values that can guide the delivery
of housing programs:






Choice and Control: Tenants choose the housing and related support services that
are appropriate for them and have control over the services they receive.
Quality: Tenants have access to good quality housing, in terms of its physical and
social qualities, and its location.
Community Integration: Tenants have access to housing that is non-stigmatizing and
that provides opportunities to participate and to develop meaningful relationships.
Access and Affordability: There is an adequate range of resources available that
reflect the choices of tenants and tenants can afford these options.
Accountability: Stakeholders in housing systems are accountable to one another.
Housing Rights and Legal Security of Tenure: Consumers are entitled to the same
degree of access to quality housing, and the same legal protections as other owners
or tenants of housing.
33
2.
Housing, Health and HIV/AIDS
The Need for Housing
Key Message
Good quality affordable housing is in short supply and is needed to prevent illness and
maintain health.
There is a great need for good quality and affordable housing in Canada. The Policy
Research Institute of Canada (2005) states that the problem of homelessness and housing
instability in Canada has become entrenched. Among more vulnerable populations, it is
likely that housing needs become even greater. The link between housing instability and
HIV/AIDS is strong. According to the U.S. based National AIDS Housing Coalition (2005),
studies in various U.S. cities have reported lifetime experience of housing instability and
homelessness among PHAs ranging from 17% to 60%. Furthermore, the prevalence of
HIV/AIDS is from three to nine times higher among persons who are homeless or unstably
housing than among people with stable and adequate housing. In addition, rates of infection
are also three to ten percent higher among the homeless population than in the general
population.
The Link between Housing and Health
Two Key Messages
For the general population the quality of housing has a direct effect on health,
indirect/intermediary effects on social support, stress, identity, and meaning.
For the PHA population, health benefits and lower mortality are associated with good
housing.
Although it is difficult to prove causally, we have known for a long time that the
strongest social determinants of health are social economic factors (Dunn 2002). Housing
is among the most critical social determinants of health. As far back as 1944, the London
Association for Education established that bad housing is associated with high sickness
rates, especially infectious illness. (Public Health Agency of Canada, 2004). More recently,
Fuller-Thomson, Hulchanski, and Hwang (2000) conducted a review of evidence of the
effects of various housing characteristics on health. Their review showed that there is
evidence of negative effects on physical health arising from exposures to a variety of
substances in the home, as from various physical characteristics of housing related to
safety, density and overcrowding, poor indoor air quality, poor ventilation and no control
over temperature.
34
Parkinson et al. (1999) have reported similar findings showing that housing concerns
such as odour, noise, and condition of furniture are negatively correlated with satisfaction
with housing, satisfaction of basic needs, and overall life satisfaction among people with
serious mental illness. These housing qualities have been shown in longitudinal research to
be associated with negative affect and maladaptive behaviour, and larger and less
individualised settings are associated with lower levels of independence (Parkinson et al.,
1999).
Beyond its direct influence on health, housing may have indirect influences via its
effects on social support. Dunn (2000) has suggested that housing may contribute to social
support through its suitability as a base for social interaction. Marginal housing, such as
rooming houses and single-residence occupancy housing, can present barriers to forming
relationships when tenants are not allowed to have guests. Alternatively, the quality of the
housing and the space it provides, may influence an individual’s willingness to welcome
guests. Dunn (2000) has also suggested that a sense of security and stability can arise
from knowing or believing that neighbours are trustworthy and are willing and capable of
providing help in the event of an emergency or crisis.
Aidala (2006) has identified housing as a “vector” or “vehicle” that acts as an
intermediary by which social and economic inequalities directly affect individuals.
Homelessness and unstable housing denies individuals benefits that come from good
housing, such as lowered stress, increased social capital, improved identity and increased
meaning. Housing helps to structure the private sphere and build relationships. The stress,
social isolation, and marginalization associated with unstable housing and homelessness are,
in turn, associated with increased risk for behaviours that may lead to HIV infection or
transmission (e.g., unprotected sex, needle sharing) as well as to deteriorations in health
and well-being.
Health benefits from housing have been shown among PHAs. NAHC (2007, p. 1) reports
that housing status is independently predictive of HIV risk and health outcomes,
controlling for a wide range of individual (poverty, race/ethnicity, history of substance
use, mental illness) and service use (primary care, case management, substance abuse
and/or mental health treatment) variables. Moreover, mortality rates associated with the
virus are substantially higher in those that are homeless. NAHC (2007) reports that death
of PHAs is seven times higher among single homeless adults who use New York City
shelters than in the general population. HIV is the leading cause of death among sheltered
women, among whom the death rate is nine times higher than in the general population.
A recent national study conducted by the Centers for Disease Control and Prevention in
the U.S., with a sample of 7,925 PHAs from across the country, found that housed PHAs
rated their mental and physical health significantly better than homeless PHAs who were
more likely to have higher CD4 counts, and to have an undetectable viral load (Kidder et al.,
2006, cited in NAHC, 2007).
35
Housing is HIV/AIDS Treatment
Key message
Multiple studies now show a relationship between more stable housing status and
improved engagement, adherence to, and continuity of care, including HAART.
To some extent these health benefits from stable housing may be attributable to the
relationship between housing and improved access to health care. Multiple studies now
show a relationship between more stable housing status and improved engagement,
adherence to, and continuity of care, including HAART (NAHC, 2005; 2007). NAHC (2005,
p.7) reports that PHAs who are homeless are, at all stages of the illness, almost three
times as likely as those with stable housing to be outside of the HIV medical care system.
The benefits of housing and access to medical care are associated with lower viral loads
and reduced mortality (NAHC, 2005, 2007).
In essence, housing can be seen as an essential part of a treatment strategy that
ensures that people gain access to and adhere to treatment. Without stable housing,
doctors may be unwilling to prescribe HAART medications to individuals. If medications
are prescribed, the stress and distractions that accompany unstable housing or
homelessness can easily interfere with treatment adherence. Some treatment regimens
also require a strict schedule of twice daily injections and/or the need to refrigerate the
medication. Addressing the housing challenges of PHAs must, therefore, be seen as an
essential part of HIV/AIDS treatment, and not an ancillary concern.
36
Housing is HIV/AIDS Prevention
Key Message
A range of published studies are now showing that people who are stably housed are
less likely to engage in behaviours likely to lead to infection or transmission of the
virus thus making housing a key part of a comprehensive prevention strategy.
In addition to being a key part of a comprehensive treatment strategy, housing is also a
key part of a comprehensive prevention strategy. A recent study of administrative data
from the New York City Departments of Homeless Services and Health and Mental
Hygiene showed that the rate of new diagnoses among shelter system users was 16 times
greater than the rate in the general city population (Kerker et al., 2005; cited in NAHC,
2007). Culhane et al. (2001) found that male shelter users in Philadelphia with substance
abuse history and a history of serious mental illness were significantly more likely to be at
risk for an AIDS diagnosis than the general population. A range of studies are now
showing that people who are stably housed are less likely to engage in behaviours likely to
lead to infection or transmission of the virus (Leaver et al., 2006; NAHC, 2005; 2007). For
example, Aidala, Cross, Stall, Harre, and Sumartojo (2005) found that PHAs who homeless
or unstably housed were two to four times more likely to have engaged in recent drug use,
needle use, or sex exchange at a baseline interview. Over time, improvements in housing
status at a follow-up interview with a 50% reduction in drug use, needle use, needle
sharing, and unprotected sex.
This research suggests that structural interventions, such as housing, are critical
components of HIV/AIDS prevention strategies. Whereas most current prevention
efforts aim to directly change individual behaviour (e.g., needle sharing, unprotected sex),
these findings suggest that improvements in housing status can also have an important
effect on these behaviours. In the words of Aidala (2007), addressing “risky contexts” (by
improving housing status) is a critical and effective prevention strategy that achieves the
aims of our current strategies based on a “risky persons” perspective.
3.
Housing Programs and Systems
Key Message
As many PHAs are living longer, and as PHAs are increasingly presenting with multiple
and complex challenges, there has been a shift toward supported housing approaches
characterized by independent apartments and flexible and individualized supports.
Housing and Support Programs
Consensus is emerging that housing and support programs that are based on custodial
approaches (e.g., board and care facilities) are not supported by any research evidence and
37
are inappropriate for people with special needs, including PHAs who have had experiences
of housing instability and homelessness. When HIV/AIDS supportive housing was first
developed congregate models were the norm, and still remain popular. Indeed, research
with people with serious mental illness suggests that there were benefits associated with
these approaches (Parkinson, Nelson, & Horgan, 1999). However, as PHAs are living longer,
and as PHAs are increasingly presenting with multiple and complex challenges, there has
been a shift toward supported housing approaches characterized by independent
apartments and flexible and individualized supports (AIDS Housing Corporation, 2003).
These apartments may be acquired through housing subsidies or headlease
arrangements. In the U.S., Section 8 certificates have enabled people “to pay a fixed 30%
of their income for a private rental unit” (Hurlburt, Wood, & Hough, 1996, p. 310). This
policy provides individuals with the financial resources to access typical rental unit housing
rather than specialized housing programs. Most people who use this program rent private
apartments. Sylvestre, Nelson, Sabloff and Peddle (in press) report that there are several
controlled, longitudinal studies that have evaluated Section 8 certificates or some other
rent-geared-to-income scheme for those who have been homeless and who have
experienced mental illness. This research shows that individuals are able to maintain more
stable housing and reduce homelessness and psychiatric hospitalization to a significantly
greater extent than individuals who received standard care or case management alone.
Increasingly, supported housing is associated with a “housing first” approach. Research
by Tsemberis and his colleagues (Padgett, Gulcur, & Tsemberis, 2006; Tsemberis &
Eisenberg, 2000; Tsemberis, Gulcur & Nakae, 2004) has shown people with complex mental
health problems, histories of substance abuse and homelessness can achieve stable housing
when they are first offered housing that is not contingent on accepting other services.
Using a harm reduction approach, support services are offered by a 24/7 ACT team with
nursing staff and a housing specialist to coordinate housing. The only program
requirements were that individuals had to commit 30% of their income to rent, participate
in a money management program and meet with staff member a minimum of twice a month.
This approach is now being adopted by a number of providers of housing for PHAs, most
prominently Housing Works Inc. of New York City.
In addition to housing, a key form of support is income support. The Ontario Disability
Support Program (ODSP) is the primary income benefit program in Ontario for people with
disabilities. Three recent reports have been critical of this program, agreeing that the
income provided to recipients is insufficient to enable them to escape lives of poverty. The
Street Health Community Nursing Foundation (2006) claimed that allowing people with
disabilities to be poor and homeless only serves to increase costs to individuals, the health
care and the shelter systems. These reports are also critical of the ODSP’s complex
application process, noting that it is severely restrictive of the number of people able to
receive income support. The Ontario Ombudsman (2006) noted the program used a
stringent definition of “a person with a disability” and that there were lengthy delays by
ODSP in determining eligibility.
38
4.
Creating Systems That Work
Key Message
Characteristics of well-functioning systems include policy development, funding,
planning and strategic priority setting, extensive collaboration and partnership
between the HIV/AIDS sector and the broader housing and support services.
Ongoing research and evaluation activities support system improvement and
development.
The new material coming from New Hampshire (Needs Assessment and Action Plan) and
Massachusetts (Moving Forward A Massachusetts HIV/AIDS Housing Resources and
Needs Assessment Report, 2003), Washington State, the Summits on Housing and
HIV/AIDS Research is instructive for our purposes because much of it focuses on the
‘system as a whole’ and develops strategies for ‘system change’.
The reports from New Hampshire and Massachusetts are research informed, as well as
stakeholder informed using processes similar to those used by Housing Solutions. The New
Hampshire Plan focuses its recommendations on three areas, the expansion of affordable
housing, homelessness prevention and housing information, and advocacy services. In their
discussion related to housing models, the recommended housing is ‘as independent as
possible’, and scattered site. Services would be provided through existing providers
including ASOs and would include case management. This ‘non-development’ approach
extends the capacity of the existing system in ways that are feasible.
Integral to this strategy was securing funding for tenant-based rental vouchers and
securing set-aside units within larger affordable rental projects. Housing need was
ascertained by estimating that 1/3 of people who accessed HOPWA assistance in one
twelve month period were deemed in need of long-term assistance. To prevent
homelessness, the report advocates making available emergency rent and utilities
assistance resources. Although they do not deal with homelessness directly, these
initiatives are viewed as cost-effective and effective for disabled and low-income
households.
To expand housing information and advocacy services, they recommend educating
providers (ASOs) who work with PHAs be educated about basic housing information (e.g.,
eviction prevention, affordable housing). They recommend that these organizations
network with the other service and housing providers and that providers participate in city
planning exercises to achieve an impact on local priorities.
39
The Massachusetts Report starts with the assertion that housing is a ‘right not a
reward’ and that access to housing is essential to health and well-being. The document
outlines the need for a flexible, targeted array of housing (given the diversity of needs)
and recommends:







More scattered sites
More flexible time limits for congregate housing
Lower the threshold for entry for all housing
Homelessness prevention
Rental start-up funds
Housing information services
Harm reduction approach should be the standard
In addition they could not recommend single room occupancy or congregate housing
settings as they are not suitable in most cases.
Specific system level recommendations included a state compliance panel to coordinate
funding of AIDS Housing Services. In their recommendation to expand and preserve
affordable housing, they recommend the creation of new units in addition to establishing
relationships with other affordable/supportive housing providers.
Washington State organizes its housing along a continuum - emergency, transitional,
permanent and specialized care. Its goal is to create a ‘high functioning system’ and it does
this by filling in gaps or adapting existing programs. Where possible, they opt to train
others to work with PHAs rather than creating new facilities/programs.
The most recent 2nd Summit on Housing and HIV/AIDS Research (2006) provided
overall direction to the field in the form of The Summit paper that put forward 4 key
imperatives:
1.
2.
3.
4.
Make subsidized affordable housing available to all persons with HIV
Make the housing of homeless persons a top prevention priority
Incorporate housing as a critical element of HIV healthcare
Continue to collect and analyze data to assess the impact and effectiveness of
various models of housing as an independent structural intervention.
40
5.
The Question of Cost
Key message
“Based upon estimated discounted lifetime medical costs of $221,000 per new HIV
infection, the H&H (Housing and Health) analysis shows that an average of just one
transmission per 19 clients must be averted in order for housing services to be cost
saving, and only one transmission per 69 clients served must be prevented in order
for housing services to be cost-effective.” (Holtgrave, HIV/AIDS Housing Summit
2006)
The costs to society from HIV/AIDS and homeless are great. Culhane (2006; NAHC,
2007) reports that that the costs of service use by homeless people in New York City
ranges from $12,000 per year for people who use shelters and to over $20,000 annually
for homeless people who ‘sleep rough’. Recent analyses suggest, however, that housing
interventions are almost cost neutral, in terms of reductions of use of services, and are
potentially cost saving in their ability to reduce risk of HIV transmission.
Culhane (2006; NAHC, 2007) reports that in New York City, 95% of supportive housing
costs (about $17,000 per year) can be offset by reductions in annual service costs (about
$16,000 per year). Holtgrave (2006; NAHC, 2007) has reported the great potential for
housing interventions to reduce health care costs by preventing the transmission of HIV.
In his research in progress, Holtgrave has estimated costs of housing (including case
management support) in three U.S. cities ranging from $10,000 to $14,000 annually. Based
on an estimate of lifetime medical costs of $221,000 per new HIV infection, Holtgrave
reports that the prevention of just one HIV transmission per 69 clients housed would
make such housing services cost-effective, and just the prevention of transmission per 19
clients would produce actual cost savings.
41
B
HIV/AIDS Provider Survey
“Funding, changing trends, and the number and availability of support workers
have created difficulties in several areas of specific services. Providing safe, affordable
permanent/transitional housing for the hard to serve population remains difficult.
Providing services that meet the specialized cultural and legal, financial and spiritual
needs of refugee clients requires specialized services as do services that meet the needs
of the increasing number of affected children. Strained resources have made it difficult
to maintain programs such as access to complimentary therapies, vitamins, food
supplements (vouchers), Ensure, and others.” Survey respondent
Key Messages
Organizations providing services to PHAs have broad mandates including prevention,
health promotion, education, advocacy, and support for inclusion in the community.
HIV/AIDS organizations are increasingly serving people from countries where
AIDS is prevalent, more women, older people, people with complex dementias, mental
health, substance use problems and chronic homelessness.
HIV/AIDS organizations are stretched to provide a full range of services to a
population of increasingly complex needs with limited resources.
HIV/AIDS organizations devote precious resources to securing funding to keep
essential programs available. This is due to the large proportions of their budgets that are
not permanent/stable.
Although there are model housing programs in some major cities across Ontario,
with a large number located in Toronto, there is an insufficient number of units to meet
the current need.
A majority of ASOs offer key ‘getting and maintaining’ housing support services,
such as housing referral/information and case management.
Although partnerships tend to be informal, and are valued and beneficial, they are
also resource intensive activities. This limits the extent to which they are implemented to
meet the needs of PHAs.
Although the current service system has many strengths, most notably a committed
workforce, model programs and strong community partnerships, it suffers from a lack of
affordable housing, and limited supports services due to insufficient funding.
42
Survey Background
The goal of the Housing Survey was to fill in gaps in our knowledge about housing and
related support services currently available in Ontario, that are directly targeted to
persons living with HIV/AIDS or that are routinely accessed by them. The Housing Survey
had three objectives: 1) to provide a description of housing and related support services
currently available in Ontario, 2) to provide a description of the values and objectives of
these services and 3) to identify housing and support system gaps, challenges and
opportunities for change
The survey was completed by 33 organizations/programs, resulting in an overall
response rate of 45%. These organizations are spread across Ontario, with at least 1
located in 12 of 14 the new Local Health Integration Networks (LHINs) (see Appendix B).
Based on their principal mandate, the participating organizations were divided into three
categories: housing (70%), support services (35%) and healthcare (41%). Two other also
organizations responded, a legal services and an advocacy organization. (See Table 7.1).
1.
Organizations providing services to PHAs have broad mandates including
prevention, health promotion, education, advocacy, and support for inclusion in
the community.
Table 7.1 shows the six most common mandates named by organizations. The diverse
goals of these organizations include supporting PHAs and members of their social support
network, prevention, health promotion, education, advocacy and improving community
inclusion and citizenship.
Table 7.1: Six most common goals named by organizations
Main goals (N=33)
1.To assist and support all persons affected by or at risk for
HIV/AIDS including people living with HIV/AIDS, their partners,
family members and friends
2.To limit the spread of the virus through innovative
prevention/health promotion, education and outreach strategies
3.To advocate with or on the behalf of individuals, families, or groups
infected or affected by HIV/AIDS
4.To improve the physical health and emotional well being of people
infected with HIV/AIDS
5.To provide education as well as to the community about HIV/AIDS
and those living with it
6.To improve community integration and citizenship
Frequency
11
6
5
4
4
4
43
2.
HIV/AIDS organizations are increasingly serving people from countries where
AIDS is prevalent, more women, older people, people with complex dementias, mental
health, substance use problems and chronic homelessness.
When asked to choose from a list of populations of PHAs their organization served,
77% (24 of 31) indicated they served all of the populations provided in the list (Table 7.2).
These data demonstrate the openness of HIV/AIDS organizations to all who request
service and the broad range of people with HIV/AIDS seeking help. The broad range
reflects a generic approach to service delivery rather than a specialized approach where
only one or two populations would be served.
Table 7.2: Populations being served by Housing Survey Sample
Population
Men
Women
GLBTTQ
Families
People with Mental Illness
Homeless
People with substance abuse problems
People with co-occurring mental and substance abuse problems
People with problems with the law
Youth
Aboriginal communities
Refugee/immigrant
No defined populations
Other
Other: Babies/infant
Other: Children
Frequency (N=31)
31
31
29
28
28
27
27
27
27
25
24
24
4
8
1
1
3.
HIV/AIDS organizations devote precious resources to secure funding to keep
essential programs available. This is due to the large proportions of their budgets
that are not permanent.
Housing and support service organizations generally have multiple sources of funding.
The provincial government is the largest single source representing 69% of the total
funding for housing and 53% for support services. 5 Support services organizations
reported a greater number of funding sources than organizations providing housing (an
average of 5.3 versus 3.4 sources of funding). Other funding sources include federal,
municipal, fundraising and other sources.
5
Please note this sample did not include the agencies with single source funding, namely Toronto Community
Housing Corporation and HIV/AIDS clinics.
44
In terms of the stability of their funding, 77% of the funding received by housing
organizations was reported to be stable funding. Only 59% of the funding received by
support service agencies was stable. Both types of organizations have problems with
stability of funding but it is much greater for support service agencies.
Insufficient funding for both core and specific programs and services was described
by 50% of organizations responding to the survey. The number of funding sources, the
reliance on fundraising, and the lack of stability of this funding means that many agencies
are using scarce resources to report on spending and to prepare proposals and budgets for
different funders, and are investing considerable time, effort and resources in seeking
new funding. The organizations linked the unstable funding to understaffing and difficulty
in offering services to meet the needs of demanding clients or those who have complex
needs.
4.
Although there are model housing programs in some major cities across
Ontario, with a large number located in Toronto, there is an insufficient number of
units to meet the current need.
Housing programs refer to the direct provision of housing (the "bricks and mortar") to
people living with HIV/AIDS. This includes housing service providers who exclusively play a
landlord function, as well as those who play both a landlord function and offer support
services. The types of housing include the full range of places where people with
HIV/AIDS can live (e.g., transitional or permanent housing, congregate or scattered
housing, and independent or supportive housing). Multi-service agencies were asked only to
report on those programs that serve people with HIV/AIDS.
A total of 8 organizations answered this section of the survey. These agencies greatly
range in size, from providing housing for 6 to 330 people. These services are also spread
out across the province, although all are located in major cities in Ontario (e.g. Ottawa,
Toronto and St. Catharines). Many of Ontario’s larger cities are not represented and
among these at least one, London, has HIV/AIDS housing-The John Gordon Home. Other
housing programs in Toronto that either did not respond to the survey or were not
contacted were the Margaret Lawrence Coop, Myrmex Non-Profit Housing and Bleeker St.
Co-op.
Agencies were asked about inclusion/exclusion criteria. In general, these agencies
accept most, if not all, groups of people living with HIV/AIDS. Inclusion criteria are often
broad, and linked to program goals. For example, persons must provide proof of HIV/AIDS
status, and demonstrate need for the services of the program they are entering.
Depending on the type of housing provided, individuals are required to be able to function
relatively independently and require limited supports to live on their own. In cases of
congregate settings one common criterion was that individuals must be able to live in a
shared facilities/communal setting.
45
All agencies responding to the housing section of the survey indicated that they
provide some form of supportive housing (N=7). These 188 supportive housing units are
offered in both transitional and permanent housing models, mostly in congregate settings
with subsidies. Three agencies also indicated that they provide supported housing, most of
which is scattered-site permanent housing. Subsidized, municipal non-profit housing
programs and room and board housing were also identified, all of which are offered in
congregate settings with subsidies as permanent housing (with the exception of some room
and board housing being transitional).
Finally, the composition of the waitlists confirmed what we had been hearing from
other sources about trends in the population being served. There is:




An increase in the number of PHAs who originate in countries where AIDS is known
to be especially prevalent
An increase in the number of women
An increase of older PHAs, with a shift from people who are palliative to those with
intense chronic illness needs, such as dementias and concurrent disorders
A large number of people who are living with substance use issues, chronic
homelessness, and mental health issues.
To conclude, because people accessing housing services over the last two years are
presenting with greater and more complex needs, they also require more support services.
5. A majority of ASOs offer key ‘getting and maintaining’ housing support services,
such as housing referral/information and case management.
This section of the Housing Survey included both organizations whose primary mandate
is to provide housing services as well as those whose primary mandate is to provide support
services (i.e., ASOs). Support services were defined as those services aimed at supporting
individuals in maintaining their housing, meeting their daily needs, and achieving their
personal goals. The supports described in this section may be offered in the home or may
involve assisting individuals to engage with services in the community. These services are
frequently provided by trained staff and may also include peer support and/or volunteers.
They may also be provided in partnership with other organizations or by agencies on their
own.
The thirty-one organizations responding to this section were offering a wide range of
services, an average 10 different types of services (range between 1 and 21). When
agencies provide services in partnership with other organizations the five most commonly
provided support services were:
 Education about health and treatment
 Housing information
 Case management
46


Food services
Benefits counselling
More specifically housing information was provided by 71% of the organizations, and
case management provided by 68% in partnership and are deemed primary support
services for ‘getting and keeping housing’ by our expert key informants and in the
literature scan.
Table 7.3 lists the frequency and types of support services provided by agencies on
their own.
Table 7.3: Most Common Support Services Delivered Alone
Frequency
Support services (N=31)
Education about health and Treatment
Caregiver support
Case Management
Counsellor (e.g., mental health, addictions,
nutrition)
Benefits Counselling
Housing Information
Assisted Transportation
Food Services
Needle Exchange Programs
In terms of service
pressures, one third of
organizations (similar to
housing organizations)
described significant changes
with an increase in clients with
multiple/complex issues.
Specifically, there was an
increase in ‘hard to house’
clients, including PHAs with
mental health and substance
use problems. Organizations
also reported an increase in
the number of refugees and
immigrants, and the need to
20
15
14
13
13
12
12
11
11
Table 7.4: Service pressures experience in providing
support services
Support services (N=30)
Frequency
Funding (core and program)
15
Increasing clients with special needs
10
Programs are understaffed
7
Difficulty finding adequate housing
6
Transportation
5
47
provide culturally diverse services to this population. Three organizations reported
increases in their total client base. The five most commonly reported service pressures
are described in Table 7.4.
When asked about the additional services and supports that they would like to provide,
most agencies identified “offering more targeted services for special needs populations of
PHAs. “ Table 7.5 shows the most frequently named services agencies would like to be able
to provide.
Table 7.5: Additional Support Services Providers believe are needed, but are unable to
provide
Additional Support Services (N=30)
Frequency
More targeted services; outreach for IDUs; harm reduction
clinics; service for mentally ill
Housing
More social activities for clients (e.g. day programs)
Transportation
Access to health professionals
8
6
5
5
4
6. Although partnerships tend to be informal and are valued and beneficial,
they are also resource intensive activities. This limits the extent to which they are
implemented to meet the needs of PHAs.
Many of these support services are delivered in partnership with other organizations.
The majority of agencies reported delivering essential support services through
partnerships. This speaks to a measure of integration with other local service providers
and a reliance on them in order to provide a comprehensive range of supports. It also
suggests that the complexity of people’s needs requires this range of available supports
and use of partnerships. Please see Table 7.6 for more detail. In addition, although these
partnerships are largely informal (75%), the agencies reported a high degree of
satisfaction (81%) with them. Two of the most common support services provided through
partnerships were community-based support/advocacy/PHA resources and housing.
Table 7.6: Most commonly described support services offered
through partnerships
Support Services (N=30)
Medical care, pharmacy, psychologist
Community-based support/advocacy/PHA
resources
Housing (bricks and mortar)
Food services (e.g., food bank)
Needle exchange program
Housing Referrals
Percent of
organizations
providing service
36%
36%
32%
20%
20%
12%
48
Ten organizations indicated that they had plans to develop new formal partnerships to
find designated rent-geared-to-income housing for their clients, to provide mental health
services, and to provide food vouchers.
When asked about the barriers to working in partnership, agencies cited the following:




Agencies have limited resources and that makes delivering on partnerships very
difficult
High staff turnover
Differences in religious/cultural beliefs, language and different types of practices,
e.g. harm reduction methods.
Stigma both directly related to HIV/AIDS status of client population, but also
other related to marginalized populations such as clients with mental illness,
persons with substance abuse, clients with concurrent disorders
Three strategies that agencies found useful to overcome these barriers were: 1)
educating other organization about HIV/AIDS; 2) improving cross-organization
communication through open dialogue with a clear set of expectations; 3) developing
structured formal written agreements. It was mentioned several times that ongoing
funding from all levels of government would help to retain staff and allow organizations to
provide consistent services as well as create new partnerships.
7
“Although the current service system has many strengths, most notably a
committed workforce, model programs and strong community partnerships, it suffers
from a lack of affordable housing and limited supports services due to insufficient
funding.”
Respondents identified several strengths in the current system. Frequently mentioned
were the excellent housing programs and the range of support services offered in the
province. For example, Fife house, John Gordon Home, AIDS Niagara, Loft’s McEwan
House, Bruce House, and the Toronto People with AIDS Foundation were all regarded as
leaders in providing housing and support services to their communities. Also, the ongoing
commitment to advocacy for safe affordable housing by community and individuals was
seen as a strength of the system.
A third very important strength is the dedicated and knowledgeable long-term
managers of the provider organizations. They were identified for their expertise
regarding living with HIV/AIDS, the social determinants of health, strong leadership
capabilities, and grassroots advocacy and activism.
The current state of cross-agency partnerships was seen as another significant
strength. One respondent noted, “the strong connections between a number of ASOs,
49
hospitals and other service providers lead to strong case management that is well rounded
and holistic in focus.” Others noted the importance of their connections with mental
health organizations to provide housing for clients with HIV and mental illness.
Concerning the limitations of the current system, the lack of clean, safe, affordable
housing was most frequently mentioned. The lack of housing for specific populations was
also mentioned such as for people being released from the prison system, those living in
smaller communities, families infected/affected by HIV/AIDS, and for those with chronic
illness including dementias, and addictions. These gaps are made more apparent by the long
waiting list for RGI housing.
Additionally, agencies stated that often the appropriate support services are not
available, especially for high needs clients with severe substance abuse and mental illness.
There are concerns that presently these individuals often ‘fall through the cracks’. It was
noted that organizations need more drug and alcohol treatment facilities and spaces and
clinical settings that practice harm reduction strategies.
Agencies again mentioned the lack of necessary resources needed to address some of
the identified gaps and limitations, and provide the necessary services to their clients. As
one respondent stated:
“The main gap is a funding gap. We need sustainable funding for the
development of supportive housing for PHAs, which will include on-site
support workers and social service workers to address the advocacy and
education needs of clients and the support needs of people with
addictions and mental health issues.”
Respondents noted that additional resources are needed to address the gaps and
limitations of housing and support services. There was a common perception that greater
political will and vision with regards to HIV/AIDS services was necessary along with
greater societal recognition of the importance of social determinants of health and the
relationship between housing and health. There was also a perceived lack of knowledge
about the variety of challenges facing PHAs, in general, and within specific populations of
PHAs (e.g., homeless PHAs).
When asked for their three top strategies for improving the housing and support
service system for PHAs in Ontario, 59% described some type of increase to current
levels of funding. This included more funding for HIV/AIDS housing, more sustainable
funding for ASOs, and more funding for rent supplements targeted towards those on
fixed incomes and the working poor.
Additionally, 52% of organizations believed that creating affordable, appropriate,
subsidized and safe housing in various communities was a good strategy for improving the
system. One suggestion was to accomplish this through an aggressive building program of
50
social housing to bring RGI units on stream. Another was to dedicate more existing
housing units for PHAs, particularly to underserved populations such as families. To
accomplish this goal, one recommendation was to increase the number of dedicated units
by increasing the percentage of RGI within co-ops, allowing people with disabilities to have
access to housing.
Another recommended strategy was to increase social supports and outreach for
populations disproportionately affected by the HIV/AIDS epidemic (such as people who
are ‘hard to house’, active substance users, aboriginals and homeless people). To improve
accessibility, greater inter-agency collaboration was also suggested, particularly with
respect to ASOs, mental health and addictions providers. Finally, education and training
around HIV/AIDS were key themes for improving the system, within housing, support
services and organizations working with PHAs in the broader community.
51
C
Provincial Focus Groups Findings
This section summarizes the responses to questions posed to the five focus groups
involving HIV/AIDS organizations and the broader housing, healthcare and social services
sectors.
Question 1: What strategies/mechanisms have helped you/your clients get into and keep
their housing? What has worked well/been the most effective?
Key message
“Many of these clients need assistance both in getting and keeping their housing.”
Strategies/mechanisms



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Developing affordable housing that is safe, affordable, supported, non-stigmatizing,
mixed/integrated, providing a sense of community/belonging/ connected and
flexible
Developing close working relationship with individual staff in relevant agencies and
develop effective cross-agency links
The creation of a dedicated housing/housing outreach worker position
Providing coordinated case management (e.g., through partnerships with mental
health agencies)
Linking with local CCAC to retain a social worker to assist clients
Ontario Works (OW) barrier support group monthly meetings for providers to
“brainstorm” complex cases, OWs mental health specialist, ODSP support workers
Providing individualized support services once housing is obtained
Using “head leases”/rent subsidies (e.g., the rent subsidy component of the
MOHLTC Homelessness Initiative Phase II is viewed as being very helpful)
A variety of broader community supports were identified as being helpful such as the
local Legal Aid Clinic to assist clients with landlord/tenant issues and the housing staff of
other agencies to provide information to their clients.
Workers also identified various approaches they used that were helpful in delivering
service and engaging clients such as: focusing on stabilizing clients vis-à-vis their housing
and other basic needs before addressing HIV/AIDS issues; finding ways to address the
co-morbid HIV and mental health and/or substance issues of clients; engaging families and
friends in helping clients to access services; and, tailoring services as much as possible to
the individual.
52
Question 2: What are the most critical housing and support service issues facing
you/your clients? Have these issues changed? Are things better or worse?
Key Message
Poverty is a basic underlying issue and there is an inadequate amount of appropriate,
affordable housing as well as the supports many of these PHAs need.
Critical Issues

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Critical shortage (lengthy wait times) of affordable and appropriate social housingindividual needs to be in full crisis to get housing
The “bureaucratic maze” and inflexibility of ODSP and other human service
application processes
Low/inadequate level of income support (OW and ODSP) for PHAs, both individuals
and families
Inadequate resources to provide appropriate supports/assistance for clients both
in getting and keeping housing
Stigma persists, may be increasing, particularly for PHAs from countries where the
prevalence of AIDS is high
Limited hospice/palliative care services and shortage of transitional facilities
especially for families
Abstinence based programs are not effective
Funding disparities across communities/regions
Housing and health are intertwined yet this is not translated into policy and its
implementation- “not on the government’s radar screen”
Several special populations were noted as facing additional challenges over and above
these in relation to housing issues- families/women/youth (in relation to emergency
housing), people with criminal histories and immigrants. Clients with multiple
challenge/diagnoses (e.g., HIV/AIDS, mental health and/or addictions problems) are the
most difficult to house and require intensive ongoing support. The “episodic nature of the
illness” makes it difficult to maintain stable housing. It was also noted that given the range
of housing options currently available, each has its limitations in terms of serving people
with HIV/AIDS. Inpatient medical detox/withdrawal services and hospice service were
identified as being in short supply.
Support services have difficulty in responding to the wide range of individual needs of
the population-from people with AIDS-related dementia to people with little or no English.
There were also comments that the current ‘health care worker view that all HIV/AIDS
clients do well on anti-retroviral drugs and that their illness is now considered ‘chronic but
manageable’ and that this is neither realistic nor helpful. This is coupled with an increasing
risk for poverty, homelessness, resulting in “people living longer but not necessarily
better.”
53
There was strong agreement around the inadequacy of income supports and that having
HIV/AIDS seriously impacts earning ability, making poverty a basic underlying issue for
many PHAs -“the poverty is often a worse trauma than the HIV/AIDS.” The point was also
made that these support programs create a “vicious cycle of dependence” where individuals
may want to work but don’t want to jeopardize their benefits, e.g., the ODSP drug card.
Question 3: If you could make one improvement to the housing and support services
for PHAs in your area, what would it be?
Key Message
Housing = health and is a basic human right. There is a need for informed and
committed political leadership at the federal, provincial and municipal levels.
Key Improvements
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Need for governments to view safe, affordable housing as a basic human right
and an important determinant of health
“Housing = health”, including health promotion and illness prevention
Housing alone is not enough, need to increase the appropriate support through
provision of adequate funds: HOUSING + SUPPORTS is key
Develop more mixed/integrated, affordable and supportive housing recognizing
one size doesn’t fit all
Increase the number of rent supplements, ensuring a mix of portable and nonportable
Provide stable, annualized funding to agencies and encourage cross-agency
collaboration on funding proposals
Improve co-operation/co-ordination between federal and provincial policy
makers and program funding bodies (particularly re: aboriginal services) and
across provincial government ministries
Many specific suggestions were made for particular types of housing such a being
creative around using rental properties in communities where the vacancy rates are high
(e.g., Thunder Bay), and providing incentives towards ownership in social housing. A few
mentioned the need to increase access to long-term care placements for some people.
Scattered site programs were preferred over congregate.
Additional suggestions concerning support related to garnering more staff in relevant
agencies that are dedicated to finding housing and support service solutions along with
increasing the funding for case management services to allow for smaller caseloads. People
identified the need for programs/services with a prevention focus and for programs using
outreach models, harm reduction and stages of change models.
54
At the system and policy levels the suggestion was made to identify one agency in a
community as the “lead” in a partnership approach to developing housing options for their
collective “hard-to-house” clients. And, at the policy level, it was suggested that new ways
are needed to make senior bureaucrats/decision-makers fully appreciate the realities
facing front-line agencies and their clients regarding housing, support services and income
supports
Question 4: What are the key values that should guide the development of housing
and support services in Ontario?
Key Values
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Key message
No more “poor services” for “poor people”
Less “warehousing”/ “ghettoizing” and provide housing that is more integrated
with community and promotes optimal living
Take a determinants of health perspective that views housing = health
Provide housing options and choice – “one size doesn’t fit all”
Safe, affordable housing is a basic human right and providing it should be a
government and societal priority
Ensure respect, dignity and compassion
Adopt a “recovery” perspective – i.e., hope, choice, non-judgmental, personal
responsibility
Respondents also offered suggestions for the organization and delivery of services
that included the need for effective coordination and information flow across service
providers and agencies. They stressed it was important that services be flexible, proactive
and needed to provide easy access to clients concerning information regarding local
resources and legal rights. If there was one message to policy makers it was:
Housing = health + prevention + access to healthcare and is a good economic investment.
Policy/Research/System Level Focus Group
The sixth group was held for leaders of provincial organizations, research, government
and key organizations to obtain their views on the overall system changes that need to
take place to support improved housing and support services. The following summary
highlights the contributions made by this focus group.
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1.
Scope of the problem (i.e., how many PHAs need affordable housing and/or
support services?)
Key Message
It is difficult to quantify the number of PHAs in need of housing,
At best we have indirect measures.
Currently Toronto has 13,000 – 16,000 identified PHAs and only 131 dedicated
supportive housing units and two for aboriginal PHAs. It is difficult to know exactly how
many of these individuals need housing and support services. It would be helpful to see
what the number on the social housing medical priority wait list is but our understanding is
that information is not available.6 Also, we do not know what the prevalence rate is for the
homeless population. It has been suggested that 3% might be reasonable.7
In the Positive Spaces Healthy Places study, 31% of the sample identified their housing
to be at risk however their sample did not include the shelter population. Also it would be
helpful to separate those who need housing from those who need support services (e.g.,
health, ADL, assistance to keep housing) in terms of assessing need for housing and those
at risk of losing their housing. We do know that .8% (1600) of ODSP clients are PHAs and
in the recent Toronto Community Planning Report housing is a top priority. Also,
Aboriginals and families are definitely underserved in terms of housing in general.
2.
Critical shortcomings in present system
Key Message
In Ontario we cannot speak of a system of housing and support services, in part due
to the lack of an overall policy and funding framework for these services.
There was strong agreement that Ontario does not currently have a system of housing
and support services for PHAs. In other words, what we have is not planned on the basis of
assessment of need and priority setting given the resources. There is a noticeable lack of
coordination, cross-sectoral linkages, common assessment tools, centralized source(s) of
housing information and integration with health and other supports.
Contributing to this is the absence of a housing policy framework such as is present in
other jurisdictions (e.g., Massachusetts, New Hampshire and Washington State). These
systems demonstrate how thinking about the broader system is translated into decisions
about services, funding and service priorities. An articulated policy framework also has
the capacity to mitigate the stigma and discrimination currently experienced by PHAs. For
example, in Ontario we need to think more broadly about a system that will meet the
6
Subsequent to this meeting Housing Solutions obtained the waitlist and placement numbers for
Toronto Community Housing for 2006/2006. Please see Section III.
7
Key informant interviews gave an estimate of 3% to 10% of homeless population having HIV/AIDS.
Please see Section III for results of Toronto Homeless Study.
56
particular housing and support needs of a variety of sub-populations and how to provide a
greater range of housing options.
3.
Barriers to developing a good system
Key Message
The lack of a coordinated governmental approach involving all relevant divisions and
ministries coupled with the lack of a coordinated advocacy approach by the field
maintains the status quo.
The elimination of HIV as a medical priority for social housing in mid-2003 (in Toronto)
had a significant impact on access to social housing. Members of the policy focus group
discussed re-establishing this as a priority social housing population on a ‘municipality by
municipality’ basis though the local Service Managers. Once again the poverty issue was
raised as a barrier and it was noted that the Positive Spaces Healthy Places data showed
that 75% of the sample has an income of less than $1500/month.
At the ministerial level there is no inter-ministerial mechanism for developing a
coordinated approach by which to address these issues. The group noted the lack of a
concerted, cross-sectoral advocacy program (with mental health for example) on the need
for supportive housing for PHAs. Finally, with the transformation the healthcare system is
undergoing, it will be important for HIV/AIDS organizations to put this issue on the
LHINs’ radar screens.
4. Role of provincial associations
Key Message
Provincial organizations have a key role to play in bringing together the relevant
players, developing an agenda for housing and support services
and in advocating for it.
There is a very definite role for provincial organizations. For example, the OAN has a
very important lead role in developing partnerships. One suggestion made was for the OAN
to bring together all relevant provincial associations for a focused discussion and strategy
development Summit on housing and supports services. Also, mental health and HIV/AIDS
organizations could be excellent/complementary partners along with the large, emerging
community health organization coalition in Ontario. At the Ministry level it was suggested
that OACHA could play an important role in advancing the agenda.
57
D
HIV/AIDS Housing Expert Key Informant Interviews
Rationale
The purpose of this component of the work was to gain perspectives on the challenges
and opportunities in developing housing options for PHAs from outside the province of
Ontario. We sought to include those individuals who were directly involved in the delivery
of recognized programs as well as leaders in research, policy, and advocacy.
Findings
1. What percentage of the larger PHA population needs access to a specialized
system of housing?
Key Message
Estimates vary for the percentage of PHAs requiring specialized housing and there
was agreement that individual needs varied in terms need for long-term/short-term
housing and in terms of the intensity of support services required.
Five respondents answered this question. Their estimates of need ranged from 25% to
70%, with three of the respondents agreeing that over the course of a person’s lifetime,
about 50% of PHAs in the U.S. would have some housing needs. One respondent cited data
from Alberta suggesting that 70% of PHAs identified access to affordable housing as a
priority for them.
Respondents agreed that these needs would be varied, with some needing long-term
housing support, and others needing more short-term support. People with experiences of
homelessness were identified as needing longer-term and more intensive housing and
support options. It was noted that the link between HIV/AIDS and homelessness arises
because PHAs either are at greater risk for losing their housing, or because people who
are homeless are at a greater risk for contracting HIV/AIDS. The needs for services
could extend from counselling and housing search services, to rental subsidies, to access
to some form of case management support. One respondent spotlighted the challenges of
addressing the needs of the small group of individuals who were unwilling or unable to take
necessary precautions to prevent the transmission of infections.
One respondent identified the significance of housing as being a pre-requisite for
access to other important resources and services such as case management, treatment and
other medical care, and employment. Housing was also identified as significant for
promoting greater social connections.
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2. Please describe current systems of housing and support for PHAs
Two Key Messages
The range of types of housing services described were congregate living for specific
populations requiring additional support, single scattered site apartments, portable
rent subsidies, residential care for those
needing medical case management.
Housing support services that were viewed as being important in ‘getting and keeping’
housing were housing search, short-term rental programs, rental assistance
to prevent homelessness, housing start-up assistance, utilities assistance,
nutritional services, substance abuse and mental health counselling
and case management.
Respondents were asked to describe the current system of housing and support with
which they were familiar. Taken together, their responses described the elements of a
comprehensive system of housing and supports. Notably, two Canadian key informants from
different provinces, stated that there was no “system” to speak of.
Respondents described congregate housing approaches in which individuals lived within
a single building. Most commonly, these programs involved multiple apartments clustered
within a single building. These programs were developed and operated by non-profit
agencies. Programs were sometimes targeted to particular populations such as single adults
or families with children. Program participants typically received some form of income
support, with a portion going to pay for their rent. Programs could be more or less
intensive and structured (in terms of amount of presence of program staff on site). These
programs provided access to additional services (e.g., mental health, substance abuse, case
management).
A second housing approach involves portable rent subsidies for acquiring independent
apartments. In the United States, these rent subsidies may be specific for PHAs (through
the federal HOPWA program) or more general subsidies (e.g., federal Section 8
certificates or state alternative housing voucher programs). Whereas sometimes these
independent housing programs were seen as a “graduation” from more structured
congregate approaches, they were also characterized as part of a “housing first” approach.
A third housing approach was residential care. This consisted of more structured
medical care. This form of housing could be temporary or permanent.
Other features of a housing and support service system were funding for other
housing supports such as housing search, short-term rental programs, rental assistance to
prevent homelessness, housing start up assistance, and utilities assistance. In the U.S., the
funding for these programs was sometimes made available from the Ryan White legislation.
59
3. Strengths and limitations of current housing and support systems
Two Key Messages
System strengths pointed to innovative programs that took a harm reduction
approach, promoted resident empowerment, had strong partnerships in place and
served diverse populations in a mix of types of units.
System limitations were noted as being the lack of affordable housing, the lack of
acceptance by the larger community and agencies working in silos.
Respondents were asked to reflect on the strengths and limitations of the housing
programs and systems with which they were most familiar. In terms of strengths, several
pointed to the importance of a dedicated staffing group with low turnover, effective
board members, or to the innovative nature of their programs. Innovative programs had
characteristics such as serving a diverse population, having no requirements around
desistance from substances, having a mix of types of units, being co-located primary care
services, establishing a rental assistance program, and having a commercial component to
the residential building.
Several pointed to key efforts at promoting empowerment and community among
residents. Some programs included residents in key decision-making roles (such as
membership on the board of directors) and created opportunities for consumers to
develop a sense of community and provide help and support to one another. The
development of community extended to efforts to learn how to be good neighbours and to
developing a neighbourhood community advisory group to gain buy-in from the community.
Other strengths involved developing a range of partnerships to strengthen the program,
including collaborations with other service providers, working with the Department of
Public Health to establish good standards of care, and working with advocacy organizations
for PHAs.
In terms of limitations, most respondents pointed to a lack of adequate funding and
the challenges of working in expensive housing markets. Some identified particular
challenges of housing clientele with multiple challenges and the need to work with landlords
and neighbourhoods to change attitudes and gain acceptance for this population.
Respondents also pointed to challenges associated with the broader lack of recognition of
housing as a health-related service. In terms of specific program issues, respondents
pointed to the need for better planning for partnerships to overcome service silos,
allowing for more resident voice in program decision-making, and employing annual client
surveys.
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4. Strategies for improving current system
Key Message
Two key strategies for systems improvement were working across sectors through
partnerships/networks and public awareness campaigns aimed at gaining acceptance
and increased access to housing and supports.
Respondents were asked to describe effective strategies of improving their system or
program of housing and support. Many of these strategies involved efforts to connect with
other groups. They described participating in networks of housing providers, partnering
with health agencies, sponsoring research summits, developing partnerships with private
sector providers and landlords, and working openly with city and state officials. More
broadly, public awareness campaigns to prevent discrimination were identified, along with
efforts to increase access to housing subsidies and rent supplements, and expanding
available housing. More specific strategies for program improvement included engaging
clients in housing management and decision-making, making use of needs assessments, and
participating in program planning and community planning activities.
5.
Role of government and advocacy groups in improving housing and support
services for PHAs
Key Message
Most fundamentally, the roles identified for government were the recognition of the
fundamental right to housing, and assumption of responsibility for ensuring that
individuals had access to housing.
Respondents were asked to comment on the role of government and advocacy groups in
improving housing and support services for PHAs. Most fundamentally, a role identified for
government was the recognition of the fundamental right to housing and taking on the
responsibility to ensure that individuals had access to housing.
One of the major roles of government, be it at federal, state/provincial, or municipal
levels, was providing adequate funding. The provision of funding included both housing (e.g.,
housing vouchers) and support (e.g., case management). The provision of funding for
housing and supports was characterized as a cost effective investment given the role
housing can play in preventing transmissions. Government was also seen as providing
funding and a policy context to ensure that sufficient wraparound services were available
to people as they became housed. This involves coordinated policy development that
overcame service silos so that people could have all of their needs addressed.
Government was also identified as playing a role collecting and disseminating
information on best practices in housing and support, and ensuring that funds were
available for education and training to optimally deliver services.
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Recommendations for the role of advocacy groups included learning to work more
effectively with the broader housing and support sector. It was suggested that
HIV/AIDS advocacy groups initially had to work in parallel with other groups due to the
stigma associated with HIV/AIDS. This early work typically did not focus on housing.
Increasingly, as the importance of housing is being recognized, there is an imperative that
these groups learn to collaborate with a broader range of groups. This work must focus on
addressing needs as identified by PHAs, collecting and disseminating information to a
broader range of groups, and ensuring that it is used in the creation of policy.
6. Values that inform housing and support programs and systems for PHAs
Key message
Most generally, it was suggested that these programs should be based on a broad
definition of health, including physical health, mental health,
and social domains. It was also suggested that housing should
be valued from a social justice perspective,
as a basic human right.
Respondents were asked to identify the values that they believed should inform the
delivery of housing and support programs for PHAs. Most generally, it was suggested that
these programs should be based on a broad definition of health, including physical health,
mental health, and social domains. It was also suggested that housing should be valued
from a social justice perspective as a basic human right.
One respondent suggested that the delivery of housing programs should proceed from
a perspective of protecting rights, rather than a value of benevolence. Rather than a
reward for good behaviour, housing should value dignity and respect, and not have rules or
restrictions different from housing that is purchased or rented on the open market. This
housing should be provided in a manner that is non-discriminatory and non-judgemental,
and adaptable and flexible to the changing needs of tenants. It was suggested that
tenants should have a voice in the management of the program, such as by having a role on
the board of directors.
Finally, it was suggested that programs should value staff retention, and should engage
in periodic program reviews. It was suggested that up to date information on a broad range
of topics related to housing support should be distributed to a range of stakeholders,
including tenants, housing providers, community members and policy-makers.
62
E
Key Informant Interviews from the Broader Housing Sector
Housing Solutions gathered information on unknown, unexplored or under-utilized
housing types in the broader housing sector that could be enlisted to broaden the range of
housing alternatives accessible to PHAs. The following description of housing alternatives
is an attempt to capture and categorize rather than place in a continuum form. The
depiction recognizes that people have a range of needs that can change over time but it is
not meant to imply that people ‘graduate’ from one form of housing to another, or that
they require a period of time to become ‘housing ready’. The latter view, emblematic of a
“housing continuum” perspective, is increasingly falling out of favour in North America with
the emergence of the “housing first” approach.
In an ideal system there will be a mix of housing types that can respond to changing
circumstances in the individual and/or his support services. Overall, there is a serious
shortage of safe, affordable housing for all low-income citizens in Ontario and those on
ODSP all face the challenge of an inadequate accommodation portion of the benefit.
Temporary
Permanent
Elderly/End of Life
1.Emergency shelters and
hostels
2. Transitional Housing
1. Private market rentals
/ownership
2. Not-for-profit:
a) Social housing (both RGI
and market rental)
b) Cooperative Housing
3. Domiciliary hostels
1. LTC Homes
3.Respite Beds
2.Hospice:
a) Visiting
b) Residential
3. Palliative Care:
a) In home
b) In hospital
4. Supportive housing:
a) Generic
b) HIV/AIDS
c) Mental health
1. Temporary Housing
Emergency Shelters/Hostels
Shelters offer temporary accommodation of up to a maximum of 3 months. Ontario has
approximately 100,000 beds that are funded on a cost-shared basis by the municipalities
(20%) and the province (80%). Some communities have no beds as a result of not having
the funds to cost share. The size, target population and availability of on-site services
vary highly from community to community. For example, in London, all the shelters are
sponsored by religious organizations and are largely abstinence-based.
The majority of shelter users are on OW. They receive this benefit on admission, along
with a drug card. Residents rarely go from shelters directly into social housing (due to the
63
lengthy waiting lists) and more likely to enter sub-standard private market rentals
(including rooming houses), other shelters or the street.
It is not known how many shelter users are PHAs because disclosure is an individual’s
decision and shelters can be unsafe for people who have disclosed their status. There are
instances where people have been segregated because of their HIV status in shelters.
Problems with medications are also noted in shelters where there is limited capacity to
protect the medication against being stolen or to privately refrigerate it or where there is
a policy concerning needles making it difficult for those on injection medication.
To provide more responsive service to shelter users with HIV/AIDS, shelter workers
would benefit from training and education around the illness and medications. Closer
contact with specialized HIV/AIDS programs is needed because hostel staff lacks
expertise in this area.
The other problem facing people with HIV/AIDS who use shelters is their need for
continuous-24/7- access to services because regular office hours do not meet the needs
of this population (e.g., infirmary services, counselling, harm reduction services).
Transitional Housing
Transitional Housing is a type of social housing. It is relatively new category of
provincial government funded housing that is developed and administered by municipal
Service Managers. The primary target population are homeless shelter users, in particular
high need groups such as homeless families, women and youth. There is no particular
transitional housing presently targeted to people with HIV/AIDS.
Transitional housing is usually medium term in length and comes with support services,
to help people prepare for permanent housing. The housing for single individuals is usually
in the form of small bachelor units or single room occupancy units. The Supporting
Communities Partnership Initiative provided money for support services to transitional
housing programs. It is not known how many transitional housing units there are across
Ontario and what the distribution is, although it is thought the number is low.
It appears that this is a limited housing option and one that provokes debate amongst
housing providers. Simply put, many believe that the money is better spent on permanent
affordable housing, and that transitional housing operates in a vacuum when the access to
permanent affordable housing is so limited.
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2. Permanent Housing
Private Market Rentals/ownership
The estimated annual need for rental housing in Ontario is three times what was
produced annually between 2000-2005 and is in the order of 10,000 to 12,000 units.
Vacancy rates in Ontario cover a wide range from 10% in Windsor to 1% in Sudbury with
Toronto at 3.2% and the province as a whole at 3.4% down from 3.8% from last year. At
the same time, home ownership costs are rising which puts additional pressures on the
rental market.
Social Housing
Social housing is permanent housing that is subsidized or assisted rental housing
provided by non-profit community agencies, municipalities and co-ops as well as through
landlords both profit and non-profit who have entered into rent supplement agreements
with the government. Social housing mixes rent-geared-to-income with market rent,
70/30% approximately. The administration of the social housing portfolio takes place
through the 47 municipal governments and its Service Managers (Social Housing Reform
Act, 2000). Each municipality operates a housing access program and maintains a waitlist.
Legislation requires tenants to be able to live independently and therefore most social
housing provides minimal supports. There are instances of creative partnerships where for
example in a downtown Toronto Community Housing building that is exclusively for PHAs,
there is an on-site support service staffed by Fife House workers, as well as a community
kitchen and other resident programs.
Bruce House in Ottawa is an example of another creative solution. Bruce House has an
agreement with Centretown Citizens Ottawa Corporation, a private, non-profit social
housing corporation to block lease a number of apartments that it in turn rents to clients
on an RGI basis while providing the appropriate supports.
On the supply side government building programs have not kept pace with demand
resulting in very long wait periods, in most cases years, for social housing. In 2006,
122,426 households in Ontario were on the wait list and 80% had incomes of than 20,000.
In addition, the government has built or has underway 6,724 of the 20,000 units of
affordable housing it pledged to build. In Toronto Fife House and WoodGreen Community
Services and the Wellesley Institute, are building a new supportive housing apartment
complex The building will have 112 apartments units: 56 will be for people living with
HIV/AIDS and operated by Fife House; and 56 will be for seniors and operated by
WoodGreen Community Services.
Contributing to the backlog throughout the province is the provincially legislated
priority for victims of domestic violence (2000). While Service Managers have discretion
65
over which other population(s) gets priority there is a hesitation in using this power given
the long wait period. It is not known what the overall number of tenants currently in social
housing is who are PHAs. We do know that in Toronto, last year there were 248
HIV/AIDS households on the wait list, 39 were housed representing a total of 287 and an
increase over 2005. Of these, males represented 74%, females 26% and seniors 4%.
Eighty-four percent of households had no dependents.
A demand side solution, that of rent supplements is another form of social housing and
tends to work best when the vacancy rates are high, which is not the case presently in
most urban centres. Rent supplements can also go to non-profit or co-operative housing. In
both instances tenants pay the RGI portion (30% of their income) of their rent to the
landlord and the rent supplement bridges the gap between market rent and the tenant’s
RGI rent.
While some PHAs have concerns about social housing due to stigma, the managers we
interviewed saw no particular challenges with PHAs unless mental health and/or addictions
problems were present. These two are highly problematic issues for managers of social
housing, especially in the current system where the connections with appropriate supports
are often not in place. It appears too that the number of tenants with these problems is
increasing and that only a “systems” approach to developing appropriate housing options
for these “hard-to-house and support” can work to reach a solution.
Co-operative Housing
Co-operative Housing, another type of social housing is divided between federally
funded programs (no federal funds since 1992) and municipally funded/administered
programs. There are 554 co-ops in Ontario representing 44,109 units of housing. Co-ops
have a mixed income approach with RGI units and market rental units. They tend to be
geared to low-moderate income households. Co-ops differ from social housing in that they
are collectively owned and run by the residents. In some instances this can create
problems in the management and administration of the buildings.
Ontario has the largest number of federally funded co-ops among the Provinces - 18,
559 units (approx. 11, 000 units in Toronto). These programs required 25-50% of co-op
units in each project to be RGI and each federally funded co-op keeps its own wait list. We
do not know how many are on the wait list for RGI, but it is known to be long. However
market rental units are more available than the RGI units and a rent supplement program
would be an option for PHAs in terms of enabling access to this type of housing. Also, some
co-ops designated a small number of units for PHAs, particularly in Toronto.
At the same time the province funds co-ops through the municipalities and they are
part of the Service Managers social housing portfolio.
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Domiciliary Hostels
Domiciliary hostels are a form of permanent housing that were created (1970 by
Ministry of Community and Social Services) to house frail, elderly adults. The population is
mostly middle-aged males and seniors with mental health problems although that is
changing with more women and people with other histories such as substance use. Most
tenants are on ODSP or CPPD and many come from shelters. Each tenant also receives a
Personal Needs Allowance of $119/month. Eligibility is determined by need for support
and affordable housing. The residents are covered under the landlord tenant act.
Twenty-five of the 47 municipalities have domiciliary hostels (4700 beds) and these
are all privately owned/operated and provide room and board. They are typically viewed as
being “custodial” model although steps are being taken to change it to a more “
independent living” model when in Sept/06 a new “Program Framework” with revised
expectations was introduced. Local municipal Service Managers must now develop
standards and service contracts with providers.
The actual number of PHAs in domiciliary hostels is not known but it is considered to
be very small and there does not appear to be a trend upwards. Hostel operators are open
to serving PHAs and would need education and training. On the other hand there is limited
privacy and independence, and many have a no drugs/alcohol policy. In addition, these
facilities are limited in terms of their lack of privacy, choice, control, and the minimal
support that is provided. Although this form of housing may be suitable to address current
need, it does not reflect many of the values established in this report and would not be a
“first choice” option.
Supportive Housing
Supportive housing is considered a form of permanent housing. It provides access to a
range of support services either on-site through agency staff or off-site through
arrangements with other agencies. MCSS and the MOHLTC both fund supportive housing.
MCSS has decentralized their portfolios-namely youth and developmentally disabled to
regional offices and the MOHLTC maintains them centrally through its Supportive Housing
Unit. These serve the ‘hard to house’, namely the homeless and people with mental health
problems. There are three aspects to this program:



Working with private landlords to provide RGI housing based on rent supplements
(attached to the unit not the person)
Purchasing case management services from existing agencies (like CMHA branches,
Mainstay, Houselink) for these new units
Buying and renovating buildings as well as purchasing the case management services
for these units
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Providers of supportive housing with on-site serves are non-profit agencies, some are
multi-service agencies and some faith-based. For the most part this housing falls under
the purview of the local municipal Service Managers.
It is not known how many supportive housing beds for PHAs exist in Ontario nor how
many PHAS are being served. In a small sample of mental health supportive housing
providers (3), there was very little connection between the sectors and in terms of
numbers; two agencies thought they might have one or two PHAs. They did not note any
significant barriers due to the HIV/AIDS status as long as the person met the criteria
for a mental health problem.
Since 1999, 5,800 new units have been developed by the Supportive Housing Unit or
are currently under development– for homeless mentally ill, and mentally ill with a current
involvement with the criminal justice system. Most recently, the new federal-provincial
Affordable Housing Program has added a small number of units of supportive housing (700)
for mentally ill individuals. Municipal Service Managers will administer these units. In the
newer projects there is a shift away from congregate models towards independent living
units and the best practice guideline is 10-15 units per building.
3. Elderly/End of Life Housing
Long-Term Care
The Ontario Long-term Care Association has 450 member homes with 77,000 beds
across Ontario and these represent a combination of private and non-profit homes. Homes
vary in size, age (old, new, renovated) and type of accommodation (private or shared) and
PHAs represent from 0-1%.
Despite the massive expansion of beds in recent years, the current occupancy rate is
98% and 18,466 individuals are currently on the wait list although it varies across
communities. There is increasing preference among consumers for private accommodation.
Concerning PHAs, LTC facilities are experienced in managing people with dementias but
the perception is PHAs that would require more specialized care. It was suggested that
one option would be for HIV/AIDS organizations to canvass LTC homes in their areas to
assess the feasibility of developing a specialized program, a ten bed unit for example, for
PHAs.
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Hospice and Palliative Care
Hospice and palliative care services in Ontario have developed as separate sectors
unlike all other provinces and hospice service through the Ontario Hospice Association
encompasses two components: a visitor service with 13,000 volunteers active in 450
communities across Ontario and 10 member residential hospices including Casey House.
These hospice services combined with hospital-based palliative care units/programs
provide a continuum of care so individuals can choose their preferred place to die – at
home, LTC facility, residential hospice or palliative care unit. The volunteer visitor can
follow the client across any and all of the above settings and provide the psycho-social
element of support. There is an increasing emphasis within the field that hospice care is
broader than “end of life” care – it’s for those diagnosed with a terminal illness and death
may be some time away.
In 2004 the volunteer programs served 5700 individuals/families in 2004, of which
300 were identified as PHAs. Volunteers are very open to ongoing HIV/AIDS education/
training. Local hospice agencies partnering with local ASOs would help to improve their
ability to serve this population.
4. Housing Related Supports
Income Supports
OW and ODSP are primary programs and the accommodation portion of OW and ODSP
is viewed as being inadequate to access appropriate housing. The accommodation portion
the same even though rental costs vary across the Province and it is not tied to increases
in cost of private market rentals.
The number of PHAs on OW is not known and 0.8% or 1600 ODSP (2005) clients were
PHAs out of a total of 295,000 beneficiaries. The number does not appear to be
increasing.
In November 2006, ODSP regulations changed to introduce a comprehensive set of
incentives and supports intended to encourage beneficiaries to enter the labour market or
enhance their current work situations. To date the current provincial government has
raised welfare rates by 5% after 10 years of having the rates frozen and after having
failed to follow through on its promise to eliminate the clawback of the National Child
Benefit. This is considered inadequate by the Interfaith Social Assistance Coalition and
ONPHA.8
8
Globe and Mail, April 18, 2007 “Ontario Failing it Poor”
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Community Care Access
As of January, 2007 the numerous Community Care Access Centres (CCACs) across the
Province were consolidated to create 14 CCACs to match the geographic boundaries of the
14 LHINS. CCACs provide a range of support services arranged by Care Coordinators to
eligible clients such as nursing, OT, PT, Personal Service Workers, speech language
therapists, social workers. Also provided are some supplies and equipment, a drug card
(during time of service), assistance with “system navigation”, nursing services in 14
shelters (in Toronto), in-home palliative care and access to LTC beds.
The number of PHAs being served by CCACs is not known but could be determined. The
Toronto Central CCAC has noticed a change in the PHA population being served over last
few years- men are aging, more women and more clients from diverse cultural and language
groups.
An emerging issue for Toronto Central is the increasing number of LTC applications
from PHAs and the resistance of some LTC homes to accepting them – the CCAC has begun
to work with a select group of LTC homes to address this through training/education and
support – Casey House may be the agency to do the training and provide the support.
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VIII Recommendations
Making Housing for People with HIV/AIDS a Priority in Ontario
The overall goal of these recommendations is to make housing a priority for PHAs
They are based on the research and recognition that show that housing plays a central in
the promotion of health and the prevention of infection and illness. In other words –
Housing = health + prevention + access to healthcare. These recommendations are aimed
towards improving access to housing and support services, housing stability, and to
reducing the risk of homelessness. They are built upon the foundation laid by organizations
throughout the province that have already established successful housing and support
programs. To realize the opportunities herein will require change at all levels of the
system: the individual program; regional service provider; advocacy organizations; and,
municipal/provincial governmental policy and funding.
Currently, data are not being collected systematically to enable precise assessments of
the need for housing. The following data may be viewed as indicators of need until such
time as we are able to more accurately track the actual numbers of people in need of
housing. They suggest that this is a manageable problem that would not require massive
resources in order to address effectively.




The data provided by Housing Connections in Toronto show an increase in the
number of people with HIV/AIDS on both the waitlist and those who received
placement from 215 in 2005 to 287 in 2006
Data from Positive Spaces Healthy Places indicate that 1/3 of those sampled (over
600, included ASO clients, others but did not include the homeless) had unstable
housing
0.8% of ODSP recipients have HIV/AIDS representing 1600 individuals. The
majority of those being placed and on the waitlist for social housing receive ODSP
and so to some extent there is an overlap
An ongoing Toronto study of the homeless population found that less than 1% of
men and 2.8% of women had HIV/AIDS.
The recommendations are consistent with the Housing Solutions Values Framework and
with the overarching principle of the recommendations being ‘doable and desirable’. As
well, the recommendations acknowledge that a range of housing alternatives and support
services are needed to meet the needs of a diverse population at different stages of
wellness and that a well designed PHA housing system will be elastic enough to
accommodate these variations. Examples of this diversity include race, culture, language,
71
IDU, women and mental health. The recommendations cluster into five categories: broader
housing sector; support services; income supports; partnerships; and, policy, funding, and
research.
I
Broader Housing Sector
“Explore and build on interest in the broader housing sector to increase capacity”
This first set of recommendations is targeted at the broader housing sector and
contains specific recommendations aimed at developing more affordable, appropriate
housing for PHAs by increasing the range and responsiveness of housing and support
options for individuals, families, and culturally diverse populations.
A
TEMPORARY HOUSING
1. Shelters/hostels
Recommendation-1
Create more support services for people living with HIV/AIDS who use the shelter
system, recognizing that they may have other complicating conditions including
health/mental health, addictions, problems with the law and as well, recognizing the
large variance in shelters/hostels across the province (size, services offered, linkages
with other providers, population being served).
Approach
This recommendation can be approached in two ways. In areas where there is a well
developed service delivery system and capacity, shelter/hostel organizations could explore
the potential of establishing appropriate support services for people with HIV/AIDS
preferably on-site, through service agreements with ASOs and other appropriate
organizations, e.g. mental health, addiction agencies. In addition to providing support
services, ASOs could advise shelters on how to better meet the safety needs of PHAs.
Appropriate training would be provided for those agencies, organizations and shelters that
will be involved in the provision of services to PHAs.
Alternatively, shelters could seek funding for support workers with the specific
expertise needed by their clientele (see Section II). This can be done on their own or
through developing joint proposals with other agencies, e.g., ASOs and mental health
agencies, directed at the appropriate body, e.g. the MOHLTC.
72
Opportunities/partners
The Ontario Hostel Association, the Ontario AIDS Network and Ontario Municipal
Social Services Association could play lead roles at the provincial level in moving this
recommendation forward.
Recommendation-2
Provide HIV/AIDS education and training tailored to the needs of shelter/ hostel
staff to increase understanding and skills.
Approach
Shelter/hostel organizations could approach local ASO and HIV/AIDS clinic staff and
public health units to provide staff training for the purpose of helping staff to respond
appropriately to people with HIV/AIDS. Education is required on the various aspects of
the illness, illness management and issues around confidentiality, disclosure, discrimination
and stigma. This is to ensure that staff in shelters are better informed on HIV/AIDS
issues and are prepared to identify the signs of HIV/AIDS illness, understand the mental
health implications of HIV and mental health needs of PHAs, and to encourage safer
sexual and drug practices.
The Ontario AIDS Network and the Canadian AIDS Treatment Information Exchange
have partnered to create an HIV 101 web based training course that is freely available. As
well the Toronto Department of Public Health has developed a 3day educational programAIDS 101 that could be an educational resource to others.
B
Transitional Housing
Recommendation
Seek opportunities to advocate for the full uptake of available funding for
transitional housing by municipal Service Managers and seek funding for necessary
supports through the MOHLTC. Target transitional housing options to special
populations, e.g. youth and families.
Approach
To be consistent with the Values Framework and the ‘Housing First’ approach,
transitional housing should only be considered when there is availability of permanent
housing so that it serves a defined, time-limited purpose in providing housing and support
for a defined population in need. During this stage especially, support services for PHAs
are of extreme importance if the transition to, and maintenance of, permanent housing is
73
to be successful. There a broad range of supports that are necessary in order for people
to ‘get and keep’ housing.
In the past, considerable support for transitional housing came through the federal
government ‘Supporting Communities Partnership Initiative’. It is not yet clear whether
the new Federal program (announced by the Conservative Government in 2007) will offer
the same potential.
C
Respite Beds
Recommendation
HIV/AIDS organizations should seek opportunities to create more respite care by
working with supportive housing providers with 24/7 staff to designate one or two
beds for respite care.
Approach
Given the limited resources but considerable need for respite care to assist people
when their illness fluctuates, opportunities for respite should be explored between ASOs,
HIV/AIDS clinics and supportive housing providers. Additional resources may be required.
The HIV/AIDS sector might also want to consider alternative approaches such as the
‘adopt a family’ approach developed in France and used for both respite and transitional
care.
LOFT housing in Toronto is an example of a program that has developed a small
capacity to offer respite services and may be a model for other supportive housing
providers.
D
PERMANENT AFFORDABLE HOUSING OPTIONS
“An appropriate affordable housing policy needs to have a mix of strategies for the
construction of new permanently affordable housing, the acquisition and renovation of
existing rental housing, and the use of rent supplements to bridge the gap between
ongoing rents and what tenants can afford. It also needs to be part of long-term
consistent plans that are bottom-up and locally driven and supported by the
long-term commitments from the senior levels of government.” 9
9
Where’s Home? 2006, A Picture of Housing Needs in Ontario, ONPHA, Co-operative Federation of
Canada, Ontario Region
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1
Private Rental Market
Recommendation
HIV/AIDS agencies should first seek rent supplements for PHAs from the various
sources including the provincial (e.g., MOHLTC) and municipal governments, for the
purpose of securing affordable rental accommodation. Once this is in place and, where
there is sufficient need, ASOs should establish connections with landlords willing to
work with them in providing affordable, appropriate housing within the context of
available agency supports.
Approach
Rent supplements through the MOHLTC and municipalities are needed for people with
HIV/AIDS and an agency should be tasked and resourced to establish service agreements
with identified landlords willing to offer appropriate accommodation. Appropriate
assessment tools to select qualified landlords, as well as appropriate training mechanisms,
must be developed and delivered to ensure the best possible provision of services to PHAs.
This alternative works best in areas where the vacancy rate is high and there is a stock
of good private sector rental. The OAN needs to be pro-active in advancing the agenda of
rent supplements people with HIV/AIDS with the MOHLTC and municipalities.
Not-For-Profit-Housing
2
Social Housing
Recommendation-1
ASOs should explore the feasibility of increasing the number of rent supplements
specifically for PHAs through municipal and provincial (e.g. MOHLTC) governments.
Approach
Recognizing that vacancies exist in social housing for market rental units
(especially true for municipalities with higher vacancy rates) it would be appropriate for
the OAN to take the lead in developing a population specific proposal for the MOHLTC to
expand the definition of ‘hard to house’ to include PHAs in the rent supplement program.
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ONPHA should be approached around partnering on the expanded definition of ‘hard to
house’. AIDS Niagara and Bruce House are examples of organizations that have had
considerable success in working with their municipal housing providers and the MOHLTC.
These organizations could be approached for advice and information. For example, the
landlord with whom AIDS Niagara has established a very solid relationship has housing
across the province and might be open to working with other ASOs.
Recommendation 2
ASOs, with the support of the OAN, should explore with local municipal Service
Managers the feasibility of giving more priority to PHAs in social housing at the local
level.
Approach
Because municipal Service Managers may be reluctant to give priority to any one special
needs group due to the long waiting lists for housing, HIV/AIDS organizations need to
participate in local social housing priority setting forums to make social housing providers
aware of the need and to gain increased access to rent supplement allocations as they
become available as well as wait list priority.
These organizations should engage with municipal Service Managers in estimating the
housing needs of PHAs to enable the system to better assess the capacity of the system
to accommodate them. One step towards doing this would be requesting municipal Service
Managers to track the need for PHA housing based on waiting list statistics and to track
agency demand, where feasible and appropriate.
3
Co-operative Housing
Recommendation 1
In federally funded co-ops the OAN should recommend an expansion of rent-gearedto-income (RGI) units to allow greater access for PHAs.
Approach
CO-OPs represent a significant amount of housing and an effort should be made to
identify those federal coops that could be approached to alter their ratio of RGI/market
rental units and to set aside a portion of these for PHAs.
The OAN could take the lead with the Ontario Federation of Cooperative Housing to
identify possible candidates for expansion of RGI units.
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4.
Domiciliary Hostels
Recommendation 1
Explore whether this type of housing could be adapted to better meet the needs of
some people with HIV/AIDS.
Approach
This recommendation is optional and should be carefully researched before committing
to using this type of housing. The appeal of domiciliary housing lies in its affordability,
unused capacity and the openness of the private providers to accommodating people with
HIV/AIDS. On the other hand there are serious doubts about its appropriateness given
the communal nature of the setting and issues around disclosure of HIV/AIDS status, the
population currently being served and the level of staff education/awareness of the needs
of PHAs. It is being mentioned here as a possible source of housing for a probably very
small number of individuals. Nonetheless, the provider community should be aware of these
facilities and open to seeing whether in a few instances it might be a source of
accommodation.
5
Supportive Housing
Recommendations - 1
It is recommended that the MOHLTC Supportive Housing Unit and the AIDS Bureau
work together to develop supportive housing for PHAs.
Approach
Given that there may be opportunities within existing housing projects in the MOHLTC
Supportive Housing Unit portfolio, the AIDS BUREAU and the Supportive Housing Unit
should develop a plan that would enable the uptake of these opportunities for the
HIV/AIDS population. Any supportive housing initiative will require funds for support
services and alternatives for funding should be explored by the AIDS Bureau.
Opportunities/Partners
HIV/AIDS organizations should engage in collective advocacy with ONPHA around
some of the new going into supportive housing and rent supplements money ($393 million
for capital expenses was announced in February 2007).
77
Recommendation – 2
Develop formal partnerships with community mental health supportive housing providers
such as CMHA willing to accept PHAs with mental health issues.
Approach
The mental health sector has very little contact with the HIV/AIDS sector but has
expressed openness to becoming more engaged. Given that many PHAs have co-occurring
illnesses it would benefit these clients for the HIV/AIDS sector to establish formal
relationships with supportive housing providers to enable appropriate referrals into
supportive housing. It should also be recognized that in 2008 the budgets for the many of
the support services needed by PHAs swill be the responsibility of the LHINs making
connection with the LHINs an important part of the approach.
The provincial organizations- CMHA, the Ontario Federation of Community Mental
Health and Addictions Programs and the Ontario AIDS Network could collaborate in
putting this issue on the agenda of supportive housing providers.
C
Elderly/End of Life
1
Long-term Care Homes
Recommendations
HIV/AIDS organizations should seek partnerships with select long-term care Homes
to allocate a small number of units for PHAs.
Approach/partners
The long-term care sector has indicated a willingness to explore partnerships with
ASOs on a “one off” basis. CCACs can be asked to help identify those homes that might
be amenable to working with ASOs. Through the partnerships ASOs and HIV/AIDS
specialists could deliver HIV/AIDS training and education.
2
Hospice services
Recommendation
HIV/AIDS agencies should consider partnering with local hospice service providers to
support their work with HIV/AIDS clients.
78
Approach
Hospice volunteers are very open to ongoing HIV/AIDS education and training. In
communities where the numbers warrant, HIV/AIDS organizations should consider
partnering or connecting with local hospice services to provide the support needed to
improve their ability to serve this population.
In Ontario, both visiting and residential services are a resource to the entire
population of people who need end-of-life care and support. The announcement of new
monies for residential hospice services might represent an opportunity for the HIV/AIDS
sector to identify its needs in this area and to gain access to these new resources as they
come on stream.
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II
Support Services
“Increase cross-sectoral collaboration and partnerships to provide
housing support services, training and education.”
Recommendations - 1
Develop cross-agency linkages and partnerships between HIV/AIDS and nonHIV/AIDS organizations to enhance housing support services that will enable PHAs to
‘get and keep’ housing and to prevent homelessness. Recognize that partnerships and
collaboration require resources and that additional resources will be needed to be
effective.
Approach
1.
Services that help people get housing are housing information, assistance in
obtaining housing and financial assistance-first and last months rent, and rent
supplements. HIV/AIDS organizations should make housing information and provision of
assistance a staffing priority, to enable the gathering of housing information and building
of relationships with the broader housing sector. Alternatively, housing information
services for PHAs could be consolidated across the Province with a pool of funds from
providers/ Ministry grant, to create one service that would develop the necessary crosssectoral linkages (see Massachusetts).10 Recently the City of Toronto created a housing
allowance (January 2007) for immuno-compromised individuals in the shelter system or
living on the street.
2.
Services needed to help people keep their housing include:
• Emergency rental assistance, utilities assistance
• Dedicated housing outreach services
• Case management services to provide support and assistance in accessing
other needed support services (ASOs, mental health)
• HIV/AIDS medical care issues, harm reduction
• Supportive services including mental health and addictions, assistance with
daily living, nutritional, CCAC social work services
Many of these services could be enhanced or developed through collaborative activities
with non-HIV/AIDS service providers. For example an HIV/AIDS mobile multi-disciplinary
team that included mental health, substance use, crisis intervention, HIV/AIDS and
nursing specialists could be called upon by both HIV/AIDS organizations and nonHIV/AIDS providers to intervene with individuals living in the community in need of
10
Moving Forward A Massachusetts HIV/AIDS Housing and Resources Needs Assessment Report
2003
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assistance. This would require additional funding and would be most appropriate in larger
centres with a number of service providers and larger PHA community. These services
need to be mobile in order to reach individuals who are located in diverse communities
throughout urban centres or in rural settings where people may be unable or unwilling to
enter into an HIV setting due to the shame and stigma that persists.
Housing providers can develop contractual service agreements with local CCACs in the
event that the client’s health begins to show signs and symptoms of decline, (ambulation,
wasting, difficulty in transporting, etc.). CCACs have the resources to provide
physiotherapy and/or occupational therapy evaluation of the client, case management, pain
management and professional nursing services.
3.
Services needed to prevent homelessness are mainly financial such as emergency
rental assistance and utilities assistance. Social support services also play an important
role in mitigating isolation, which can increase the risk of homelessness for vulnerable
populations. These are widely viewed as being an extremely cost-effective means of
avoiding the costs of losing housing. In Ontario, in the absence of a government program,
AIDS Service organizations provided $680,000 to financially assist clients (in 2005/06),
but the unmet need is much greater.
Opportunities
The MOHLTC recently provided additional funds for mobile crisis services across the
Province. This might represent an opportunity for, e.g., an ASO to team up with a newly
forming service to create a specialized mobile team with a focus on helping people with
HIV/AIDS and other complex problems to maintain housing. These new mobile crisis teams
at the very least could be given some orientation to HIV/AIDS to enable them to work
effectively with this population.
Provide training and education initiatives to increase understanding, skills and
responsiveness of both non-HIV/AIDS and HIV/AIDS sectors:
•
•
The non-HIV/AIDS housing sector requires education in the areas stigma
reduction, HIV/AIDS health related issues and how to deal with issues around
confidentiality, disclosure, information sharing during emergencies when the client
may be unresponsive, declining health etc.
HIV/AIDS sector requires education on mental health/addictions issues and mental
health and the law issues. For example, AIDS Niagara supportive housing staff have
a minimum qualification of Personal Support Worker and many staff have additional
specialized training in Palliative Care, Mental Health, Chemical Dependency
Counselling, and Social Service Work.
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•
Housing needs to be viewed as a priority service by HIV/AIDS organizations. The
HIV/AIDS sector should prioritize learning more about the range of housing in the
broader housing sector, how to access it and how to communicate this information
to the clients in need of these services.
Approach/Partners
There is a large need for cross-sectoral training and education. ASOs will need to be
strategic about this because of their limited resources. For example, depending on the
priorities of the clients being served through the agency it might be appropriate for an
ASO to offer training to a local LTC home as part of a partnership agreement around
creating more appropriate care for PHAs with AIDS related dementia. The Canadian
Association of Nurses in AIDS Care could also play a role in offering professional support
and training. Similarly, if a partnership is being formed with a supportive housing provider,
the HIV/AIDS agency may provide training specific to that environment and staff needs.
The OAN also has a role to play by providing training on housing in its skills development
sessions for AIDS support workers.
III
Income Support
Recommendation - 1
That the government fully fund cost of living increases for social assistance.
Approach and partners
Join with ONPHA and other alliances such as the Interfaith Social Assistance Reform
Coalition to advocate for the enactment of the cost of living increases to income support
in Ontario.
Recommendation - 2
The HIV/AIDS sector should take a position on the provision of emergency housing
allowance as a cost-effective measure in preventing homelessness.
Approach/partner
Given the high costs, both health and economic, associated with losing housing, every
effort should be made to prevent homelessness by making available emergency housing
allowances to enable people to keep their housing. ASOs should monitor their clients at
risk for losing their housing and intervene as early as possible. The OAN could seek out a
partnership with ONPHA on this issue, or alternatively this might be an issue for the
cross-sectoral housing advocacy group (please see Section IV).
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IV
Partnerships
“Partnerships are needed to build a system.”
Recommendation - 1
The OAN/OHTN should invite ONPHA and other relevant provincial housing
associations to co-host a strategy and partnership development Summit with the goal
of creating an ongoing provincial cross-sectoral HIV/AIDS Housing policy work group.
This group should also include PHA representation and funding bodies. Its purposes
would be to:
•
•
•
‘Get and keep housing’ on the agenda of policy-makers, decision-makers and
housing providers
To achieve agreement on the characteristics of a high-functioning housing
system for PHAs
To discuss the report’s findings and to develop an implementation plan for the
recommendations
Approach
HIV/AIDS agencies should plan for, using this report, the characteristics of an ideal
housing and support services system for PHAs, that specifically targets the fulfillment of
the needs of PHAs in Ontario. This together with the recommendations will provide the
foundation for the work of the HIV/AIDS Housing policy work group. Specific targets
should be set for years one and two and resources should be obtained such as a one-time
grant to support the secretariat needs of this group.
ASOs and housing and support services providers (at the local and regional levels)
should jointly take the initiative to look at opportunities to increase the capacity of
safe, affordable, appropriate housing for PHAs in their communities.
Approach
These activities should be governed by two principles: working in networks, new and
existing, and adopting a systems approach to reduce fragmentation. These emerging
groups will:
• Where possible build on the Community Planning Initiative partnerships and work
groups and identify new partnership opportunities in other communities
• Develop available resources
• Identify target populations in need, e.g. ‘hard to house’, aboriginals, women, youth
• Convene regional supportive housing networks, where appropriate
83
Progress in this area is already underway as several ASOs have organized community
development meetings with housing agencies, reflecting the increased emphasis on service
coordination. The former have also delivered the several presentations to these groups,
furthering the opportunities for collaboration and cooperation.
OAN and OHTN should seek opportunities to collaborate with the Service Manager
Housing Network and the Ontario Municipal Social Services Association in their
efforts to explore the process, challenges and issues of human services integration,
which includes a systems approach.
V
Policy, Funding, Research
“Promote coordinated provincial policy, funding, research, development through a
focused, cross-sectoral, advocacy program.”
Recommendation - 1
With the support of the provincial cross-sectoral HIV/AIDS housing policy work
group, the HIV/AIDS provincial organizations should work with relevant ministers and
ministry staff in partnership to develop a policy position on housing and support
services for PHAs, one which reflects the fact that housing and health are
inextricably intertwined.
Approach
This will require:
• Increasing understanding within government of the role of housing in the
prevention of illness, promotion of health and improvement in quality of life of
PHAs
• Increasing awareness of the detrimental and costly effects of the fragmented
non-system on front-line agencies and their clients.
• Bringing new knowledge to bear on the policy development process, effects of
stable housing, cost effectiveness of housing interventions
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Recommendation - 2
Lead by the MOHLTC and the LHINs, create an interdepartmental/ ministerial
working group to work together and bring together housing, health, addictions, labour,
education to increase cooperation and collaboration around housing and housing support
services for PHAs that is supervised by a steering committee.
Approach
The approach should be governed by the housing and health perspective described in
this report.
Improve cooperation and co-ordination between federal/ provincial policy makers and
program funding bodies for aboriginal services.
With the support of the HIV Housing policy work group, provincial HIV/AIDS
organizations in conjunction with regional networks, should advocate with municipal
Service Managers across the province to institute/re-institute the social housing
priority for people with HIV/AIDS who may not be imminently dying, but who are ill
and need to be appropriately housed.
Recognizing the vital role that ASOs play in offering support services to help people
‘get and keep’ housing and recognizing the current lack of stability in funding,
additional funding is needed to ensure funding is adequate, stable and provides the
additional resources required for the range of cross-sectoral partnership development
activities recommended in this report.
The MOHLTC should expand the program definition of new supportive housing for the
‘hard to house’ to include PHAs; furthermore, the program should embrace all
provincial agencies serving PHAs, rather than just those agencies that are currently
funded.
85
The OHTN should continue to develop an HIV/AIDS housing (and support services)
program of research into the economic argument for housing and the social
determinants of health, in particular the role housing plays in health. Specific
mechanisms for tracking housing need should be developed by researchers in
conjunction with the field.
With the support of the Ontario HIV Treatment Network externally and the AIDS
Bureau internally, action should be taken to put the HIV/AIDS Housing research
priorities on the research agenda currently being developed in the MOHLTC.
86
IX Appendices
Appendix A: Housing Solutions Provincial Knowledge
Exchange Group (PKEG) Membership List
Nancy Bradley, Executive Director, The Jean Tweed Centre and
Representative, Ontario Federation of Community Mental Health and
Addiction Programs
Steve Byers, Executive Director, AIDS Niagara
Brian Davidson, Manager, Housing Support Unit, Mental Health and Addiction Branch,
MOHLTC
Ivy France, Manager, Housing Policy, Region of Peel Housing and Property Department and
Representative, Municipal Service Managers Group
Angie Hains, Executive Director, Ecuhome Corporation and Past President and Current
member of the Board of Directors, Ontario Non-Profit Housing Association
J.J. (Jay) Koornstra, Executive Director, Bruce House and Representative of ‘Positive
Spaces, Healthy Places’ Study
Joanne Lush, Program Supervisor, Community-based AIDS Education & Support Program,
AIDS Bureau, MOHLTC
Dan Malette, Community Housing Services District of Nipissing Social Services
Administration Board
Mark McCallum, PKEG Volunteer, Sarnia
Jim Nason, Director of Operations, Loft Community Services
Ron Renner, PKEG Volunteer, Sault Ste. Marie
Vinod Sharma, Community Housing Manager, Toronto Community Housing
John Trainor, Director, Community Support and Research Unit, CAMH
Brigitte Witkowski, Executive Director, Mainstay Housing
87
List of Provincial Workshop Participants
Peter Amenta, Disability Support Program Branch, Ministry of Community and Social
Services (MCSS)
Nancy Bradley, The Jean Tweed Centre, The Ontario Federation of Community Mental
Health and Addictions Programs
Leslie Cochran, Hamilton Niagara Haldimand Brant, Local Health Integration Network
Liz Creal, Casey House
Brian Davidson, Housing Support Unit, Mental Health and Addiction Branch, Ministry of
Health and Long-Term Care (MOHLTC)
Mike Dowdall, Ontario Homes for Special Needs Association (OHSNA)
Keith Hambly, Ontario Association of Hostels (OAH)
Angelika Gollnow, Toronto Central Local Health Integration Network
Dan Malette, Community Housing Services, District of Nipissing Social Services
Administration Board
Jim Nason, Loft Community Services
Kay Roesslein, McEwan House, Loft Community Services
Dr. Sean Rourke, Ontario HIV Treatment Network (OHTN)
Deborah Schlicter, Ontario Non-Profit Housing Association (ONPHA)
Vinod Sharma, Toronto Community Housing Corporation (TCHC)
John Spavor, Community Support and Research Unit, Centre for Addiction and Mental
Health (CAMH)
Ruthann Tucker, Fife House
Brigitte Witkowski, Mainstay Housing
88
Appendix B: Housing Survey
89
90
91
92
93
94
95
96
97
98
Housing Survey: List of Participating Organizations by LHIN
LHIN 1: Erie St. Clair
AIDS Committee of Windsor
LHIN 2: South West
AIDS Action Perth
AIDS Committee of London Ontario
St. Joseph's Health Centre - Infectious Diseases Care Program
LHIN 3: Waterloo Wellington
AIDS Committee of Guelph & Wellington County
A.C.C.K.W.A (Kitchener)
LHIN 4: Hamilton/Niagara/Haldimand/Brant
AIDS Niagara
Hamilton Health Sciences - McMaster site – Special
LHIN 5: Central west
Peel HIV/AIDS Network
LHIN 6: Mississauga Halton
LHIN 7: Toronto Central
Africans Community Health Services
Barrett House
Centre d'Accueil Heritage
Fife House Foundation
HIV/AIDS Legal Clinic of Ontario
LOFT Community Services
Mount Sinai Hospital - Clinic for HIV-Related Concerns
Ontario AIDS Network
Prisoners HIV/AIDS Support Action Network (PASAN)
St. Michael's Hospital - HIV Service & Positive Care Clinic
Teresa Group
Toronto Community Housing Corporation - 330 Jarvis
99
LHIN 8: Central
AIDS Committee of York Region
LHIN 9: Central East
AIDS Committee of Durham
LHIN 10: South East
HIV/AIDS Regional Services (HARS) Kingston
Kingston General Hospital - Clinical Immunology Outpatient Clinic
LHIN 11: Champlain
Bruce House
Oasis
The Ottawa Hospital - Immunodeficiency Clinic (HIV / AIDS)
LHIN 12: North Simcoe/ Muskoka
LHIN 13: North East
Access AIDS Network Sault Ste Marie
Access AIDS Network Sudbury
AIDS Committee of North Bay & Area
Sudbury Regional Hospital, Laurentian Site – HAVEN
LHIN 14: North West
AIDS Thunder Bay
100
Appendix C: Focus Group Sites and Participant List
Ottawa
Rob Boyd, Oasis, Sandy Hill Community Health Centre
Doug Cooper, Bruce House
Jennifer Crawford, Ottawa Mission
Robert Desarmia, Champlain Regional Community Planning for HIV/AIDS Services
Jay Koornstra, Bruce House
David Laut, Housing Branch, City of Ottawa
Wendy Muckle, Ottawa Inner City Health, Inc.
Richard Naster, Bruce House
Andrea Poncia, Youth Services Bureau of Ottawa
Susan Rogerson, Options Bytown
Judith Taylor, Ottawa Public Health
St. Catharines
Peggy Allen, Canadian Mental Health Association Niagara
Steve Byers, AIDS Niagara
Judy Doxtater, Fort Erie Native Friendship Centre
Patti Laney, Ontario Disability Support Program
Dave Pelette, Niagara Regional Community Services
Alan Spencer, Region of Niagara Public Health Department
Len Trebley, AIDS Niagara
Thunder Bay
Janet Adams, Consultant
Melinda Arnold, Community Care Access Centre
Gloria Casey-Clibbery, Nor-West Community Health Centres
Collin Graham, Ontario Aboriginal HIV/AIDS Strategy
Phil Jamieson, Canadian Mental Health Association
Prudence Jones, St. Joseph’s Care Group, Lakeview Clinic
Arlene Lesenke, Northwestern Health Unit
Pat Lillington, NOW Concurrent Disorders Program
Gail Linklater, AIDS Thunder Bay
Lillian Napierala, North of Superior Programs
Tracy Sauls, Anishnawbe Mushkiki
Michael Sobota, AIDS Thunder Bay
101
Toronto – November 9, 2006
Alan Li, Regent Park CHC
Terry McCullum, LOFT
LaVerne Monette, Ontario Aboriginal HIV/AIDS Strategy (regrets, but provided
feedback through email)
Lynn Muir, Casey House
Koshala Nallanayagam, Prisoners’ HIV/AIDS Support Action Network (PASAN)
Vinod Sharma,Toronto Community Housing Corporation
Jason Zigelstein, Fife House (regrets, but provided feedback through email)
Toronto – November 10, 2006
Amrita Ahluwalia, Ontario HIV Treatment Network
Murray Jose, Toronto People with AIDS Foundation
Barb MacPherson, Toronto Public Health
Enid Moscovitch, Shelter, Support and Housing Administration, City of Toronto
Jessica Msamba-Lewycky, African Community Health Services
Karen Vance-Wallace, The Theresa Group
Toronto – Policy Focus Group
Mike Bannon, Ministry of Community and Social Services
Patti Bregman, Ontario AIDS Network
Ivy France, Regional Municipality of Peel
Karen McGraw, CMHA – Ontario
LaVerne Monette, Ontario Aboriginal HIV/AIDS Strategy
Dr. Sean Rourke, Ontario HIV Treatment Network
Ragaven Sabaratnam, Ministry of Municipal Affairs and Housing
Ruthann Tucker, Fife House
102
Appendix D: Expert Key Informant List
Nancy Bernstine, Executive Director, National AIDS Housing Coalition
Joe Carleo, Executive Director, AIDS Housing Corporation (Boston)
Dr. John P. Egan, Centre for Clinical Epidemiology & Evaluation, University of British
Columbia
Dr. David Holtgrave, Chair, Department of Health, Behavior and Society, Johns Hopkins
University, Bloomberg School of Public Health
Charles King, Founder and President, Housing Works Inc.
Don Mason, President and CEO, AIDS Services of Dallas
Stephen Smith, Manager, Blood Borne Pathogens Communicable Disease and Addictions
Prevention, BC Ministry of Health
Floyd Visser, Executive Director, The Sharp Foundation, Alberta
103
Appendix E: Broader Housing Sector Key Informant List
Non-Profit Housing
Debbie Barton, Rental Manager, Centretown Citizens Ottawa Corporation
Carol Conrad, Nipissing District Housing Corporation
Deborah Schlichter, President of ONPHA and Executive Director of House of Friendship
Homelessness/Outreach
Kevin Leal, Coordinator of Homeless Outreach Program, Fife House
Domiciliary Hostels
Charene Gillies, Domiciliary Hostels, Ministry of Community and Social Services
Tom Howcroft, President, Ontario Homes for Special Needs Association (OHSNA)
Georgette Patenaud, Owner/Operator, The Champagne Residence
Dr. Rob Wilton, Professor, Geography Department, McMaster University
Hostels/Shelters
Keith Hambly, President, Ontario Association of Hostels (OAH)
Learuie Noordermeer, Director, Rotholme Family Shelter and a member of Ontario
Association of Hostels board
Mental Health
Brian Davidson, Manager, Housing Support Unit, Mental Health and Addiction Branch,
MOHLTC
Marion Quigley, Executive Director, Sudbury CMHA
Harry Spindel, Executive Director, Bayview Community Services
Cooperative Housing
Jane Davidson-Neville, Relationship Manager, The Agency for Cooperative Housing,
Ontario and PEI Regional Service Centre
Diane Miles, Acting Manager, Co-op Services CHF Canada - Ontario Region
104
CCAC-LTC
Bonnie Painter, Client Services Manager, Toronto Central Community Care Access Centre
Krista Robinson-Holt, Director of Health Planning and Research, Ontario Long Term Care
Association
Hospice
Denise Larocques, Interim ED, Hospice Association of Ontario
Palliative Care
Dr. Larry Librach, Director of the Tammy Latner Centre for Palliative Care, Mt Sinai
Hospital
ODSP/OW
Andre Aguilar, Junior Policy Analyst, ODSP Branch, Ministry of Community and Social
Services
Peter Mehta, Ministry of Community and Social Services
Brian Montoux, Policy Analyst, ODSP Branch, Ministry of Community and Social Services
105
Appendix F: Values Framework
Values
Human rights and
equity
Empowerment, control
and choice
Human dignity and
worth
Supportive and
compassion
Confidentiality
Co-operation and
collaboration
Accountability
Objectives/Definitions
Most importantly recognition that housing is a basic human
right. Along with housing, culturally sensitive services should
be provided that respect the diversity and uniqueness of
individuals and their needs. These services should also
promote equity, acceptance, and freedom from discrimination
as well ass people’s ability to succeed.
The greater involvement of people infected and affected by
HIV/AIDS e.g. empowerment and control over their own lives,
informed choices and client centered services
Promote and defend human dignity, worth and mutual respect.
Services should be provided in a compassionate and caring
fashion. For example, many organizations support a harm
reduction approach to service delivery
Service providers should protect the right of all persons living
with HIV or AIDS with regards to disclosure of their
HIV/AIDS status.
HIV/AIDS service providers can benefit from being open and
accessible for community partnerships and engagement with
stakeholder and other service providers.
Accountable: clients/community and each other, customer
service/ Open, honest, ethical communication/decisionmaking/client centered care
106
Appendix G: Glossary of Terms
Case management: Case management is a collaborative process that assesses, plans,
implements, coordinates, monitors, and evaluates the options and services required to meet
the client's health and human service needs. It is characterized by advocacy,
communication, and resource management and promotes quality and cost-effective
interventions and outcomes.
Congregate housing: Housing where a person lives with other people, either as neighbours
or by sharing an apartment or house.
Emergency housing, including hostels, shelters and crisis accommodations: Temporary
housing for the homeless.
Head leases: The lease of multiple units in a private rental building to a non-profit housing
provider, who then sublets the units to tenants from its own waiting list (and may also
provide support to those tenants).
Independent housing: Individual lives in their own room, apartment, house that is either
rented from a private landlord or personally owned. There are no supports connected to
this type of housing.
Market rental unit, including cooperatives: House, condominium or apartment or room
(without board) rented at current, market rates.
Municipal non-profit housing: Facilities owned by the municipal or city government hat
offers rent-geared-to-income and market rental units (e.g., Toronto City Homes).
Rent-Geared-to-Income (RGI) Rent Subsidy: The subsidy paid to a social housing
provider and guaranteed for the life of the mortgage (usually 25 years). The RGI Rent
Subsidy equals the difference between the actual rent paid by a low-income tenant (paying
approximately 30% of their income), and the government-approved market rent of a unit.
Rent supplements: The subsidy paid to private landlords or non-profit/co-operative social
housing providers that bridges the gap between the tenant’s rent-geared-to-income
portion of the rent (30% of their incomes) and actual market rent. Rent supplements
involve a contract between the private landlords or non-profit/co-operative social housing
provider and the government.
Residential hospice: a home-like environment where people with life-threatening illnesses
receive end-of-life care. Residential hospices provide compassionate care and comfort to
people who, in the last stages of their lives, cannot be cared for at home.
107
Room and board housing: Rented room in a house where meals are provided (e.g., Habitat).
Scattered site housing: These are apartments in buildings that are spread throughout the
community.
Subsidized housing (including private house and apartment): Apartment buildings or town
homes owned or rented by a group of people who share maintenance duties. The housing
may be subsidized or individuals may have rent supplements.
Supported housing: The key elements of supported housing are: role of the tenant as a
citizen, role of staff as a facilitator, an intervention orientation focused on strengths, the
potential for tenant empowerment, and tenant control of staff support. Case management
is often been used to offer portable support for this type of housing. Typically, supported
housing has been identified with apartments, housing co-ops or other government funded
social housing for people with low incomes. Supported housing is increasingly associated
with “housing first” approaches in which people are first offered housing before they are
offered other services, and the acceptance of treatment or other supports is not required
to access.
Supportive housing: Supportive housing focuses on assisting individuals to live in the
community by developing lifeskills through community-based treatment and rehabilitation.
Supportive housing can be in the form of:
Converted house: Type of supportive housing where rented room that is part of a house
where bathrooms and kitchen in which tenants may share responsibilities for household
upkeep, and in which there is supportive environment and support services are provided.
Clustered apartments: Type of supportive housing where a rented apartment in a building
in which many or all apartments are provided to people with special needs, and in which
there is support provided by staff within the building.
System: A system is a set of interacting units with relationships among them and where
there is some commonality among them. Each unit is constrained, dependent, upon, or
conditioned, by the other units and decisions by which the system must operate are made
within the system. In a system the whole is greater than the individual parts
Transitional housing: Medium-term accommodation for those who have experience
homelessness or shelter use. Transitional housing usually involves support services
delivered on site, building on those available at emergency homeless shelters. This type of
housing is used as a bridge from emergency housing to more permanent types of housing.
108
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AIDS Housing Corporation. (2006). New Hampshire AIDS Housing Needs And Resource
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Bryant, T. (2004). Housing as a social determinant of health. In J.D. Hulchanski & M.
Shapcott (Eds.), Finding room: Policy options for a Canadian rental housing strategy (p.
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Community Support and Research Unit. (2001). Evaluating Housing Stability for People with
Serious Mental Illness at Risk for Homelessness. Canada Mortgage and Housing
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Culhane (October, 2006). Cost Offsets Associated with Supportive Housing for Persons
with Special Needs. Presentation at the 2006 National Housing and HIV/AIDS Research
Summit. Baltimore, Maryland.
Culhane, D.P., Gollub, E., Kuhn, R., and Shpaner, M. (2001). The co-occurrence of AIDS and
homelessness: Results from the integration of administrative data for AIDS surveillance
and public shelter utilization in Philadelphia. Journal of Epidemiology and Community
Health, 55(7), 515-520.
109
Dunn, J.R. (2002). A population health approach to housing: Towards a research
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112

Making Housing A Priority for People with HIV/AIDS in Ontario

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