Transitioning from a life on the streets to permanent supportive housing undoubtedly has benefits for individuals experiencing chronic homelessness.

Researchers have found that the stability of having a place to call home may enable individuals to seek treatment for drug use problems, develop stronger ties to positive sources of support such as friends and family, and receive medical care for chronic health conditions. However, the shift to housing may result in unexpected and unintended changes.

“For all of the emphasis on improving health and health behaviors, including substance use and mental health, there has been surprisingly little attention paid to risks like HIV,” said Suzanne Wenzel, a professor at the USC School of Social Work and principal investigator of a new four-year, $2.7 million grant from the National Institute on Drug Abuse.

The funding will enable Wenzel and several colleagues, including Assistant Professors Benjamin Henwood and Eric Rice and Research Assistant Professor Harmony Rhoades, to examine how moving to permanent housing affects HIV risk and prevention behaviors, social networks, drug use and mental health symptoms among chronically homeless individuals in Los Angeles.

Inspired by discussions with housing providers in downtown Los Angeles that revealed issues related to retaining people in permanent supportive housing, Rhoades and Wenzel led a recent pilot study to explore changes in risk behaviors and relationships among 25 individuals in the months after they entered housing.

“One of the primary things we saw was that people were having more sex and were having more unprotected sex,” Rhoades said. “Romantic, sexual relationships are a huge part of people’s lives. Even though we want people to use condoms and we want to reduce HIV risk behavior, we also want people to live really wonderful, fulfilling lives, and having a partnership that may be represented by the sexual behavior we’re seeing is in some ways a positive sign.”

An overlooked issue

Surprised to find a dearth of research on HIV risk and the provision of HIV prevention services for people in permanent supportive housing except for individuals who had already been diagnosed with HIV or AIDS, the research team devised a longitudinal study to track chronically homeless individuals as they transitioned to housing.

In addition to surveying residents at key points during the course of one year, the researchers plan to conduct interviews and focus groups with housing supervisors and frontline employees to gain a better sense of how HIV and risk behaviors are addressed.

“Many homeless adults are sexually active, do not have safe sex and have multiple partners,” Wenzel said. “HIV/AIDS risk reduction, promotion of sexual health and service access must be part of the conversation about health and should be incorporated into the package of integrated services if the evidence indicates that it is important.”

Working with five of the largest providers of permanent supportive housing in Los Angeles including the downtown area known as Skid Row, which has a large population of homeless individuals, the research team will recruit approximately 400 people as they transition to housing. In addition to discussing health and sexual risk, participants will describe how they are adjusting to living alone, whether they have remained in touch with friends from the street and whether their drug use behaviors have changed.

Interviewing individuals before they enter housing is crucial, said Henwood, noting that a previous study he conducted involved interviewing people an average of 70 days after they moved into their new home.

“We didn’t see a lot of change in quality of life,” he said. “It could be that a lot happens during that initial period when people first move into housing. When there’s that kind of dramatic change, you might be missing a lot.”

Henwood, who specializes in qualitative and mixed-method research, will shadow approximately 30 residents of permanent supportive housing as part of the new study, following them as they go about their daily routine to add a depth of understanding about their lifestyle.

“We’ll be able to see and describe and understand risk and changes in social networks,” he said. “What’s actually causing that? What are people thinking? Having that experience of going out with them and hearing what they have to say in real time does add a nice dimension.”

Mapping networks

A key aspect of the study is its reliance on social network analysis. Using an iPad application, researchers will ask participants to describe people they have had contact with during a certain time period. The application will visually map out each study participant’s social network, allowing them to answer specific questions about their friends and peers with a simple tap of their finger.

Rice, who designed the app with Rhoades and project specialist Hailey Winetrobe, said initial results from the pilot study suggested that the transition from chronic homelessness to housing has a positive influence on some individuals in terms of their interpersonal relationships, but may result in negative changes for others.

Citing anecdotal evidence, he said some individuals see the shift to housing as an opportunity for a fresh start, whereas others may invite friends from the streets to stay with them despite prohibitions on such behaviors.

“A lot of these people have been on the streets for years and have long-term ties to other home-less people,” he said. “We’re curious to see if moving into housing is going to be disruptive to those relationships. The hope is that by moving into housing, they will be in networks with more people who are stable, fewer people who are consuming drugs and fewer people who are engaging in risky sexual behavior.”

One of the ultimate goals of the research is to inform interventions and programs that can address the lack of HIV and sexually transmitted disease prevention in permanent supportive housing. How those programs are developed or adapted from existing models will depend on study findings and the policy and service context, Wenzel said.

However, because the housing model has proven to be a solid foundation for the provision of other health services, the researchers expect that introducing programs focused on HIV risk prevention and treatment should not be a problem.

Housing is a net positive

Although the study will examine potential negative consequences of housing, Wenzel and her colleagues were careful to note that they are not suggesting the permanent supportive housing approach should be abandoned.

People who have lived on the street for lengthy periods of time have significantly higher rates of morbidity and mortality, Wenzel said, and a chronically homeless individual is five to nine times more likely to die compared to someone with stable housing.

“It is simply more cost-effective to provide permanent supportive housing to such a person than to allow him or her to languish on the streets, end up in hospital emergency departments and cycle through other institutions,” she said. “There can be so many other benefits as well, some that are not so easily assessed in terms of dollars and cents, like achieving a sense of safety, security and privacy. Housing is also a human right.”

Wenzel noted that positive changes in the social networks of newly housed individuals, such as increased contact with family and friends who engage in healthy behaviors, may decrease the risk of HIV and other negative outcomes.

“It’s very clear that housing works to end homelessness, but there’s nothing to say it addresses everyone’s problems or that it won’t create some other problems,” Henwood added. “It’s definitely a life-altering, complicated move. Any time you give people more independence, there is always risk that comes along with that.”

Team approach proves successful

Examining that risk is clearly a priority at the federal level. The grant proposal received a perfect score, placing it in the upper echelon of submissions. Wenzel said it was particularly gratifying to receive such a positive response because obtaining funding through the National Institutes of Health has become more competitive and challenging in recent years.

“Hours and hours of extremely careful work and attention to detail were poured into that proposal,” she said. “It was a great reward to get a score that said the proposal has no weaknesses and stands to make a highly significant contribution.”

She added that the research team benefited from a new, innovative approach at the USC School of Social Work, which has created research clusters designed to promote scholarly interaction and activity on critical topics, including the Homelessness, Housing, and Social Environment cluster.

“This study may not have happened without the cluster,” she said, “It may not have happened without the formal means of bringing us together under one umbrella, without the resources from our dean, Marilyn Flynn, to support a pilot study, and without the common cause of addressing homelessness and the well-being of homeless people.”