Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
UBCV
Lehmann, Beatrix
Master of Science - MSc
University of British Columbia
Background: Eviction, generally defined as when individuals are forced to leave their home, is a severe form of housing need. However, little research has explored eviction among women living with HIV who may face intersecting barriers to stable housing. Drawing on frameworks related to intersectional stigma and discrimination, life course theories, and syndemic theory, the objectives of this thesis were to understand the prevalence and social-structural correlates of eviction, and associations between eviction and HIV-related syndemic outcomes. Methods: This thesis utilized data (2015-2023) from a community-based open cohort study of cis and trans women (14+ years old) living with and/or accessing HIV care in Metro Vancouver. Social-structural correlates hypothesized to be associated with eviction reflected systemic marginalization and stigmatization. Syndemic outcomes included: gender-based violence, depression, food insecurity and criminalized stimulant and opioid use. All variables, unless otherwise specified, referred to the previous six months before each study visit. Bivariate and multivariable logistic regression with generalized estimating equations (GEEs) were used to examine relationships between explanatory variables and binary outcomes; bivariate and multivariate ordinal logistic regression with GEEs were used in models with ordered outcomes. Results: Among 361 participants, the study sample had disproportionately high representations of Indigenous women (53.5%, n=193) and women with marginalized and minoritized sexual (47.4%, n=171) and gender (15.5%, n=56) identities, relative to the Canadian population. In multivariable logistic regression analysis using GEEs, being removed from parents as a child (adjusted odds ratio[aOR]: 2.11, 95% confidence interval [95%CI][1.13-3.92]) and criminalized substance use (aOR daily versus none: 3.87, 95%CI[1.44-10.44]; less than daily versus none: 2.79, 95%CI[1.03-7.57]) were significantly associated with increased odds of eviction. In multivariable logistic regression analysis with GEEs, eviction was significantly associated with depression (aOR: 2.07, 95%CI[1.15-3.74]). In multivariate ordinal regression analysis with GEEs, eviction was significantly associated with increased frequency of criminalized stimulant (aOR:2.56, 95%CI[1.26-5.16]) and opioid use (aOR: 2.03, 95%CI[1.03-4.03]). Conclusion: Prevention of eviction among women living with HIV must include systemic changes to housing policy and programs to support individuals at greater risk of eviction. A variety of affordable and/or supportive housing solutions are needed, incorporating culturally safe, trauma-informed, and gender-responsive approaches.
EVICTION PREVALENCE, CORRELATES AND SYNDEMIC OUTCOMES AMONG WOMEN LIVING WITH HIV IN METRO VANCOUVER, CANADA by Beatrix Lehmann B.A., McGill University, 2021 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Population and Public Health) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) December 2024 © Beatrix Lehmann, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: EVICTION PREVALENCE, CORRELATES AND SYNDEMIC OUTCOMES AMONG WOMEN LIVING WITH HIV IN METRO VANCOUVER, CANADA submitted by Beatrix Lehmann in partial fulfilment of the requirements for the degree of Master of Science in Population and Public Health Examining Committee: Dr. Kathleen Deering, Assistant Professor, Division of Social Medicine, Faculty of Medicine, UBC Co-supervisor Dr. Anne Gadermann, Associate Professor, Human Early Learning Partnership, UBC; Research Scientist, Centre for Advancing Health Outcomes, Providence Health Care Research Institute Co-supervisor Dr. Amanda Slaunwhite, Assistant Professor, School of Population and Public Health, UBC; Affiliate Investigator, BCCDC; Scientific Director, Correctional Health Services, BC Mental Health and Substance Use Services Additional Examiner Additional Supervisory Committee Members: Dr. Trevor Dummer, Professor, School of Population and Public Health, UBC Supervisory Committee Member iii ABSTRACT Background: Eviction, generally defined as when individuals are forced to leave their home, is a severe form of housing need. However, little research has explored eviction among women living with HIV who may face intersecting barriers to stable housing. Drawing on frameworks related to intersectional stigma and discrimination, life course theories, and syndemic theory, the objectives of this thesis were to understand the prevalence and social-structural correlates of eviction, and associations between eviction and HIV-related syndemic outcomes. Methods: This thesis utilized data (2015-2023) from a community-based open cohort study of cis and trans women (14+ years old) living with and/or accessing HIV care in Metro Vancouver. Social-structural correlates hypothesized to be associated with eviction reflected systemic marginalization and stigmatization. Syndemic outcomes included: gender-based violence, depression, food insecurity and criminalized stimulant and opioid use. All variables, unless otherwise specified, referred to the previous six months before each study visit. Bivariate and multivariable logistic regression with generalized estimating equations (GEEs) were used to examine relationships between explanatory variables and binary outcomes; bivariate and multivariate ordinal logistic regression with GEEs were used in models with ordered outcomes. Results: Among 361 participants, the study sample had disproportionately high representations of Indigenous women (53.5%, n=193) and women with marginalized and minoritized sexual (47.4%, n=171) and gender (15.5%, n=56) identities, relative to the Canadian population. In multivariable logistic regression analysis using GEEs, being removed from parents as a child (adjusted odds ratio[aOR]: 2.11, 95% confidence interval [95%CI][1.13-3.92]) and criminalized substance use (aOR daily versus none: 3.87, 95%CI[1.44-10.44]; less than daily versus none: 2.79, 95%CI[1.03-7.57]) were significantly associated with increased odds of eviction. In iv multivariable logistic regression analysis with GEEs, eviction was significantly associated with depression (aOR: 2.07, 95%CI[1.15-3.74]). In multivariate ordinal regression analysis with GEEs, eviction was significantly associated with increased frequency of criminalized stimulant (aOR:2.56, 95%CI[1.26-5.16]) and opioid use (aOR: 2.03, 95%CI[1.03-4.03]). Conclusion: Prevention of eviction among women living with HIV must include systemic changes to housing policy and programs to support individuals at greater risk of eviction. A variety of affordable and/or supportive housing solutions are needed, incorporating culturally safe, trauma-informed, and gender-responsive approaches. v LAY SUMMARY Women living with HIV face barriers in accessing stable housing, despite the importance of housing for wellbeing. Eviction happens when someone is forced to leave their home and is an example of very unstable housing. However, there is limited understanding of eviction among women living with HIV. This thesis aimed to investigate social and structural factors associated with eviction among women living with HIV, as well as understand whether eviction was associated with other health and social outcomes. Analysis found that being removed from oneâs parents as a child and using criminalized substances were associated with eviction. Eviction was also associated with depression and increased frequency of criminalized stimulant and opioid use. It is critical to develop policies to prevent eviction, particularly for women at higher risk of being evicted. Additionally, increased supportive and affordable housing, tailored with and for women living with HIV, is needed. vi PREFACE Data for this research was drawn from the Sexual Health and HIV/AIDS: Womenâs Longitudinal Needs Assessment (SHAWNA; 2010-present). SHAWNA is a longitudinal, community-based, open cohort study with women living with and/or accessing HIV care in Metro Vancouver, Canada. The study is hosted by the Centre for Gender and Sexual Health Equity (CGSHE). The project was approved by the Providence Health Care/University of British Columbia (UBC) Research Ethics Boards and BC Womenâs Hospital (H14-01073). All data collection, entry, coding and cleaning was conducted by SHAWNA staff at the CGSHE. With feedback and direction from my supervisory committee (Research Supervisor: Dr. Kathleen Deering, Nominated Co-Supervisor: Dr. Anne Gadermann, Committee member: Dr. Trevor Dummer), I conceptualized the research designs (Chapters 2 and 3), and in collaboration with statisticians, I developed a data analysis plan for each chapter, after which they carried out the analyses in SAS based on continued feedback. Tables were created using Microsoft Excel and Microsoft Word. Versions of Chapter 2 and 3 are being produced with co-authors and will be submitted to peer-reviewed journals. vii TABLE OF CONTENTS ABSTRACTâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦. iii LAY SUMMARYâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦. v PREFACEâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦. vi TABLE OF CONTENTSâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦ vii LIST OF TABLESâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦ xi LIST OF FIGURESâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦... xiv LIST OF ABBREVIATIONSâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦. xv GLOSSARYâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.. xvii ACKNOWLEDGMENTSâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦. xx CHAPTER 1: INTRODUCTION â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦... 1 1.1 Background and objectivesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦1 1.2 Conceptual frameworkâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...5 1.3 The SHAWNA cohortâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..12 1.4 Housing instability and housing need among people and women living with HIVâ¦14 1.5 Eviction and social-structural correlatesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦.17 1.6 Eviction and HIV-related syndemic outcomesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.26 CHAPTER 2: PREVALENCE AND SOCIAL-STRUCTURAL CORRELATES OF EVICTION â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..30 2.1 Introductionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..30 2.2 Methodsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦31 2.2.1 Variablesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦31 2.2.1.1 Primary outcome variableâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..31 viii 2.2.1.2 Sociodemographic and explanatory variablesâ¦â¦â¦â¦â¦â¦â¦...32 2.2.2 Statistical analysisâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.36 2.3 Results â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.37 2.3.1 Sample characteristicsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...37 2.3.2 Statistical analysis resultsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.41 2.4 Discussionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦46 CHAPTER 3: EVICTION AND HIV-RELATED SYNDEMIC OUTCOMES OF CRIMINALIZED SUBSTANCE USE, DEPRESSION, FOOD INSECURITY AND GENDER-BASED VIOLENCEâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦56 3.1 Introductionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦56 3.2 Methodsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦57 3.2.1 Variables â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦â¦â¦â¦â¦57 3.2.1.1 Primary outcome variablesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦57 3.2.1.2 Explanatory variableâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦59 3.2.1.3 Potential confoundersâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦60 3.2.2 Statistical analysisâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦62 3.3 Resultsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦â¦63 3.3.1 Sample characteristicsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦â¦â¦â¦â¦â¦â¦63 3.3.2 Statistical analysis resultsâ¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦64 3.4 Discussionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦72 CHAPTER 4: DISCUSSION AND CONCLUSIONâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦77 4.1 Summary of findingsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦77 4.2 Recommendationsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦79 ix 4.2.1 Preventing evictionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦â¦79 4.2.1.1 Addressing eviction related to non-payment of rentâ¦â¦..â¦â¦â¦80 4.2.1.1.1 Emergency financial aidâ¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦81 4.2.1.1.2 Rent supplementsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦82 4.2.1.1.3 Financial managementâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦84 4.2.1.2 â Addressing âno-faultâ eviction â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦..â¦84 4.2.1.2.1 Vacancy controlâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...85 4.2.1.2.2 Tenant protection against dishonest evictionâ¦â¦â¦â¦..86 4.2.1.3 Providing access to legal advice and representationâ¦â¦â¦â¦..â¦88 4.2.2 Supporting individuals at greater risk of evictionâ¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦90 4.2.2.1 Government careâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦91 4.2.2.1.1 Increase supports for those who have been in government careâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦91 4.2.2.1.2 Provide support for families to remain togetherâ¦â¦.â¦91 4.2.2.2 Criminalized substance useâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦92 4.2.2.2.1 Harm-reduction-focused housing approaches â¦â¦â¦â¦93 4.2.2.2.2 Comprehensive support servicesâ¦â¦â¦â¦â¦â¦â¦â¦.â¦95 4.2.3 Providing housing for a variety of needs and preferencesâ¦â¦â¦â¦â¦â¦â¦96 4.2.3.1 HIV-specific housingâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦99 4.2.3.2 Culturally safe housingâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦98 4.2.3.3 Trauma-informed designs for housingâ¦â¦â¦â¦â¦â¦â¦â¦â¦.......99 4.2.3.4 Gender-responsive housingâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..100 4.2.3.4.1 Women-specific, trans-inclusive housing â¦...â¦.â¦â¦100 x 4.2.3.4.2 Housing that supports and is accessible to sex workers â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..101 4.2.4 Identify and support women at risk of, or who have experienced evictionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.102 4.2.4.1 Food banks and drop-in mealsâ¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦103 4.2.4.2 Safe consumption sitesâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦103 4.2.4.3 Health care centresâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦â¦104 4.2.5 Summary of recommendations â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦105 4.3 Strengths and Limitationsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦106 4.3.1 Strengthsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.106 4.3.2 Limitationsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..108 4.4 Implications for future researchâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦111 4.5 Conclusionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦113 BIBLIOGRAPHYâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦115 APPENDICES â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...159 Appendix A - Methods and results of sensitivity analyses (Chapter 2)â¦â¦â¦â¦.â¦159 A.1 Methodsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦159 A.2 Resultsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦â¦â¦â¦â¦.â¦â¦160 Appendix B - Methods and results of sensitivity analyses (Chapter 3)â¦â¦â¦â¦â¦.164 B.1 Methodsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦164 B1. Resultsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦.â¦â¦â¦â¦â¦165 Appendix C â Derivation of eviction variableâ¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦172 xi LIST OF TABLES Table 2.1 â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canadaâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦39 Table 2.2 â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between social-structural variables and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...42 Table 2.3 âBaseline prevalence of intimate partner violence (IPV) by cis men, and bivariate (unadjusted, OR) odds ratios and 95% confidence intervals (95% CIs) and p-values for the relationship between IPV and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, who reported having an intimate cis man partner in the last six months, 2015 to 2023â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦45 Table 3.1 â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canadaâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦65 Table 3.2a â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of gender-based violence in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦...â¦â¦â¦â¦69 Table 3.2b â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of depression in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦69 xii Table 3.2c â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of food insecurity in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦69 Table 3.2d â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized opioid use in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦â¦â¦...â¦â¦70 Table 3.2e â Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized stimulant use in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦â¦...â¦â¦â¦70 Table A.1 â Bivariate (unadjusted, OR) and 95% confidence interval (95% CI) and p-values for the relationship between pandemic period and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦161 Table A.2 â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between social-structural factors and eviction in the last six monthsâ¦â¦â¦.â¦â¦.163 Table B.1â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of gender-based violenceâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦.167 xiii Table B.2â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of depressionâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦168 Table B.3 â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of food insecurityâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦â¦169 Table B.4 â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized opioid useâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦170 Table B.5 â Social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized stimulant useâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦â¦â¦â¦.171 Table C.1 â Coding of the responses included in the variable capturing eviction in the last six month, for individuals who reported that they had âchanged where they sleep overnightâ in the last six monthsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦173 xiv LIST OF FIGURES Figure 1.1 â Conceptual framework guiding the investigation of the variables included in this thesis, based on existing theoretical frameworks â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦5 Figure A.2 â Point prevalence of eviction during study period â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..â¦161 xv LIST OF ABBREVIATIONS aOR adjusted Odds Ratio BC British Columbia CI Confidence Interval EDS Everyday Discrimination Scale DTES Downtown Eastside GEE Generalized Estimating Equation GIPA Greater Involvement of People Living with HIV/AIDS HF Housing First HSD Health Stigma and Discrimination (Framework) IPV Intimate Partner Violence MAR Missing At Random MCAR Missing Completely At Random OR Odds Ratio RAP Rental Assistance Program RTB Rental Tenancy Branch SAFER Shelter Aid for Elderly Renters SAVA Substance Use, Violence and AIDS SHAWNA Sexual Health and HIV/AIDS: Womenâs Longitudinal Needs Assessment SRO Single Room Occupancy Hotel/Accommodation STI Sexually Transmitted Infection TRAC Tenant Resource & Advisory Centre Q1-Q3 First to third quartile xvi USA United States of America WHO World Health Organization xvii GLOSSARY Affordable housing refers to housing costs that are less than 30% of a householdâs before-tax income. Eviction refers to forced residential moves, and usually has the connotation of tenants forced to leave a rented dwelling by a landlord. Financialization is the process by which rental units are acquired by investors, often resulting in the prioritization of profits rather than other housing aims. Government care is used throughout this thesis to refer to foster care, group homes, and other institutionalized care for children and youth provided by the government. Foster or ministry care is used when referring to papers that use these terms. Housing First is a housing approach that, rather than requiring an individual to begin treatment for substance use or psychiatric history, provides individuals with unconditional housing. Housing First usually incorporates other supports for housing recipients. Housing instability has various definitions; however, instability may encompass unplanned or undesired residential moves, lack of permanent housing tenure, moving frequently, and/or facing difficulties affording housing. âLandlordâs Useâ is a legal eviction mechanism in British Columbia that allows a landlord to evict a tenant if the landlord or a close family member of the landlord plans to move into the unit and is a type of âno-faultâ eviction. Marginalization refers to the social exclusion or disadvantage of certain people or groups in society, and can, for example, be based on individualsâ gender, sexuality, race/ethnicity, health status, economic status, employment, and/or dis/ability. xviii Marginalized and minoritized gender identities include transgender, transsexual, transfeminine, transmasculine, gender diverse (non-binary, Two-Spirit), and other non-cis gender identities. Two-Spirit is an Indigenous-specific way to describe oneself that reflects a diversity of nation-specific identities, roles, and norms used by First Nations across Turtle Island prior to colonial contact, including sexual identities, gender identities, and gender expressions (Pruden, 2019; Pruden & Salway, 2020). In this context, marginalization refers to the systemic exclusion and disempowerment of non-cis gender people, and minoritization refers to the heightened stress experiences and stigmatization of non-cisgender people. Marginalized and minoritized sexual identities include lesbian, gay, bisexual, Two-Spirit, asexual, queer and other non-heterosexual identities. Two-Spirit is an Indigenous-specific way to describe oneself that reflects a diversity of nation-specific identities, roles, and norms used by First Nations across Turtle Island prior to colonial contact, including sexual identities, gender identities, and gender expressions (Pruden, 2019; Pruden & Salway, 2020). In this context, marginalization refers to the systemic exclusion and disempowerment of non-heterosexual individuals, and minoritization refers to the heightened stress experiences and stigmatization of non-heterosexual people. âNo-faultâ eviction refers to legal eviction that is not initiated due to late/non-payment of rent or disruptive tenant behaviour. In British Columbia, landlords can legally evict tenants if they or a close family member plan to inhabit the unit, if they plan to demolish or sell the unit, or undertake major renovations that require a unit to be empty for an extended period. âRenovictionsâ refer to evictions landlords initiate to perform unit upgrades and are a type of âno-faultâ eviction. xix Safe consumption sites are harm reduction initiatives that provide medical supervision for people who use substances. Depending on the facility, services offered may include supervised injection and inhalation, education, overdose reversal, and referrals to treatment and other services. Safe consumption sites have been shown to reduce overdose mortality, reduce substance-related harms, and increase access to treatment. Single room occupancy hotels/accommodations are low-income housing that usually provide private bedrooms with access to communal kitchens and bathrooms. This type of housing may be owned and operated privately, or by government or non-profit agencies. Supportive housing is housing that provides affordable, stable housing, paired with programs and staff that help residents access healthcare, food, government benefits, and harm reduction. Trans women include transgender, transexual, and other transfeminine identities. Two-Spirit reflects a diversity of terms used by First Nations across Turtle Island prior to colonial contact and refers to nuanced and often nation-specific identities, roles and norms, including sexual identities, gender identities, and gender expressions (Pruden, 2019; Pruden & Salway, 2020). xx ACKNOLWEDGMENTS I would like to thank my incredible committee, including my co-supervisors, Dr. Kathleen Deering and Dr. Anne Gadermann, and committee member, Dr. Trevor Dummer, for their guidance and expertise during the production of this work. In particular, Dr. Deering provided invaluable and ongoing feedback during the drafting of this thesis. Thank you to my fellow trainees at the CGSHE, who provided insight and camaraderie, as well to the wonderful staff, researchers and team at the CGSHE. And a huge thank you to the statistical team for your assistance, especially in the final push. My time with the CGSHE was generously funded by a graduate research assistantship fellowship, and I am extremely grateful for this financial support. SHAWNA research is supported by grants from the Canadian Institutes of Health Research (PJT-169119), the National Institutes of Health (1R01MH123349-01A1), and the Canadian HIV Trials Network (CTN-333). Of course, this research could not be possible without the time given by the individuals in SHAWNA: thank you for sharing your experiences, and I hope this work reflects them faithfully. Thanks to my friends, near and far â your encouragement has been more important than you can know. Thank you to my partner for believing in me, and for feeling close even when you were across the world. Finally, I am forever grateful to my parents and grandmother for your love and support. 1 CHAPTER 1: INTRODUCTION 1.1 Background and objectives Housing has been established as a social determinant of health by the World Health Organization (WHO) (World Health Organization, 2008, 2018) and is one of the key health inequalities identified by the Pan-Canadian Health Inequalities Initiative, a collaboration with the Public Health Agency of Canada, the Pan-Canadian Public Health Network, Statistics Canada, the Canadian Institute for Health Information and the First Nations Information Governance Centre (Public Health Agency of Canada, 2018). Housing instability is one pathway through which housing inequality contributes to health disparities (Swope & Hernández, 2019). While variably defined, housing instability generally refers to unplanned or undesired residential moves, lack of permanent housing tenure, moving frequently, and/or facing difficulties affording housing. Research has shown that housing instability is associated with a variety of sub-optimal outcomes. These include mental (Talmatzky et al., 2023) and physical health outcomes (Arum et al., 2021; Gu et al., 2023), food security (Chang & Chatterjee, 2022; King, 2016; Lee et al., 2021), violence (Breiding et al., 2017; Goldenberg et al., 2023; Groves et al., 2022; Wilson et al., 2021), and substance use (Mehtani et al., 2023; Smith et al., 2017). HIV is now considered a long-term manageable disease (Deeks et al., 2013) with consistent access to and use of anti-retroviral treatment combined with other factors such as housing, nutrition, and social and psychological support. Substantial evidence shows that housing not only supports well-being and quality of life among people living with HIV, but also influences clinical HIV health outcomes (Aidala et al., 2016; Leaver et al., 2007; Milloy et al., 2012). However, people living with HIV experience considerable housing need, including reporting high levels of housing instability and houselessness (Milloy et al., 2012). 2 Women living with HIV may face additional barriers to stable housing based on gendered and structural factors, including income disparities, exposure to violence, and underrepresentation in leadership and policy-making roles (Parker & Leviten-Reid, 2022). Canadian women report substantial housing need, with 25.9% of women-led single-parent families and 24.1% of women living alone in core housing need, compared to 10.6% of the total population in Canada in 2016 (CMHC, 2019).1 Housing need for women in Canada is linked to poverty and can result in houselessness (Schwan et al., 2021). Furthermore, emerging research suggests that eviction may be a common and profoundly negative experience for women (Schwan et al., 2021). In the current study setting of women living with HIV in Vancouver, 71.7% of women reported unstable housing or being unsheltered while only 11.9% reported living in supportive housing and 16.4% in stable housing at baseline interviews (Zhao et al., 2022). Another cross-sectional study that included three Canadian sites found that 51.5% of women living with HIV experienced housing instability (Logie et al., 2018). Eviction, an extreme form of housing instability, is a disruptive event that can cause or compound other social, health, and economic outcomes. Eviction may happen formally, through a legal process initiated by the landlord, or informally, where a landlord asks a tenant to leave, or exerts pressure such as harassment, rent increases, or even changing the lock (Zell & McCullough, 2020). There is evidence that informal evictions account for the majority of forced moves in other study contexts (Desmond et al., 2015). In a study of eviction using data from the 2021 Canadian Housing Survey, where eviction was defined as having been forced to move from a rented dwelling by a landlord, it was found that the current setting of Vancouver, British Columbia (BC), had the highest eviction rate of any major metropolitan area in Canada (Xuereb 1 In Canada, core housing need is defined as living in housing below standards in terms of crowdedness, affordability, and/or in need of major repairs (CMHC, 2019). 3 & Jones, 2023). Some people who face structural marginalization may be more likely to experience housing instability and evictions, such as discrimination and stigmatization based on race (Brisson & Covert, 2015; Desmond, 2012; Himmelstein & Desmond, 2021; Rodrigue, 2016), gender and sexual identities (Abbate et al., 2023; Friedman et al., 2013; Kattari et al., 2016; Koehler et al., 2018; Schwegman, 2019), HIV status (Bhatta et al., 2021; Logie et al., 2016, 2023; Wolitski et al., 2009), disability (Aranda, 2015; Paradis, 2016), sex work (Lyons et al., 2021; Macon & Tai, 2022), and substance use (Fleming et al., 2019; Phinney et al., 2007; Van Laere et al., 2009). Eviction may also lead to other sub-optimal social and health outcomes, including exposure to violence (Goldenberg et al., 2023; Groves et al., 2022; Reed et al., 2011), mental health conditions (Chisholm et al., 2022; Desmond & Kimbro, 2015; Hatch & Yun, 2021; Rojas & Stenberg, 2016; Vásquez-Vera et al., 2017), greater economic insecurity, including food insecurity (Cutts et al., 2022), and use of criminalized substances (Damon et al., 2019; McNeil et al., 2021). Previous literature identified co-existing, interactive epidemics of several of these factors, resulting in syndemic theory. Syndemic theory describes how diseases and health conditions interact with one another and the social environments they exist within to influence health outcomes (Singer et al., 2020). The original conceptualization described epidemics of substance use, violence, and HIV, termed SAVA, in a community of low-income, urban Puerto Ricans (Singer, 1996). The impact of SAVA among women has been explored (Meyer et al., 2011), including associations between syndemic factors and sub-optimal mental health (Illangasekare et al, 2013), and potentially, food insecurity (Leddy et al., 2021). Limited studies have also begun to include housing as a potential HIV-related syndemic factor (Glynn et al., 2019; Nydegger & Claborn, 2020), however, there continue to be calls to understand whether 4 and how structural factors, such as housing, interact with other syndemic factors (Logie & Gadalla, 2009; Martínez et al., 2020; Perlman & Jordan, 2018). The scientific literature on eviction among women living with HIV is extremely limited, with no peer-reviewed studies identified that examined prevalence or correlates of eviction among women living with HIV specifically. Furthermore, no studies were found that examined whether eviction is associated with syndemic outcomes for women living with HIV. Given evidence that women living with HIV experience disproportionate levels of housing instability, along with evidence that housing is critical for the well-being and quality of life for people living with HIV, a greater understanding of eviction among women living with HIV is urgently required. The main objectives of this thesis were to: 1. Describe the prevalence of and social-structural factors associated with eviction among women living with HIV; and 2. Investigate the association between eviction and HIV-related syndemic outcomes of gender-based violence, food insecurity, depression, and criminalized substance use. 5 1.2 Conceptual framework Figure 1.1 - Conceptual framework guiding the investigation of the variables included in this thesis, based on existing theoretical frameworks. 2 Figure 1 shows the proposed relationship between social-structural factors, eviction, and HIV-related syndemic factors, as was used to guide this thesisâ investigation. Experiences of structural marginalization and stigmatization were hypothesized to increase individualsâ risk of eviction. These factors should be understood both as intersectional, in that individuals may face multiple, intersecting experiences of stigma, as well as occurring over the life course. These overarching concepts are included in Figure 1, pictured above and below the social-structural factors included in this framework. Individuals who are evicted may also have increased odds of experiencing HIV-related syndemic factors, as shown to the right of eviction in Figure 1. In this thesis, food insecurity, depression, gender-based violence and criminalized substance use were considered, as 2 This figure represents the hypothesized associations between variables included in this thesis in the form of a conceptual framework. However, there are several limitations to this conceptualization. Figure 1 does not include all potential factors associated with eviction. As well, this illustration does not show potential inter-relationships between explored variables or the potential direct effect of social-structural variables on HIV-related syndemic factors. Finally, this figure does not address the potential for reverse causation or bi-directional relationships. 6 they have been previously studied in syndemic research among women living with HIV (Illangasekare et al., 2013; Leddy et al., 2021; Meyer et al., 2011) . While the directionality of relationships as shown in Figure 1 is proposed in this thesis, given the methodological approach, reverse causation is possible. The thinner arrow between eviction and HIV-related syndemic factors is used to note that the temporal relationship between these variables may be bidirectional. For example, criminalized substance use was identified in the literature as both a potential driver and an outcome of eviction and was included as both in the framework. This conceptual framework was built on Stangl et al.âs Health Stigma and Discrimination (HSD) Framework (Stangl et al., 2019), intersectionality theory as originally conceptualized by Kimberlé Crenshaw (Crenshaw, 1989), life course approaches to health disparities as explained by Jones et al (Jones et al., 2019), and Singerâs syndemic theory (Singer, 1996). Objective 1 (Chapter 2) examined the prevalence of eviction within the SHAWNA cohort and the social-structural factors hypothesized to be associated with eviction, guided by the HSD Framework, intersectionality theory, and life course theory. Objective 2 (Chapter 3) explored potential associations between eviction as an explanatory variable and social and health outcomes, based on HIV-related syndemic theory. Chapter 2 was guided by the HSD Framework as well as intersectionality theory and life course approaches. The HSD framework recognizes that health stigma, such as HIV stigma, is a product of multiple forces: stigma drivers and facilitators. Stigma drivers, which include fear of infection, stereotypes, and social judgement, are inherently negative. Stigma facilitators include cultural and social norms, provision of safety supplies, and policy decisions, and may positively or negatively affect stigmatization. Together, drivers and facilitators may result in stigma âmarkingâ (i.e. whether a stigma is applied to a health condition) (Stangl et al., 2019). By 7 understanding that stigma is a product of drivers and facilitators, the HSD framework highlights the broader social, systemic and structural factors that contribute to stigmatization, rather than considering stigma only as imposed upon individuals by others. Figure 1 illustrates the hypothesis that experiencing women living with HIV, who may experience HIV-related health stigma, may be at greater risk of experiencing eviction. Furthermore, the HSD framework describes how health stigma often occurs with other stigmas, such as stigma against different races/ethnicities, gender identities, sexual orientations, sex work and people who use criminalized substances, thus emphasizing the intersectionality of stigmatized identities and behaviours. Intersectionality theory was first introduced by Kimberlé Crenshaw to describe the interacting experiences of discrimination of Black women, who face marginalization based on both gender and race (Crenshaw, 1989, 1991). More recently, research has emphasized that marginalized social identities reflect broader macro-structural factors such as racism and sexism (Bowleg, 2012). As well, there has been a focus on the intersections between HIV stigma and other social identities, including gender and sexual identities and race/ethnicity, as well as marginalized criminalized behaviours (e.g., substance use) and occupations (e.g., sex work) (Logie et al., 2011; Turan et al., 2017, Stangl et al., 2019). Intersectionality was not incorporated in a quantitative methodological way given the sample size was relatively small (n=361), with statistical analysis consisting of logistic and ordinal logistic regression models. However, intersectionality was used as a guiding framework to interpret and contextualize results. A life course approach to health disparities asserts that health status is influenced by previous exposures, namely physical, environmental and psychosocial factors (Jones et al., 2019). Individuals may be exposed to risk factors during certain life periods that influence later 8 health, such as socioeconomic disadvantage during childhood (Shonkoff et al., 2012; Vineis et al., 2016); Jones describes these approaches as âdevelopmental,â (2019). Individuals may also experience cumulative exposure to stressors due to structural disadvantage that can impact health, such as coping with experiencing persistent systemic inequity and stress (Geronimus et al., 2006; McEwen, 2017); these perspectives have been termed âstructuralâ by Jones (2019). The inclusion of life course experiences in Figure 1 is used to show that adverse life experiences at sensitive periods (developmental), as well as cumulative exposure to stigmatization over the life course (structural) may influence odds of eviction. In terms of a developmental perspective, a life course approach to child welfare suggests that the factors leading up to removal from parents as a child, which can include abuse, neglect, or poverty, as well as the transition to government care, can be traumatic and stressful experiences (White & Wu, 2014). These experiences influence the life trajectory of children including access to secure housing. A systematic review found that individuals with a history of government care were more likely to experience houselessness, as well as to report sub-optimal educational outcomes, lower incomes, and more mental health issues and substance use as adults (Gypen et al., 2017). These outcomes may be related to experiences of abuse and neglect, and high levels of mobility and instability during childhood, as well as more limited familial and social support following the transition from childhood to adulthood (Gypen et al., 2017). A life course perspective was used in this thesis to justify the inclusion of and interpret the association between being removed from your parents as a child with eviction as an adult. Experiencing structural marginalization can result in exposure to stressors throughout the life course, and the effort required to cope with these stressors can result in health disparities (Jones et al., 2019). For example, research has found that health inequities can be partly 9 attributed to the greater physiological burden of the stress of living in a race-conscious society among Black people as compared to White people, with this stress accumulating over the lifetime (Geronimus et al., 2006). The effects of cumulative exposure to structural marginalization and stigmatization were not assessed in a quantitative way in this thesis. However, a life course approach was used to emphasize that experiences of stigma often occur multiple times over the lifetime, rather than as singular events. Syndemic theory was used in Chapter 3 to conceptualize the social and structural (syndemic) factors that are critical to managing HIV, as well in themselves important for quality of life; eviction was hypothesized to be associated with these factors. The concept of a syndemic refers to a cluster of diseases or health conditions that interact with each other and the social environment they exist in (Singer et al., 2020). Syndemic research began with the observation of a triple epidemic of high levels of HIV diagnoses, violence within gangs, and substance use (termed âSAVAâ) in a population of Puerto Rican immigrants in Hartford, Connecticut in the 1990âs (Singer, 1996). Researchers theorized that these epidemics were interacting synergistically, and furthermore, were influenced by the socioeconomic challenges residents were facing. Since then, syndemic theory has been formalized as the clustering of at minimum two health conditions in a population, including how the conditions are biologically interacting to affect disease outcomes, and the clusters of social-structural factors that contribute to these diseases (Singer et al., 2020). To be a syndemic, there must be evidence of âtrue synergy rather than simply co-occurrence of disease or the addition of varied health and social factors,â (Singer et al., 2020). Synergy, or positive interaction, occurs when the effect of multiple exposures is greater than the sum of the effect of the exposures separately (Rothman, 1974). Some studies have been criticized 10 for only investigating whether reporting an increased count of syndemic factors was associated with the outcome of interest (Tsai & Burns, 2015). In this thesis, syndemic theory was used for the selection of outcome variables, however the methodology could not definitively establish evictions as part of the HIV-related syndemic (i.e. meet the criteria for synergistic effect) among women living with HIV. However, the first step to establishing housing within a HIV-related syndemic is understanding if there is an association with other syndemic factors, as explored in this thesis and illustrated in Figure 1. While the majority of syndemic research has focused on the HIV-related syndemic of SAVA, the framework has increasingly been used to explore other synergistic clusters of social factors and disease outcomes. For example, there is a growing body of work on the syndemic of diabetes, depression and social distress (Singer et al., 2020). In HIV-related syndemic research, frameworks have expanded from the original SAVA conceptualization to include a variety of factors including trauma, sex work, HIV stigma, discrimination, intimate partner violence, self-esteem, and mental health (Brennan et al., 2012; Glynn et al., 2019; Martínez et al., 2020; Nydegger & Claborn, 2020), however, a review of literature of HIV-related syndemic research among African-Americans found the most common factors examined were depression, substance use, and violence (Godley & Adimora, 2020). Based on the literature, the HIV-related syndemic factors of sub-optimal mental health, criminalized substance use, gender-based violence, and food insecurity were selected for investigation, as shown in Figure 1. Among women living with HIV specifically, a literature review found that syndemic research has explored the interacting nature of (intimate partner) violence (IPV), substance use and HIV status on mental health, as well as access to healthcare and medication (Meyer et al., 2011). Other research has found both qualitative (Illangasekare et 11 al., 2014) and quantitative (Illangasekare et al., 2013) evidence of sub-optimal health within syndemic frameworks for women living with HIV. More recently, Leddy et al. found qualitatively that the outcomes of criminalized substance use, depression, IPV and food insecurity resulted in sub-optimal anti-retroviral adherence and greater likelihood of missed healthcare appointments (Leddy et al., 2021). Food insecurity is an emerging factor in syndemic frameworks, with limited evidence thus far of its potential role and interaction with other syndemic factors. However, Leddy et al. qualitatively explored a potential syndemic of food insecurity, IPV, sub-optimal mental health and substance use, finding evidence that food insecurity was intersecting with these factors in the lives of women living with HIV (Leddy et al., 2021). Participants in Leddy et al.âs study reported that limited food access made it challenging to take medications that required food, as well as make it to clinical appointments (Leddy et al., 2021). These findings are supported by other evidence: food insecurity has been associated with sub-optimal HIV clinical outcomes such as viral suppression (Aibibula et al., 2017), as well as mortality (Weiser et al., 2009). In a study exclusively with women living with HIV, food insecurity was associated with higher viral load and lower CD4 counts (measured continuously) (Spinelli et al., 2017); these outcomes may be partly mediated by depression (Weiser et al., 2020). In a systematic review, food insecurity was consistently found to be associated with depression among people living with HIV (Ayano et al., 2020). At the same time food insecurity is associated with IPV as found in a review of both qualitative and quantitate research (Waterman et al., 2024), including among women living with HIV (Conroy et al., 2019). As well, food insecurity is associated with criminalized substance use among women living with HIV (Whittle et al., 2019). Given these associations, it is possible that 12 food insecurity is interacting synergistically with other HIV-related syndemic factors and HIV healthcare outcomes. Some research has examined housing as a potential HIV-related syndemic factor (Glynn et al., 2019; Nydegger & Claborn, 2020). However, Glynn et al. examined the increased odds of new HIV diagnoses per increase of reported syndemic conditions, which also included education, mental health conditions, stigma, violence and substance use, and did not report the effect of housing individually (2019). Nydegger & Claborn used qualitative data to understand how housing, as one of several syndemic factors explored, influenced substance use among Black women in a HIV-related syndemic framework (2020). Other studies have called for a deeper understanding of structural factors including housing within syndemic theory (Logie et al., 2022; Martínez et al., 2020; Perlman & Jordan, 2018). 1.3 The SHAWNA cohort Data for this thesis was drawn from the Sexual Health and HIV/AIDS: Womenâs Longitudinal Needs Assessment (SHAWNA), over eight years of follow-up from September 2015 to September 2023. SHAWNA is an ongoing, community-based longitudinal cohort study of cis and trans women living with and/or accessing care for HIV in Metro Vancouver, BC. SHAWNA was developed in extensive consultation with women living with HIV, HIV service providers, policy makers and clinical partners, with the goal of understanding the interpersonal, social, and structural factors that influence access to and experience with HIV care and health outcomes over the lifetime of women living with HIV. SHAWNA is committed to community-based research principles and to Greater Involvement of People living with HIV (GIPA). SHAWNAâs activities are guided by a Community Advisory Board, comprised of local community and HIV 13 organizations, that meets annually. A Positive Womenâs Advisory Board, comprised of women living with HIV, also meets several times a year to discuss research progress and goals. Eligibility criteria for SHAWNA include being aged 14 years or older, having an HIV diagnosis, identifying as a (cis or trans) woman, and residing in and/or accessing HIV/AIDS related care in the Metro Vancouver region. Recruitment occurs through clinical outreach, HIV/AIDS advocacy organizations, outreach by peer researchers and team members, and other care providers as well as through word-of-mouth, email and posters. The primary referral clinic for women living with HIV in BC, the Oak Tree Clinic, also provides direct referrals to SHAWNA. Following obtaining informed consent for entry to the study, baseline surveys are completed, and participants are invited to complete follow-up interviews every six months. Each semi-annual study visit consists of 1) responding to a questionnaire administered by trained community researchers, including information on a variety of socio-demographic, structural, relational and health care access factors; and 2) an appointment with a sexual health research nurse, including laboratory blood testing, with CD4 counts and viral load measured as outcomes of the study. Sexually transmitted infections (STI) testing, education, and pap smears are offered to participants during their time with the sexual health research nurse. Participants receive an honorarium for their time and expertise. The honoraria has increased over the study period. At the studyâs inception in 2014, participants received $50 for participating in the initial/baseline and each six-monthly follow-up visit ($25 for the main questionnaire and $25 for the appointment with the sexual health research nurse). In September 2021, the honorarium increased to $80 for the initial/baseline questionnaire and 65$ for each six-monthly follow-up questionnaire, and then in March 2024 increased to $100 for initial/baseline and $80 for follow-ups. The honoraria for lab testing and appointment with the sexual health research nurse has 14 remained at $25 throughout the study. Ethics approval for SHAWNA was obtained from the Providence Health/University of British Columbia Research Ethics Board, and BC Womenâs Hospital. Research Electronic Data Capture (REDCap) is used to securely collect and manage data at the University of British Columbia (UBC). 1.4 Housing instability and housing need among people and women living with HIV Housing stability is critical to health and well-being. Having stable housing for people who have experienced houselessness was associated with positive health-related outcomes in a systematic review, including improved physical and mental health, as well as increased positive health behaviours and reduced mortality (Carnemolla & Skinner, 2021). This review also found some evidence that stable housing improved community participation, employment, food security and education outcomes, and reduced substance use and emergency services use (Carnemolla & Skinner, 2021). Conversely, housing instability is negatively associated with health and well-being. A recent systematic review concluded that housing instability had a negative impact on rentersâ overall mental health, well-being and depressive symptoms (Talmatzky et al., 2023). A narrative review found housing instability was often associated with increased prevalence of obesity, hypertension, diabetes and cardiovascular disease as well as greater utilization of emergency health services (Gu et al., 2023). A meta-analysis identified significant associations between being unstably housed or recently unhoused and new diagnoses of hepatitis C and HIV among people who use substances (Arum et al., 2021). Other studies have found that housing instability is associated with IPV (Breiding et al., 2017; Goldenberg et al., 2023; Wilson et al., 2021), substance use (Mehtani et al., 2023; Smith et al., 2017), and food insecurity (Chang & 15 Chatterjee, 2022; King, 2016; Lee et al., 2021). However, the body of evidence exploring housing in/stability disproportionately draws on samples of men, with fewer studies examining outcomes for women and gender diverse people, women experiencing violence, Indigenous people, and people living with HIV (Carnemolla & Skinner, 2021). People living with HIV report high levels of unmet housing need (Milloy et al., 2011). A systematic review of housing stability and health outcomes among people living with HIV found that unstable housing was associated with hospital-based health services, hospitalization, sub-optimal anti-retroviral treatment adherence, co-infection with hepatitis C, substance use, and unprotected sex, while stable housing status was associated with medication adherence, primary care access and better physical health (Leaver et al., 2007). Another review assessed houselessness or marginal housing among people living with HIV and associations with a variety of health status indicators, finding that substandard housing status was linked to low CD4 counts, detectable viral loads, not receiving suitable HIV care, and sub-optimal anti-retroviral treatment adherence (Milloy et al., 2011). Most recently, Aidala et al found that inadequate housing status was associated with a variety of health-related outcomes, including not receiving adequate HIV care, greater utilization of emergency health care, sup-optimal adherence to anti-retroviral treatment, sub-optimal clinical outcomes such as lower CD4 count and detectable viral load, greater mortality, increased rates of hepatitis C, sub-optimal physical and mental health, increased odds of substance use and unprotected sex, and lower quality of life (2016). However, there is limited research on housing instability among women and gender-diverse people living with HIV, even though women may disproportionately experience housing need. Gendered housing disparities arise from a variety of factors, as identified by Parker and Leviten-Reid (2022). Women generally earn less income than men, are more likely to experience violence 16 at home and in communities and tend to be underrepresented in governance positions that have the influence to develop policy (Parker & Leviten-Reid, 2022). This is supported by a recent survey of 500 women and gender diverse people in Canada which identified key housing challenges facing individuals, including issues around affordability, poverty, insufficient access to services and gendered vulnerabilities, such as discrimination (Schwan et al., 2021). The effects of gendered housing inequities may be related to health and safety outcomes, with several studies finding that housing instability is associated with sub-optimal HIV-related clinical health outcomes among women and gender diverse people living with HIV. In a sample among the current cohort of cis and trans women living with HIV in Metro Vancouver, Canada, being unsheltered has previously been associated with not currently being on anti-retroviral treatment, having detectable viral load (â¥ 200 copies/mL), and unmet primary and dental care (Zhao et al., 2023). Housing instability was associated with a reduction in viral suppression (<200 copies/mL) by 51% among women living with HIV in a study conducted in the Bronx, Brooklyn, Chicago, Los Angeles, San Francisco, and Washington, USA (Galárraga et al., 2018). A San Francisco-based study found that for every ten nights of houselessness experienced by women living with HIV, the adjusted odds of having a detectable viral load (â¥200 copies/mL) increased by 11%, and for every ten nights spent sleeping in a shelter, the adjusted odds increased by 16% (Riley et al., 2019). One study of women living with HIV in the mid-South USA found that unstable housing was associated with sub-optimal emotional and physical health, criminalized injection substance use and condomless sex (Delavega & Lennon-Dearing, 2015). Research has not focused on whether housing need among women living with HIV is associated with outcomes not directly related to biological health markers, but that may still be related to quality of life and HIV health care outcomes. 17 1.5 Eviction and social-structural correlates The setting of the SHAWNA project, Metro Vancouver, BC, has the highest five-year prevalence of eviction among Canadian metropolitan areas at 10.4% compared to 5.7% in Montréal and 6.0% in Toronto, as reported in a study that asked renter households whether they had been forced to move in the past five years (Xuereb & Jones, 2023). In other contexts, most evictions occur when rent is not paid or paid late, or in response to behavioural factors such as damage to the property or disruption to neighbours (Tsai & Huang, 2019). However, in BC, 85.4% of reported evictions were classified as âno-faultâ evictions, where landlords may legally remove tenants in order to occupy, sell or renovate the building; across Canada, the proportion of âno-faultâ evictions is 64.7% (Xuereb & Jones, 2023). Evictions may be âformalâ, wherein an eviction notice is served to a tenant and can be legally contested, and also âinformalâ, which occurs when a landlord forces a tenant to leave through other means, including rent increases, harassment, or threats (Buhler, 2022). While informal evictions are harder to track, given a lack of documentation, they may make up a substantial portion off all evictions, with one study finding that 48% of forced moves were informal evictions (Desmond & Shollenberger, 2015). Furthermore, as landlords hold power in the landlord-tenant relationship, and evidence shows that tenant court disproportionately rules in favour of landlords, tenants may choose to not fight a formal eviction notice (Buhler, 2022) There is evidence that eviction may be related to economic security. Following eviction, individuals report a significantly higher proportion of disposable income coming from social assistance (Kahlmeter et al., 2018) and are more likely to experience a job loss (Desmond & Gershenson, 2016). Using an instrumental variable approach, a study of housing court and 18 administrative data in New York City and Cook County found that receiving an eviction order decreased earnings, employment, and access to credit and increased debt (Collinson et al., 2024). Eviction has also been shown to lead to housing instability, housing need, and houselessness. For example, experiencing one eviction can lead to future involuntary residential mobility, as forced moves often lead to acceptance of substandard housing and may precipitate future moves (Desmond et al., 2015). Evicted renters may move to more impoverished neighbourhoods, or areas with greater crime (Desmond & Shollenberger, 2015). Additionally, one eviction event can lead to compounding housing instability, as evictions remain visible on rental records, preventing tenants from finding adequate housing (Goplerud et al., 2021). One study found that eviction caused an increased probability of houselessness, residential mobility, and number of hospital visits (Collinson et al., 2024). Given the relationship between eviction and housing instability, the same factors associated with housing instability may be associated with eviction. Current literature has identified associations between structural inequities, including HIV stigma, racism, transphobia and homophobia, gender discrimination, including related to gender-based violence, ableism, and stigmatization of substance use and sex work, and housing need. The next section thus synthesizes the evidence between structural marginalization and eviction where the literature exists, or housing need more broadly when studies on eviction are unavailable. People living with HIV may already experience stigmatization that affects housing instability. In a study of people living with HIV in the USA, greater levels of internal and perceived HIV-related stigma were reported by participants who were unhoused (Wolitski et al., 2009). Qualitative evidence from a small study in Ottawa found that people living with HIV had concerns about finding appropriate housing as they aged, including fears around having their 19 status disclosed in HIV-specific subsidized housing, and the potential for experiencing HIV-related stigma in their housing (Furlotte et al., 2012). In a cross-sectional study with African and Caribbean Black women living with HIV in several cities in Ontario, women reporting housing instability had significantly higher HIV-related stigma scores than women with secure housing, although this result was not significant in the final model (Logie et al., 2016). In San Francisco, men who have sex with men living with HIV who were unhoused or who were unstably housed reported higher HIV stigma than men who were housed in a cross-sectional survey (Bhatta et al., 2021). Concurrent food and housing insecurity were associated with higher odds of high HIV-related stigma and every-day discrimination in the current study setting with women living with HIV in Metro Vancouver, Canada (Logie et al., 2023). Due to historical segregation, including exclusionary zoning and displacement, along with the continuation of discriminatory policies, Black, Indigenous and other racialized people face housing inequities (Swope & Hernández, 2019). This includes eviction, which is disproportionately experienced by people of colour (Himmelstein & Desmond, 2021). Racialized women, particularly Black women, may be at an even greater risk of eviction (Desmond, 2012). Even in non-market housing, eviction risk is inequitable, with one study of evictions among social housing recipients finding that being a woman and being Black was associated with increased odds of lease violation due to non-payment of rent (Brisson & Covert, 2015). A study of low- and middle-income tenants in the USA during the pandemic found that those who reported an eviction were more likely to be Black (Tsai et al., 2022). In BC, the five-year prevalence of eviction for Indigenous renters is 10.4% compared to 6.2% for non-Indigenous renters (Xuereb & Jones, 2023), and identifying as Indigenous was found to be associated with experiencing an eviction in a survey of womenâs housing need in 20 Canada (Schwan et al., 2021). While studies on eviction are limited, housing instability is disproportionately reported by Indigenous peoples in Canada. Indigenous respondents are more than twice as likely to report experiencing hidden houselessness compared to non-Indigenous respondents (Rodrigue, 2016). Additionally, approximately 19.8% of Indigenous individuals report core housing need in Canada, compared to 10.6% of the total population (CMHC, 2019). Discrimination and stigma against people with marginalized and minoritized sexual and gender identities is also related to housing need. Research looking at apartment refusal in Serbia (n=160 landlords contacted) found that 18% of same-sex couples were refused apartments, while heterosexual couples were not refused any (Koehler et al., 2018). A report from the U.S. Department of Housing and Urban Development evaluated housing discrimination against same-sex couples when inquiring by email about available units (n=6,833 inquiries) and found that heterosexual couples experienced more favourable treatment (i.e. more responses to inquiries) (Friedman et al., 2013). Another study of similar design with 6,490 landlords in 94 cities in the USA found that same-sex couples received fewer responses, with greater disparity for non-White same-sex couples (Schwegman, 2019). However, another study in the USA which sampled both urban and rural markets in states with and without anti-discrimination protections (n=445 landlords contacted in 28 housing markets) found no evidence of significant discrimination against same-sex couples in the housing market (Hellyer, 2021). In Latin America, one study of apartment refusal found that heterosexual couples with a trans woman partner received fewer responses than heterosexual couples without a trans partner (Abbate et al., 2023) Other qualitative evidence from interviews with lesbian, gay, bisexual, trans and queer youth in a city in the USA found that shelters that were accessed by youth experiencing housing need often did not affirm identity, segregated by gender in problematic ways, and employed staff 21 with discriminatory beliefs (Coolhart & Brown, 2017). Among 13-25 years old individuals in the USA, the risk of experiencing houselessness is significantly greater for lesbian, gay, bisexual or trans participants, even after controlling for several factors, including race, employment and education (Morton et al., 2018). In a USA-based study of discrimination against lesbian, gay, bisexual, trans and queer people, trans participants reported higher frequency of housing discrimination compared to cisgender participants (Kattari et al., 2016). A study of structural inequities among trans women in Los Angeles found that 40.0% of the sample was unhoused (Clark et al., 2018). Evidence from the Pan-Canadian Womenâs Housing & Homelessness Survey (n=500) found that identifying as LGBTQ2S+ was correlated with experiencing an eviction (Schwan et al., 2021). Discrimination based on sexuality and gender identities may interact with other forms of discrimination, with one study in San Francisco finding that the odds of housing instability increased for each unit increase in intersectional (racial and transphobic) discrimination (Beltran et al., 2019). In Vancouver, qualitative research with queer sex workers identified discrimination against same-sex partners as a barrier to stable housing, and some individuals also reported intersecting stigma related to substance use (Lyons et al., 2021). Other qualitative research with this sample found that trans and Two-Spirit sex workers were turned away from womenâs shelters, experienced gender policing, and were harassed at shelters both by staff members as well as other women (Lyons et al., 2016). Intimate partner violence (IPV) may increase the risk of eviction and housing instability. An exploratory study of IPV found that 20% of a sample (n=306) of evicted adults in Omaha, USA experienced domestic violence or IPV, which often preceded eviction (Benson-Goldsmith et al., 2024). Qualitative research of women living in unstable housing in Vancouver, Canada, 22 found that women who experienced IPV were targeted for evictions, often due to repeated police calls or attempts by their abusive partner to access their home (Collins et al., 2018). Research from California found that women who experienced IPV in the preceding year had nearly four times the odds of housing instability as measured by late rent or mortgage, frequent moves, and being without housing (Pavao et al., 2007). People living with disabilities experience stigma which can translate into unmet housing need. The Pan-Canadian Womenâs Housing & Homelessness Survey found that respondents with multiple disabilities had an increased likelihood of eviction (Schwan et al., 2021). Additionally, an evaluation (n=212) of a tenant advocacy program for individuals appearing in eviction hearings in Ontario found that 38% of the respondents either had a disability or had a person in their household with a disability (Paradis, 2016). People living with disabilities also report housing discrimination when trying to find housing. A study on discrimination against people with disabilities searching for housing in the USA found that housing providers were less likely to communicate with people who were deaf or hard of hearing and told them about fewer available units, compared to controls (Aranda, 2015). This study also found that housing providers were less likely to make an appointment to view a unit with people using wheelchairs and were less likely to tell them about available units (Aranda, 2015). In the USA context, many people with disabilities have limited incomes from government allowances, while at the same time housing prices have increased rapidly, leaving people with disabilities particularly vulnerable to eviction, housing unaffordability and inaccessibility (Burns et al., 2021). In the current studyâs setting of Metro Vancouver, single room occupancy (SRO) hotels make up much of the available housing for people with low-incomes, yet there are frequent reports of out-of- 23 service elevators that can render residents with physical disabilities stranded in or out of their rooms (City of Vancouver, 2020; Nowell & Masuda, 2020). Other stigmatized groups may also face increased risk of eviction and housing barriers, including people who use substances and sex workers. Research suggests that people who use substances may receive eviction notices for behaviour that is tolerated in other tenants (Fleming et al., 2019). Other studies have found that substance use is associated with greater eviction risk (Montgomery et al., 2017; Phinney et al., 2007; Van Laere et al., 2009). Evidence from a cohort of women in street-based sex work in Vancouver, BC, found that 43.3% reported being unhoused during an 18-month follow up (Duff et al., 2011). In qualitative research in the same context, women identified sex work as a barrier to housing, with some housing providers refusing to rent to them (Lyons et al., 2021). A study with sex workers in Rhode Island found that 37% of individuals in the sample were unhoused, and others were at risk of losing their housing; participants noted that discrimination against sex work was a reason they were rejected from housing benefits (Macon & Tai, 2022). Reflecting the life course approach to systemic marginalization, several studies have documented the association between youth who were in government care (e.g. foster care) and later housing instability and houselessness (Berzin et al., 2011; Dworsky et al., 2013; Kelly, 2020). A study of young adults transitioning out of care, matched with other youth on a variety of factors, found that those with a history of foster care experienced higher rates of houselessness and lower housing stability (Berzin et al., 2011). In a Canadian context, a Statistics Canada report found that individuals who were in government care were three times as likely to report experiencing hidden houselessness than those who were never in government care (Rodrigue, 24 2016). A recent report on womenâs housing need in Canada found that a history of child welfare involvement was significantly associated with experiencing an eviction (Schwan et al., 2021). At the same time, Indigenous children are over-represented in government care across Canada and thus may face intersecting barriers to housing based on both history of government care as well as racism (Barker et al., 2014; Ministry of Children and Family Development, 2023). Indigenous peoples in Canada face a history of colonial violence and intergenerational trauma, including residential schools and family separation, that continues today in the overrepresentation of Indigenous children in government care (The Truth and Reconciliation Commission of Canada, 2015). In one study in Alberta, Indigenous peoples were three times more likely to report having experienced houselessness and nearly four times more likely to have been involved in the child welfare system compared to White respondents (Alberton et al., 2020). Other important social-structural correlates of eviction within the literature include income instability, less education, financial problems, unemployment, and sudden events such as job termination and divorce (Tsai & Huang, 2019). One study found that in the two years prior to experiencing an eviction court case, households in New York City and Cook County, USA experienced substantial decreases in earnings, employment and credit scores (Collinson et al., 2024). There is also evidence of an inverse relationship between age and eviction, with several studies finding that evicted people tend to be younger (Brisson & Covert, 2015; Graetz et al., 2023; Montgomery et al., 2017; Tsai et al., 2022). A Canadian study found the highest 5-year eviction prevalence in the age category of 45-54, and the lowest for those aged 65-74 and 75+ (Xuereb et al., 2021). Larger households and households with children also experience higher risk of eviction (Brisson & Covert, 2015; Desmond & Gershenson, 2017). 25 While other studies have established associations between experiencing structural marginalization and housing instability, including evictions, very little research has focused on the eviction experiences of women living with HIV. One South Florida-based qualitative study explored barriers to HIV care among women living with HIV who had experienced houselessness, housing instability, or eviction, finding that women experiencing these forms of housing instability had difficulty safely storing medication as well as a lack of privacy that heightened the possibility of their HIV status being disclosed (Fernandez et al., 2022). This resulted in women not taking medication as prescribed and missing health care appointments. Furthermore, women also noted other unmet needs contributed to these barriers, including sub-optimal mental health, substance use, comorbidities, and food insecurity (Fernandez et al., 2022). The prevalence of and social-structural correlates associated with eviction are not known among women living with HIV. However, the previous discussion established that people facing different forms of structural marginalization experience greater housing instability and evictions, and qualitative evidence shows that women living with HIV face inequities based on intersecting, stigmatized identities, including discrimination based on HIV-stigma, sexism, racism, homophobia, transphobia and substance use and sex work stigma (Logie et al., 2011). An exploration of eviction among women living with HIV is therefore urgently needed in order identify who may be at greater risk of eviction, and tailor eviction prevention and housing interventions. 1.6 Eviction and HIV-related syndemic outcomes The original conception of syndemic theory included substance use, violence, and HIV (SAVA) (Singer, 1996), and has continued to be the foundation of HIV-related syndemic research, 26 including among women living with HIV (Meyer et al., 2011). In a recent review, gender-based violence, substance use, and HIV infection were assessed among women living with HIV, and structural, biological and behavioural mechanisms were identified (Gilbert et al., 2015). The review found that the association between substance use and gender-based violence is bi-directional, while substance use and sexual violence are both associated with HIV (Gilbert et al., 2015). There is also evidence that syndemics among women living with HIV include both sub-optimal mental health and food insecurity. Substantial literature has documented evidence of the role of mental health within HIV-related syndemic frameworks, with a recent review of syndemic research during the COVID-19 period (2020-2021) finding that over half of the papers included considered mental health factors (Logie et al., 2022). Among women in particular, a literature review found evidence of a syndemic of HIV, intimate partner violence, and criminalized substance, and associations between these factors and sub-optimal mental health (Meyer et al., 2011). Research with women of colour living with HIV found evidence of associations between and clustering of several syndemic factors, including mental distress (Illangasekare et al., 2013). Qualitative research with women living with HIV supports these findings, as women reported synergistic effects between SAVA and depressive symptoms (Illangasekare et al., 2014). While exploratory, qualitative research has suggested that food insecurity should be considered as well (Leddy et al., 2021). Important gaps remain, including a need to understand whether structural factors, including housing instability, are associated with these syndemic outcomes. The next section summarizes the evidence for the relationship between eviction and HIV-related syndemic outcomes, as well as literature on the impact of eviction on the well-being of people living with HIV. 27 Eviction has been strongly associated with sub-optimal mental health: people who were evicted were approximately four times as likely to commit suicide, controlling for sociodemographic and mental health factors, in a study out of Sweden (Rojas & Stenberg, 2016). People who were evicted also reported more mental health concerns, even years after an eviction (Hatch & Yun, 2021). As well, mothers who were evicted reported more parenting stress and were more likely to be depressed (Desmond & Kimbro, 2015). In a systematic review, the threat of evictions, measured through mortgage and rent arrears, foreclosures, and trouble making housing payments, was associated with sub-optimal mental and physical health outcomes, such as self-reported fair or poor health, depression, anxiety, and psychological distress (Vásquez-Vera et al., 2017). Eviction has previously been associated with experiencing violence: women who experienced a landlord forced move were more likely to report IPV in a USA context (Groves et al., 2022), while another study of women sex workers in Metro Vancouver also found increased odds of IPV among those who reported an eviction (Goldenberg et al., 2023). One study of sex workers in India found that eviction was associated with sexual and physical violence (Reed et al., 2011). Eviction is associated with changing substance use patterns, as found in a qualitative study in Vancouver (McNeil et al., 2021). This included increased methamphetamine use to remain awake, decreased ability to purchase substances from trusted sellers, and increased public substance use (McNeil et al., 2021). In another Vancouver-based study, eviction was significantly associated with initiation or relapse into crystal methamphetamine use (Damon et al., 2019). Recent eviction was associated with increased syringe sharing among youth in Vancouver, BC (Pilarinos et al., 2017). At a county level in the US, areas with higher eviction rates had greater 28 mortality rates attributed to opioid, heroin, benzodiazepines, and alcohol poisonings (Bradford & Bradford, 2020). Eviction may also be associated with food insecurity, with a USA based study finding that children who were evicted as infants had higher prevalence of food insecurity at age 5 (Leifheit et al., 2020). Additionally, a study of households with young children in the USA found that households that had experienced an eviction reported significantly increased odds of household and child food insecurity (Cutts et al., 2022). However, literature on eviction and food insecurity remains limited. Emerging evidence suggests that evictions may be associated with sub-optimal clinical and health care outcomes among people living with HIV. Qualitative evidence from Vancouver, Canada suggests that evictions can lead to neighbourhood displacement, increased distance from HIV support services, and breakdowns in continuity of care among people who use substances who are living with HIV (McNeil et al., 2017). In another study from Vancouver, Canada with people who use substances who are living with HIV, eviction was associated with increased odds of detectable viral load (>50 copies of HIV-1 RNA per mL of plasma) (Kennedy et al., 2017b). The association was stronger for people who became unhoused following eviction, however, the association remained significant even for those who were able to find housing post-eviction (Kennedy et al., 2017b). This early evidence suggests that eviction may be associated with healthcare and clinical outcomes for people living with HIV with one potential mechanism being increased exposure to syndemic factors that are themselves associated with HIV related outcomes. Syndemic literature has called for the integration of structural factors into frameworks theory (Logie et al., 2022; Martínez et al., 2020; Perlman & Jordan, 2018). Syndemic studies that 29 have incorporated housing often only include housing stability as one of several syndemic measures, without interrogating housingâs relationship with other syndemic factors. A syndemic requires âsynergyâ between factors, that is, the effect of one syndemic factor along with other factors is greater together than expected when considered additively. Therefore, the relationship between housing and syndemic factors must be established before including them within indices of syndemic measures. This thesis thus not only adds an important and novel contribution to the limited literature on evictions among women living with HIV, but it also presents a unique opportunity to investigate the role of housing within a syndemic frameworks. 30 CHAPTER 2: PREVALENCE AND SOCIAL-STRUCTURAL CORRELATES OF EVICTION 2.1 Introduction Housing has been recognized as a human right, yet housing need is inequitably distributed due to existing systems of power, resources, and access to goods and services (World Health Organization, 2008, 2018). Systemic and structural factors influence the substantial housing need that women face (Parker & Leviten-Reid, 2022): in Canada, women living alone or in single-parent families report more than twice the prevalence of core housing need compared to the total population (CMHC, 2019). Housing need among women stems from poverty, inadequate levels of social assistance, poorly paid jobs, and barriers to housing services (Schwan et al., 2021). Housing stability is critical for the quality of life of people and women living with HIV (Aidala et al., 2016; Leaver et al., 2007; Milloy et al., 2012). In the current study setting, 71.7% of women living with HIV reported living in unstable housing or unsheltered at their baseline survey (Zhao et al., 2022). Women living with HIV face many structural barriers and inequities, some of which may be intersecting, including sub-optimal mental health, criminalized substance use, experiences of violence, and reliance on sex work for income (Riley et al., 2007). Research has found that women living with HIV who are experiencing housing instability report lower emotional wellness and physical health scores and more safety concerns in their living situation (Delavega & Lennon-Dearing, 2015). Eviction is a severe form of housing instability, yet no identified research has investigated the prevalence of, and social-structural correlates associated with eviction among women living with HIV. Understanding which social-structural factors are associated with higher odds of eviction can help with the design of anti-eviction policies, as well as inform housing approaches. 31 This chapter will present the prevalence of eviction in a cohort of cis and trans women living with and/or accessing HIV care in Metro Vancouver, as well as the social-structural correlates associated with eviction. Drawing on the previously detailed conceptual frameworks (Chapter 1.2 and Figure 1), alongside a comprehensive literature review, it was hypothesized that marginalized and minoritized identities (e.g., races/ethnicities, gender and sexual identities), may be associated with eviction. Additionally, people who experience systematic marginalization and stigma, including sex workers, people living with disabilities and people who use criminalized substances, and facing structural disadvantage over the life course, such as being removed from parents as a child, may experience higher odds of eviction (see Chapter 1.4). The objectives of this chapter were therefore to 1) identify the prevalence of eviction in a cohort of women living with HIV in the Metro Vancouver area and 2) identify social-structural factors hypothesized to be associated with increased odds of eviction. 2.2 Methods 2.2.1 Variables 2.2.1.1 Primary outcome variable The primary outcome variable of interest was having experienced an eviction in the last six months, measured by a âyesâ response to âevicted or forced to moveâ, for participants who responded, âyesâ to âHave you changed the main place where you live/sleep overnight in the last six months?â3 As participants are invited to interviews on a bi-annual basis, the same participant could report multiple evictions over the study period. 3 Several text responses were also included, see Appendix C for complete list. 32 2.2.1.2 Sociodemographic and explanatory variables Baseline social-structural variables measured at the first visit included: race/ethnicity (Indigenous, racialized women/women of colour and White), removed from parents as a child (having ever been taken away from biological parents by the ministry as a child, e.g. government care, foster care, residential services, âyesâ vs ânoâ), and graduated from high school (âyesâ vs ânoâ). The term Indigenous was used, recognizing this includes First Nations, Métis, and Inuit, three distinct groups of Indigenous peoples with a variety of cultures, traditions, languages, and geographical locations. In the response category of racialized women/women of colour, possible responses included Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other. While recognizing that aggregated racial/ethnic categories can mask diverse experiences, due to the small sample size of minoritized races/ethnicities, non-White and non-Indigenous responses to race/ethnicity were combined in the analysis to understand the experiences of non-Indigenous racialized participants. Sexual orientation was measured at each study visit through responses to âIn the last six months, which of the following describes your sexual orientation (check all that apply)â and categorized sexual identities of âgayâ, âlesbianâ, âbisexualâ, âasexualâ, âqueerâ, âotherâ, âTwo-Spiritâ, at any study visit as marginalized and minoritized sexual identities compared to âstraightâ at all study visits. Gender identities were measured through responses to âIn the last six months, which of the following best describe(s) your gender identity (check all that apply)â, and categorized gender identities of âtransgenderâ, âintersexâ, âtranssexualâ, âTwo-Spiritâ, âgenderqueerâ, âotherâ at any study visit as marginalized and minoritized gender identities, compared to âcisgenderâ at all study visits. Two-Spirit reflects a diversity of terms used by First Nations across Turtle Island prior to colonial contact, and refers to nuanced and specific 33 identities, roles and norms, including sexual identities, gender identities, and gender expressions (Pruden, 2019; Pruden & Salway, 2020). Only Indigenous participants were asked about Two-Spirit identity. Respondents could provide multiple answers for both gender and sexual identities. Age was measured at baseline/first interview, and then time-updated at each follow up survey. Currently parenting was asked at each study visit; this variable asks parents their relationship with their <18-year-old child, and coded âyesâ to currently parenting if the response was âHave custody and child lives with meâ. HIV stigma was measured at each study visit through two measures, both measured in the last six months, and coded as âyesâ vs ânoâ: 1) HIV status disclosure without consent (âHas anyone âoutedâ you for knowing or suspecting you were HIV positive?â); and 2) enacted verbal/physical HIV stigma (âHave you been verbally or physically abused by someone because they knew or suspected you were HIV positive?â). Sex work was defined as exchanging sex for money, goods, or services in the last six months (âyesâ vs ânoâ) and was measured at each study visit. Criminalized substance use was measured through several variables, including criminalized injection substance use and frequency (âdailyâ, âless than dailyâ, vs ânoneâ), criminalized non-injection substance use and frequency (âdailyâ, âless than dailyâ, vs ânoneâ), any criminalized injection or non-injection substance use and frequency (âdailyâ, âless than dailyâ, vs ânoneâ), and was measured at each study visit, referring to the previous six months. All criminalized substance use variables excluded cannabis, alcohol, and prescribed medications. Current physical disability was measured through the question âDo you have a physical disability that limits your mobility?â (âyesâ vs ânoâ). Experiences of discrimination, measured in reference to the last six months before each study visit, were captured using a nine-item scale adapted from Williams et al.âs Everyday Discrimination Scale (EDS) (1997), one of the most commonly used measures of discrimination 34 (Paradies, 2006). The EDS asks about respondentsâ perceptions of how others treat them, such as experiences of harassment, and poorer service, as well as perceptions of negative stereotyping, such as people believing you are dishonest or not as smart. Previous research has shown evidence of construct validity for the EDS through associations with internalizing and externalizing psychological symptoms in Black adolescents (Clark et al., 2004) and significant associations with related measures of discrimination (Krieger et al., 2005). The EDS has also been shown to have good internal reliability in studies with Black and White women in the USA (Guyll et al., 2001; Schulz et al., 2000; Troxel et al., 2003) and in USA-based studies with Black and White youth (Taylor & Turner, 2002) and Black adolescent girls (Guthrie et al., 2002). While studies examining validity have not dichotomized the scale, for this study the variable âexperienced discriminationâ was coded 'yesâ for responses of âalwaysâ, âusuallyâ or âsometimesâ to any item. This was done to reduce missingness in responses; observations that had missing responses for any of the items on the scale were considered missing, while for the dichotomized variable, observations could be included even if some scale items were missing. Cronbachâs alpha, calculated at each follow-up period, ranged from 0.88-0.95. A sub-analysis of women who reported having at least one intimate cis man partner in the last six months was conducted to examine if intimate partner violence (IPV) was associated with eviction. The World Health Organization (WHO) Intimate Partner Violence Scale, designed to capture gendered violence, particularly in developing countries, was adapted to capture responses on moderate and severe physical IPV, sexual IPV, and emotional IPV (World Health Organization, 2005). The original study showed evidence of construct validity through psychometric analysis of the physical, emotional and sexual violence measures used, and found good internal consistency among the items (World Health Organization, 2005). Moderate cis 35 man IPV included responding âyesâ to having a cis man intimate partner who âslapped you or thrown something at you that could hurt youâ, or âpushed or shoved youâ. Severe cis man IPV included responding âyesâ to having a cis man intimate partner who âhit you with a fist or with something else that could hurtâ, âkicked you, dragged you or beaten you upâ, âchoked or burnt you on purposeâ, or âthreatened to use or actually used a gun, knife, or other weapon against youâ. Sexual cis man IPV included responding âyesâ to having a cis man intimate partner who âphysically forced you to have sexual intercourse when you did not want toâ, âforced you to do something sexual that you found degrading or humiliatingâ or responding, âyesâ to âhad sexual intercourse when you did not want to because you were afraidâ. Emotional cis man IPV included responding âyesâ to having a cis man intimate partner who âinsulted or made you to feel bad about yourselfâ, âbelittled you or humiliated you in front of other peopleâ, âthreatened to hurt someone you care aboutâ, or who had âdone things to scare or intimidate you on purpose (e.g. by the way he looked at you, by yelling or smashing things)â. IPV outcomes considered were any cis man (physical, sexual, emotional) IPV (âyesâ vs ânoâ), only physical (severe or moderate) cis man IPV (âyesâ vs ânoâ), only sexual cis man IPV (âyesâ vs ânoâ), and only severe physical cis man IPV (âyesâ or ânoâ). This coding follows the approach used by the original study, which provided validity evidence (World Health Organization, 2005). However, this study also included a combined measure of any cis man violence (including physical, sexual, and emotional violence). All cis men IPV variables were measured within the past six months and asked at each follow-up visit. 36 2.2.2 Statistical analysis Descriptive statistics were calculated for the outcome (eviction) and potential explanatory variables at baseline/first interview. Univariate frequencies and proportions were calculated for categorical variables, and medians and interquartile ranges (IQR) were calculated for continuous variables. Additional descriptive statistics were calculated to describe eviction patterns, including how many people in the entire study reported at least one eviction, and how many times each person who reported an eviction experienced an eviction event. Descriptive statistics were also calculated for the IPV variables. Bivariate and multivariable logistic regression models using generalized estimating equations (GEEs) were used to examine the relationship between explanatory variables and the outcome. Standard generalized linear models (GLMs) assume that all observations are independent; however, in the SHAWNA study multiple observations may come from the same participants. A GEE approach was used to account for the dependence of observations (i.e. multiple observations from an individual are likely to be correlated with each other more than multiple observations between different individuals). GEEs approximate the group-level effect. Ongoing debate about the usefulness of p-values suggest that p<0.05 is an arbitrary cut-off, and potential associations should be assessed using background knowledge as well as statistical significance (Nuzzo, 2014). Given that the sample size was small, and all assessed associations were based on conceptual frameworks, significance for bivariate analysis was set to p<0.10 to avoid missing important associations. A full model was created with all potential variables that were significant in bivariate analysis, then backwards model selection using quasi-likelihood under the independence model criterion (QIC) was performed to identify the model that best fit the data. This approach followed a complete-case analysis and observations with 37 missing responses to any of the variables were excluded from model, under the assumption that data was missing completely at random. Unadjusted (bivariate) odds ratios (ORs) and adjusted (multivariable) odds ratios (aORs) for the relationships between each variable and the outcome in the full and final models were reported, with 95% confidence intervals (95%CIs). In the sub-analysis of the sample who reported having at least one intimate cis man partner, unadjusted (bivariate) logistic regression models using GEEs were also used to calculate unadjusted ORs and 95% CIs. Given that data was collected before and during the COVID-19 pandemic (2015-2023), a sensitivity analysis was performed to assess if rental protections enacted during the pandemic resulted in an association between pandemic time and eviction. Additionally, a sensitivity analysis was used to investigate potential differences in baseline social-structural characteristics between individuals who had at least one observation included in the final multivariable model, and those who had no observations included in the final model. See Appendix A for methods and results of the sensitivity analyses. All analyses were performed with SAS version 9.4 (SAS Institute Inc., Cary, NC). 2.3 Results 2.3.1 Sample characteristics Table 2.1 presents sample characteristics, including relevant demographic and social-structural factors of participants in SHAWNA, at baseline/first interview unless otherwise specified. Between September 2015 to September 2023, 361 women provided at least one observation to the study sample, totalling 2567 observations. There was a median of seven study visits per participant, with a minimum of one and maximum of 16 (IQR: 2-11). Median age at 38 baseline/first interview was 45 years, with a minimum age of 22 and a maximum of 67 (IQR: 38-52). Indigenous women comprised 53.5% (n=193) of the sample and were overrepresented compared to the population of Indigenous women in BC; in 2021 3.0% of the total population were Indigenous women and 5.9% of women in BC were Indigenous (Statistics Canada, 2023). Overall, 11.4% (n=41) were racialized women/women of colour and 35.2% (127) were White. Capturing fluidity in sexual and gender identities over time, 47.4% (n=171) of participants reported marginalized and minoritized sexual identities and 15.5% (n=56) reported marginalized and minoritized gender identities during the study period. Of the latter, 7.2% (n=26) identified as trans women, which included transfeminine, transgender, transexual, and intersex identities, and 2.5% (n=9) reported gender diverse identities, including non-binary and genderqueer. Among Indigenous women (n=193), 13.5% (n=26) reported being Two-Spirit. Eviction in the last six months before baseline/first interview was experienced by 3.3% (n=12) of the sample, while over the entire cohort period, 13.3% (n=48) experienced at least one eviction, resulting in a total of 66 eviction events. Of those who were evicted during the study period, 70.1% (n=34) were evicted only once and 29.2% (n=14) were evicted more than one time (Table 2.1). 39 Table 2.1 â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canada Variable Overall (n) (N=361) Missing (n) Outcome Variable Experienced an eviction a 3.3 (12) 0 Experienced an eviction, during study period f 13.3 (48) 0 1 eviction g 70.1 (34) >1 evictions g 29.9 (14) Social Structural Variables Age (median, Q1-Q3) a 45 (38-52) 0 Marginalized and minoritized sexual identities b 47.4 (171) 0 Marginalized and minoritized gender identities c 15.5 (56) 2 Race/Ethnicity 0 White 35.2 (127) Indigenous d 53.5 (193) Other racialized women/women of colour e 11.4 (41) Graduated high school 51.8 (187) 0 Sex work a 21.9 (79) 2 Removed from parents as a child 34.6 (125) 15 Currently parenting a 9.7 (35) 9 Experienced discrimination a * HIV status disclosure without consent a * Enacted verbal/physical HIV stigma a * Physical disability a 44.6 (161) 3 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other f Refers to all evictions reported over entire cohort period g Among those who reported an eviction during the study period * Variables not available/asked at baseline interviews 40 Table 2.1, continued â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canada Variable Overall (n) (N=361) Missing (n) Any criminalized substance use a 58.5 (211) 3 Frequency of any criminalized substance use a 4 Daily 27.7 (100) Less than daily 30.5 (110) Never 40.7 (147) Any non-injection criminalized substance use a 44.9 (162) 2 Frequency of non-injection criminalized substance use a 3 Daily 14.7 (53) Less than daily 29.9 (108) Never 54.6 (197) Any injection criminalized substance use a 40.7 (147) 4 Frequency of injection criminalized substance use a 5 Daily 19.7 (71) Less than daily 20.8 (75) Never 58.2 (210) a Referencing the previous six months before the first study visit 41 2.3.2 Statistical analysis results Table 2.2 presents the parameter estimates for all potential variables included in analysis. In bivariate logistic regression using GEEs, the following variables were significantly associated with increased odds of eviction at a p<0.10 level: marginalized and minoritized gender identities, sex work, being removed from parents as a child, experiencing discrimination, and all criminalized substance use variables. Age and currently parenting were significantly associated with decreased odds of eviction. In multivariable logistic regression using GEE, the analysis was restricted to complete cases only, resulting in a final model with 2083 observations and 47 eviction events. To avoid collinearity with other substance use variables, only frequency of any criminalized (injection or non-injection) substance use was included. The final model, selected using backwards model selection with QIC, included: age, marginalized and minoritized gender identities, being removed from parents as a child, experienced discrimination, and frequency of any criminalized substance use. In the final model, being removed from parents as a child (aOR: 2.11, 95%CI: 1.13-3.92) and criminalized substance use (aOR daily versus none: 3.87, 95%CI: 1.44-10.44; less than daily versus none: 2.79, 95%CI: 1.03-7.57) were significantly associated with increased odds of eviction. Age (aOR: 0.97, 95%CI: 0.94-1.01), having marginalized and minoritized gender identities (aOR: 1.73, 95%CI: 0.89-3.39) and experiencing discrimination (aOR: 1.66, 95%CI: 0.79-3.50) were not significantly associated with eviction in the multivariable model. Full model estimates are shown in Table 2.2. 42 Table 2.2 - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between social-structural variables and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Experienced an eviction Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratio [95% CIs] p-value Age (median, Q1-Q3) 0.97 [0.94-1.00] 0.021 0.97 [0.94-1.01] 0.091 Marginalized and minoritized sexual identities c 1.50 [0.82-2.73] 0.187 Marginalized and minoritized gender identities d 2.42 [1.33-4.43] 0.004 1.73 [0.89-3.39] 0.108 Race/Ethnicity a White Reference Indigenous 1.06 [0.55-2.04] 0.863 Other racialized women/women of colour 0.76 [0.21-2.78] 0.676 Graduated high school a 0.91 [0.50-1.64] 0.749 Sex work b 2.23 [1.23-4.04] 0.008 Removed from parents as a child a 1.78 [0.99-3.20] 0.054 2.11 [1.13-3.92] 0.019 Currently parenting b 0.23 [0.06-0.87] 0.031 Experienced discrimination b 2.52 [1.29-4.92] 0.007 1.66 [0.79-3.50] 0.184 HIV status disclosure without consent b 1.58 [0.73-3.39] 0.246 Enacted verbal/physical HIV stigma b 1.29 [0.53-3.13] 0.571 Physical disability b 0.96 [0.54-1.72] 0.893 a At baseline/first interview b Time updated measure, capturing events in the last six months c Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit d Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit e Indigenous includes First Nations and Métis peoples and Inuit f Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 43 Table 2.2, continued - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between social-structural variables and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Experienced an eviction Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratio [95% CIs] p-value Any criminalized substance use b 2.35 [1.20-4.60] 0.013 Frequency of any criminalized substance use b Daily 2.81 [1.35-5.86] 0.006 3.87 [1.44-10.44] 0.007 Less than daily 1.91 [0.91-4.03] 0.090 2.79 [1.03-7.57] 0.044 Never Reference Reference Any non-injection criminalized substance use b 2.56 [1.39-4.71] 0.003 Frequency of non-injection criminalized substance use b Daily 2.20 [0.95-5.14] 0.068 Less than daily 2.82 [1.53-5.18] 0.001 Never Reference Any injection criminalized substance use b 2.90 [1.55-5.43] 0.001 Frequency of injection criminalized substance use b Daily 4.11 [2.08-8.11] <0.001 Less than daily 1.99 [0.90-4.38] 0.087 Never Reference a At baseline/first interview b Time updated measure, capturing events in the last six months c Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit d Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit e Indigenous includes First Nations and Métis peoples and Inuit f Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 44 Table 2.3 shows the results of the sub-analysis of individuals who reported having a cis man intimate partner in the last six months. In total, 26 eviction events were reported in the sub-sample of 227 women. As none of the associations between IPV and eviction reached significance at p<0.10, multivariable models with these variables were not explored. 45 Table 2.3 - Baseline prevalence of intimate partner violence (IPV) by cis men, and bivariate (unadjusted, OR) odds ratios and 95% confidence intervals (95% CIs) and p-values for the relationship between IPV and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, who reported having an intimate cis man partner in the last six months, 2015 to 2023 Experienced an eviction, unadjusted Variable Overall (n) (N=227) Missing (n) Odds Ratio [95% CIs] p-value Any physical, sexual, or emotional IPV by cis man partner a 18.1 (41) 22 1.22 [0.47-3.18] 0.687 Any physical (moderate/severe) or sexual IPV by cis man partner a 7.9 (18) 22 0.46 [0.07-3.04] 0.418 Any sexual IPV by cis man partner a 2.2 (5) 22 1.28 [0.18-9.11] 0.806 Any severe physical IPV by cis man partner a 5.3 (12) 22 1.02 [0.19-5.55] 0.986 a Time updated measure, capturing events in the last six months 46 The sensitivity analysis for COVID-19 period found that the pandemic period was significantly associated with decreased odds of eviction. The sensitivity analysis assessing potential demographic differences between individuals with at least one observation included in the final model compared to those with no observations included in the final model found that participants did not have significantly different baseline responses in terms of age, sexual identities, gender identities, race/ethnicity and high school graduation. See Appendix A for complete results. 2.4 Discussion This chapter found evidence that among a cohort of women living with HIV, who already face substantial barriers to housing stability, other social-structural factors reflecting systemic and structural marginalization increased the odds of eviction. Criminalized substance use and being removed from parents as a child were both significantly associated with increased odds of eviction in the final multivariable model. Results from this thesis add to growing evidence that eviction is inequitably distributed with important implications for addressing the structural and systematic factors that increase risk of eviction among women living with HIV. There is an urgent need to address discriminatory eviction among women living with HIV, as well as prioritize housing that is supportive and accessible to a variety of needs and identities, including being trauma-informed, culturally safe and gender responsive. During the study period, 48 individuals reported an eviction, with a total of 66 eviction events reported over eight years, resulting in an eviction prevalence of 13.3% in this sample. This prevalence is similar to the five-year eviction prevalence in Vancouver, at 10.4% (Xuereb & Jones, 2023), and was lower than expected, given that women in SHAWNA face high levels of 47 social and economic marginalization. However, there may have been an underreporting of or missed eviction events, as discussed later in this chapterâs limitations. As well, women are eligible for supportive housing that is only offered to people living with HIV, which may reduce housing instability and be protective against eviction. Previous research with this cohort found that, at baseline, 11.9% of SHAWNA reported living in supportive housing (Zhao et al., 2022). Women living with HIV in Metro Vancouver are eligible for several affordable and supportive housing options (e.g. (McLaren Housing Society of British Columbia, n.d.). Research in other contexts has found that social and affordable housing providers attempt to avoid eviction, considering it the âlast resort,â (Collins et al., 2022), thus individuals in this type of housing may be less likely to experience an eviction, even if experiencing other forms of housing instability. Of those who reported at least one eviction, 29.1% experienced more than one eviction event during the study period. One eviction may precipitate future instability: Desmond et al. found that, following a forced move, renters in Milwaukee reported higher residential mobility (Desmond et al., 2015). There is evidence that individuals face higher financial insecurity following an eviction event (Collinson et al., 2024), which may make it more challenging to cover moving expenses and rent, therefore compounding financial problems that may have led to the initial eviction. Reporting daily or less than daily criminalized substance use was significantly associated with increased odds of eviction in this sample. At baseline/first interview, 58.5% of participants reported using any criminalized substances in the last six months; 44.9% used non-injection criminalized substances, and 40.7% used criminalized injection substances. Current research on eviction has identified substance use as an important risk factor for eviction (Montgomery et al., 2017; Phinney et al., 2007; Van Laere et al., 2009). In qualitative research in 48 Vancouver, BC, Fleming et al found that people who use substances were targeted for eviction with nuisance complaints (e.g. noise) and policy breaches, (e.g. improper item storage), as some of the main reasonings behind eviction filings (2019). People who use substances may be considered less desirable as tenants, based on behaviours such as the accumulation of possessions for re-sale, and entering and leaving the building at odd hours (Fleming et al., 2019), as well as the stigma that comes with substance use (Wogen & Restrepo, 2020). Therefore, tenants who do not use criminalized substances may be preferred and prioritized. In Flemingâs study, participants also noted that they were evicted for behaviours other tenants also engaged in, and others reported that building managers made up violations to be able to evict them, often with no way for tenants to refute these supposed infractions (Fleming et al., 2019). Such discriminatory building policies that allow for the targeting of people who use substances exemplify how stigma and marginalization can result in evictions and housing instability. Furthermore, people who use substances may choose to not fight evictions, viewing them as inevitable, as was found in qualitative research of women who use substances in Vancouver living in unstable housing (Collins et al., 2018). People who use substances may believe they cannot win against a landlord because of existing power structures between housing providers and marginalized tenants. These results also point to the intersection of stigmatization of people who use substances and people living with HIV, as identified in Stangl et al.,âs Health Stigma and Discrimination Framework, noting that this can result in discriminatory attitudes and prejudice, and impact the quality of life of people living with HIV (2019). People living with HIV who use criminalized substances may face intersecting stigmas due to both their HIV status and substance use. Intersectional stigma (i.e. reporting stigma due to both substance use and HIV status) was 49 associated with reduced engagement in HIV care among women living with HIV in the Ukraine (Owczarzak et al., 2023). Qualitative research has found that substance use is a coping mechanism to deal with HIV-related stigma (Regenauer et al., 2020), while stigma related to substance use is at the same time a barrier to HIV care (Batchelder et al., 2021; Regenauer et al., 2020). This chapter found that being removed from oneâs parents as a child was significantly associated with increased odds of eviction. At baseline/first interview, approximately 34.6% (n=125) of the individuals in this sample reported being removed from their parents as children. Previous research has found that children aging out of foster care face higher risks of houselessness. One midwestern USA study interviewed 732 youths in Iowa, Wisconsin, and Illinois at age 17 and then followed up over the next ten years, finding up to 46% of participants experienced being houseless at least once before age 26 (Dworsky et al., 2013). Another USA-based nationwide sample of youth who were leaving foster care (n=7082) found that by age 21, 29% had experienced being unhoused (Kelly, 2020). A USA-based longitudinal study of youth in foster care (n=8894) found that, after aging out of the system, 15.4% of former foster youth reported houselessness, compared to 8.7% of a sample matched on demographic and risk factors (Berzin et al., 2011). This study, which followed the youth for over ten years, also found that former youth in care also reported more housing moves, more public housing use, and living in lower quality neighbourhoods (Berzin et al., 2011). Youth leaving foster care may have fewer supports than their peers, and lack of adult support may be one underlying mechanism between foster care and housing instability; the strongest protective factors against houselessness in Kellyâs study was having a connection to an adult and remaining in care until age 21 (2020). Berzin et al note that foster care often focuses on promoting independence among youth to 50 prepare for adult living, while peers not in foster care remain reliant on familial support into young adulthood (Berzin et al., 2011). A life course approach can help elucidate why being removed from parents as a child, depending on the circumstances, may be a major traumatic event that may be associated with future housing instability. Experiencing disadvantage at younger ages may increase future stressors that can accumulate further disadvantage (White & Wu, 2014). Children in government care may be socioeconomically disadvantaged and/or may have faced previous traumatic experiences, such as child mistreatment, that lead to foster care and placement with different families or institutions (White & Wu, 2014). Placement in itself can be a traumatic experience associated with loss of control, unknown situations, and stress (Bruskas, 2008). Adverse childhood events can then lead to adverse outcomes in adulthood, including being unhoused (Herman et al., 1997). As well, there is evidence that unstable housing experiences such as being unhoused during childhood can influence later housing stability (Parpouchi et al., 2021). As over half of SHAWNA participants are Indigenous, these results must be interpreted in the context of the historic and ongoing intergenerational trauma of residential schools and disproportionate apprehension of Indigenous children by child welfare services. Residential schools were a tactic used by the Canadian government to separate Indigenous children from their parents and home communities with the purpose of assimilation; this process has been identified as âcultural genocideâ, (The Truth and Reconciliation Commission of Canada, 2015). The âSixties Scoopâ refers to the period in the 1960s that continued into the 1970s, when many Indigenous children were apprehended into the child welfare system where they would often be separated from their families and communities and placed with non-Indigenous families. The Final Report of the Truth and Reconciliation Commission of Canada found that residential 51 schools and the âSixties Scoopâ denied children the opportunity to experience positive parenting, with intergenerational effects. Further, life course research has noted that traumatic events can transmit health disparities across generations through different pathways, such as epigenetic, cultural and socioeconomic (Jones et al., 2019). Currently, there is in an overrepresentation of Indigenous children in government care; in BC, the rate of children in care is 34.2 per 1000 for Indigenous children compared to two per 1000 for non-Indigenous children (Ministry of Children and Family Development, 2023). Given the historical and intergenerational trauma associated with government care for Indigenous children and families, removal from parents as an Indigenous child may compound other adverse implications of government care. A scoping review of houselessness among Indigenous peoples across Canada, Australia and New Zealand identified child welfare involvement as an important contributor to future housing need, due to inappropriate, abusive or neglectful placements, isolation from culture and family, and disruption of familial structure (Anderson & Collins, 2014). Qualitative research with unhoused Indigenous youth living in Toronto, Canada (n=24) found that most youth had been in government care (e.g. foster care, group homes), with many reporting extremely negative experiences, including abuse, neglect, and racism (Baskin, 2020). Some youths were forced to leave their adoptive homes, or chose to leave because of unmanageable situations, and entered situations of housing instability and houselessness (Baskin, 2020). Using a survey of 1,081 Indigenous and 23,052 non-Indigenous individuals, another study found that Indigenous identity and involvement in child welfare were both significantly associated with odds of visible and hidden houselessness, while at the same time, Indigenous participants were more likely to have been involved in child welfare (Alberton et al., 2020). From an intersectional perspective, Indigenous identity and experience of 52 government care are intersecting micro-level factors that reflect macro-level structural forces, such as racism and colonialism (Bowleg, 2012). Several social-structural explanatory variables significant in bivariate analysis were not significant in the multivariable model, including marginalized and minoritized gender identities, experienced discrimination, and age. However, this sample was relatively small, resulting in limited power to detect statistically significant associations. Existing research shows that people with marginalized and minoritized gender identities face substantial housing discrimination, with one USA-based study of trans people (n=387) finding 9% of its sample reported losing housing or been denied housing based on their gender identity (Bradford et al., 2013); an online survey of LGBTQ community members (n=3838) in the USA found that, compared to cisgender respondents, trans respondents experienced more housing discrimination (9.2% of respondents versus 5.7%) (Kattari et al., 2016) and qualitative evidence from Vancouver of trans and Two-Spirit women accessing health and housing services who reported discrimination related to gender identity and expression (Lyons et al., 2016). Other papers exploring housing discrimination among marginalized and minoritized gender identities have found that oppressive structures such as racism, misogyny, capitalism, and transphobia can intersect to increase housing discrimination (Glick et al., 2019). While experiencing discrimination was not significantly associated with eviction in the current study, other research has found that increased everyday discrimination scores are associated with increased odds of housing instability (Priester et al., 2017). Age was also not significant in the final model; however, previous research have found that younger age is associated with eviction (Brisson & Covert, 2015; Montgomery et al., 2017; Van Laere et al., 2009). In Canada, the lowest eviction rate was found in renters older than 75 (Xuereb et al., 2021). Older age may confer greater social benefits, as seniors are often 53 eligible for housing and income assistance. For example, in BC, a substantial portion of social and affordable housing is reserved for older adults, and programs such as Shelter Aid For Elderly Renters (SAFER) provide rental assistance to low-income seniors (age 60 years+) in the private rental market (BC Housing, n.d.b). In the sub-analysis of women who reported having intimate cis-man partners, no significant associations were found between IPV and eviction. However, the sample for this analysis was small (n=227) and had few eviction events (n=24), limiting the power to detect significant associations. Previous literature has found that IPV may be associated with eviction and housing instability (Benson-Goldsmith et al., 2024; Collins et al., 2018; Pavao et al., 2007). A sensitivity analysis was performed to examine whether the COVID-19 pandemic period was associated with eviction (see Appendix A), hypothesizing that the pandemic may have had a negative association with experiencing an eviction given that increased tenant protections were enacted during this period (Hepburn et al., 2023). The analysis found that the pandemic period was significantly associated with decreased odds of eviction. However, an analysis of the point prevalence of eviction over the study period found an overall downward trend in eviction after a peak in 2016 (Figure A.2, Appendix A). While the pandemic period was hypothesized to be associated with a decrease in eviction events, evidence from the point prevalence over time suggests that the downward trend over time may be unrelated to the pandemic and pandemic housing programs. Additionally, analysis of eviction notices filed in the Metro Vancouver area during the pandemic period found that any decrease in evictions that tenants experienced was temporary and rebounded (Flynn et al., 2024). Given this evidence, pandemic period was not included in the final multivariable model. 54 This chapter has several limitations and strengths. Several measurements did not come from validated measures, however, SHAWNA developed questions in consultation with community members to understand the needs and experiences of women living with HIV. In terms of the sub-analysis of IPV among women who reported intimate cis-men partners, the analysis was restricted to a smaller sample with few eviction events, which may also have resulted in reduced power to detect significant associations. Furthermore, since only violence from intimate cis-men partners was measured, the effect of IPV perpetrated by others was not captured. Bivariate and multivariable logistic models were calculated using GEEs, which do not include observations that are missing values for any variables. Thus, even though 2567 observations were available, only 2083 were included in the final multivariable model, and some participants had no observations included in the final model. To address this potential limitation, a sensitivity analysis was performed to compare the baseline social-structural characteristics of individuals who were included to those who were not included in the final model (Appendix A), with results suggesting that the individuals who were included in the final model were similar to the overall study sample in terms of these characteristics. To conclude, this chapter found that removal from parents as a child and criminalized substance use were significantly associated with increased odds of eviction among women living with and/or accessing care in Metro Vancouver in multivariable logistic regression analysis using GEEs. The mechanisms between these social-structural correlates and eviction were discussed, reflecting intersectional stigmatization and marginalization and life course frameworks. These results underscore the importance of preventing inequitable eviction, including creating and enforcing anti-eviction policies, and providing accessible legal aid for individuals facing multiple forms of marginalization. People who use criminalized substances must be supported to access 55 and maintain stable housing. There is also an urgent need for systemic change to support families to prevent child apprehension into government care, as well as greater support for adults who have exited government care. Finally, intersectional approaches to housing solutions that account for multiple, intersecting identities and needs of individuals should be prioritized. Evidence-based recommendations are discussed in Chapter 4.2. 56 CHAPTER 3: THE RELATION BETWEEN EVICTION AND HIV-RELATED SYNDEMIC OUTCOMES OF CRIMINALIZED SUBSTANCE USE, DEPRESSION, FOOD INSECURITY AND GENDER-BASED VIOLENCE 3.1 Introduction The co-occurrence of health conditions and social and environmental factors that interact synergistically to influence health outcomes has been conceptualized as âsyndemicsâ. Syndemic theory was originally developed to understand the interaction of violence, substance use, and HIV (Singer, 1996; Singer et al., 2020). Recent research among women living with HIV has focused on the relationships between gendered violence, particularly intimate partner violence (IPV), food insecurity, mental health, and substance use, finding these factors create a âvicious cycleâ that relates to sub-optimal health management and ability to engage in HIV care (Leddy et al., 2021). Other research has found these syndemic factors to be associated with sub-optimal HIV treatment and care, including research on food insecurity (Anema et al., 2009), depression (Hartzell et al., 2008), IPV (Schafer et al., 2012), and substance use (Gonzalez et al., 2011). The relationships between HIV-related syndemic factors has been described as complex, bidirectional, and cyclical (Meyer et al., 2011). A literature review of syndemic conditions experienced by women living with HIV found that experiencing unstable living situations, including engaging in substance use, was associated with greater risk of experiencing violence (Meyer et al., 2011). At the same time, substance use was identified as a coping mechanism for dealing with sub-optimal mental health related to previous experiences of trauma or violence (Meyer et al., 2011). Qualitative research with women living with HIV found that experiencing IPV, emotions related to HIV status, and/or substance use contributed to depressive symptoms 57 (Illangasekare et al., 2014). Concurrently, women reported using substances to cope with depression (Illangasekare et al., 2014). Several syndemic studies have included housing as one of several measured variables. One study in Miami including housing instability as one item in their eight-item syndemic index, finding that as the number of syndemic index items increased, so did the odds of reduced anti-retroviral medication use, detectable viral load (â¥ 200 copies/mL), and condomless sex (Glynn et al., 2019). Another USA-based study found no association between houselessness and syndemic outcomes of unprotected sex, low self-esteem, polysubstance use, and intimate partner violence (IPV) among young, trans women (Brennan et al., 2012). Research on a proposed syndemic of criminalized opioid use and overdose, hepatitis C, and HIV identified housing as an important structural factor influencing health and in particular, opioid use (Perlman & Jordan, 2018). Increased research on the structural factors underlying syndemic frameworks, including housing, has been called for (Logie et al., 2022; Martínez et al., 2020; Perlman & Jordan, 2018) and research thus far has not examined the potential relationship between unstable housing and the syndemic outcomes of food insecurity, depression, violence, and criminalized substance use among women living with HIV. This chapter begins to address these gaps by assessing whether eviction, as a measure of severe housing instability, was associated with previously identified syndemic outcomes for women living with HIV. Drawing on a syndemic framework, the objectives of this chapter were to examine the relationship between eviction and the multiple outcomes often considered to interacting synergistically with HIV treatment and care outcomes, including gender-based violence, depression, food insecurity and substance use. 58 3.2 Methods 3.2.1 Variables 3.2.1.1 Primary outcome variables The primary outcome variables were chosen based on a literature review of HIV-related syndemic factors among women living with HIV, and all refer to answers for the previous six months (âsyndemic outcomesâ). They were: 1) gender-based violence (âyesâ vs ânoâ), 2) depression (âyesâ vs ânoâ), 3) food insecurity (âyesâ vs ânoâ), 4) criminalized stimulant use frequency (ânoneâ vs âless than dailyâ, âdailyâ), and 5) criminalized opioid use frequency (ânoneâ vs âless than dailyâ, âdailyâ). All outcome measures were asked at baseline and each follow-up visit. Gender-based violence was measured through âyesâ responses to sexual or physical violence from any perpetrator in the last six months. This included reporting violence from an intimate partner for those who reported an intimate cis man partner in the last six months, using an adapted scale from the World Health Organization Intimate Partner Scale (WHO), which was originally designed to capture gender-based violence in developing countries. Good internal consistency has been reported within the study that developed the measure, and the study authors also found evidence of construct validity using psychometric analyses of the measures (World Health Organization, 2005). Participants who reported sex work were asked if they had experienced physical or sexual violence from a client. All participants were asked if they had been physically or sexually assaulted by anyone other than their primary intimate partner or a client. Depression was measured through a three-part question that asked whether individuals had been diagnosed with, had been treated or monitored for, or had received counselling or other 59 support for depression in the last six months, restricting affirmative responses to those with symptoms that had reached clinical significance, and where the participant had been able to access medical services. Food insecurity was measured through asking participants the most common way they accessed food in the last six months, with the options of: âbought fresh groceries,â âdrop-in/free meals,â ârestaurants,â âstolen/shoplifted,â âdumpster diving.â Responses of âbought fresh groceries,â were coded ânoâ for food insecurity, while all other options were coded as âyes.â The decision to assess food insecurity through where participants most often accessed food was made to understand how housing instability affects food access patterns. Criminalized stimulant and opioid use were measured through asking which non-injection and injection substances individuals had used in the past six months, and how often each substance was used. Lists of substances were extensive, including criminalized substances, as well as diverted prescription medication, and options to report âother.â 3.2.1.2 Explanatory variable The primary explanatory variable of interest was having experienced an eviction in the last six months, measured by a âyesâ response to the question of whether the participant was evicted or forced to move, for participants who responded, âyesâ to âHave you changed the main place where you live/sleep overnight in the last six months?â.4 Eviction was measured at each visit, therefore, multiple evictions could be reported by the same individual over the study period. 4 Several text responses were also included, these are listed in Appendix C. 60 3.2.1.3 Potential confounders Potential confounders were chosen based on a literature search and hypothesized associations between eviction and the outcome variables. All regression models included self-reported race/ethnicity at baseline/first interview (âIndigenous,â, âother racialized person,â or âWhiteâ). Indigenous identity encompasses First Nations, Métis, and Inuit, recognizing that these terms refer to three distinct groups of Indigenous peoples with a diversity of languages, cultures, and geographical nations across Canada. Racialized women/women of colour included Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other. Given the small sample size of participants of individual races/ethnicities, non-White and non-Indigenous responses were combined in analysis to understand the experience of non-Indigenous racialized participants. Conceptually, race/ethnicity was chosen as a confounder due to historical and ongoing systemic racism in Canadian institutions (Dryden & Nnorom, 2021), which is reflected in disparities related to housing (Choi & Ramaj, 2023; Graetz et al., 2023) as well as social and structural factors of food insecurity (Bowen et al., 2021), substance use (Gerrard et al., 2012) and violence (Cho, 2012; Sheats et al., 2018). Other social-structural variables were, as suggested by the literature, included im/migrant status (Erickson et al., 2020), graduation from high school at (Phinney et al., 2007) and having ever been removed from parents as a child (Kelly, 2020; Koegel et al., 1995), with all of these variables measured at baseline/first interview. Additional variables measured marginalized and minoritized sexual identities (i.e., as âgay,â âlesbian,â âbisexual,â âasexual,â âqueer,â âother,â âTwo-Spirit,â at any follow-up survey in the study as compared to âstraightâ at all study follow-ups) and marginalized and minoritized gender identities (i.e., âtransgender,â âintersex,â âtransexual,â âTwo-Spirit,â âgenderqueer,â âotherâ at any follow-up survey in the study as compared to âcisgenderâ at all study follow-ups). Given the 61 variety of cultures and languages among Indigenous peoples across Canada and Turtle Island, the term Two-Spirit is a way to describe oneself as well as a community organizing tool for Indigenous peoples who have diverse sexual identities, gender identities, and gender expressions (Pruden, 2019; Pruden & Salway, 2020). Prior to colonial contact, Indigenous peoples had nation-specific, nuanced gender identities and sexual identities; the term Two-Spirit thus refers to a variety of nation-specific roles. Participants could provide multiple answers for sexual and gender identities. As there were small sample sizes of respondents in these categories, participants who reported non-heterosexual sexual identities at any study visit were combined in modelling into one variable, and participants with non-cisgender identities at any study visit were also combined. Research has found that minority stress may impact both people with marginalized and minoritized sexual (Meyer, 2003) as well as marginalized and minoritized gender (Tan et al., 2020) identities relative to heterosexual and cis people respectively, which may be due to stigma and discrimination. People with marginalized and minoritized sexual and gender identities report elevated rates of housing need related to stigma (Bradford et al., 2013; Glick et al., 2019) as well as greater food insecurity (Gibb et al., 2021; Henderson et al., 2019), substance use problems (Connolly & Gilchrist, 2020; Mereish, 2019), mental health conditions (Pinna et al., 2022; Plöderl & Tremblay, 2015) and elevated risk of experiencing violence (Edwards et al., 2015; Stotzer, 2009) suggesting gender and sexual identities may be confounders. Other confounders included age, which was asked at baseline/first interview and then time-updated, and main source of income in the last six months, measured at each visit (âsex work,â âformal employment,â and âunemploymentâ) (Tsai & Huang, 2019). HIV stigma, measured at each visit in reference to the last six months, was assessed with a 9-item stigma 62 scale, adapted from Wright et al.âs 10-Item Brief HIV Stigma Scale (Wright et al., 2007). This scale included social attitudes, disclosure concerns , personalized stigma, and negative self-image, and was included based on its hypothesized relationship with both eviction and assessed outcomes (Hatzenbuehler et al., 2013). Previous research provides evidence of internal consistency and validity for the adapted 9-item HIV Stigma Scale for youth living with HIV, based on Wright et al.âs 10-Item Brief HIV Stigma Scale (Wright et al., 2007). Cronbachâs alpha for the 9-item HIV Stigma Scale, calculated at each follow-up period, ranged between 0.78-0.89. For the outcome of food insecurity, the additional confounder of parenting was identified as being associated with both eviction (Desmond & Gershenson, 2017; Graetz et al., 2023) and food insecurity (Bekele et al., 2018; Furness et al., 2004). A variable for âcurrently parenting,â was measured at each visit by asking parents their relationship with their <18-year-old child, with responses coded as âyesâ if the individual reported that they âHave custody and child lives with meâ. 3.2.2 Statistical analysis Descriptive statistics were calculated for the explanatory (eviction), confounders, and outcomes (syndemic) measures at baseline, including univariate frequencies and proportions for categorical variables, and medians and interquartile ranges (IQR) for continuous variables. Bivariate logistic regression models using generalized estimating equations (GEEs) were used to model the relationship between eviction and the outcome variables. GEEs were used to account for the non-independent nature of longitudinal data from the same respondents, as the same individual could contribute multiple observations over the study period, resulting in potential unmeasured correlation. Multivariable logistic regression models with GEEs were used 63 to assess the association between eviction and each syndemic outcome with a p-value of <0.10 in bivariate logistic regression with GEEs. For the outcomes with ordered categories (criminalized stimulant and opioid use), bivariate and multivariate ordinal logistic regression with GEEs was used. Observations with missing responses to variables were excluded from analysis, under the assumption stipulated in GEE analysis of data missing completely at random (i.e. complete-case analysis). Odds ratios (ORs), adjusted odds ratios (aORs), and 95% confidence intervals (95%CI) were calculated from these models. A sensitivity analysis was performed to assess the effect of including ârestaurantsâ within the secure food category for the food insecurity variable. Additionally, a sensitivity analysis was used to investigate potential differences in baseline socio-demographic characteristics between individuals who had at least one observation included in the final multivariable models, and those who had no observations included in the final models. See Appendix B for methods and results of the sensitivity analyses. Analyses were performed in SAS (version 9.4; SAS Institute Inc., Cary, NC) software. 3.3 Results 3.3.1 Sample characteristics Baseline socio-demographic characteristics are previously described in Chapter 2.3.1 and are reported in Table 3.1. In terms of HIV-related syndemic outcomes, at baseline/first interview and considering the previous six months, 42.2% (n=145) of women reported having insecure access to food, 29.4% (n=101) reported (diagnosis of, treatment or monitoring for, or counselling for) depression, and 14.2% (n=49) of women had experienced gender-based violence. Most women reported no criminalized opioid use in the last six months at baseline/first interview (62.2%, 64 n=214), while 17.2% (n=59) reported daily use and 20.1% (n=69) reported less than daily use. Referring to the previous six months, just over half of women had not used any criminalized stimulants (50.6%, n=174) at baseline/first interview, while 19.2% (n=66) had used criminalized stimulants daily and 29.1% (n=100) had used criminalized stimulants less than daily. 65 Table 3.1 â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canada Variable Overall (n) (N=344) Missing (n) Explanatory Variable Experienced an eviction a 3.3 (12) 0 Confounders Age (median, IQR) 45 (38-52) 0 Marginalized and minoritized sexual identities b 47.4 (171) 0 Marginalized and minoritized gender identities c 15.5 (56) 2 Race/Ethnicity 0 White 35.2 (127) Indigenous d 53.5 (193) Other racialized women/women of colour e 11.4 (41) Im/migrant to Canada 12.2 (44) 0 Graduated high school 51.8 (187) 0 Employment a 13 None/informal 66.5 (207) Sex work 25.2 (55) Legal/formal 14.7 (53) Removed from parents as a child 34.6 (125) 15 Currently parenting a 9.7 (35) HIV Stigma * a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other * Variable not available/asked at baseline interviews 66 Table 3.1, continued â Baseline social-structural characteristics among a sample of 361 women living with HIV in Metro Vancouver, Canada Variable Overall (n) (N=344) Missing (n) Syndemic Outcomes Food insecure a 40.7 (152) 5 Criminalized opioid use a 4 Daily use 18.6 (67) Less than daily 18.0 (65) None 62.3 (225) Criminalized stimulant use a 4 Daily 18.3 (66) Less than daily 31.9 (115) None 48.8 (176) Depression a 21.9 (79) 3 Gender-based violence a 12.7 (46) 31 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other * Variable not available/asked at baseline interviews 67 3.3.2 Statistical analysis results Tables 3.2a-e present bivariate (unadjusted) and multivariable (adjusted) odds ratios from logistic regression models. In bivariate logistic regression using GEEs, at a p<0.10-level, eviction was significantly associated with gender-based violence (OR: 2.38, 95%CI [1.21-4.66]), food insecurity (OR: 1.97, 95%CI [1.16-3.33]) and depression (OR: 1.81, 95%CI [1.08-3.03]. In bivariate ordinal logistic regression with GEEs, for women who were evicted, the unadjusted odds of increased frequency of criminalized stimulant substance use was 2.73-times greater (95%CI: [1.59-4.68]) than for women who were not evicted, holding all other variables constant, and the unadjusted odds of increased frequency of criminalized opioid substance use was 2.69-times greater for women who were evicted than those who were not (95%CI: [1.53-4.74]). In multivariable logistic and ordinal regression using GEEs, analysis were restricted to complete cases only, which resulted in a decrease from 2567 available observations to 1814 used in the model with depression as the outcome, 1793 used in the model with criminalized opioid use as the outcome, 1790 used in the model with criminalized stimulant use as the outcome, 1789 used in the model with food insecurity as the outcome, and 1702 used in the model with gender-based violence as the outcome. In multivariable analysis, eviction was significantly associated with depression (aOR: 2.07, 95%CI: [1.15-3.74]), as measured by diagnosis of, treatment or monitoring for, or counselling for depression. The adjusted odds of increased frequency of criminalized stimulant substance use was 2.56-times greater (95%CI: [1.26-5.16]) for women who were evicted than women who were not evicted, and the adjusted odds of increased frequency of criminalized opioid substance use was 2.03-times greater (95%CI: [1.03-4.03]) for women who were evicted than women who were not evicted. In multivariable logistic regression using GEE, experiencing 68 eviction was no longer significantly associated with gender-based violence (aOR: 1.80, 95%CI: [0.86-3.76]) and food insecurity (aOR: 1.52, 95%CI: [0.94-2.44]). 69 Table 3.2a - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of gender-based violence in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Gender-based violence Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratioa [95% CI] p-value Eviction, last six months 2.38 [1.21-4.66] 0.012 1.80 [0.86-3.76] 0.120 a Adjusted for age, HIV stigma, marginalized and minoritized sexual and marginalized and minoritized gender identities, race, removed from parents, graduated high school, employment, and im/migrant to Canada Table 3.2b - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of depression in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Depression Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratioa [95% CI] p-value Eviction, last six months 1.81 [1.08-3.03] 0.025 2.07 [1.15-3.74] 0.016 a Adjusted for age, HIV stigma, marginalized and minoritized sexual and marginalized and minoritized gender identities, race, removed from parents, graduated high school, employment, and im/migrant to Canada Table 3.2c - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of food insecurity in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Food insecurity Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratioa [95% CI] p-value Eviction, last six months 1.97 [1.16-3.33] 0.012 1.52 [0.94-2.44] 0.085 a Adjusted for age, HIV stigma, marginalized and minoritized sexual and marginalized and minoritized gender identities, race, removed from parents, graduated high school, employment, im/migrant to Canada, and currently parenting 70 Table 3.2d - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized opioid use in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Criminalized opioid use Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratioa [95% CI] p-value Eviction, last six months 2.69 [1.53-4.74] <0.001 2.03 [1.03-4.03] 0.042 a Adjusted for age, HIV stigma, marginalized and minoritized sexual and marginalized and minoritized gender identities, race, removed from parents, graduated high school, employment, and im/migrant to Canada Table 3.2e - Bivariate (unadjusted, OR) and multivariable odds ratios (adjusted, aOR) and 95% confidence intervals (95% CIs) and p-values for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized stimulant use in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Criminalized stimulant use Unadjusted Adjusted Odds Ratio [95% CI] p-value Odds Ratioa [95% CI] p-value Eviction, last six months 2.73 [1.59-4.68] <0.001 2.56 [1.26-5.16] 0.009 a Adjusted for age, HIV stigma, marginalized and minoritized sexual and marginalized and minoritized gender identities, race, removed from parents, graduated high school, employment, and im/migrant to Canada 71 The sensitivity analysis to assess the effect of including ârestaurantsâ within the âsecureâ category of food insecurity found that when ârestaurantsâ was included, eviction was still significantly associated with food insecurity in bivariate analysis (OR: 2.03, 95%CI [1.20-3.43]), with an effect size difference between the two models of 3.1% (See Appendix B). The sensitivity analyses to assess potential differences between individuals with at least one observation included in each of the final models compared to those with no observations in the final models found no significant (at p<0.10) differences across all models for age, marginalized and minoritized gender identities, race/ethnicity and being removed from parents as a child. In all models, compared to being missing from the final multivariable models, those who were included had a significantly lower prevalence of graduating high school at baseline. In the final multivariable model where depression was the outcome, those who were included in the final model had a significantly lower prevalence of being an im/migrant to Canada, and in the final model were criminalized opioid use was the outcome, those who were included in the final model had a higher prevalence of reporting marginalized and minoritized sexual identities. See full results in Appendix B. 72 3.4 Discussion This chapter examined the association between eviction and HIV-related syndemic outcomes, finding that eviction was associated with depression and increased frequency of criminalized stimulant and criminalized opioid use. This research advances an understanding of the role of housing instability in an HIV-related syndemic among women living with HIV. These findings have important implications for the urgent need to address evictions among women living with HIV, and to consider including eviction within future syndemic studies. In multivariable logistic regression using GEEs, eviction was found to be significantly associated with depression. One study using data from the 2012 Canadian Community Health Survey Mental Health found that 4.6% of the population of BC reported major depressive disorder in the past year (Palay et al., 2019). In comparison, women in the SHAWNA study reported high prevalence of depression: at baseline/first interview, 21.9% of participants reported depression in the last six months. As depression was measured by a diagnosis of, treatment or monitoring for, or counselling for depression, the true prevalence of individuals with depressive symptoms is likely underestimated. The association between recent eviction and depression builds on previous work focusing on depression in HIV-related syndemic research among women living with HIV (Illangasekare et al., 2013, 2014; Leddy et al., 2021). Previous studies have found links between eviction, or the threat of eviction, and depression (Acharya et al., 2022; Hatch & Yun, 2021; Qvarfordt Eisenstein, 2016; Vásquez-Vera et al., 2017). One study found that even when controlling for demographic, socioeconomic and health factors, eviction was associated with suicide (Rojas & Stenberg, 2016). Eviction may cause a sense of grief and loss, and increase stress (Chisholm et al., 2022). Research suggests that eviction may act like other disruptive life events, such as sudden unemployment, financial loss, the death of a loved 73 one, or a family memberâs imprisonment (Qvarfordt Eisenstein, 2016). It has been hypothesized that the sense of loss associated with eviction â both material as well as the disturbance of familiarity and identity, coupled with a sense of defeat â makes eviction a disruptive life event that acts as a mechanism to depression (Qvarfordt Eisenstein, 2016). Eviction was significantly associated with increased criminalized opioid use frequency and increased criminalized stimulant use frequency. A different study of the same cohort found that the unadjusted odds of criminalized stimulant and criminalized opioid use was associated with being unsheltered, in unstable housing, or in supportive housing (Zhao et al., 2022). Eviction has been associated with increased public substance use and more polarized substance use patterns (McNeil et al., 2021). People who use substances who are evicted may relapse into or initiate criminalized stimulant use (Damon et al., 2019). Criminalized opioid use has previously been associated with unmet housing need. Unhoused as compared to housed veterans are more likely to report opioid use disorder, as found in an American study (Manhapra et al., 2021). Another study found that unhoused individuals had greater odds of opioid-related emergency department visits and overdose events compared to housed individuals, controlling for age, sex, race, and insurance type (Yamamoto et al., 2019). In terms of mechanisms, some qualitative work has suggested that substances may be used as a coping mechanism to attenuate mental health impacts of food insecurity and violence (Leddy et al., 2021); similarly, they may be used to cope with eviction and housing instability. For those who are evicted into houselessness, stimulants may be used to remain awake and alert when unsheltered (Damon et al., 2019; McNeil et al., 2021). In other contexts, criminalized opioids have been reported as particularly desirable for their emotionally analgesic and dissociative effects (Somer, 2005; Somer, 2019). 74 This chapter found significant direct bivariate associations between eviction and food insecurity and gender-based violence, but these associations were no longer significant in multivariable analysis. However, the small sample size may have underpowered the analysis, resulting in significant associations being missed. Gender-based violence was measured through reporting physical or sexual violence from any perpetrator rather than exclusively IPV, as restricting the analysis to only respondents with intimate partners would substantially reduce sample size, however, previous research has found IPV to be associated with housing instability (Breiding et al., 2017) and eviction (Goldenberg et al., 2023; Groves et al., 2022; Schwab-Reese et al., 2016). Existing research on food insecurity has found a consistent relationship between food insecurity and housing instability, with research identifying material hardship as the common cause (King, 2016; Lee et al., 2021). The results of this chapter should be considered in relation to several strengths and limitations. While some measures included in this study have been assessed for evidence of construct validity (HIV stigma scale, WHO Intimate Partner Scale), this research comes from dissimilar samples and contexts. These measures, and others which were not assessed for reliability and validity, may not have accurately captured variables of interest. However, overall, questions in SHAWNA were developed in consultation with community members to appropriately assess the experiences of women living with HIV. Depression was measured by asking if participants had received a diagnosis of, treatment or monitoring for, or counselling for depression in the last six months. Thus, participants who had symptoms of depression but who did not have access to care or who were been mis/underdiagnosed were not included in this measure, likely resulting in the under-reporting of depression. Food insecurity was assessed through reporting the most commonly accessed food source, with anything other than buying 75 fresh groceries considered food insecure to understand changing food access patterns. However, this is a novel measure of food insecurity and has not been validated. A sensitivity analysis was conducted to assess to effect of inclusion of ârestaurantsâ within the food secure access (Appendix B). Given the negligible difference found, and based on conceptual understanding and previous literature, ârestaurantsâ was excluded from the food secure category for the multivariable model. In multivariable logistic and ordinal logistic regression using GEEs, analysis was restricted to cases with complete data only, resulting in a reduced total number of observations used, and fewer individuals who had at least one observation included in the final models. To address this limitation, analyses were performed to compare baseline social-structural characteristics of individuals who were included and who were not included in the final models (Appendix B). There is some evidence that individuals who were not included in the final models were different on several key social-structural characteristics (Tables B.1-5, Appendix B). However, overall, results suggest that the individuals who had at least one observation included in the final models were similar to those who were not included. In conclusion, this chapter examined the association between eviction and the HIV-related syndemic outcomes of criminalized substance use, depression, gender-based violence, and food insecurity, in the context of overarching social and structural marginalization experienced by women living with HIV. In multivariable logistic regression analysis using GEEs, eviction was significantly associated with increased odds of depression and increased frequency of criminalized opioid and stimulant use among women living with HIV in Metro Vancouver. These results add to HIV-related syndemic literature by providing the first analysis of eviction within a syndemic framework, and filling gaps in the literature of structural factors (Logie et al., 2022). Addressing eviction among women living with HIV will require improved 76 housing solutions and protections within the housing system, as well as providing additional support for women at risk of, or who have recently experienced eviction. Recommendations based on these results and interpretations are discussed in Chapter 4.2. 77 CHAPTER 4: DISCUSSION AND CONCLUSION 4.1 Summary of findings There is limited research on eviction among women living with HIV, despite the importance of housing for the well-being of people living with HIV (Aidala et al., 2016; Leaver et al., 2007; Milloy et al., 2011), and evidence that women in Canada face substantial housing need (CMHC, 2019; Schwan et al., 2021). This research filled an important gap in knowledge by investigating eviction among women living with HIV in Metro Vancouver, BC, a setting which has the highest overall eviction rate in Canada (Xuereb & Jones, 2023). Drawing on the Health Stigma and Discrimination framework (Stangl et al., 2019), intersectionality frameworks (Crenshaw, 1989, 1991; Logie et al., 2011), and life course approaches (Jones et al., 2019), this research explored whether some women living with HIV are at a greater risk of experiencing eviction based on structural and systemic marginalization, including according to race/ethnicity, gender and sexual identities, criminalized substance use, sex work, physical disability, being removed from parents, and experiencing discrimination and HIV stigma. Additionally, this research investigated whether eviction was associated with outcomes identified as HIV-related syndemic factors among women living with HIV, including food insecurity, gender-based violence, sub-optimal mental health, and criminalized opioid and stimulant use. Drawing on data from a study with women living with HIV, two objectives were achieved in this thesis: 1) examining the prevalence and social-structural factors associated with eviction (Chapter 2), and 2) exploring the association between eviction and HIV-related syndemic outcomes (Chapter 3). Chapter 2 found that approximately 13.3% (n=48) of the study population experienced an eviction, resulting in 66 eviction events over nine years, and that several participants experienced 78 more than one eviction during this time. Criminalized substance use and being removed from parents as a child, both social-structural factors that reflect broader structural marginalization and stigmatization, were significantly associated with increased odds of eviction. Drawing on life course approaches, the discussion explored how traumatic events that may lead to government care, the stress associated with being removed from your parents, and reduced access to familial or adult support in the transition to adulthood can impact future housing instability. From an intersectional perspective, women living with HIV who use substances may face compounding substance use and HIV-related stigmatization that lead to housing discrimination and eviction. Chapter 3 measured the association between eviction and HIV-related syndemic outcomes of food insecurity, depression, gender-based violence, and criminalized opioid and stimulant use, finding significant bivariate associations for all variables. Eviction was significantly associated with increased odds of depression and both criminalized substance use outcomes in multivariable analysis. Eviction has been reported to cause grief, a sense of loss, and greater stress (Chisholm et al., 2022); therefore, eviction may act like other sudden, traumatic events in a personâs life to precipitate depression (Qvarfordt Eisenstein, 2016). In terms of criminalized substance use, eviction may lead to increased substance use as a coping or survival mechanism following an eviction (Damon et al., 2019; McNeil et al., 2021). This final chapter discusses solutions to address evictions among women living with HIV, including recommendations for preventing evictions due to non-payment of rent, as well as âno-faultâ evictions, providing additional support to people who are using substances and those who have been in government care, improving the housing supply for diverse needs and preferences, and identifying and providing support for those who are at risk of being, or who have recently 79 been evicted. This chapter also discusses overall study strengths and limitations as well as future directions for research based on the findings of this thesis. 4.2 Recommendations Recommendations based on the results of this study include measures to prevent evictions related to financial need, as well as âno-faultâ evictions. Specific recommendations for women living with HIV who have been in government care and use criminalized substances are discussed. Strategies to improve the supportive housing stock to meet the needs of people facing multiple forms of structural marginalization are explored. Finally, contact points for reaching women at risk of or who may have recently experienced eviction are discussed. Where relevant, recommendations will be tied to experiences women have that specifically relate to living with HIV; however, women living with HIV in our study and other settings experience multiple forms of social and structural marginalization, including financial insecurity, racism and discrimination based on sexual and gender identities, and stigmatization based on sex work, HIV status, and substance use. An HIV diagnosis and challenges and opportunities related to living with HIV sits at the intersections of these multiple forms of marginalization. Thus, many of the recommendations, even if not specifically linked to living with HIV, may be critically important to support housing stability among women living with HIV. 4.2.1 Preventing eviction Evictions occur for a variety of reasons. Landlords may file an eviction notice when a tenant fails to pay rent, does not pay in full, or has damaged the property, among other reasons (Residential Tenancy Act, 2002). Additionally, landlords may give âno-faultâ eviction notices if they or a close 80 family relative wish to occupy the unit themselves, or if they plan to renovate, sell, demolish, the unit, or convert to strata or cooperative housing (Residential Tenancy Act, 2002). While much harder to track, evictions may also happen informally, when a tenant leaves a unit outside of the formal or legal process. Informal evictions can include the landlord asking a tenant to leave, increasing the rent beyond what a tenant can afford, refusing to complete needed repairs, or when a landlord harasses, bullies or intimidates a tenant (Zell & McCullough, 2020). The current study was not able to assess the type of eviction or forced move experienced by participants. However, many women living with HIV, including in our study setting, face substantial economic marginalization, suggesting that they could be at risk for evictions stemming from non-payment of rent. These types of evictions can be addressed through programs to provide emergency financial support, and longer-term financial management programs. Concurrently, the Metro Vancouver context reflects growing financialization of the rental market, which has resulted in a high proportion of âno-faultâ evictions. Individuals living in neighbourhoods that typically offered housing at low rents are now facing gentrification and rapidly increasing rents. These include women living with HIV in this thesisâ context, who may be at risk of eviction due to these economic forces. Vacancy controls can help reduce incentives to evict tenants, as well as programs to protect tenants from bad-faith evictions. Finally, the provision of free legal advice and aid can support individuals to understand their legal rights as a tenant, and challenge eviction notices. 4.2.1.1 Addressing eviction related to non-payment of rent One of the main reasons renters face evictions is due to non-payment of rent. A systematic review of ten papers on factors associated with eviction found that 60% of the studies reported 81 financial hardship and low-income contributed to eviction risk (Tsai & Huang, 2019). Data from the US Census Bureau found that the average annual eviction rate declines as income increases (Graetz et al., 2023). In the current study, participants faced substantial economic instability which may affect the ability for individuals to pay rent. At baseline, 15.2% of respondents reported sex work (n=55) and 66.5% informal employment/unemployment (n=240) as their main source of income. Furthermore, eviction filings for non-payment of rent result in eviction in the majority of cases: in Metro Vancouver, an examination of eviction filings between 2010 and 2022 found that that 75.1% of eviction filings by landlords against tenants for non-payment of rent or utilities resulted in an eviction decision (Flynn et al., 2024). Thus, solutions for addressing financial causes of eviction are needed. 4.2.1.1.1 Emergency financial aid When a large or unexpected financial expense presents itself, low-income households may struggle to afford rent (Desmond, 2012). One strategy is to provide emergency financial support (Holl et al., 2016), which is directed at tenants and usually occurs when an individual is under immediate threat of eviction (Brennan, 2020; Zell & McCullough, 2020). Emergency financial aid can be provided through loans, usually interest-free and sometimes forgivable, or in the form of grants (Zell & McCullough, 2020). Several programs available to residents in Metro Vancouver offer emergency rental supplements. For recipients of some types of welfare in BC (including disability and income assistance), a crisis supplement is available to cover one-time unexpected financial crises (Government of British Columbia, 2024a). These unexpected circumstances can include sudden illnesses, high utility bills, or a roommate moving out without warning (Government of British 82 Columbia, 2024a). Another program, the Vancouver Rent Bank, provides interest-free loans for those who are at imminent risk of eviction because of temporary financial hardship, however, applicants must be able to prove that they will be able to continue to pay their rent, and are ineligible if they live in subsidized housing (NICCSS, n.d.). While these programs offer needed financial support for tenants in crisis, households must meet stringent eligibility criteria to qualify for them, and in some cases, must repay the money received, which may be a challenge for those already facing economic uncertainty. These programs also operate on a one-time basis, with the expectation that individuals will be financially stable in the long-term (Zell & McCullough, 2020). However, given the high prevalence of financial insecurity reported in our cohort, repayment of loans may be unfeasible (e.g. 86.9% of this studyâs cohort receive income or disability assistance, therefore their income is fixed). Programs offering emergency financial aid should be expanded and consider moving to grant-based rather than loan-based methods or incorporate forgivable loans. Furthermore, emergency financial aid must be coupled with longer-term, comprehensive support to be effective (Zell & McCullough, 2020). 4.2.1.1.2 Rent supplements Many tenants spend a large proportion of their monthly income on housing. For example, in Vancouver, at least 22.6% of renters are in unaffordable housing, defined as paying 30% or more of their income on housing, while 33.6% of women living alone, and 51.4% of women-led single parent households are in unaffordable housing (CMHC, 2020). Providing supplemental rental assistance has been previously identified as an eviction prevention strategy as these programs 83 can help reduce the burden of paying for housing, reduce the chances of falling behind on rent, and help avoid eviction due to rental arrears (Brennan, 2020). There are currently several programs in place in BC to provide ongoing rental assistance. The provincial government provides rental assistance for low-income households through the Rental Assistance Program (RAP) and the Shelter Aid for Elderly Renters (SAFER) programs (BC Public Service, 2022). These subsidies provide a variable contribution to monthly shelter costs, depending on income, rent and where in the province the applicant lives. However, both programs only apply to those renting in the private market, and have stringent requirements, including not receiving several forms of government welfare. In the case of RAP, the applicant must have at least one dependent child, while to qualify for SAFER, the applicant must be over 60 years of age (BC Public Service, 2022). Another program, the Canada-BC Housing Benefit, provides housing benefits, based on available funding, to recipients identified within a registry of subsidized housing applicants as priority groups for housing support (BC Housing, n.d.a). Expanding the available rental assistance programs would allow more individuals to access them. For example, at baseline, the median age of women living with HIV in the SHAWNA study was 45, while only 9.7% of respondents were currently parenting, suggesting that many individuals in SHAWNA would not qualify for either RAP or SAFER. The Canada-BC Housing Benefit is only offered to individuals identified as having high need and cannot be applied to. While these programs are important, many individuals struggling to make monthly rent payments may not be able to benefit from them, thus, policymakers should expand rental assistance programs to include a greater proportion of tenants. Following from this thesisâ results, programs could be tailored to reach women living with HIV with marginalized and 84 minoritized gender identities, who are engaged in sex work, who have experience with government care, and/or who use criminalized substances. 4.2.1.1.3 Financial management Another important support to avoid rental arrears and address eviction based on non-payment of rent may be through financial management, such as enabling automatic rental payments. Third-party financial management, or automatic rental payments, is a situation in which a tenantâs rent is automatically withdrawn and paid to the landlord or housing provider (Zell & McCullough, 2020). In qualitative research with social housing providers and tenants in Alberta, pre-authorized withdrawals were identified as particularly important for avoiding eviction (Collins et al., 2022). Many individuals in SHAWNA receive either income assistance or disability assistance from the provincial government (86.9%), both of which include shelter allowances. Automating these payments to landlords can increase housing instability and help prevent rent arrears. In terms of policymaking, while social housing may be amenable to working directly with tenants to set up automatic payment systems, future policy work should consider the feasibility of introducing a program to allow private landlords to set up similar systems with tenants. 4.2.1.2 â Addressing âno-faultâ eviction Despite the importance of providing financial assistance and management to tenants who struggle to pay rent, evictions related to rent arrears continue to make up a small proportion, approximately 5.5%, of overall eviction filings in Canada (Xuereb & Jones, 2023). In BC, approximately 85% of evictions in the past five years were âno-faultâ evictions, compared to a 85 nationwide average of 65% (Xuereb & Jones, 2023). While the reasons behind eviction events was not recorded in the data used, given the widespread reports of âno-faultâ evictions, women living with HIV in this context are also likely at risk of this type of forced move. One cause of âno-faultâ evictions is financialization. Financialization of the rental market refers to the transformation of rental properties into investment products for private individuals or corporations (August, 2022). As housing becomes assets, profits are prioritized over other housing goals, such as affordability or building quality (August, 2022). Currently, approximately 20% of Canadaâs purpose-built rental properties are owned by financial firms (August, 2022). In the Vancouver context, a 2017 report found that 55% of the SRO stock5 in the city were owned privately (City of Vancouver, 2017), which may place this type of low-income housing at risk of the forces of financialization. To address the proliferation of âno-faultâ evictions motivated by financial incentives, policies to establish vacancy control and monitor dishonest âno-faultâ evictions are needed. 4.2.1.2.1 Vacancy control Deregulation of rent controls in Canada occurred throughout the 1980s and 1990s (August, 2022). An important form of rent control, vacancy control, regulates the increase in rent that can occur when a tenant leaves a unit (August, 2022). In BC, legal rent increases are allowed every year, with a limit set by the Residential Tenancy Branch (RTB) (Government of British Columbia, 2024c). The 2024 rent increase limit was 3.5%, while in 2023 the limit was 2%, in 2022 the limit was 1.5% and no increase was allowed during 2021 (Government of British Columbia, 2024c). However, rent controls extend only as long as a tenant remains in a unit, so 5 SROs are rental units that share bathrooms and kitchens and have historically provided affordable housing to low-income tenants (City of Vancouver, 2020). 86 when a renter vacates a property, a landlord is able to list the property at what the market will bear (First United, 2023; Geddes & Holz, 2024). High housing prices in BC thus provide an incentive for private landlords to evict current tenants in order to increase rents or sell the unit or building (Xuereb & Jones, 2023, Flynn et al., 2024), resulting in high tenant turnover (August & Walks, 2018; Geddes & Holz, 2024). Recent policy amendments have begun to establish vacancy control in SROâs located in Vancouverâs Downtown Eastside (DTES), a low-income area (City of Vancouver, n.d.). Approximately 30.7% of individuals in SHAWNA live in Vancouverâs DTES because of the high concentration of community-based health services, including health providers who are familiar with HIV (Zhao et al., 2022). However, rents have increased steadily over the years, with 86% of SRO units renting in 2009 for 450$ and under, while only 35% of units rented at 450$ and below in 2019 (City of Vancouver, 2020). Approximately 60% of SRO residents in 2019 were receiving income assistance, with a monthly shelter portion set at 375$, suggesting that SROs are becoming increasingly unaffordable for low-income tenants. The new policy introduced by the City of Vancouver limits the amount rent may increase following a tenancy turnover, depending on the cost of room, for example, rooms renting at or above $500 are limited to inflation (City of Vancouver, n.d.). While this policy is a promising first step, vacancy control should be expanded to other forms of rental housing to reduce housing providersâ incentives to evict tenants. 4.2.1.2.2 Tenant protections against dishonest evictions While there is financial incentive for tenant turnover to increase rental revenue, landlords may dishonestly use eviction mechanisms (Zell & McCullough, 2020). Previous work identified ârenovictionsâ, the legal eviction of tenants in order to upgrade units (Zell & McCullough, 2020), 87 as a serious threat to tenants (British Columbia Rental Housing Task Force, 2018). In response, the BC government increased the documentation needed to evict tenants to perform renovations, resulting in a substantial decrease of eviction for renovation (First United, 2023). However, since this change, there is emerging reports of increased âno faultâ evictions for âlandlordâs useâ. Landlords are legally allowed to evict tenants to either occupy the unit themselves or have a close family member move in (Residential Tenancy Act, 2002). An open, online survey of 698 tenants in BC who experienced eviction between June 2022 and September 2023 found that âlandlordâs useâ accounted for 62% of formal evictions reported (First United, 2023). Given that requiring evidence to serve an eviction notice for renovations decreased this type of eviction, requiring a similar burden of proof for landlords who wish to evict based on âlandlordâs useâ may also help address this type of eviction. The BC government has begun to take steps to this goal with the forthcoming launch of a website portal for landlords to generate eviction notices for âlandlordâs use.â This site will gather information on how often this type of eviction is occurring, as well as information that tenants can use to challenge the eviction (Government of British Columbia, 2024b). This process aims to also educate landlords on the penalties around dishonest âlandlordâs useâ evictions, which include paying the evicted tenant one yearâs worth of rent if the unit is not found to be occupied by the landlord or a close family member (Residential Tenancy Act, 2002). However, tenants must bring forward a challenge against their landlord if they believe the eviction is in bad faith and some tenants may not feel comfortable, fear retaliation, or may not have the capacity to do so, including women living with HIV who face multiple forms of structural marginalization. Future policy can legislate compliance audits for âlandlordâs useâ evictions and mandate evidence of 88 who will occupy the unit following the eviction to further disincentivize dishonest use of this type of eviction. 4.2.1.3 Providing access to legal advice and representation In BC, formal evictions can be disputed by tenants through the RTB (Tenant Resource & Advisory Centre, n.d.a). While the dispute resolution mechanism is not the same as a court hearing, the arbitrator has the power to make decisions on enforcing or cancelling evictions, and the system follows court-like procedure (Tenant Resource & Advisory Centre, n.d.a). Landlords may have greater familiarity with the RTB, have experienced eviction disputes previously, and enjoy systemic advantages such as economic power, while tenants may have little to no experience in the dispute process, and find the process intimidating, stressful, or adversarial (Buhler, 2022). Given these power imbalances in the landlord-tenant relationship, tenants are at risk of exploitation (Buhler, 2022). Other research has noted power differentials between tenants and landlords, with the outcome of reduced housing quality and experiences for tenants (Chisholm et al., 2020; Li, 2023). Tenants with previous negative experiences of the legal system may choose to avoid engaging with quasi-legal proceedings, such as the process of disputing an eviction notice. A report on tenants accessing the Landlord and Tenant Board in Ontario (similar to the RTB in BC) found that some individuals who had previous involvement with criminal courts believed that the Landlord and Tenant Board was part of the same legal system, and due to this, did not challenge their case (Paradis, 2016). Women living with HIV who face structural marginalization based on criminalization, including individuals who use criminalized substances and/or who are sex workers, may avoid challenging their landlords. In SHAWNA, individuals report a 89 disproportionately high prevalence of previous incarceration, with a previous study finding that 76% of the cohort had been incarcerated in their lifetime (Erickson et al., 2020). There is evidence that providing legal advice and representation is an effective mechanism for preventing evictions (Holl et al., 2016). An important initial step is providing access to legal advice to educate tenants of their rights. In a qualitative study of people who use substances in non-profit housing in Vancouver, participants reported being unaware they had tenant rights, such as the ability to contest eviction (Fleming et al., 2019). Other qualitative work with women living in SRO buildings in Vancouver found that when women were aware of their rights, they were willing to refuse to vacate rooms when they believed an eviction was unjust (Collins et al., 2018). For those wishing to dispute formal eviction notices, legal advocates can ensure evictions are legitimate (i.e. the reason for eviction is lawful as per BCâs Residential Tenancy Act), provide support for their client in a dispute resolution hearing, and, even if their case is unsuccessful, help negotiate better terms on which the eviction will occur, such as extra time to move out, or avoiding the eviction being entered on the tenantâs record (Pollock, 2018). However, tenants in BC do not have mandated access to legal representation (Buhler, 2022) and a recent report on housing need among women in Canada found that nearly one-third of respondents facing eviction needed legal help but were unable to access it (Schwan et al., 2021). Thus, providing legal advice and representation can help reduce eviction. However, given the high prevalence of trauma among women living with HIV, including within our sample, ensuring that legal aid offered to tenants facing eviction is trauma-informed is critical. Trauma-informed approaches to the law are relatively new, and encompass a range of actions, including understanding the causes and prevalence of trauma, providing services that do not perpetuate further trauma, and fostering resilience (Randall & Haskell, 2013). Legal representatives as well 90 as arbitrators can ensure adequate time is taken to understand root causes of housing instability, rather than just proximal causes of eviction orders, focus on relationship building between legal advisors and the tenant, and ensure that the tenantâs decisions on pursuing a dispute hearing or other legal action is respected (Reeves, 2015). Policymakers should ensure adequate funding is available for existing legal advocacy groups. For example, the Tenancy Resource Advocacy Centre (TRAC) is a non-profit provider of legal representation in BC. However, they note that they can only assist a small number of clients, and usually focus representation on groups of tenants facing mass evictions (Tenant Resource & Advisory Centre, n.d.b). Another legal advocacy group, the HIV Legal Network, has provided education on rights, promoted community mobilization, and litigated against unjust laws that target people living with HIV since 1992 (HIV Legal Network, 2022), although they have not specifically focused on housing and tenancy law. Through grants and ongoing funding to groups such as these, accessible legal advice and advocacy can be provided to women living with HIV facing eviction. 4.2.2 Supporting individuals at greater risk of eviction This research identified associations between being removed from parents as a child and criminalized substance use with eviction. Women living with HIV with histories of government care, as well as individuals who use substances may require additional supports to prevent eviction and ensure housing stability. 91 4.2.2.1 Government care 4.2.2.1.1 Increase supports for those who have been in government care In this thesis, it was found that women living with HIV who were removed from their parents as a child had greater odds of eviction, which may be related to compounding effects of reduced access to material and emotional support from adults in the transition from adolescence to adulthood, as well as latent effects of instability during sensitive periods of development (e.g., childhood, adolescence), following from a life course perspective (Jones et al., 2019). Improving the supports available to those who have been involved in ministry care, such as through extending the legal age through which youth in government care are supported beyond 19 years of age and ensuring that young adults are connected to a support system rather than focusing exclusively on building independence, can improve stability (Doucet et al., 2022). BC has taken some steps to support youth aging out of government care, including rent supplements and income supports (Government of British Columbia, 2022), however, youth must apply for these programs and less than one-third of youth aging out are able to access the program (Ministry of Children and Family Development, 2022). Thus, additional action is needed to ensure that all youth aging out of government care benefit from these programs. 4.2.2.1.2 Provide support for families to remain together Due to colonial violence, socio-economic disadvantage, and other health inequities, the prevalence of HIV is disproportionately high among Indigenous people (Hillier et al., 2020). Indigenous people also experience greater housing need (CMHC, n.d.; Schwan et al., 2021; Xuereb & Jones, 2023) and at the same time, Indigenous children are overrepresented in government care (Hahmann et al., 2024). Efforts to break cycles of Indigenous child 92 apprehension should be prioritized to avoid adverse outcomes of government care. This can include increased support for families, such as providing affordable and/or supportive housing, and the promotion of kinship care, where a child is cared for by the extended family. Supporting Indigenous self-determination in child welfare through transferring ministry care to First Nation control is also a critical priority, as called for by the Union of BC Chiefs in 2022 (Union of B.C. Indian Chiefs, 2022), alongside adequate funding of services and cross-cultural, collaborative partnerships between governments (Paul, 2016). Prioritizing housing solutions that are both acceptable to Indigenous women living with HIV, and that support Indigenous families to remain together, can help address the systematic barriers that undermine both the housing stability of women living with HIV who have aged out of government care, as well as work to break oppressive, social-structural, and generational cycles of family disunification. 4.2.2.2 Criminalized substance use Criminalized substance use was associated with increased odds of eviction in this research. This association may be related to a combination of factors such as landlord discrimination and unequal power dynamics which creates systemic housing barriers for people who use substances (Fleming et al., 2019). Specialized supports to ensure housing stability for people who use substances is needed, including the provision of housing that does not require treatment or abstinence (i.e. Housing First), maintaining privacy in housing, and providing additional and comprehensive supports. 93 4.2.2.2.1 Harm-reduction-focused housing approaches Housing First (HF) is a housing approach that originated in the 1990s in New York City with a program called Pathways to Housing (Tsemberis et al., 2004). Rather than requiring unhoused people who used substances to begin treatment for psychiatric conditions and substance use prior to moving into independent housing, this program provided individuals with their own apartment without prerequisite (Tsemberis et al., 2004). Individuals were also offered support from a team of social workers, nurses, substance use counselors, and psychiatrists. In a randomized control trial comparing the standard, treatment-based housing approach and HF, individuals in HF had more stable housing over the follow-up period, with no differences found for substance use (Tsemberis et al., 2004). These results led to governments embracing HF approaches to houselessness, particularly among those with mental health challenges and who use substances. In the context of this thesis, the government of Canada found success with pilots of HF programs across five Canadian cities, including Vancouver (Homeless Hub, 2013). HF has also faced criticism. A review of existing evidence in 2009 found that, while case series and some trials reported excellent housing retention, HF did not reduce substance use (Kertesz et al., 2009). Moreover, evaluation of the available studies found some trials had not recruited people who used substances heavily, and substance use among the people who entered the studies was lower than unhoused people in general (Kertesz et al., 2009). Another review found that, outside of the original Pathways to Housing study, there was little high-quality evidence for the efficacy of HF approaches due to limitations with small sample size, random assignment, and retrospective analysis (Waegemakers Schiff & Schiff, 2014). This review also noted a lack of research with young people, women, those with history of substance use, and with cultural housing needs (Waegemakers Schiff & Schiff, 2014). In a recent systematic review, 94 the authors concluded that, while some studies have found HF is associated with reduced substance use (Mares & Rosenheck, 2010; Padgett et al., 2011), overall evidence of HF on substance use outcomes is limited (Woodhall-Melnik & Dunn, 2016); furthermore, the original randomized control study found that HF participants actually used less substance use treatment services (Tsemberis et al., 2004) Despite these challenges, HF and other harm-reduction-focused approaches still can provide important, needed housing for people who use substances who are unable or unwilling to enter treatment or maintain abstinence. A systematic review found HF was associated with housing stability in all studies reviewed that assessed housing retention (Woodhall-Melnik & Dunn, 2016). In addition, HF was associated with decreased criminal legal system involvement, and improved quality of life (Woodhall-Melnik & Dunn, 2016). Additionally, previous research has found that people who use substances report unmet needs for privacy and control of personal space in their housing. Qualitative work out of Vancouver, BC, among people who use substances living with HIV who were living in low-income housing found that participants emphasized a need for housing privacy and control, and the ability to create a sense of home and control their own space, such as locking doors away from common areas (Fleming et al., 2020). Women who use criminalized substances living in SROâs reported low sense of security and privacy in their current housing, noting that housing providers were able to access their rooms without notice, and presence of security cameras and constant surveillance (Collins et al., 2018). Thus, while HF approaches often incorporate supports and building staff, based on this feedback, efforts should also be made to ensure that residents are given privacy and control over their homes. 95 While there are criticisms of HF approaches, and limited investigation with women living with HIV who use substances for this type of housing program, HF approaches continue to offer consistent evidence for providing housing stability. Access to stable housing can improve HIV clinical markers, such as viral suppression, among people living with HIV who use substances (Wiewel et al., 2020). HF options may also help reduce conflicts between tenants and landlords. Best practice for housing for people who use substances must also emphasize the need for housing that also allows residents to retain autonomy, including the provision of private spaces and limited surveillance. 4.2.2.2.2 Comprehensive support services For individuals who use substances, housing providers have pointed to the importance of providing comprehensive support services upon arrival at a housing facility (Zell & McCullough, 2020). These could include a variety of programs, such as budgeting and financial skills, conflict resolution and advocacy, service navigation assistance, including assisting people to access benefits they are eligible for, and help with maintaining good relationships with landlords (Zell & McCullough, 2020). Qualitative research with social and affordable housing providers highlighted that tenant supports are critical in eviction prevention, including linking tenants to external service providers (Collins et al., 2022). Recent clinical guidelines for individuals facing houselessness or housing instability in Canada have strongly recommended supportive housing as a solution, including for individuals who use substances (Pottie et al., 2020). In the Vancouver context, qualitative research with people who use criminalized substances living in a HF building was undertaken to understand how individuals in the building perceived an on-site clinic. The multi-disciplinary clinic provided access to a social worker, a 96 nurse and a part-time physician, along with a connection to a pharmacy that delivers medications (MacKinnon et al., 2022). Residents found that the care provided by this clinic was accessible, stigma-free and improved their sense of wellbeing (MacKinnon et al., 2022). For women living with HIV who use criminalized substances, these comprehensive support services can be intersectional. For example, qualitative research with individuals in SHAWNA has previously found that the daily delivery of anti-retroviral treatment (ART) by nurses within their housing programs facilitated adherence to medications (Czyzewski et al., 2016). For women living with HIV who use criminalized substances, these daily visits could also include services such as delivery of opioid agonist therapy (a medication for those who are in recovery from substance use), and primary care such as the provision of harm reduction supplies, wound management, and screening for infections (Visconti et al., 2019). MacKinnon et al. also found in their qualitative research that access through the onsite clinic to daily medication delivery improved medication adherence, including to opioid agonist treatment and HIV treatments (2022). Ensuring that housing solutions for women living with HIV who use criminalized substances include access to comprehensive services, either through connection to external providers, or within-housing support, is essential. 4.2.3 Providing housing for a variety of needs and preferences Policies addressing upstream eviction prevention are needed, including greater investment in affordable housing. Research has shown that living in this affordable housing, where rent is subsidized or geared to income, is a protective factor against eviction because of both lower rents along with efforts made by housing providers to prevent rent arrears and eviction (Xuereb & Jones, 2023). Qualitative research with housing providers in Alberta found that social and 97 affordable housing providers went to extreme lengths to prevent evictions among their tenants, describing evicting tenants as a âlast resort,â (Collins et al., 2022). Evidence from national data shows that non-profit, government, and co-operative landlords have five-year eviction rates between 2.6% and 3.6%, compared to 6.8% for private landlords (Xuereb & Jones, 2023), suggesting that the landlord type may be related to eviction risk, and that non-private landlord housing provision should be prioritized for women at risk of eviction. However, for some women living with HIV, housing solutions must go beyond simply affordable units. Supportive housing, which can provide low-cost, stable housing, alongside programs that may assist with accessing healthcare, government benefits and harm reduction (Hall et al., 2019; Quinn et al., 2021), is uniquely positioned to offer intersectional solutions. Results from this thesis suggests that enhancing supportive housing solutions to meet the diverse needs and preferences of women living with HIV is critical. Therefore, a broad range of supportive housing options should be offered, including housing that is specific to people living with HIV, as well as housing that prioritizes culturally safe practices, trauma-informed designs and policies, and gender-responsive approaches. Housing programs, additionally, must be tailored for and with input and guidance from women living with HIV. The next section details different qualities that supportive housing can prioritize, and examples of these approaches. 4.2.3.1 HIV-specific housing Supportive housing specifically tailored for people living with HIV may improve HIV-related medical outcomes (Hall et al., 2019). While some women living with HIV could avoid HIV-specific supportive housing out of concern that living in this type of housing could disclose their HIV status and expose them to stigma (Chambers et al., 2014), there is evidence that living in 98 supportive homes specifically for people living with HIV can remove the burden of disclosing HIV status (Tryon et al., 2022). People and women living with HIV are living longer and healthier lives, thus require housing that meets changing needs with age. A study from Ottawa, Canada found that people living with HIV shared concerns about appropriate housing that would meet healthcare needs, signalling that HIV-supportive housing for older adults and seniors is also an important consideration, however, this studyâs participants also noted fears of being âoutedâ in HIV-specific housing (Furlotte et al., 2012). Women living with HIV should have the option to choose supportive housing tailored to the needs of people living with HIV - as well as other housing programs that do not stipulate HIV status - and all housing providers must emphasize confidentiality and autonomy, for example, through the provision of private apartments or rooms where medications can be safely and privately stored. In Metro Vancouver, one HIV-specific housing option is provided through the McLaren Housing Society. Housing with the McLaren Housing Society also provides programs and support services, along with referrals and connections to community-based organizations (McLaren Housing Society of British Columbia, n.d.). However, the program currently has a waitlist, suggesting that funding to expand HIV-specific housing programs is needed. 4.2.3.2 Culturally safe housing Given that more than half of women living with HIV in SHAWNA are Indigenous (53.5%), ensuring that supportive housing is available that is tailored with and for Indigenous women is important. Culturally safe housing is a housing approach that prioritizes Indigenous peoplesâ unique needs, including supporting Indigenous homemaking practices and culture (Christensen, 2016). Research with Indigenous people living with HIV on housing solutions identified four key 99 recommendations to create âculturally relevantâ housing, which included facilitating ceremonial practices and cultural traditions, prioritizing Indigenous community members involvement in the development of housing, ensuring communication and collaboration across health and housing providers, and providing wrap-around case management (Ion et al., 2018). Examples of culturally safe initiatives that the Indigenous housing provider Aboriginal Housing Management Association have initiated include having Indigenous community partners in leadership roles in housing projects, training employees in cultural safety, and providing homes that accommodate socialization needs and promote cultural programming, for example, with gathering spaces and connected family units (Aboriginal Housing Management Association, 2016). Culturally safe housing can also incorporate intersectional approaches, for example, the Aboriginal Mother Centre Society provides housing for Indigenous mothers and their children at risk of houselessness or of child welfare involvement (BC Housing, 2022). Alongside other supportive services, such as housing search assistance, weekly nurse visits, and referrals to other service providers, the Aboriginal Mother Centre Society provides cultural activities such as drumming, medicine walks, access to an Elder, and healing circles (BC Housing, 2022). 4.2.3.3 Trauma-informed designs for housing Supportive housing can incorporate trauma-informed designs, where trauma is defined as overwhelming occurrences outside of an individualâs control, including child abuse, violence, and sudden loss (BC Provincial Mental Health and Substance Use Planning Council, 2013). Women living with HIV who have experienced housing instability report high levels of violence (Zhao et al., 2022), suggesting that trauma-informed practices should be incorporated into housing solutions. Trauma-informed practice acknowledges how trauma and violence can 100 perpetuate housing need, and focuses on safety, trust, collaboration and agency when finding solutions (BC Provincial Mental Health and Substance Use Planning Council, 2013). For example, a recent supportive housing project for people who have experienced long-term houselessness included trauma-informed design, such as building windows within interior walls, providing a variety of common areas, and allowing residents voice and agency in decision-making within the building (Bollo & Donofrio, 2022) 4.2.3.4 Gender-responsive housing Gender-responsive approaches prioritize addressing inequities based on gender, including participation and distribution of benefits (Nelson, 2015). Gender-responsive approaches can be incorporated into supportive housing that is appropriate and safe for cis and trans women, as well as housing that supports sex workers, with all programs designed with input and guidance from individuals with lived experience. 4.2.3.4.1 Women-specific, trans-inclusive housing Women living with HIV may face gendered violence and marginalization. In SHAWNA, other research has found that 19.4% of individuals reported experiencing physical and/or sexual violence at baseline, and of these women, 92.3% reported unstable housing (Ohtsuka et al., 2023). Qualitative research with women who previously experienced houselessness found that housing must include options for women-only housing (Brunn, 2019). Women-specific housing can also include intersectional approaches, for example through providing trauma-informed approaches and harm reduction; in Vancouver, raincity Housing incorporates these approaches in 101 a building they operate for cis- and trans- women facing structural marginalization and housing instability (raincity Housing, n.d.). Women-specific housing must also ensure that trans women are able to safely access their services, as trans people continue to face higher frequency of housing discrimination (Glick et al., 2019; Kattari et al., 2016). Transgender women may face transphobia at shelters, where staff may harass or refuse service to trans women (Yarbrough, 2023). In qualitative research, trans women reported being housed with men, experiencing mis-gendering, and other instances of gender regulation that prevented women from accessing resources (Yarbrough, 2023). Other qualitative work with trans women and Two-Spirit individuals living in Vancouver found similar reports of exclusion from housing and services, gender policing, and harassment from cis women when accessing services (Lyons et al., 2016). Housing providers can support trans women by encoding and enforcing trans-inclusive policies. Buildings can be updated to include gender neutral washrooms (Lyons et al., 2016). Staff can show respect by using preferred pronouns and promote safety by not tolerating harassment (Lyons et al., 2016). Housing providers can also post signs in communal areas that prominently state that transgender people are welcomed and respected (Mottet & Ohle, 2006). Intake forms or rental agreements can allow individuals to self-identify, if needed, and also be a place to signal to all residents that trans individuals are welcome in the building (Mottet & Ohle, 2006). 4.2.3.4.2 Housing that supports and is accessible to sex workers Sex workers face structural barriers to safe and secure housing, such as restrictive building policies (e.g. curfews and strict guest policies) (Lazarus et al., 2011). Qualitative research with 102 cis and trans women who use substances living in SROs in Vancouver found that surveillance and disciplining measures were experienced more by sex workers (Collins et al., 2018). As a result, women worked outside, which negatively affected their ability to negotiate sex work transactions (Collins et al., 2018). Lazarus et al. found that curfews reduced womenâs ability to accept or decline clients, as they had to contend with a time limit to earn income (Lazarus et al., 2011). Strict guest policies, including those that did not allow any guests, also reduced womenâs ability to reduce risk by forcing sex work outdoors (Lazarus et al., 2011). Supportive housing can implement gender-responsive policies by ensuring that women are able to safely and freely host guests, including sex work clients. Buildings can also implement flexible curfew policies. For example, Lazarus et al. highlight a strategy used by housing providers that required a daily check-in with building staff, rather than a set curfew (Lazarus et al., 2011). 4.2.4 Identify and support women at risk of, or who have experienced eviction This research found that in that eviction was associated with experiencing depression, food insecurity, gender-based violence, and increased frequency of criminalized substance use. While this research could not establish causality, findings suggest that women who may be at risk of eviction, or women who have recently experienced an eviction, may access services related to mental health, food security, violence, and substance use. These contact points may create opportunities to reach women with assistance for stabilizing housing and avoiding eviction, as discussed in Chapters 4.2.1-4.2.2, or finding suitable housing to meet needs and preferences, as discussed in Chapter 4.2.3. 103 4.2.4.1 Food banks and drop-in meals Food insecurity was measured through asking individuals where they most often accessed food. The results of this thesis provide evidence that women living with HIV at risk of eviction, or who have recently experienced an eviction, may be more likely to visit food banks and drop-in meals. Staff at these food access points should be made aware that their clientele may be facing housing instability and understand what resources are available to offer, including referrals to housing providers. Outreach for programs suggested previously, such as low-barrier legal aid, and emergency rental assistance can also occur at these contact points. 4.2.4.2 Safe consumption sites Increased frequency of criminalized substance use was associated with eviction in Chapter 2 of this thesis, and eviction was associated with increased frequency of both criminalized stimulant and opioid use in Chapter 3. Given the analysis method used, causality cannot be inferred. In the literature, substance use may increase individualsâ risk of eviction, while eviction may also lead to increased criminalized substance use, particularly stimulants (Damon et al., 2019; McNeil et al., 2021). However, regardless of whether substance use precipitates or follows eviction, or a combination of both, safe consumption sites provide a contact point to reach women in unstable housing situations. Safe consumption sites are harm reduction initiatives that provide medical supervision to people who use substances (Kerr et al., 2017). Facilities vary in the services offered, but can include supervised injection and/or inhalation, provision of injecting supplies, education on safer substance use strategies, and connection to substance use treatment and other social services (European Monitoring Centre for Drugs and Drug Addiction, 2018; Kennedy et al., 2017a). Safe 104 consumption sites are associated with decreased overdose mortality and other harms, increased substance use treatment uptake, and reduced public substance use and publicly discarded injection equipment (Kennedy et al., 2017a). People who use substances who have been recently evicted may be more likely to access safe consumption sites (McNeil et al., 2021) and research has found that safe consumption sites can link users to substance use treatment options and other health services (Potier et al., 2014). Adding housing support to the referral services available may be one avenue to help women living with HIV who use substances access appropriate housing and housing support, as detailed in Chapter 4.2.2.2. 4.2.4.3 Health care centres Another avenue to reach women facing eviction may be through health care centres. In this research, eviction was associated with gender-based violence, and research has found that women facing violence can be identified at health care centres (Ellsberg et al., 2015). Furthermore, depression was defined as having been diagnosed with, monitored for, or treated for depression. The significant association between eviction and depression suggests that women are accessing clinical support for mental health either prior to or following eviction. Given this, health care centres present an important avenue to reaching women. One suggested tool is screening questionnaires to assess the social and structural challenges a patient may be facing, including housing status (Bourgois et al., 2017). Bourgois et al. suggest an questionnaire that can be used by clinicians with limited time, and who may operate with limited resources (2017). Scores from this screening tool would then be used to connect patients to resources, including other health and social care workers (Bourgois et al., 105 2017). Reflecting the results of this thesis, health care centres should incorporate screening questions for assessing eviction risk, or recent eviction events. Health care centres can then provide referrals and direct women towards supports to preserve housing and prevent eviction, or towards options for finding housing if eviction has occurred, as detailed in Chapters 4.2.1-3. 4.2.5 Summary of recommendations In conclusion, addressing eviction among women living with HIV requires a multi-level approach with policy action on several fronts. These can include: 1) Prevent evictions related to non-payment of rent by providing emergency financial aid. 2) Support tenants to avoid rent arrears through expanded programs for rental assistance. 3) Offer financial management services for individuals to prevent rent arrears. 4) Address financialization in the rental market by enacting vacancy control across all rental units. 5) Provide women with the ability to access legal advice and aid to better understand their legal rights and challenge eviction notices with representation. 6) Increase supports for youth aging out of government care, with longer lengths of time in care and greater housing support following aging out. 7) Work to interrupt intergenerational cycles of Indigenous child apprehension caused by oppression and colonial violence, including increased support to keep families together, policies to increase Indigenous self-determination in child protective services, along with ongoing efforts to ensure Indigenous peoples have everything needed to thrive. 8) Implement and enhance Housing First approaches for women who use substances, while ensuring this type of housing maintains individualsâ privacy. 106 9) Provide women who use criminalized substances access to comprehensive services when entering housing. 10) Provide options for supportive housing for a variety of needs and preferences, including housing that is: a. HIV-specific b. Trauma-informed c. Culturally safe d. Gender-responsive 11) Provide outreach and referrals at locations that women may access when at risk of or following eviction, including food banks, safe consumption sites and health care centres. 4.3 Strengths and Limitations There are several important strengths as well as some limitations to this thesis which are detailed in the next sections. 4.3.1 Strengths The SHAWNA project has many important strengths, including being a community-based cohort that is guided by women with lived experience and community partners. These partners include a Community Advisory Board which meets annually, and a Positive Womenâs Advisory Board that meets several times a year. These boards help set research priorities, including understanding how structural factors, such as housing, influence the well-being of women living with HIV. The long-standing nature of SHAWNA, with more than a decade of data collection, has resulted in a wealth of data. To address potential limits of generalizability, extensive efforts are made to reach 107 as many women who meet the eligibility criteria as possible, resulting in a sample reflecting diverse lived experiences. SHAWNA staff are trained in trauma-informed care, cultural safety and harm reduction, and build relationships with individuals in SHAWNA, including spending time helping individuals access services and address challenges they may be facing. While some questions are sensitive and can cause discomfort, relationship building and trauma-informed approaches help reduce the risk of re-traumatizing respondents. Furthermore, these efforts to create a supportive environment help reduce the risk of social desirability/reporting bias. While not all measures used to capture information in the SHAWNA questionnaire are validated, the study uses questions that were that were developed in consultation with women with lived experience and their service providers to capture important information. An overall strength of this thesis was the wording of the question measuring eviction, which asked individuals whether they had been evicted or forced to move. Given that many evictions may occur informally, without eviction notices, this measure was likely able to capture more accurately the true prevalence of eviction. The longitudinal study design increased the number of observations available for analysis. Logistic and ordinal logistic regression analysis with generalized estimating equations were used in analysis, which allows for repeated measures of the same individual and effectively increases the sample size, as each individual can provide multiple observations included in the final model. This increased power and the improved the ability of models to detect significant associations between variables. 108 4.3.2 Limitations In addition to strengths, there are several limitations to this thesis. Despite substantial efforts made to create safe, trauma-informed and supportive environments, and adapt questionnaire language, the sensitive nature of questions could result in re-traumatization and inadvertent harm for respondents. Recall bias and social desirability bias may be present, as study data was self-reported. Finally, findings from this thesis may not be generalizable to contexts outside of the small geographical area of the study (Metro Vancouver). Another limitation is the low number of eviction events, especially given that previous research with samples from the same cohort found that housing instability is highly prevalent (Zhao et al., 2022). The dataset included only a small number of reported evictions (n=66) during the study period; over eight years, 13.3% of the sample experienced an eviction, which is only slightly higher than the five-year prevalence previously found among renter households in Vancouver at 10.4% (Xuereb & Jones, 2023). This lower-than-expected prevalence of eviction may be due to a range of factors, including an under-reporting of evictions. A previous study has shown that respondents to surveys may not classify involuntary moves as evictions, even if these moves have similar causes and effects to eviction (Desmond & Shollenberger, 2015). As previously discussed, women in the SHAWNA project may have greater access to supportive housing, with evidence that this type of housing avoids evictions if possible (Collins et al., 2022). Finally, individuals did not all complete surveys every six months, with a range of study visits from one to 16. Given that the measure used to assess eviction asks about the previous six months, eviction events may have been missed for those who did not have a study visit directly following an eviction. 109 The decision to aggregate race/ethnicity, and gender and sexual identities may have resulted in categorization in ways that may not accurately reflect individualsâ self-identification or experience. Possible response categories for race/ethnicity were Black (inclusive of responses of African, Afro-Caribbean, African Canadian descent), East/Southeast Asian (inclusive of responses of Chinese, Korean, Japanese, Filipino, Vietnamese, Cambodian, Thai, Indonesia, other Southeast Asian descent), Latinx/Latino/a (inclusive of responses of Latin American, Hispanic descent), Middle Eastern (inclusive of responses of Arab, Persian, West Asian descent, Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish), South Asian (inclusive of responses of Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean), Other, White (inclusive responses of European descent), and Indigenous (First Nations, Métis, Inuk/Inuit descent). All race/ethnicity responses, other than White and Indigenous, were combined into âOther racialized women/women of colour.â All sexual identities (including gay, bisexual, lesbian, asexual, queer and other) were collapsed into one category (marginalized and minoritized sexual identities) as compared to heterosexual. Responses to gender identity other than cisgender were aggregated as marginalized and minoritized gender identities (including trans, transgender, transsexual, person with trans experience, transfeminine, non-binary, genderqueer, bigender, agender, gender neutral, demigirl and other). Collapsing categories resulted in the diverse experiences of women with different gender, sexual and racial identities being masked. Aggregation and categorization of racial/ethnic identities has been criticized for failing to measure how individuals self-identify, including losing information on people with bi-racial or multi-racial identities or from small population groups with unique experiences (Kaplan, 2014). In terms of measuring gender, researchers have suggested that recoding gender responses into larger categories may not be ethical when respondents are originally given the option to self-identify more broadly (Glick et 110 al., 2018). The choice to aggregate sexual and gender identities and race/ethnicity was due to small sample sizes in categories with implications for reduced power as by aggregating responses, power was increased for statistical analysis. Bivariate and multivariable logistic regression models, and bivariate and multivariate ordinal logistic regression models using generalized estimating equations (GEEs) for repeated measures analysis were used to assess associations between variables. GEEs allow for an estimate of the population effect to be calculated, adjusting for unmeasured correlation between observations from the same individual at different time-points. While the strengths of this analysis method had been detailed above (Chapter 4.4.1), there are also important limitations. The analysis method used restricted observations to complete cases only, that is, observations were not included if they contained missing responses to any of the variables specified in the multivariable models. This sometimes resulted in a substantial reduction between the number of available observations, and the number of observations included in the final models. This may have resulted in underpowered analyses and missed significant associations. Moreover, while some individuals with missingness in one study visit had other, complete observations that were included, some individuals had no observations included due to missingness in all available observations. Sensitivity analysis of baseline characteristics of individuals with at least one observation included in models compared to those with no observations included was performed to address potential differences, with methods and results detailed in Appendices A and B. Additionally, regression analysis with GEEs assumes that missingness is completely at random (MCAR) and unrelated to any of the measured or unmeasured variables. Therefore, removing incomplete observations should not bias model results, but only decrease power. However, individuals may have underreported sensitive information, resulting in incomplete 111 observations that are not MCAR. For example, individuals who experienced stigmatizing or traumatizing events may have chosen to not respond to questions asking about these experiences, and their observations would not be included in the model due to missing variables. If a true association existed between these events and eviction, removing these observations may have biased results towards the null. Statistically significant results reported likely show a strong association while other variables showed important trends towards significant associations. The methodological approach in this thesis was not causal and data was not time-lagged (i.e. the outcomes are measured in the same period as the exposure of eviction). Associations could happen in the opposite direction than hypothesized, or both precede and follow eviction, thus the evidence presented is limited in terms of establishing causality. For example, the literature review conducted as part of this thesis found examples of substance use as both a risk factor for, as well as a potential outcome of, eviction. Criminalized substance use was therefore conceptually included as both a factor that could increase risk of eviction, as well as a potential outcome of eviction (Figure 1). 4.4 Implications for future research While this research is an important contribution towards understanding the prevalence of eviction, and the types of structural marginalization that are associated with increased odds of eviction among women living with HIV, more investigation is required. Future research can help address previous limitations identified (Chapter 4.3.2) as well as build on results from this work. Intersectional theory was relied on to hypothesize the types of intersecting identities that could influence eviction risk; however, it was not feasible to use a quantitative intersectional methodological approach in data analysis given sample size limitations. Qualitative research can 112 elucidate the complex relationships between experiencing different types of structural marginalization and housing stability. Future research can also incorporate quantitative methods, although cautiously: a systematic review of quantitative approaches to intersectionality found studies often had limited engagement with theoretical understanding of intersectionality and its relationship with social power, flaws in measuring and categorizing constructs, and used methods that did not adequately take into account the complexity of intersectionality, or allow for recommendations for policy and decision-making (Bauer et al., 2021). Bowleg also considered methodological issues in both quantitative and qualitative intersectional research, such as assessing identities as additive (e.g. gender and race and sexuality) (Bowleg, 2008). Bowleg concludes that appropriate methodological approaches are limited, despite the value of an intersectional framework to understand structural inequity, and therefore researchers have the responsibility of interpreting data in an intersectional lens, particularly making the power structures that create structural inequities explicit (Bowleg, 2008). There were small sample sizes in many of the response options for gender identities (with options including transgender, transsexual, person with trans experience, transfeminine, intersex, Two-Spirit, genderqueer, bigender, agender, gender neutral , demigirl and other) and sexual identities (including gay, lesbian, bisexual, asexual, queer and other), which had implications for reduced power when considering these identities as their own separate categories in regression analysis. Several variables combined gender identities and sexual identities to address this potential limitation, as well as to reflect shared experiences of minority stress that is experienced by people with minoritized and marginalized sexual (Meyer, 2003) and gender (Tan et al., 2020) identities, compared to heterosexual and cisgender individuals. However, the experiences of women living with HIV with respect to eviction may differ according to diverse gender and 113 sexual identities. Qualitative studies are uniquely positioned to overcome limitations around small sample sizes and represent diverse experiences and challenges. More research is needed to understand causation as hypothesized in this thesis. While quantitatively assessing temporality may pose similar methodological challenges as was experienced in this thesis, qualitative studies can help understand individualâs perceptions of the direction of causality and complex interrelations between social-structural factors and eviction. As well, qualitative studies can explore the mechanisms between these factors to tailor interventions appropriately. Future research should also continue to explore the role of eviction and housing stability in HIV-related syndemic frameworks for women living with HIV, for example, understanding whether housing has a synergistic effect with other syndemic factors. Examples of future quantitative research can assess whether experiencing eviction as well as syndemic factors has a greater effect on the ability of women living with HIV to take medication or attend appointments. Qualitative research can also help elucidate how housing instability and experiencing eviction is pre-empted by or can result in experiencing other syndemic factors and assess complex interrelationships. 4.5 Conclusion Important contributions to the limited research on eviction among women living with HIV, who already experience disproportionally high housing instability, was made in this thesis. Based on an extensive literature review and conceptual framework (Chapter 1), this research first investigated the prevalence and social-structural correlates of eviction among women living with HIV, finding that criminalized substance use and removal from parents as a child were both 114 significantly associated with higher odds of eviction (Chapter 2). Chapter 3 found significant bivariate associations between eviction and the HIV-related syndemic factors of depression, criminalized opioid and stimulant use, gender-based violence, and food insecurity, and in multivariable models, eviction remained significantly associated with depression and increased frequency of criminalized opioid and stimulant use. These findings point to a need for policies that protect tenants at risk of eviction, as well as to rapidly increase access to a variety of stable housing options for unique needs and preferences, with all interventions sensitive to intersecting forms of structural marginalization that women living with HIV face, as detailed in Chapter 4. While more research is required to fully understand evictionâs role in the lives of women living with HIV, the findings of this thesis point to an urgent need to prevent and address this severe form of housing instability. Women living with HIV continue to face structural marginalization, including based on intersecting stigmatized identities, behaviours and life course factors that can result in housing discrimination, instability and eviction. 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AIDS and Behavior, 27(7), 2271â2284. https://doi.org/10.1007/s10461-022-03957-2 159 APPENDICES Appendix A - Methods and results of sensitivity analyses (Chapter 2) A.1 Methods COVID-19 period A sensitivity analysis was performed to better understand the effects of rental protections implemented during the COVID-19 pandemic on eviction. In the USA, a review of eviction filings in cities that implemented eviction moratoria or other renter protections during the pandemic found a substantial reduction in evictions filed during this time (Hepburn et al., 2023). In BC, several housing protection programs were also implemented. These programs included a rent freeze from March 30, 2020, until January 2022, an eviction moratorium from March until September 2020, a rental supplement program from April until August 2020, and several income support programs, with the last ending May 2022 (Flynn et al., 2024). However, these resulted in only a small decrease in eviction filings that quickly rebounded following the end of the moratorium (Flynn et al., 2024). A study of eviction filings in the USA also found that eviction filings surged after moratoria expired (Cowin et al., 2020). A variable, pandemic period, was used to capture the pandemic period. Pandemic period was coded as âyesâ if the observation was recorded on or after April 1, 2020, and ânoâ if the observation was recorded March 31, 2020, or earlier. An unadjusted (bivariate) logistic regression model using GEEs was then used to examine the relationship between pandemic period and experienced an eviction. The unadjusted OR was reported with 95%CI (Table A.1). 160 Missing data in multivariable model A sensitivity analysis was performed to assess if participants who had at least one observation included in the final model in Chapter 2 differed from those who had no observations included, following from the complete-case analysis. A variable, included in model, was defined as having at least one observation in the final model (âyesâ vs ânoâ). Participants were compared on baseline/first available observation on several social-structural characteristics, including age, race/ethnicity, gender identities, sexual identities, and education. Bivariate analysis was performed, including Pearsonâs chi-squared test for categorical variables and Wilcoxon Two-Sample Test for continuous variables, with significance reported at p<0.10. The distributions and p-values are reported in Table A.2. A.2 Results COVID-19 period In Table A.1, the results of the sensitivity analysis for pandemic period are presented. In bivariate logistic regression using GEEs, pandemic period was significantly associated at a p<0.10 level with decreased odds of eviction (OR: 0.58 [0.32-1.03]. Figure 2 illustrates the point prevalence of eviction over the study periods (September 2015-March 2023). The start of the pandemic period is shown through the vertical line on April 1, 2020. Overall, a peak in eviction events is seen during the September 2016 follow-up period, although there is an overall downward trend in eviction. 161 Table A.1 - Bivariate (unadjusted, OR) odds ratio and 95% confidence interval (95% CI) and p-values for the relationship between pandemic period and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015 to 2023 Experienced an eviction, unadjusted Variable Missing (n) Odds Ratio [95% CIs] p-value Pandemic period a 0 0.58 [0.32-1.03] 0.064 a Observations from September 1, 2015-March 31, 2020, coded as pre-pandemic, and observations from April 1, 2020, onward coded as pandemic period Figure A.2 - Point prevalence of eviction during study period 162 Missing data in multivariable models Table A.2 presents the study characteristics at baseline/first interview stratified by being included and not included in the final model. In the final multivariable model where eviction was the outcome, 302 individuals had at least one observation included in the final model, and 59 had no observations included. Compared to being missing from the final model, participants who were included in this model did not have responses that were significantly different at a p<0.10 level in terms of age, marginalized and minoritized sexual identities, marginalized and minoritized gender identities, race/ethnicity and graduated high school at baseline. 163 Table A.2 â Baseline social-structural characteristics between individuals included or not included in the final multivariable model for the relationship between social-structural variables and eviction in the last six months among women living with HIV in Metro Vancouver, Canada, 2015-2023 Included (n) (N=302) Not included (n) (N=59) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 45 (36-53) 0 0.865 Marginalized and minoritized sexual identities b 48.3 (146) 42.4 (24) 0 0.401 Marginalized and minoritized gender identities c 15.9 (48) 13.6 (8) 2 0.723 Race/Ethnicity a 0 0.290 White 36.8 (111) 27.1 (16) Indigenous d 52.7 (159) 57.6 (34) Other racialized women/women of colour e 10.6 (32) 15.3 (9) Graduated high school a 51.0 (154) 55.9 (33) 0 0.487 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 164 Appendix B - Methods and results of sensitivity analyses (Chapter 3) B.1 Methods Food insecurity variable The food insecurity outcome measure included all responses other than âbought fresh groceriesâ as âyesâ to food insecure. The inclusion of restaurants within the insecure classification was based on literature that suggests that frequent restaurant and fast-food dining is associated with food insecurity (Burns et al., 2015; Hollis-Hansen et al., 2022). However, to identify the possible effect of including ârestaurantsâ within the food secure category, a sensitivity analysis was performed. Bivariate logistic regression models using GEEs was used to calculate the association between food insecurity and eviction, including and excluding ârestaurantsâ from the secure category. The difference between the effect sizes of the two models were compared by subtracting the odds ratio including ârestaurantsâ from the odds ratio excluding ârestaurantsâ and dividing by the odds ratio excluding ârestaurantsâ. Missing data in multivariable models A second sensitivity analysis was performed to assess if participants who had at least one observation included in the final model in Chapter 3 differed from those who had no observations included, following from the complete-case analysis. A variable, included in model, was defined as having at least one observation in the final model (âyesâ vs ânoâ). Participants were compared on baseline/first available observation social-structural characteristics, including age, race/ethnicity, gender identities, sexual identities, education, im/migrant status, and removed from parents. Bivariate analysis was performed, including Pearsonâs chi-squared test for 165 categorical variables and Wilcoxon Two-Sample Test for continuous variables, with significance reported at p<0.10. The distributions and p-values are reported in Table B.1-5. B.2 Results Food insecurity variable As reported before, in bivariate logistic regression using GEEs, eviction was significantly associated with experiencing food insecurity (OR: 1.97, 95%CI [1.16-3.33]). The analysis found that when ârestaurantsâ was included within the food secure category, eviction was still significantly associated with food insecurity (OR: 2.03, 95%CI [1.20-3.43]). The effect size difference between the two models was 3.1% (see Equation 1). !.#$%&.'(!.#$ = 0.03045 â 100% = 3.1% Equation 1 â Effect size difference calculation Missing data in multivariable models Tables B.1-5 present study characteristics at baseline/first interview stratified by being included and not included in each model. In the final multivariable model where gender-based violence was the outcome, 293 individuals had at least one observation included in the final model, and 68 had no observations included. Compared to being missing from the final model, participants who were included in this model had a lower prevalence of reporting graduating high school (p=0.036). In the final multivariable model where depression was the outcome, 296 individuals had at least one observation included in the final model, and 65 had no observations included. 166 Compared to being missing from the final model, participants who were included in this model had a lower prevalence of reporting graduating high school (p=0.045) and a lower prevalence of reporting being an im/migrant to Canada (p=0.088). In the final multivariable model where food insecurity was the outcome, 295 individuals had at least one observation included in the final model, and 66 had no observations included. Compared to being missing from the final model, participants who were included in this model had a lower prevalence of reporting graduating high school (p=0.033). In the final multivariable model where criminalized opioid use was the outcome, 293 individuals had at least one observation included in the final model, and 68 had no observations included. Compared to being missing from the final model, participants who were included in this model had a lower prevalence of reporting graduating high school (p=0.068) and a higher prevalence of reporting marginalized or minoritized sexual identities (p=0.094). In the final multivariable model where criminalized stimulant use was the outcome, 292 individuals had at least one observation included in the final model, and 69 had no observations included. Compared to being missing from the final model, participants who were included in this model had a lower prevalence of reporting graduating high school (p=0.052). 167 Table B.1 â Baseline social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of gender-based violence Included (n) (N=293) Not included (n) (N=68) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 44 (35.5-53) 0 0.652 Marginalized and minoritized sexual identities b 49.2 (144) 39.7 (27) 0 0.160 Marginalized and minoritized gender identities c 16.0 (47) 13.2 (9) 2 0.627 Race/Ethnicity a 0 0.284 White 36.5 (107) 29.4 (20) Indigenous d 53.2 (156) 54.4 (37) Other racialized women/women of colour e 10.2 (30) 16.2 (11) Graduated high school a 49.2 (144) 63.2 (43) 0 0.036 Im/migrant to Canada a 10.9 (32) 17.7 (12) 0 0.127 Removed from parents a 36.9 (108) 25.0 (17) 15 0.505 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 168 Table B.2â Baseline social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of depression Included (n) (N=296) Not included (n) (N=65) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 44 (36-53) 0 0.690 Marginalized and minoritized sexual identities b 49.3 (146) 38.5 (25) 0 0.112 Marginalized and minoritized gender identities c 16.2 (48) 12.3 (8) 2 0.485 Race/Ethnicity a 0 0.227 White 36.5 (108) 29.2 (19) Indigenous d 53.4 (158) 53.9 (35) Other racialized women/women of colour e 10.1 (30) 16.9 (11) Graduated high school a 49.3 (146) 63.1 (41) 0 0.045 Im/migrant to Canada a 10.8 (32) 18.5 (12) 0 0.088 Removed from parents a 36.5 (108) 26.2 (17) 15 0.735 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 169 Table B.3 â Baseline social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of food insecurity Included (n) (N=295) Not included (n) (N=66) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 44.5 (36-53) 0 0.796 Marginalized and minoritized sexual identities b 49.2 (145) 39.4 (26) 0 0.151 Marginalized and minoritized gender identities c 16.3 (48) 12.1 (8) 2 0.451 Race/Ethnicity a 0 0.279 White 36.3 (107) 30.3 (20) Indigenous d 53.6 (158) 53.0 (35) Other racialized women/women of colour e 10.2 (30) 16.7 (11) Graduated high school a 49.2 (145) 63.6 (42) 0 0.033 Im/migrant to Canada a 10.9 (32) 18.2 (12) 0 0.100 Removed from parents a 36.6 (108) 25.8 (17) 15 0.653 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 170 Table B.4 â Baseline social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized opioid use Included (n) (N=293) Not included (n) (N=68) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 44.5 (36-53) 0 0.747 Marginalized and minoritized sexual identities b 49.5 (145) 38.2 (26) 0 0.094 Marginalized and minoritized gender identities c 16.0 (47) 13.2 (9) 2 0.627 Race/Ethnicity a 0 0.284 White 36.5 (107) 29.4 (20) Indigenous d 53.2 (156) 54.4 (37) Other racialized women/women of colour e 10.2 (30) 16.2 (11) Graduated high school a 49.5 (145) 61.8 (42) 0 0.068 Im/migrant to Canada a 10.9 (32) 17.7 (12) 0 0.127 Removed from parents a 36.5 (107) 26.5 (18) 15 0.721 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 171 Table B.5 â Baseline social-structural characteristics of 361 women living with HIV in Metro Vancouver, Canada, 2015 to 2023, stratified by being included in the final multivariable model for the relationship between eviction in the last six months and HIV-related syndemic outcome of criminalized stimulant use Included (n) (N=292) Not included (n) (N=69) Missing (n) P-value Age (median, Q1-Q3) 45 (38-52) 45 (36-53) 0 0.921 Marginalized and minoritized sexual identities b 49.3 (144) 39.1 (27) 0 0.128 Marginalized and minoritized gender identities c 16.1 (47) 13.0 (9) 2 0.588 Race/Ethnicity a 0 0.279 White 36.6 (107) 29.0 (20) Indigenous d 53.1 (155) 55.1 (38) Other racialized women/women of colour e 10.3 (30) 15.9 (11) Graduated high school a 49.3 (144) 62.3 (43) 0 0.052 Im/migrant to Canada a 11.0 (32) 17.4 (12) 0 0.142 Removed from parents a 36.6 (107) 26.1 (18) 15 0.642 a Referencing the previous six months before the first study visit b Responses of yes to sexual orientation other than heterosexual, which includes gay, lesbian, bisexual, asexual, queer, and other at any study visit c Responses of yes to gender identities other than cisgender which includes transgender, transsexual, person with trans experience, or any other transfeminine identities, non-binary, which includes genderqueer, bigender, agender, gender neutral, demigirl, and other, at any study visit d Indigenous includes First Nations and Métis peoples and Inuit e Other racialized/women of colour includes Black, East/Southeast Asian, Latinx, Middle Eastern, South Asian, and Other 172 Appendix C â Derivation of eviction variable The primary outcome variable of interest was having experienced an eviction in the last six months, measured by a âyesâ response to âevicted or forced to moveâ, for participants who responded, âyesâ to âHave you changed the main place where you live/sleep overnight in the last six months?â. In addition, several text responses for individuals who reported âyesâ to âHave you changed the main place where you live/sleep overnight in the last six months,â were coded as âevicted or forced to move,â as listed in Table C.1. 173 Table C.1 â Coding of the responses included in the variable capturing eviction in the last six month, for individuals who reported that they had âchanged where they sleep overnightâ in the last six months Number (N=66) Any or most to âevicted or forced to moveâ 58 Fire â her building burned down 1 Building being torn down 1 Lease ran out than homeless 1 Overstayed her second stage recovery placement 1 Time limit was up at shelter, had to leave 1 Transition housing (Dr. Peter Center) 1 Transitional program at bridge was over 1 Building burnt down 1
Thesis/Dissertation
Downtown-Eastside (Vancouver, B.C.)
eng
Population and Public Health
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Deering, Kathleen N.
Gadermann, Anne
Eviction prevalence, correlates and syndemic outcomes among women living with HIV in Metro Vancouver, Canada
Text