"The way I see it": Towards a Community-informed understanding of the relationship between housing and health among people living with HIV in Vancouver, B.C.

Background: Vancouver, British Columbia has one of the highest HIV prevalence rates in Canada and a growing housing crisis. The limited data available on the impact of housing instability on the health of people living with HIV in this setting has been generated without meaningful involvement of the community. In order to fill this gap, we launched a community-based research project aimed at developing an understanding of the housing-health nexus that is grounded in the experiences of people living with HIV. Methods: Eight Community Researchers – people living with HIV who have experienced homelessness in Vancouver - were recruited and trained by the Project Coordinator to co-facilitate this community based participatory action research project. The Project Coordinator proposed the use of Photovoice to ensure the meaningful engagement of the Community Researchers. Photovoice is a research method that assists people, often marginalized by social-structural inequity, to reflect on their capacities and needs, engage with policymakers and encourage social change. Results: The Community Researchers generated over 300 photographs and engaged in facilitated discussion with the Project Coordinator to identify emergent themes. The Community Researchers described the detrimental impact of inadequate housing on their physical and mental health, and the resiliency promoted by healthy environments. The analysis culminated in the development of a multi-level ecological framework mapping the determinants and impacts of housing instability in this population, representing the first step towards building a comprehensive, community-informed definition of healthy housing as viewed through the eyes of people living with HIV. Interpretation: The findings underscore the need to expand the focus of housing strategies to incorporate the broader political, economic and social context, and to meaningfully engage affected populations in developing policy and programming targeting housing instability.