Trends in emergency department visits during cold weather seasons among patients experiencing homelessness in Ontario, Canada: a retrospective population-based cohort study.

PURPOSE: Recent anecdotal reports suggest increasing numbers of people experiencing homelessness are visiting emergency departments (EDs) during cold weather seasons due to inadequate shelter availability. We examined monthly ED visits among patients experiencing homelessness to determine whether there has been a significant increase in such visits in 2022/2023 compared to prior years. METHODS: We used linked health administrative data to identify cohorts experiencing homelessness in Ontario between October and March of the 2018/2019 to 2022/2023 years. We analyzed the monthly rate of non-urgent ED visits as a proxy measure of visits plausibly attributable to avoidance of cold exposure, examining rates among patients experiencing homelessness compared to housed patients. We excluded visits for overdose or COVID-19. We assessed level and significance of change in the 2022/2023 year as compared to previous cold weather seasons using Poisson regression. RESULTS: We identified a total of 21,588 non-urgent ED visits across the observation period among patients experiencing homelessness in Ontario. Non-urgent ED visits increased 27% (RR 1.24 [95% CI 1.14-1.34]) in 2022/2023 compared to previous cold weather seasons. In Toronto, such visits increased by 70% (RR 1.68 [95% CI 1.57-1.80]). Among housed patients, non-urgent ED visits did not change significantly during this time period. CONCLUSION: Rates of ED visits plausibly attributable to avoidance of cold exposure by individuals experiencing homelessness increased significantly in Ontario in 2022/2023, most notably in Toronto. This increase in ED visits may be related to inadequate access to emergency shelter beds and warming services in the community.

RéSUMé: OBJECTIFS: Des rapports anecdotiques récents suggèrent qu'un nombre croissant de personnes en situation d'itinérance visitent les services d'urgence (SU) pendant les saisons froides en raison de la disponibilité insuffisante d'hébergement d'urgence. Nous avons examiné les visites mensuelles aux urgences chez les personnes en situation d'itinérance afin de déterminer s'il y a eu une augmentation significative de ces visites en 2022-2023 par rapport aux années précédentes. MéTHODES: Nous avons utilisé des données administratives de santé liées pour identifier les cohortes de personnes en situation d'itinérance en Ontario entre octobre et mars des années 2018/2019 à 2022/2023. Nous avons analysé le taux mensuel de visites aux urgences non urgentes comme mesure approximative des visites vraisemblablement attribuables à l'évitement de l'exposition au froid, en examinant les taux chez les personnes en situation d'itinérance par rapport aux patients logés. Nous avons exclu les visites pour surdose ou COVID-19. Nous avons évalué le niveau et l'importance du changement dans l'année 2022/2023 par rapport aux saisons froides précédentes en utilisant la régression de Poisson. RéSULTATS: Nous avons recensé un total de 21 588 visites non urgentes aux urgences au cours de la période d'observation chez des personnes en situation d'itinérance en Ontario. Les visites aux urgences non urgentes ont augmenté de 27 % (RR 1,24 [IC à 95 % 1,14-1,34]) en 2022­2023 par rapport aux saisons froides précédentes. À Toronto, ces visites ont augmenté de 70 % (RR 1,68 [IC à 95 % 1,57-1,80]). Parmi les patients logés, les visites aux urgences non urgentes n'ont pas changé de façon significative pendant cette période. CONCLUSIONS: Les taux de visites aux urgences attribuables vraisemblablement à l'évitement de l'exposition au froid par les personnes en situation d'itinérance ont augmenté considérablement en Ontario en 2022­2023, surtout à Toronto. Cette augmentation du nombre de visites aux urgences peut être liée à un accès inadéquat aux lits des refuges d'urgence et aux services de réchauffement dans la collectivité.

Cold-related injuries among patients experiencing homelessness in Toronto: a descriptive analysis of emergency department visits.

PURPOSE: Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless. METHODS: This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups. RESULTS: We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4 years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness. CONCLUSION: Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.

RéSUMé: OBJECTIF: L'itinérance augmente le risque de blessures liées au froid. Nous avons examiné les visites aux urgences pour des blessures liées au froid à Toronto sur une période de quatre ans, en comparant les visites de patients en situation d'itinérance aux visites de patients pas en situation d'itinérance. MéTHODES: Cette analyse descriptive des visites aux services d'urgence à Toronto entre juillet 2018 et juin 2022 a utilisé des données administratives de santé liées. Nous avons mesuré les visites aux services d'urgence avec un diagnostic de blessure liée au froid parmi les patients en situation d'itinérance et ceux pas en situation d'itinérance. Les taux ont été exprimés en nombre de visites pour les blessures liées au froid par 100 000 visites au total. Le rapport de taux ont été utilisés pour comparer les taux entre les groupes en situation d'itinérance et ceux pas en situation d'itinérance. RéSULTATS: Nous avons identifié 333 visites pour des blessures liées au froid chez les patients en situation d'itinérance et 1126 chez les patients pas en situation d'itinérance. Au cours de chacune des quatre années d'observation, les rapports de taux variaient entre 13,6 et 17,6 pour l'ensemble des blessures liées au froid, 13,7 et 17,8 pour l'hypothermie et 10,3 et 18,3 pour les engelures. Les taux par 100 000 visites au cours de la quatrième année (de juillet 2021 à juin 2022) étaient considérablement plus élevés que pendant la période précédant la pandémie. Les patients de sexe masculin affichaient des taux plus élevés, peu importe leur statut d'itinérance; les patients de sexe féminin en situation d'itinérance affichaient des rapports de taux plus élevés que les patients de sexe masculin en situation d'itinérance. CONCLUSION: Les patients en situation d'itinérance qui se rendent à l'urgence sont beaucoup plus susceptibles d'être vus pour des blessures liées au froid que les autres. Des efforts supplémentaires sont nécessaires pour prévenir l'exposition au froid et les blessures qui en découlent chez les personnes en situation d'itinérance.

Incidence of SARS-CoV-2 Infection Among People Experiencing Homelessness in Toronto, Canada.

Importance: People experiencing homelessness are at high risk of SARS-CoV-2 infection. Incident infection rates have yet to be established in these communities and are needed to inform infection prevention guidance and related interventions. Objective: To quantify the SARS-CoV-2 incident infection rate among people experiencing homelessness in Toronto, Canada, in 2021 and 2022 and to assess factors associated with incident infection. Design, Setting, and Participants: This prospective cohort study was conducted among individuals aged 16 years and older who were randomly selected between June and September 2021 from 61 homeless shelters, temporary distancing hotels, and encampments in Toronto, Canada. Exposures: Self-reported housing characteristics, such as number sharing living space. Main Outcomes and Measures: Prevalence of prior SARS-CoV-2 infection in summer 2021, defined as self-reported or polymerase chain reaction (PCR)- or serology-confirmed evidence of infection at or before the baseline interview, and SARS-CoV-2 incident infection, defined as self-reported or PCR- or serology-confirmed infection among participants without history of infection at baseline. Factors associated with infection were assessed using modified Poisson regression with generalized estimating equations. Results: The 736 participants (415 of whom did not have SARS-CoV-2 infection at baseline and were included in the primary analysis) had a mean (SD) age of 46.1 (14.6) years; 486 (66.0%) self-identified as male. Of these, 224 (30.4% [95% CI, 27.4%-34.0%]) had a history of SARS-CoV-2 infection by summer 2021. Of the remaining 415 participants with follow-up, 124 experienced infection within 6 months, representing an incident infection rate of 29.9% (95% CI, 25.7%-34.4%), or 5.8% (95% CI, 4.8%-6.8%) per person-month. Report after onset of the SARS-CoV-2 Omicron variant was associated with incident infection, with an adjusted rate ratio (aRR) of 6.28 (95% CI, 3.94-9.99). Other factors associated with incident infection included recent immigration to Canada (aRR, 2.74 [95% CI, 1.64-4.58]) and alcohol consumption over the past interval (aRR, 1.67 [95% CI, 1.12-2.48]). Self-reported housing characteristics were not significantly associated with incident infection. Conclusions and Relevance: In this longitudinal study of people experiencing homelessness in Toronto, SARS-CoV-2 incident infection rates were high in 2021 and 2022, particularly once the Omicron variant became dominant in the region. Increased focus on homelessness prevention is needed to more effectively and equitably protect these communities.

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial.

INTRODUCTION: People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have not been rigorously evaluated. The Navigator Programme is a Critical Time Intervention case management programme that was developed to help homeless patients with their postdischarge needs and to link them with community-based health and social services. This randomised controlled trial examines the impact of the Navigator Programme on posthospital outcomes among adults experiencing homelessness. METHODS AND ANALYSIS: This is a pragmatic randomised controlled trial testing the effectiveness of the Navigator Programme at an urban academic teaching hospital and an urban community teaching hospital in Toronto, Canada. Six hundred and forty adults experiencing homelessness who are admitted to the hospital will be randomised to receive support from a Homeless Outreach Counsellor for 90 days after hospital discharge or to usual care. The primary outcome is follow-up with a primary care provider (physician or nurse practitioner) within 14 days of hospital discharge. Secondary outcomes include postdischarge mortality or readmission, number of days in hospital, number of emergency department visits, self-reported care transition quality, and difficulties meeting subsistence needs. Quantitative outcomes are being collected over a 180-day period through linked patient-reported and administrative health data. A parallel mixed-methods process evaluation will be conducted to explore intervention context, implementation and mechanisms of impact. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Unity Health Toronto Research Ethics Board. Participants will be required to provide written informed consent. Results of the main trial and process evaluation will be reported in peer-reviewed journals and shared with hospital leadership, community partners and policy makers. TRIAL REGISTRATION NUMBER: NCT04961762.

COVID-19 Vaccine Coverage and Sociodemographic, Behavioural and Housing Factors Associated with Vaccination among People Experiencing Homelessness in Toronto, Canada: A Cross-Sectional Study.

People experiencing homelessness were prioritized for COVID-19 vaccination in Toronto, Canada, due to the high risk of infection and associated complications relative to the general population. We aimed to ascertain COVID-19 vaccine coverage in this population and explore factors associated with the receipt of at least one dose. We collected survey and blood sample data from individuals ages 16+ recruited by random selection at 62 shelters, hotels and encampment sites between 16 June 2021 and 9 September 2021. We report vaccine coverage by dose number and explored sociodemographic, behavioral, health and housing factors associated with vaccination using multivariable modified Poisson regression. In total, 80.4% (95% CI 77.3-83.1%) received at least one vaccine dose, and 63.6% (CI 60.0-67.0%) received two or more doses. Vaccination was positively associated with age (every 10 years adjusted rate ratio (aRR) 1.05 [95% CI 1.03-1.08]), and receipt of influenza vaccination (aRR 1.19 [95% CI 1.11-1.27]). Factors negatively associated with vaccination included female gender (aRR 0.92 [95% CI 0.85-1.0]), Black racial self-identification (aRR 0.89 [95% CI 0.80-0.99]) and low frequencies of masking in public places (aRR 0.83 [95% CI 0.72-0.95]). COVID-19 vaccine coverage is very high among people experiencing homelessness in Toronto, suggesting advocacy and outreach efforts may have been effective.

Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study.

INTRODUCTION: People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population. METHODS AND ANALYSIS: The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence. ETHICS AND DISSEMINATION: Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.

Legal, geographic and organizational contexts that shape knowledge sharing in the hospital discharge process for people experiencing homelessness in Toronto, Canada.

People experiencing homelessness use acute healthcare at higher rates than the general population, yet hospitals frequently discharge them to the streets or emergency shelters. Available literature on the hospital discharge process for people experiencing homelessness identifies knowledge sharing as an important and challenging part of the discharge process; however, it does little to explain what generates these challenges or what might support knowledge sharing. In this study, we explain under which contexts certain mechanisms are triggered to facilitate knowledge sharing between hospitals and shelters during the discharge process. Between September 2018 and April 2019, we interviewed 33 participants: hospital workers on general medicine wards across three hospitals; shelter workers; researchers, policy advisors or advocates working at the intersection of homelessness and healthcare in Toronto. We find that within the legal context of health information protection, the concept of "circle of care" has created barriers to knowledge sharing between hospitals and shelters by excluding shelter workers from discharge planning. We note, however, that the degree to which hospital workers have navigated these barriers and brought shelter workers into the discharge process varies across hospitals. We explore this variation and find that certain geographic and organisational contexts have activated the development of institutional- and individual-level relationships between hospitals and shelters or their workers, respectively. We suggest that these relationships generate increased trust and communication and have led to knowledge sharing between hospitals and shelters. These findings are applicable in most urban centres with hospitals and where people experiencing homelessness live. Understanding the role of context is imperative for developing appropriate and effective interventions to improve hospital discharge processes. The development and implementation of more effective discharge processes can contribute to improved post-discharge care and recovery for this patient population and contribute to addressing health equity.

Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada.

OBJECTIVES: A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. METHODS: Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. RESULTS: Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. CONCLUSION: Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.

RéSUMé: OBJECTIFS: L'un des principaux éléments des sorties d'hôpital consiste à trouver pour la patiente ou le patient une destination qui répond à ses besoins post-hospitalisation. Au Canada, il est difficile d'atteindre cet objectif pour les patients sans abri, qui se retrouvent souvent dans la rue ou dans des refuges à leur sortie de l'hôpital. Nous avons cherché à savoir pourquoi et comment la capacité du personnel hospitalier de trouver des destinations appropriées pour les patients sans abri à leur sortie de l'hôpital est influencée par des contextes sociaux et économiques dynamiques. MéTHODE: Guidées par le réalisme critique, nous avons mené des entretiens en profondeur semi-structurés avec 33 participants : des membres du personnel hospitalier des services de médecine générale de trois hôpitaux urbains; des membres du personnel de refuges; et des chercheurs, des conseillers en politiques et des porte-parole travaillant au croisement des services aux sans-abri et des soins de santé. RéSULTATS: Les contextes sociaux et économiques historiques et contemporains (p. ex. les compressions budgétaires) ont déclenché l'adoption de mesures d'efficience et de responsabilisation dans les hôpitaux, et de critères et de règles d'exclusion dans les refuges, deux éléments que nous caractérisons comme étant des mécanismes dans le présent article. Les hôpitaux sont contraints de donner leur congé aux patients dès que ceux-ci sont jugés médicalement stables, mais ils ont du mal à les envoyer dans des refuges, car pour prévenir les sorties inappropriées, certains refuges ont adopté des règles et des critères d'exclusion et d'admissibilité. Ces mécanismes expliquent en partie la difficulté de trouver une destination appropriée pour les patients sans abri à leur sortie de l'hôpital. CONCLUSION: Nos résultats font état d'une lacune systémique dans le parcours des sorties d'hôpital : les personnes sans abri qui n'ont plus besoin de soins de courte durée n'ont aucun endroit où aller, mais leurs besoins sont trop complexes pour les refuges. Des changements systémiques sont nécessaires pour mieux aider les intervenants de première ligne des hôpitaux et des refuges à améliorer le processus de sortie.

Hospital Discharge Planning for People Experiencing Homelessness Leaving Acute Care: A Neglected Issue.

People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.

Exploring the Potential of Participatory Theatre to Reduce Stigma and Promote Health Equity for Lesbian, Gay, Bisexual, and Transgender (LGBT) People in Swaziland and Lesotho.

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

Marginalization and social change processes among lesbian, gay, bisexual and transgender persons in Swaziland: implications for HIV prevention.

Swaziland has among the highest national adult HIV prevalence globally. There is limited knowledge of HIV vulnerabilities and prevention engagement among lesbian, gay, bisexual and transgender (LGBT) persons in the context of Swaziland's criminalization of consensual same-sex practices. This study explored social processes of marginalization to assess how they could potentiate HIV vulnerabilities and limit engagement in HIV prevention services. Additionally, we assessed positive change to better understand existing strategies employed by LGBT persons to challenge these HIV prevention barriers. Guided by community-based research methodology and conducted in Mbabane and Manzini, Swaziland, data were collected by LGBT peer-research assistants (PRA) in collaboration with an LGBT community organization in Manzini. Semi-structured interviews were conducted by trained PRAs and explored HIV prevention, including experiences of stigma and coping. Audio files were transcribed verbatim, translated to English, and analyzed using thematic techniques. Among participants (n = 51; mean age: 26.47, SD: 4.68), 40 self-identifed as gay or lesbian (78.4%), 11 bisexual (22.6%), and 12 (23.5%) identified as transgender. Findings highlighted three primary processes of marginalization and positive change in structural, community, and internal domains. First, structural marginalization, which included criminalization, healthcare discrimination, and a scarcity of LGBT tailored HIV prevention resources was challenged by grassroots networks created to access and share specific HIV resources with LGBT persons and the Ministry of Health. Second, community marginalization included stigma and multi-dimensional forms of violence, however, this was met with LGBT persons providing mutual peer support, including for accessing HIV testing services. Thirdly, internal marginalization comprised of self-stigma and associated sexual risk practices was contrasted with coping strategies focused on self-acceptance, stemming from social support and leading to healthcare utilization. Jointly, these findings can inform the implementation of community-based and rights affirming HIV prevention and care cascade strategies that improve coverage of services with LGBT persons in Swaziland.

A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada.

African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ2 (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.