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Background: Cisgender (cis) and trans women living with HIV experience numerous barriers to stable housing and health services. With most research focusing on HIV care continuum outcomes and homelessness, there remain substantial gaps in research on more nuanced forms of housing precarity and broader health services access outcomes. This study is the first to apply the Canadian Definition of Homelessness (CDOH), a national, inclusive guideline, to the housing status reported by women living with HIV with the objective to investigate the prevalence and correlates of housing status and examine the associations between housing status and health services access. Methods: This study utilized data (2010-2019) from a longitudinal community-based open cohort of cis and trans women living with HIV aged 14+. Housing status derived from CDOH included four categories: unsheltered, unstable, supportive housing, and stable housing (reference). Health services access outcomes included: unmet primary, dental, and mental health care needs, HIV viral load, CD4, currently taking antiretroviral (ART), and self-reported ART adherence. Bivariate and multivariable analyses using generalized linear mixed models (GLMM) or generalized estimating equations (GEE) examined associations between social-structural correlates and housing status and associations between housing status and health services access over time. Results: Among 336 participants (1930 observations), the study sample had disproportionately high representations of Indigenous women (57%) and women with sexual (33%) and gender (10%) minority identities, relative to the Canadian population. Multivariable GLMM analyses identified that: Downtown Eastside (DTES) residence, hospitalization, physical/sexual violence, and stimulant use were associated with being unsheltered, compared to stable housing. DTES residence, hospitalization, and physical/sexual violence were associated with unstable housing, compared to stable housing. In multivariable GEE analyses, being unsheltered was independently associated with unmet primary and dental care needs, not taking ART, and detectable viral load. Conclusion: Prevention of housing precarity with women living with HIV should address affordability, systems and institutional barriers, gendered violence, and reformation of landlord and tenant laws. To ensure equitable access to new and existing housing and health services, trauma- and violence-informed principles, cultural safety, cultural humility, gender-responsiveness, and harm reduction practices are critical.
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