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One third of Canadians rent their homes, but more people than ever are at risk of eviction. What’s going on with Canada’s housing crisis? And how does it affect people living with HIV?

Jonathan Valelly investigates.

The Canadian housing supply has been falling behind demand for decades. Today, Canada has the lowest number of housing units per person of any G7 country and would need 1.8 million units to catch up to the group average. At the same time, property values are exploding across the nation. As prices go up, rent follows, which tempts landlords to evict their tenants in search of new ones with bigger budgets. This means there aren’t enough housing units for prospective homeowners, fewer people can afford them and people who rent live in fear of eviction. The result is a national housing crisis.

Hundreds of thousands of people experience homelessness in Canada every year, with an estimated 35,000 sleeping rough on any given night. This doesn’t include people who are sheltered in situations like couch-surfing or hostels, or people who are awaiting eviction. Data show that communities at risk of HIV and hepatitis C—racialized people, gay and bisexual men and people who use drugs—have lower average incomes and are more likely to live in poverty. This makes them more likely to be renters instead of home owners.

Unstable housing can worsen people’s health outcomes. One 2021 study found a robust link between evictions and HIV sexual risk, and a recent study in The Lancet found that unstable housing among people who inject drugs was linked to a 139% higher risk of HIV. This study also found that unstable housing significantly raised someone’s chance of having a detectable viral load. Community-led research from organizations like the Ontario HIV Treatment Network backs up these findings: it shows that unhoused people living with HIV have less access to primary care, are less likely to be on medications and are less able to stay on track with treatment. Policy-makers have been slow to respond to this national crisis, and as a result, HIV organizations are aiming to fill the gaps.

An evolving crisis

Donald Keeping never imagined that he’d end up on the streets. The Newfoundland father of two enjoyed a quiet life and a stable job working as a fisherman in Nova Scotia for years. But when he got injured at work, he was handed a prescription for painkillers. “I couldn’t work, and I worked on the sea all my life. It was like a life sentence, like, ‘you can’t do this ever again,’” he recalls. Losing his work felt like losing his identity and he soon became dependent on opioids. “I got hooked on the morphine, and after a couple years I lost my marriage, my siblings. I ended up homeless. I used all my money for drugs.”

In the years that followed, Keeping passed through multiple shelters before arriving at the Tommy Sexton Centre Shelter, a four-bed shelter in St. John’s that is managed by the AIDS Committee of Newfoundland and Labrador (ACNL). There, he got onto methadone treatment to help manage his drug use. He also tested positive for hepatitis C. After getting Keeping on treatment to cure the infection, ACNL invited him to live in one of their six longer term supportive housing units. These are affordable apartments earmarked for people diagnosed with hepatitis C or HIV. Housing has made all the difference for Keeping, who said he prays that people in a nearby tent city can find something similar so they can heal. “If you want to get close to sober, you need that mental state, to be safe,” Keeping reflects. “And you’ve got to have somewhere to sleep. Having your own place gives you all that.”

Gerard Yetman co-founded ACNL in the late 1980s, and he returned as executive director in 2012 after 20 years in Ontario. When he came home, he noticed things had changed. In ACNL’s early years, clients were mostly gay men returning from Toronto or Vancouver to spend their final days at home. Decades later, the number of people applying to live in the agency’s housing had dropped and it was struggling to shake its reputation as a hospice. Also, clients were only eligible if they were living with HIV. Meanwhile, ACNL’s short-term Tommy Sexton Centre Shelter was busy with new faces. “We saw a big change in the demographics,” recalls Yetman. “So, our housing became more for people at risk of HIV or hepatitis C.”

Many new clients were people who use drugs, so ACNL pivoted to make mental health and harm reduction part of its mandate. This proved to be a good choice, as the overdose crisis swelled in the years following. Housing costs in the province also spiraled, and an influx of workers to the Muskrat Falls dam project in Labrador put more strain on the housing supply. Community members face these crises as immediate, material issues, but they have bigger root causes: colonialism, resource extraction, income inequality and stigma, to name a few.

Housing and harm reduction

Sanctum was created to solve a problem playing out in Saskatoon’s hospitals. People who inject drugs were arriving with opportunistic infections, wounds and other acute conditions, but they weren’t staying to finish their treatments. Ultimately, the hospital environment didn’t provide for the specific needs of such patients, who may be expected to suddenly be abstinent in a sterile, lonely place. Hospital clinicians weren’t equipped with the resources, trust or cultural understanding to make people who use drugs feel safe and comfortable; Sanctum formed in 2015 to offer another option.

For people who use drugs, “the model of care in a hospital is like a jail sentence,” explains Sandra Blevins. Blevins is a longtime board member who also acted as interim executive director in 2021. Clients “were having to stay when they were still very active in their addictions,” she explains. “It was just a real clash with the system.” Sanctum offers an alternative: they offer people treatment at home and offer the home, too. Its flagship 10-bed facility offers transitional care to people who use drugs and don’t have anywhere to go, let alone a place to address their health concerns. Sanctum’s model of care champions unconditional compassion and respect for residents, regardless of their substance use.

“Sanctum accepts people with this beautiful mission of being a place that is non-judgmental, meeting people where they are, and practising—truly practising—harm reduction and trauma-informed care,” explains Blevins. Sanctum’s outcomes speak for themselves: twice as many residents leave the program with undetectable viral load than when they arrive, and 72% of residents report good or excellent mental health at discharge, compared with 40% at admission.

When COVID-19 arrived, Sanctum’s harm reduction principles were put to the test. The organization didn’t require residents to be abstinent, but they banned substance use in their housing. At first, stay-at-home orders didn’t clash with this policy—most residents at the time weren’t using drugs, and they had little reason to leave home. But by the time that cohort moved out in summer 2021, Sanctum had loosened its visitor policies as the province opened up. A spate of overdoses among the new residents followed. This showed that unsupervised drug use was now happening on site, which caused staff to reassess their approach. Sanctum could have cracked down on residents using on the premises, but this would have forced residents to go outside more, raising the risk of COVID-19 for those living and working there. Instead, its board of directors voted to move toward a safe consumption policy on site during lockdowns. Other local policy changes continue to put a strain on Sanctum’s capacity: the province changed their rental assistance program and stopped paying rent directly to landlords, while the fire department closed two densely populated, low-income high-rises. “We’re in a new place now,” Blevins sighs.

Women-centred care

For decades, Saskatoon hospital staff, police and welfare services have been called in to delivery wards to take newborns into public guardianship straight out of the hospital. Birth alerts, as they are known, are coordinated communications between hospital staff and social workers or law enforcement. They flag pregnant women who are presumed to be “unfit parents” because of mental health issues, addiction or housing instability. Typically, alerts lead to newborns being placed into the foster system. In 2020, about 70% of these alerts flagged Indigenous mothers. This continues centuries of state-sanctioned disruption to Indigenous families, and as a result, Indigenous children are massively over-represented in the foster care system.

In 2019, the final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls condemned the practice of birth alerts as “racist and discriminatory” and “a gross violation of the rights of the child, the mother, and the community.” Soon after, Saskatchewan and other provinces announced that they would abolish the practice. However, the number of apprehensions in the province remains steady each year, even as Canada grapples with the legacy of child abuse in residential schools. Because of policies like these, many Indigenous mothers and mothers-to-be are wary of medical and social institutions. “These moms were not seeking any kind of prenatal care because they were scared of that interaction at the hospital, and of the system, of being found and flagged,” explains Blevins. “So the transmission of HIV was happening [during pregnancy and childbirth] as well.”

Transmission of HIV during pregnancy and childbirth can be prevented with effective HIV treatment. But trauma and mistrust collide with many more challenges for Indigenous women. Expenses for daily living and healthcare, lack of Internet access, transportation and childcare issues, language barriers and homelessness all work against these mothers. Saskatchewan has the highest rate of HIV of any province in Canada, with triple the number of new diagnoses per year compared with the national average. About 80% of new diagnoses in the province are in Indigenous people. But given the culture of fear surrounding birth alerts and the numerous barriers to HIV-related care, there is a real crisis for pregnant women living with HIV in Saskatchewan, one where immediate health issues are amplified by social inequity.

In response, Sanctum launched a new program in 2018 known as Sanctum 1.5. This is a holistic pre- and post-natal housing option for women living with HIV or hepatitis C and their newborns. Ten housing units also come with HIV case management and holistic treatment for neonatal abstinence syndrome, along with community-based services. These include peer support, spiritual care with elders, and parenting and life skills development for mothers and their trusted family members. Since its inception, at least 41 women have gone through the prenatal care home. None of the children so far have been born with HIV, nor have any been apprehended. Sanctum 1.5 is the only program of its kind in Canada.

Challenges ahead

“I never thought I would ever be in this field. Like, here I am doing social work stuff,” says Keith Bowering, Sanctum’s housing coordinator and a harm reduction advocate. “But this is just how my life has turned out, right?” Having used and sold crystal meth for 22 years—including 10 without a home—his skills and experience have come in useful. Before formally working as a social worker, Keith was already an advocate for his community. He distributed safe supplies and information around the city, and he still does so after hours. Today, he’s often seen biking around town handing out kits, promoting drug safety at a music festival or doing workshops with SayKnow.org, a project that advocates for the decriminalization of drugs.

Bowering has had an outsized impact on local harm reduction efforts, but he’s candid about the fight ahead in Saskatchewan. The province recently rolled out a single-channel social assistance program, when previously it paid rent to landlords directly to prevent evictions. The new Saskatchewan income support program puts a total amount of $575 per month directly in the hands of individuals to be used for rent, utilities and necessities. The result is that people are losing their homes faster than ever. “It has never been so bad. You’ve never seen so many people wandering with blankets and carts. Everybody is screwed,” says Bowering. “You can’t even find an apartment for $575, let alone an apartment where you can pay your power bill and your damage deposit.”

These situations show how one policy change can send a housing crunch into overdrive, and all that comes with it—overdoses from the toxic drug supply, high rates of HIV and hepatitis C, and brutal disparities marked by race and class. So far, Sanctum has maxed out at 28 housing units. AIDS Committee of Newfoundland and Labrador have 10, four of them short-term. Without the proper resources, there’s only so much organizations can do. That’s why Bowering and his colleagues demand structural and legal changes that could create more equity for those with complex needs. That means decriminalizing and ensuring a safe supply of drugs; restoring and improving social assistance programs; regulating private real estate; and, of course, building accessible, affordable and supportive housing.

Jonathan Valelly is a queer writer, editor and organizer based in Toronto. Ask him about zines, harm reduction, ballroom, prison abolition and Prince.