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Eviction as a Social Determinant of Sexual Health Outcomes.

The United States (US) is in the midst of a housing affordability crisis and an eviction epidemic, which is particularly impacting vulnerable populations: low-income households, people of color, single mothers, and children. Two thirds of low-income US families live in rental housing, a proportion that has grown in the wake of the 2008 Great Recession. Since the Recession, low-income households have experienced rising housing costs while their incomes have remained stagnant. As a result, most poor renting households spend over half of their incomes on housing, whereas nearly 1 in 4 spends over 70%. As more and more families struggle to pay rent, the rate of evictions has increased. Recent estimates suggest that 2% to 3% of renters nationwide experience eviction, with rates of eviction as high as 16% (ie, 16 eviction judgments per 100 renter-occupied homes) in some parts of the country. Although the links between housing instability and population health more broadly arewell established, there is a dearth of research specifically examining the connections between eviction and health, including sexual health outcomes. This is an important gap for 2 key reasons. First, evictions are considered by experts to be among the most deleterious sources of housing instability in that they often come about suddenly, create extreme financial strain and stress, and carry lasting legal consequences that can preclude families from accessing quality, affordable housing in the future. This suggests that eviction may have profound health effects and may operate both as a fundamental cause of disease, operating through poverty, and a pathway through which poverty becomes embodied in health outcomes. Second, eviction as a source of housing instability is both specific and policy-sensitive. Levers at the city and state for eviction may include reforming eviction law, changing rent court processes, or expanding existing housing voucher programs. In this issue of Sexually Transmitted Diseases, Linda Niccolai and colleagues investigate the ecological (county-level) relationship between eviction and 2 sexually transmitted infections (STIs) (ie, chlamydia and gonorrhea), an interesting foray joining a long line of research demonstrating that STI incidence is highly sensitive to social processes. The authors leverage a novel data source, the Eviction Lab National Database, to answer this research question. The Eviction Lab data represents the first attempt to compile court records of eviction filings and judgments on a national scale. After controlling for a number of county-level demographic, social, and geographic covariates, the authors found that, on average, counties with high eviction rates (>1.9 eviction judgments per 100 renter-occupied households) had 63.8 (95% confidence interval, 45.1–82.5) more chlamydia cases and 20.4 (95% confidence interval, 13.5–27.4) more gonorrhea cases per 100,000 population 1 year later, when compared with counties with low eviction rates (<0.59 judgments per 100 renter-occupied households). These findings were statistically significant and proved robust to a number of thoughtful sensitivity analyses. The authors present several plausible explanations for the identified associations between eviction rates and STIs 1 year later at the county-level. In general, the authors make the case that eviction may increase sexual and/or social vulnerabilities in ways that increase community levels of STIs. For example, individuals may change their behavior including engaging in sex work or increasing risky sexual behaviors in exchange for housing or other material needs (eg, food, transportation). They may also change their behavior in ways that increase risks for STIs (eg, alcohol or drug use) in an effort to cope with the stress that housing instability and the associated material hardship presents. Evictions may also cause changes to relationships (ie, disruptions in monogamous relationships, initiation of new relationships), resulting in changes to sexual network structures and increasing STI transmission potential within communities. Eviction and the resultant displacement may also disrupt health care access and decrease opportunities for STI testing and treatment, resulting in longer durations of infection. These mechanisms may impact vulnerable populations in particular who have little or no buffer to safeguard against the more deleterious outcomes related to eviction. Although we find this a well-conceptualized study, we offer 1 comment and 2 potential limitations. The authors suggest that the study's ecological design is a limitation. Although we agree that the results cannot be interpreted as the effect of individual-level eviction on individual STI risk, it is also