N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) ‘forgetting’ was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants ( The challenges inherent in taking medication daily for a chronic and stigmatised condition such as HIV infection cannot be overstated  and/or evidence HIV viral suppression (51%) , to uncover the structural, social, and individual-level factors that influence ART adherence, including individual decision-making about what it means to be optimally adherent. Guided by the theory of triadic influence , and these participants were invited to recruit their peers to enroll in the study. Recruitment efforts concentrated on enrolling participants with variability in length of time living with HIV and periods of optimal adherence/less-than-optimal adherence to ART. Recruitment continued until saturation was reached on core themes , motivation/readiness to take ART (Would you say you ‘wanted’ to take HIV medication? Did you feel ‘ready’ to take HIV medication?), and emotions about ART (How much do your feelings about HIV medications help or hinder your ability to take ART every day?). Social-level factors included relationships with providers  and stigma. Structural-level factors included factors such as stable housing . Throughout the interview process, the interview guide was updated to reflect newly emergent codes. Indeed, as noted above, the theme of forgetting to take ART was not emphasised in the first version of the semi-structured interview guide. However, we found it was a compelling and recurring construct early in the data collection process and was added to the guide. We also assessed a set of socio-demographic and background characteristics; namely, age, sex, race/ethnicity, number of years since HIV diagnosis, number and duration of times taking ART in the past, whether on ART in the past month, and the average level of adherence to ART on a 4-point Likert-type scale .The data analysis strategy was both theory-driven and inductive, and utilised a directed content analysis approach , and the remainder were Hispanic/Latino. All were from low socio-economic status backgrounds and received public health insurance for low-income individuals (Medicaid). Participants ranged between the ages of 50 and 69 years and had been living with HIV from between 3 and 33 years, with an average of 21 years living with HIV. Most had participated in HIV-related support or therapy groups and substance use treatment programmes, although the duration of their involvement varied. All had taken ART for substantial periods in the past, along with episodes of ART discontinuation. At the time of the present study, 60% reported taking ART with optimal adherence in the past month. Although not included in the assessment of sociodemographic characteristics, we found substance use, past and/or current, was highly prevalent in this sample. During their interviews, most participants (78%) mentioned tobacco use or smoking, 61% discussed crack or powder cocaine, and alcohol, ‘dope’, heroin, injection drug use, and pills were also mentioned commonly in transcripts. A third of participants discussed past incarceration, jail, or prison, suggesting involvement in the criminal justice system was fairly common. Thus, participants exhibited a substantial number of serious risk factors that have the potential to interfere with optimal ART adherence. Names used below are pseudonyms and some identifying details have been changed to protect participants’ anonymity.Participants in the present study recounted their histories, generally very long histories, of managing HIV infection and ART adherence. Thus, results yielded a rich retrospective overview of the challenges inherent in maintaining optimal adherence to ART over decades of living with HIV, as well as successes and lessons learned. We found participants understood the importance of optimal ART adherence as their best chance for a long and healthy life. Moreover, they identified a number of factors that either promoted or impeded optimal ART adherence, some of which are fairly well-described in the literature to date, such as the importance of stable housing, as well several under-studied factors, as described below. Overall, participants highlighted the challenges inherent in taking medication for a chronic health condition that is both complex and stigmatised, particularly in the context of chronic poverty. Findings highlighted that the larger social and organisational structures in which African American/Black and Hispanic/Latino PLWH were embedded did not sufficiently support optimal ART adherence.Consistent with existing epidemiological studies, optimal ART adherence, even once achieved, was not a static state or phenomenon, and participants described factors driving the dynamic nature of ART adherence patterns. These included the evolving nature of their perspectives on what it meant to be living with HIV. Further, life circumstances such as lost housing and changes in social/romantic relationships, which often triggered mental health and substance use problems, influenced ART adherence decisions and behaviours. Participants reported the ability to take ART optimally when using alcohol and/or illicit drugs socially or at non-hazardous levels. However, it was substantially more difficult for participants to prioritise ART in times of heavy or problematic substance use, although participants did often still consider missing or stopping ART a choice in this context. Nonetheless, those who missed ART doses, including in times of heavy substance use, generally re-grouped and started again. Moreover, participants described their complex and often shifting emotional responses to ART. Indeed, taking ART was rarely described as habitual, easy, or emotionally neutral. Participants viewed intrinsic motivation to take ART as fundamental to optimal ART adherence, but such motivation was both hard-won and commonly disrupted in times of hardship. Thus, ART adherence decisions and behaviours required constant recalibration. Missed ART doses commonly led to long periods of ART discontinuation, and it was often challenging for participants to harness internal and external resources to re-initiate ART and re-establish optimal adherence patterns. Overall, participants described the strategies they had developed to manage and sometimes redefine ART adherence, and the contextual and psychosocial factors that influenced those decisions and behaviours.The concept of forgetting to take ART doses was prominent in participants’ narratives of managing ART adherence. However, as we describe below, forgetting to take one’s HIV medications was far more complex than a simple lapse of memory, and findings underscored the need for a closer examination of both what it means to be optimally adherent to ART and what it means to forget to take ART. Throughout the interviews, participants shifted between various explanations for the reasons they forgot to take ART doses. At times, forgetting was mentioned as occurring most frequently during times of high emotional stress and/or depression. At others, forgetting to take ART was closely associated with an ambivalent or even traumatic emotional response to both their HIV medications and the burden of HIV-related stigma. Moreover, forgetting to take ART frequently involved participants taking intentional or semi-intentional ‘holidays’ from their regimens. In still other cases, forgetting to take ART was associated with external circumstances that precluded taking medication doses altogether. Thus, we found forgetting to take ART emerged as a primary means of managing ART, and coping with living with HIV, over the long term. Importantly, participants highlighted that the line between true forgetting and intentionally missing doses was frequently blurred. Indeed, throughout the interviews, participants often either implicitly or explicitly declined a clear-cut distinction between accident and intent. Moreover, depending on the age of the participant, ambivalence about taking ART was often closely linked with direct memories of, or the historical legacy of, knowledge about AZT monotherapy in the early days of the epidemic, which participants described as experimental, being given in high doses, and causing serious side effects but with limited efficacy.Health care providers were described as vital to participants’ abilities to manage HIV infection. However, participants experienced health care providers as a variable in how well they understood the complexities of managing HIV infection and optimal ART adherence. Participants commonly told their providers they forgot to take ART, but without disclosing or being asked to disclose the intentional, semi-intentional, or unintentional decisions or circumstances, whether internal or external, that contributed to those forgotten ART doses. Indeed, in the present study, participants repeatedly described forgetting as the reason for suboptimal ART adherence and only linked forgetting to its underlying causes  through a process of extended reflection. Conversely, patient-provider relationships in which patients were encouraged to contribute to the consultation dialogue contributed to what participants viewed as more favourable HIV outcomes.Study findings were grouped into six interrelated themes: (1) forgetting to take ART served as a shorthand description of a complex phenomenon, but was rarely a simple lapse of memory, and often involved intentional or semi-intentional breaks from ART; (2) forgetting was described as a means of handling the difficult emotional context within which HIV management and optimal ART adherence take place, including regarding the challenge of adaptation to the HIV diagnosis and HIV-related stigma; (3) adverse life events played a primary role in contributing to mental health distress and substance use problems, which in turn was related to disrupting optimal ART adherence, especially because living in poverty allowed for few buffering resources; (4) the legacy of AZT monotherapy and its relationship to present-day ART adherence, often grounded in trauma and loss, disrupted optimal adherence, including by contributing to medical distrust; (5) aspects of patient-provider interactions promoted or impeded the discussion of the factors underlying forgetting and optimal ART adherence; and (6) intrinsic motivation was critical for optimal ART adherence and as a buffer against forgetting. The findings focused mainly on the challenges inherent in sustained optimal ART adherence for this population living in the lowest socioeconomic strata, but also imply or describe strategies participants used to successfully sustain optimal ART adherence, along with factors that supported optimal ART adherence. Some themes address the issue of forgetting to take ART doses directly and others describe factors that make forgetting more or less likely. We describe each of these six themes below.And, to me, every time I was using [drugs], you know, if I had the choice or to wait – take your medication, get high, take your medication, get high, I would end up getting high, getting high and forgetting the medication if I could sell it, you know.Indeed, selling ART to corrupt pharmacies was a common survival strategy in this sample, although doing so is illegal for pharmacies and places them at risk for criminal prosecution  during most weekdays, and an intervention using a smartphone-based application that provided compensation for optimal adherence by self-report. Nevertheless, she often intentionally missed ART doses, particularly on the weekends, in order to avoid the side effects of what she referred to as ‘very toxic’ medication:Something I have done since I have been on these meds and since I noticed the meds messed up with my body, I take one day off a month. Every month, I take one day off. The doctor told me, you should not do that. I said, listen, I think my body needs a rest for one day, just for one day. I do not think it is hurting me because I get right back on my regimen. That is what I do now is just take one day a month. Take that one day off and then I get right back on the pills.After initially isolating herself for eight years because, as she noted, ‘I felt I had a big “A” on my chest and everybody knew about (my HIV status),’ Jade regarded these short breaks as a key part of her own current adherence and HIV management strategy.Similarly, Jade, an African American woman in her mid-fifties who had been living with HIV for approximately 20 years, described taking an occasional ‘hiatus’ as her personal strategy for staying simultaneously healthy and at least moderately adherent to ART:Yeah, I struggled [with my diagnosis]. That was the hardest part about it – accepting that I was going to have to die. Even though you know you’re eventually going to die but to have something accelerate it like HIV could – it was hard for me. I mean, I was thinking of all the possibilities I was losing as in having kids, having a meaningful relationship and so forth. So, I lost my purpose to live. That was my reason for struggling with the whole thing [taking ART without forgetting doses]. […] But [even] now I’m stuck with this stigma of either I’m gay or I’m strung out on crack or something like that, and I get treated as such. And that’s like stuff that I’m still dealing with now with the stigma of [HIV].Although Harold understood the role of discrimination in his reluctance to accept his diagnosis and therefore to regularly take HIV medication without forgetting doses, feeling disrespected and marginalised nonetheless remained significant obstacles to optimal ART adherence. He went on to describe how he managed stigma and took ART consistently:But I’m getting to the point now where I don’t care [about the stigma], I’m living with it. I’m not that stereotypical person [with HIV] and that’s what driving me to keep taking my medication. […] Because now a days if you’re not taking your medication, it’s something deep. You know what I’m saying? [It’s] stigma.Samuel was an African American man in his early fifties who was diagnosed approximately 10 years ago, who took occasional breaks from his medication, firmly understood HIV as ‘man-made’, a common counter-narrative about HIV, and had struggled with disclosing his HIV status to his partner. He described experiencing denial after his initial diagnosis, related in part to HIV-related stigma, as follows:It was just that [when diagnosed] I was in denial, too. Like, damn, how did this happen to me? You know what I’m saying? I was in disarray. I didn’t know what to take, should I trust this [medication], is it really gonna make me better? Or worse? … It’s a lot of [expletive], man. People are scared to admit up with what they have, or what they’re dealing with and that’s real. It is. And it’s all out here, you know what I’m saying? Either you own up [to] it, and that’s why a lot of people have passed for not owning up to it and taking their meds. See then a lot of people they’re like, oh damn, they’re gonna think I’m gay, or, you know what I’m saying?Patricia, a 50-year-old Black woman diagnosed with HIV approximately 10 years ago, discussed how despite having accepted her HIV diagnosis, she continued to hide her medication from others and keep her HIV status ‘on the down low’ because, as she described, stigma associated with HIV affected her ability to take ART, which she viewed as a visible reminder of her HIV status both to herself and to others. Despite having accepted her diagnosis, optimal adherence remained challenging. She noted:Back then [when I was diagnosed] it was like you got the monster. How did you get it? You are nasty. You are going to die and hurt people. They are going to throw something at you. That is the whole thing about this disease. You do not know which way to go with it [in terms of disclosure]. […] Now, I have fatigue. Runny diarrhoea sometimes, night sweats, and I get dizzy sometimes. That is not as bad as other people that is living with it, so I am grateful. I try not to complain. Sometimes, I forget my meds because I just forget. Now, I have a pill bottle [which reduces forgetting]. […] [But], I forget. There are other things on my plate.Similarly, for Beatrice, introduced above, anxieties related to disclosing her HIV status, whether intentionally or unintentionally, remained a direct, concrete barrier to ART adherence at times:I’m a little ashamed to take my medication in front of people I have not disclosed to … . And I’m not gonna take my medication sitting in a restaurant. Like, I’m just not gonna do it, you know? I’ll sit in the restaurant because there’s other people sitting there eating, but I’m not gonna pull out my medication and take it.Relatedly, when reflecting on the experience of living with HIV and HIV stigma more generally, Fred, introduced above, linked his desire to live, and therefore to take his ART regularly, directly to the stigma surrounding HIV:Because yeah, after a while [living with HIV stigma] you lose your purpose to live, like what is the purpose of living? If you don’t find it within yourself because you have to have some kind of human contact, a hug, a kiss or what have you, what have you, and a lot of people they don’t have that for the simple fact they living with this HIV. Because people got disowned by their family. Even though that’s not in all cases, I’m just painting the whole bush.For these and other participants, despite having sometimes overcome their initial reluctance to accept their HIV diagnosis, and despite having developed innovative strategies to deal with HIV-related stigma, the emotional contexts within which HIV and ART are situated nonetheless continued to significantly impede consistent use of ART and contributed to missed or forgotten doses. In most cases, the primary barrier to ART adherence was HIV stigma, and ART use was a signal to oneself and possibly others that the individual was living with HIV, thus raising the possibility of being stigmatised.Participants stressed that their perspectives on living with HIV and their feelings about ART and ART adherence were dynamic and influenced by both internal/psychosocial and external factors. Participants’ perspectives on ART were related in large measure to their initial reactions to receiving their HIV diagnosis and the difficulties they faced adapting to the new diagnosis. The process of adaptation to the HIV diagnosis was typically complicated by continuous and re-lived emotional trauma and a number of internalised stigmas. Indeed, we found stigma surrounding HIV remained a critical barrier to sustaining optimal adherence to ART. Harold, a Black man in his early fifties diagnosed with HIV while incarcerated about a decade years ago, described that he continued to struggle with both acceptance of his diagnosis as well as ART adherence, and attributed these struggles directly to HIV-related stigmas:Right now, I never heard nobody talking about not taking their meds [intentionally], but other stuff going on like the kids, the grandkids, the rent. [They have issues like] they want to work, they cannot [work], their health. It takes a toll. When you keep taking medication, it takes a toll. The doctors want to give you this, give you that, give you this. Take this. There are side effects … Some days, we, as humans, forget.Thus, Patricia’s experience serves as a reminder that daily adherence is challenging for all individuals, and that persons living with HIV commonly experience a wide range of issues that ‘take a toll’. Similarly, despite generally feeling positive about taking HIV medications, Terence, an African American man in his early fifties diagnosed with HIV approximately 20 years ago, nevertheless described being unable to see himself taking ART indefinitely, and situated regularly forgetting to take his medication within the context of a ‘screw-it attitude’ resulting from chronic stress and depression:So, it was because my situation I was in, I was moving and I was staying from place to [place] – I was staying with this person and that person, and I was in a shelter, then I was staying with somebody else. And then I was stressed, so I just stopped taking my meds all together. And I haven’t took my meds in, like, almost 30 days now … No, it was never a conscious decision. No, I wouldn’t just say no I’m not gonna take it. I just kept forgetting every day … Yeah, so this is like, for me taking my medication, if I’m not stressed and I’m not doing a lot, I can take my meds, you know. It’s just that, ‘cause right now, I’m just, I’m not happy. I’m just not happy with my living situation, I’m not happy with the – not even the job situation. I’m just not happy, like, with the environment, you know, of people that I’m around right now.Relatedly, for many participants forgetting to take ART doses had to do with a ‘frame of mind’ most frequently described as depression. Lawrence, an African American man in his early fifties who was diagnosed with HIV over 30 years ago, situated his tendency to forget his medication within the context of the material and emotional difficulties of ‘getting back on the right track’:You forget [to take an ART dose] because you’re rushing and things of that nature. Or a person may have emotional problems. They may get depressed over anything. Oh, [expletive], it’s raining. Get depressed. And, you know, and through the depression, they don’t take the med … You know, I got two jobs, I got two kids who’re living with me all of a sudden. So, you know, I’m busy with them, I forget. But, you know, I can’t double up on the meds, so then I have to skip one and I have to wait ‘til the next day. And, you know, I’ve been doing that lately. That’s been going on with me pretty much in a nutshell.Sal, introduced above, had what he now described as a heavily ritualised relationship with ART adherence that nonetheless included occasionally ‘breaking the cycle’:It’s really bad if you start forgetting to take your medication or you get into an argument or you’re going through a bad day and you say, ah, I’m not gonna take it. Or you’re gonna turn around and have a fight with your girlfriend and you’re gonna go and go pick up and use drugs. Some people can’t just do it by themselves, you know.Thus, participants identified critical relationships among acute life stressors (i.e. ‘having other stuff on your plate’), depression and other mental health issues, and substance use, all of which in turn contributed to forgetting one’s medication, whether intentionally, semi-intentionally, or unintentionally, which, in turn, regularly interfered with achieving their overall goal of good health. For these participants, while ART adherence and overall good health were valued and prioritised in a general sense, forgetting to take or choosing to miss an occasional dose of ART was nonetheless viewed as oftentimes necessary for medical, social, and psychological reasons.Participants pointed out that difficulties adhering to ART often stemmed from immediate and pressing emotional and material factors. They noted that forgetting to take one’s HIV medication frequently occurred during bouts of depression related to acute life stresses, which also commonly coincided with periods of increased substance use. Lapses in adherence were commonly associated with emotional distress related to such concerns as paying rent and other bills, caring for children or grandchildren, managing health-related obligations such as doctor’s appointments, and experiencing relationship problems. Patricia, introduced above, described how everyday pressures in her life related to forgotten ART doses:not taking AZT monotherapy when it was available. Indeed, achieving optimal adherence, however defined, often meant navigating a complex landscape partly composed of medical distrust, past losses and trauma, and ongoing continuous traumatic stress, as well as fears regarding long-term side effects of ART such as organ damage and neuropathy, largely influenced by the scientific community’s first efforts at controlling HIV beginning in the late 1980s; namely, AZT monotherapy. Emmett was a 55-year-old Black man who was diagnosed with HIV 36 years ago, and who described a lack of readiness to initiate ART until 18 years after his diagnosis. He spoke of ‘skipping around’ and ‘going on little vacations’ from ART and explained that this is in part because he understands that ‘the AZT is still in the meds’, albeit in smaller quantities. As he explained:Because [when I was first diagnosed] I was afraid. I lost a lot of associates, a lot of friends. I was feeling, you know – that’s the thing. This is funny, but people of colour, we have nappy hair. Then you see them again and it’s all straight, you know there’s a problem there. And then sometimes then you see the skin tone looks ashen grey – ashen grey. I don’t want to look like that. And then you could see – change in the face. You know the loss of weight in the face. That was one of those [side effects]. I wasn’t vain, but then people were dying from [AZT].The effects of AZT monotherapy’s legacy were similar for Jared, a Black man in his early fifties who learned he was living with HIV approximately 30 years ago. While he proudly stated that he had consistently achieved undetectable HIV viral load levels for approximately 10 years, Jared remembered struggling to trust HIV medications after having experienced the negative effects of AZT:Off and on I was like basically non-compliant for a long time because I’m from back in the dinosaur days when there was like terrible side effects and I wasn’t adherent for a long time. […] I only became adherent when I was placed on [a newer ART regimen]. I just wasn’t educated, didn’t know and there was just so much stuff [so many different regimens]. And being sick wasn’t part of my daily – I couldn’t do it. […] I began to become adherent, and my viral load started to come down and my CD4 went up.Notably, for Jared, part of his own strategy for achieving an undetectable HIV viral load included making a clear distinction between ‘adherence’ and ‘compliance’, with the former being far more in line with his own ideas about how to manage his health than with his health care provider’s views. Indeed, the term ‘compliance’ highlights acting in accordance with a directive from another, while ‘adherence’ is defined as persistence or steady maintenance, suggesting the individual’s agency in medication-taking behaviour  recounted how being allowed to freely delve into his thoughts and feelings with what he referred to as ‘running and ripping’ in regard to his at-risk lifestyle correlated with his gradually improved adherence:When I first was diagnosed … I remember her name; my first physician. And when we had this discussion about the medications and my substance abuse, she says, I’m not so worried about you with the cocaine and crack cocaine. What I would encourage you to do is in the same kind of routine that you use your street drugs, you take these HIV meds. So, it was like a piggyback kind of routine … And it worked, because I became adherent. So, over the course of, I guess years, I just became more adherent to taking the meds and I would slowly wean myself off of the other street drugs, you know.In addition to his experience of interconnectivity between positive patient-provider dynamics and HIV medication, Tyler discussed how matters ‘clicked’ following his physician’s advice to think of taking his HIV medication using a similar routine as his street drugs:By her not stigmatizing a label – because I’ve had other physicians that they’re very judgmental. You know, you’re doing drugs, you’re not going to take these meds, you’re going to sell them, so I’m not going to give you these medications. […] They figured this is just going to make you worse. But she was very proactive of her telling me, well, I just would like you to [use] the same routine that you do [for] your street drugs, I would like you to take these HIV meds [the same way]. […] So, that kind of clicked in and that made me adherent.Lennard, introduced above, is a participant who had been on and off his ART regimens in part due to the lasting negative effects of his first experiences with AZT and resultant medical distrust. Lennard commended his physician for acknowledging that absolute adherence cannot be considered a realistic scenario for all patients to experience:You miss doses here and there. But then one doctor was brave enough to say basically if you’re regular enough about it you’re pretty pickled . So that’s not supposed do so much damage missing a dose here and there. And that’s reality. Anyone who says much else besides from citing serious circumstances for huge blocks of missed doses is lying.Indeed, for the majority of participants, independent attempts to improve ART adherence seemed to occur when an environment of refuge was created by the physician. It was a common theme that normalising a patient’s struggle, as well as the absence of criticism and judgment towards at-risk behaviours, catalysed the patient to improve or re-commit to optimal adherence. Often times, promoting adaptation of street drug routines to HIV treatment could be seen as serving as a type of memory tool to organically integrate ART into the participant’s daily events, habits, and routines. Further, providers’ non-judgmental and accepting attitudes allowed participants to analyse and address the factors underlying forgotten or otherwise missed ART doses.In a similar narrative, Tyler (mentioned above) shared how his physician opted to use a harm-reduction strategy rather than insisting that he completely refrain from substance use:It’s like you can take the horse to the water but you can’t force him to drink, you know. And I was already determined to just get that help [to take ART], you know. And, once I started getting the help and I seen, you know, doors opening up for me, I just started like, you know, boom, let me see what this is about, let me see what this is about, and, you know, gave me motivation and stuff.For many, overcoming barriers to optimal adherence such as substance use, stigma-based concerns regarding being seen taking HIV medication, or depression need to be grounded in a genuinely internal desire to maintain good health. Nita (mentioned above), for instance, saw the utility of external incentives to take ART, such as financial compensation programmes provided in some community-based organisations and HIV care settings, but noted the following:But it’s up to you to stand up on your own two feet and do it [take ART]. […] It has to come from the person, themselves, you know.Similarly, Maria (mentioned above) expressed a common sentiment amongst people who are currently optimally adherent to ART:I could give you a bottle of medication, but if you don’t want to take it, you know, it’s up to you not to take it. But, if you want something – if you wanna be healthier and live a little longer, you could take your medication. It’s up to you if you wanna live, you know. I don’t understand why people sell their medication when it’s something that’s helping you.Once again, however, it must be noted that being intrinsically motivated to become or to remain optimally adherent to ART was not always synonymous with being compliant. Indeed, several participants in this study distinguished clearly between adherence and compliance, with the former being more autonomously shaped than the latter, which was more often used to describe the degree to which participants followed advice from their health care providers.As noted above, participants uncovered and described factors that interfered with optimal ART adherence, including life stressors, depression, substance use, the fear of ART toxicity, medical distrust, and HIV-related stigma, as well as one factor that promoted optimal ART adherence; namely, open and honest patient-provider relationships. Moreover, participants noted that feeling intrinsically motivated to take ART was a necessary first step in developing an adherence strategy, and high levels of intrinsic motivation to take ART could help buffer against challenges to good adherence and also reduce forgetting. For instance, participants such as Sal (mentioned above) frequently repeated the idiom that ‘you can lead a horse to water, but you can’t make it drink’, and stressed the importance of intrinsic motivation for optimal adherence to ART:In nearly all instances noted above, forgetting to take one’s ART medication, intentionally or semi-intentionally missing doses, describing one’s inability to take ART, or configuring a personal definition of ‘good adherence’ all emerged in part as socially acceptable responses to both internally and externally directed questions regarding why one was not optimally adherent to ART. That is, within the context of perceived pressure from health care providers, friends, family, or even oneself, forgetting to take ART frequently sidestepped a more or less conscious intention to miss doses or to redefine what it means to be optimally adherent to ART, and in this sense might also be seen as a relatively passive form of an individual’s assertion of autonomy. Moreover, in many cases forgetting or intentionally missing ART doses allowed participants to focus on other life priorities. That is, whether or not directly attributed by participants to stress, substance use, depression, or inattention, forgetting to take ART carved out a space within which participants could attend to other aspects of their lives.Adherence to medications is a universal challenge for individuals across the spectrum of chronic health conditions Tobias, , and hasStudy findings indicate that many participants are aware, on some level, of the degree to which forgetting to take ART doses may provide an opportunity to focus on other priorities, whether in regard to their health or other domains. Some past research has focused on the concept of ‘intentional non-adherence’ . Thus, forgetting is one strategy participants use to manage their medication in the way they deem optimal. While optimal adherence is generally defined as taking ‘every dose, every day’, participants may have discovered that they can forget to take or otherwise miss ART doses and still achieve HIV viral suppression , and in others, forgetting arises from ambivalence about ART, or may be semi-intentional. We also found that participants at times cannot describe why they forgot to take ART. Thus, in many cases, it appears forgetting lies somewhere between intentional and non-intentional processes. In other cases, PLWH may be unable to take ART. Moreover, a range of factors make forgetting, whether intentional, not intentional, or somewhere in-between, more or less likely. For example, stable housing and social support can buffer challenges to adherence and reduce the chances of forgetting, while depression, extreme poverty, stigma, and substance use at hazardous levels increase the chances of forgetting. Strong patient-provider relationships can help patients move beyond a description of simple forgetting as the main reason for missed ART doses, to the underlying meaning of forgetting, to help PLWH articulate their approaches to ART adherence and identify behavioural practices they can put in place to maximise optimal ART adherence and health.This study was carried out in accordance with the recommendations of the University Committee on Activities Involving Human Subjects (UCAIHS) at New York University (FWA#00006386). The protocol was approved by the Institutional Review Board at New York University. All subjects gave written informed consent for study activities in accordance with the Declaration of Helsinki.


Little is known about how permanent, inclusive, affordable, and supportive long-term housing may affect the health of low-income lesbian, gay, bisexual, transgender, queer, intersex, asexual and/or another identity (LGBTQIA+) older adults. Focus group interviews were conducted with 21 older adults to explore the lived experiences and potential health benefits of living in a new LGBTQIA+-welcoming senior housing. Participants reported that moving into the housing was associated with benefits for health and well-being, especially for psychological health. Community, social support, and in-house services were particularly important. However, the combined nature of LGBTQIA+-welcoming and older adult only housing evoked mixed feelings. Appropriate and accessible housing solutions are essential for LGBTQIA+ older adults and may help address health disparities for these populations. Older adults who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual and additional identities (LGBTQIA+) experience significant health disparities compared to heterosexual cisgender  counterparts. They report higher rates of disability and poor physical and mental health, and they are less likely to be partnered or married . LonelinIt has been suggested that LGBTQIA+ older adults would likely need to rely on senior housing earlier than their cisgender, heterosexual counterparts, given the need for inclusive and supportive environments and fears of discrimination in long-term care settings ,6,7. A qLGBTQIA+ older adults are also more likely to rent their homes (54%), while 28% owned their home but were still making mortgage payments, and only 13% owned their homes outright; 5% reported having to rely on financial support for housing. Nearly 70% of LGBTQIA+ older adults reported low confidence in their ability to stay in current housing ,11. ThisLGBTQIA+ older adults are significantly burdened by health conditions compared to their cisgender, heterosexual peers, including poor general health, physical disabilities, chronic conditions, including living with HIV/AIDS up to 25%), and greater mental health distress and depression ,13. LGBT%, and grLinks between housing and health status for non-LGBTQIA+ populations are well established. Experiencing housing disadvantage  has negative effects on future mental health , and pooHowever, there is limited data on the relationship between housing and health for LGBTQIA+ older adults. Housing is frequently reported as a concern in studies on the needs of LGBTQ aging populations ,33,34,35Little is currently known about how permanent, inclusive, affordable, and supportive long-term housing environments may affect the health of low-income LGBTQIA+ older adults. Only one published study reports on the experiences of older adults living in LGBT senior living communities . Major tWe explored experiences of older adults living in an LGBTQIA+-welcoming and affordable senior housing building in a Western U.S. Metropolitan area by conducting a series of three focus groups from July to August 2018. It is estimated that between 18,000 and 20,000 LGBTQIA+ older adults aged 60 years or older currently reside in this Western U.S. Metropolitan area . These gThe setting was an LGBTQIA+-welcoming and affordable senior housing development that opened in 2017, after almost ten years of planning and negotiation. We use the pseudonym WESTHOME throughout this manuscript. It was developed as a partnership between a local nonprofit and a national affordable housing provider, with support from the local city administration. This redevelopment of an historic site retained many esthetic features of the original building, which was previously a school. The housing site includes ten studio apartments, 26 one-bedroom apartments, and four two-bedroom apartments, with eight units set aside for people who were previously homeless and living with HIV/AIDS. Monthly rents ranged from $800–$1200 (considered affordable for the region). The units were allocated through the local city government’s lottery system, in which people aged 55 and older with an income not exceeding 50% of Area Median Income  were eligible to apply; over 1800 people entered. People of any gender identity and sexual orientation were eligible, and over two-thirds of those who moved in identified as LGBTQIA+, likely due to the local LGBTQIA+ aging nonprofit’s advocacy for community members to apply. The housing is co-located with an LGBTQIA+ senior center and features on-site case management and social activities as well as regular community events.The theoretical framework for this study was “health equity promotion”, which provides a life course perspective on how historical and social factors have influenced the health of LGBTQIA+ older adults . We chosFocus group procedures involved two facilitators being present for each focus group; one led the group and the other took notes on dynamics that might not be discernible from the audio recording alone. At the beginning of each focus group, the facilitator presented information on informed consent, including risks, benefits, and confidentiality, inviting participants to ask questions before they consented verbally to participate. We also asked participants to complete a demographic survey. Our semi-structured focus group guide was developed by the authors and included questions on: (1) how participants felt when they heard they would be moving to the housing site; (2) what they liked most about the housing site; (3) how comfortable they felt being open about their sexual and/or gender identity in their current living situation; (4) health challenges; (5) changes in health since moving to the housing site; and (6) current service utilization. Additional probes prompted participants to reflect on their past experiences and potential future health and aging needs, as well as encouraging them to consider health in a broad sense, encompassing social and psychological well-being as well as physical conditions. Each focus group was audio recorded and transcribed verbatim.For data analysis, we used a “flexible coding” approach adapted from the analytic process described by Deterding and Waters . After rWe recruited 21 participants, with seven in the first group, nine in the second, and five in the final focus group; Most participants described living in unstable or unsuitable housing prior to moving into WESTHOME. Their experiences indicated a range of stressful housing situations that LGBTQIA+ older adults may face. Some had been previously homeless, and others were in temporary or precarious housing. Many described improvements in their health and well-being now after moving to a more stable situation at WESTHOME.My mental well-being seems to be healthier, [and] my physical [well-being]. Financially, it’s affordable for me, so that relieves a lot of the stress and stuff. Because coming up with the rent that we had to come up with before was like … exhausting. So we get to kind of enjoy a little bit more free time, in essence, for me personally. My health seems to be relatively good.A Mexican American transgender woman in her late 50s had been living temporarily in an expensive apartment with two other transgender women before moving to WESTHOME; she described that arrangement as “buying time, in essence”. Moving to stable, subsidized housing was a great relief for her, meaning that she no longer had to worry about money and now had more time to care for herself:It helps my confidence. I don’t bring [over] people that I know don’t deserve it [even if] I sometimes desire to hang with. I can go to their neck of the woods. But they’re not invited to mine. I’m not saying I’m better than anybody around this area but this is like a safe, honest-system place.The stability of living at WESTHOME also enabled residents to address other stressors in their lives. A Black, straight, transgender woman in her early 60s was living in one of the units reserved for those who had experienced homelessness. Prior to moving to WESTHOME she lived in a single room occupancy where she did not always feel safe. As soon as she saw WESTHOME, she recalled thinking: “I knew I was gonna stay here”. She described how she now felt safe and respected; part of this was living in a well-lit area with vigilant neighbors, but she also felt more control over her environment:WESTHOME offered both increased opportunities for security compared to her previous housing and a sense that she deserved to live in a positive and safe space, where she could protect herself from negative influences.I wake up and I say, “Oh, did I dream that or is it real.” And I get up and I realize, man, I’ve died and gone to heaven. This is perfect. I have a beautiful, one-bedroom garden apartment. I love that. It’s just … I just feel so at home.For a white gay cisgender man in his mid 60s who used a wheelchair, moving to WESTHOME represented a huge change. He had been living in an assisted living facility for 20+ years, including five years in hospice care. In the assisted living, he experienced homophobia and felt that he did not need the level of care provided. Moving after so long was a major upheaval, but he said: “I thought to myself, I been through so much in the past 25 years that if I don’t make this move, I’m never going to get another chance. And I just went for it”. He described how he now felt each morning:Like many other participants, the relief of having stable housing played a significant role in his improved well-being: “It’s hard to describe, but it really is an uplifting thing. Because number one, you have the weight of trying to find housing off your shoulders. […] And once that goes, anything is possible”. His own trajectory exemplified this: “I went from hospice care, to assisted living, I now live independently. I went back to work and I’m not stopping”. These exemplars demonstrate the extent of the health benefits associated with reduced housing stress for new residents at WESTHOME.In addition to the general sense of stability WESTHOME provided, residents also felt pride in their home environment. Some participants reported issues with the move-in process, but once they were in, they described having housing at WESTHOME as “a gift from the universe” and “the greatest prize that I could have”. In every focus group, participants praised the physical appearance of the building, describing it as “historic”, “beautiful”, and a “terrific space”; one resident summarized: “You upgraded”. Others appreciated the location and quiet space, the light, and opportunities to exercise by walking around the building, while the elevator was reassuring to a participant who was having surgery soon.The architecture… it’s round… so energy flows really amazingly here, even just walking down the hallway, I get a sense of relief, whereas I’m walking in other apartment buildings, visiting friends, the hallways are about as wide as this [arm length indicated a narrow space], it seems very sterile.An American Indian/white straight trans woman in her 50s had been selected to live at WESTHOME through a homeless support program. She described having loved her old apartment, but moving to WESTHOME was a whole new experience: “Even just as I walk in my entry way, I get this sense of “wow”, I get this whole like “wow” moment”. The layout and feel of the building were especially important to her:The building design also contributed to her health: “When I am in a space where my positive energy can flow I think my health is way better. Mentally, physically, spiritually. All of it”. After recent surgeries, she recognized how being in a positive space, both in terms of the physical environment and the community around, had helped her to recover: “I really believe my mind can heal it all, but if you’re in a space where that’s not able to flourish, your body suffers”.I’m glad I’m in this building because there’s an elevator. I don’t have to take any stairs. Because I’m on the third floor, I can walk. And I think I can heal faster because I’m in this building.Other participants focused on more tangible aspects of the building. A Black heterosexual cisgender woman in her late 50s had been renting an apartment in a rent-controlled building that had since been sold, and she was anxious about what would happen to her. After moving to WESTHOME, she felt much more relaxed: “I have really good neighbors. I feel comfortable. I feel safe. In the building, I feel safe”. She had experienced some physical health issues since moving in but felt better mentally without the anxiety associated with her previous housing. Reflecting on an upcoming surgery, she felt that living at WESTHOME with all the facilities available to her would help her heal:A Latinx/white gay cisgender man in his early sixties, who was an AIDS survivor, had been living in a historically gay neighborhood since the early 90s but did not feel much of a sense of security, worrying about the high cost of rent: “In this town, if you lose your place, it’s goodbye”. He described his tiny apartment and stressful experiences with neighbors as a “hell situation that I was stuck in for eight years”. The contrast he described after moving to WESTHOME was striking, in terms of both emotional well-being and access to amenities: “That sense of relief […] having a full-size refrigerator, a bathroom, a bathtub, and stuff like that, and not fearing every time you went out of your room”. The unique feel of the building was important for his well-being: “it’s a beautiful building. It’s not like the cookie cutters we see going up the city, which is really kind of horrifying”. Tracing his feelings since moving in, he described having felt “really small in these giant hallways” at first but was now feeling “bigger”—taking up more space as his physical and emotional health improved.So many of my friends had simply been driven out of the city by the levels of rent that they had to pay. Ended up in Florida and other ghastly places. And here I’m allowed to stay. It’s wonderful.Several participants had been familiar with the building in its previous incarnations, and one had even designed some of the original décor. Personal connections with the building’s history made it especially attractive. One resident, a white gay cisgender man, had taken classes in the building previously. The high ceilings allowed him to install plenty of storage cabinets in his apartment, and the amount of natural light felt special: “You just don’t find that in a modern building. I walk up here and see these poor people paying $3000, $4000, $5000 a month for these little boxes! And I think, ‘Jesus, how did I fall into this?’” He was also very aware of how rare it was to be able to stay in the city:He had chosen a studio apartment, which he found less stressful: “To me, living in a smaller space relieves a lot of good pressure, housekeeping all the time. I’ve got time to work now. I don’t have to fuss with dusting every five minutes”.The unity in this building is phenomenal. We’re all different walks of life, different ethnicities, but when we all come together, we’re all one. […] Everybody supports everybody. We look out for each other and we make sure that everybody is well taken care of and that’s rare. (African American straight cisgender woman)The combination of the well-designed physical space and the strong social bonds they had created helped residents feel supported and included. They saw themselves as having actively “created” rather than simply “joined” a community, a feeling that was perhaps encouraged by the founder of WESTHOME who was reported to have said: “We’re giving this group of people this situation, to take it and run, and develop it into whatever kind of community they want it to be […] that’s never going to happen again so take that opportunity and run with it”. Several participants pointed to the fact that they had a “common bond of all coming at the same time” and “being part of the beginning”, which generated mutual respect and a lack of hierarchy. The sense of community and harmony among the residents was seen as particularly impressive given their diverse backgrounds and experiences:Once I got here, everybody was saying, “Welcome to the community”, and all this stuff. I was like, what is this whole community thing? I had no idea that this place had even existed. I realized that I really needed that. That I needed a supportive environment because I was starting to feel isolated, getting older. So for me it’s been a really positive experience.Several residents were surprised to realize how much they valued the sense of community and presence of social support at WESTHOME. A white asexual/bisexual man in his late 50s had been living with his brother for nearly 30 years, but the situation was becoming untenable due to his brother’s increasingly severe issues with hoarding. He was allocated one of the units reserved for people who had previously been homeless. He described how he had not realized how isolated he had become until he moved to WESTHOME:My mood has gotten much better and my health has improved. I wake up with a smile on my face, I don’t feel isolated. I’m just taking much better care of myself, so it’s really helped a lot. And if you do have a bad day, you can talk to a social worker, you can talk to somebody else in the building. There’s always that support system here. So that helps a lot with not feeling isolated.He reported feeling better both physically and emotionally, as well as being able to take better care of himself:A white gay cisgender man in his early 70s had been living in a rent-controlled unit, but his landlord was in his 90s and he worried that when the landlord died, his children would move in and force him out. Since moving, he had noticed significant changes in his social life and sense of self. Describing himself as “not really a joiner […] kind of private”, he had nonetheless become a regular presence at a weekly breakfast event. After he broke his hip, the community “really came into focus” for him, with many neighbors offering help, checking in regularly, and picking up groceries: “And I have like 12 numbers that are my circle now on my message center. If anybody’s going to Safeway, and two people will immediately message back, ‘I’m going. I can pick something up for you’.” WESTHOME provided an ideal combination of independent living and privacy with community available whenever it was desired. As he put it: “I just go upstairs and close my door and I’m alone. But then if I open the door, I know I’m not going to be alone. Which is… I never had that before”.As well as facilitating community support, WESTHOME also provided formal services and activities, including lunches, language classes, housing advice services, case management, advocacy services, financial advice services, Tai chi, yoga, and synagogue services. Referring to the wealth of services offered, one resident said that WESTHOME “provides for everybody”, and another described it as “housing plus plus”, saying “I thought this was housing, but it’s so much more”. Some participants were aware of services and felt they didn’t need them just yet, whereas others attended events somewhat reluctantly, aware that without sufficient uptake the funding for such services might be canceled. The housing services coordinator received extensive positive feedback. A Black gay cisgender man in his late 50s had initially felt ambivalent about moving to WESTHOME; he was relatively happy with his previous housing and didn’t want to be “apartment rich and money poor”. However, after moving in, he was relieved to have joined such a diverse and supportive community: “Wow. I’ve used up all of my good luck for the rest of my life. Thank you”. He was one of several participants who mentioned having regular medical procedures requiring general anesthesia, meaning he needed someone to escort him home afterwards. After he mentioned this to the services coordinator in passing, she immediately arranged to help him: “To have somebody here who you can count on, in a situation like, just makes life so much easier. You might have to postpone your procedure if you can’t find anybody”.The housing at WESTHOME was defined in several different ways—affordable, open to older adults only, and LGBTQIA+-welcoming—and residents’ responses to these markers of identity and potential vulnerability varied widely. The LGBTQIA+-welcoming nature of the building was more important to some participants than to others. For one American Indian straight transgender woman, stability was the key benefit of living at WESTHOME, much more so than the LGBTQIA+-welcoming aspect: “I feel very strongly, it’s not just the hallmark property for the LGBTQIA+ [nonprofit] thing, it’s my home because I didn’t pick it for that reason”. An American Indian/white straight transgender woman also shied away from the LGBTQIA+-welcoming nature of the building: “Well, I can only speak for myself. This space is my palace, it’s my castle, it’s my sanctuary. It’s my home. I don’t want to be identified as what the building stands for, this is my home”. For these residents, both transgender women, living in a specifically LGBTQIA+ space seemed to be incompatible with being truly at home, although they did both identify WESTHOME as their home, indicating its inclusive and supportive nature.Other residents were very committed to WESTHOME’s LGBTQIA+-welcoming mission. One participant, an African American straight cisgender woman in her late 50s, grew up nearby but had been living in another city for 20 years. Coming home and moving to an LGBTQIA+-welcoming space meant a lot to her, although she personally identified as cisgender and heterosexual: “I mean, first of all, to be blessed to come back to the city and to be able to live in an historic building and to be around a community that I’m allied with. My children are gay and lesbian”. Being in an explicitly LGBTQIA+-welcoming environment was particularly appreciated by participants who had experienced homophobia, transphobia, and racism in previous housing. At WESTHOME, they felt able to trust others and described feeling respected, as when neighbors used their correct pronouns, for example. For others, it was important to have this community because they did not have children to look after them, had lost many friends to HIV/AIDS, or did not feel welcome in other LGBTQ spaces. For example, a resident who was a long-term HIV/AIDS survivor described how moving to WESTHOME had helped relieve some of the sadness he felt about the past, as well as the isolation he experienced due to a “lack of empathy sometimes for elder gay people” among the wider LGBTQIA+ community.When asked about the fact that WESTHOME was for older adults only, residents reflected on the design of the apartments as well as the experience of living alongside people of similar ages. In response to Americans with Disabilities Act (ADA) adaptations such as grab rails and sliding doors, participants reported that they did not see these features as intrusive or offensive; they might have been puzzled by them at first but had to come to appreciate their presence. For example, one resident didn’t realize at first that the bathroom was larger than typical apartment bathrooms in order to accommodate a wheelchair or walker: “I was kind of like miffed that the bathroom was as big as the kitchen, because even though I’m a senior I didn’t go there just because my spirit is young, but the body tells you something else. Completely something else”.A queer cisgender man in his late 50s, who was an architect, praised the design of the building. After moving in, he initially found it depressing to see the community room, which reminded him of his mom’s senior housing, and the rail in the bathtub. However, he had since come to value these adaptations: “It turns out that those two things are my gift. I use them all the time. I’m always in that tub, and I’m always pulling on that rail, so goes to show you that time takes its course”. However, although he was satisfied with the building, he did not feel that the policies and management were designed with older adults in mind. For example, having to use a mobile app when problems arose instead of being able to go to a full-time on-site manager for help was frustrating to him, and issues with the building’s security features made it hard for emergency services to get into the building quickly. As he put it, “That’s not really what I would call senior-friendly”.A white gay cisgender man who had lived in the city since 1969 and taken classes in the building in the past did not see himself being able to keep living at WESTHOME indefinitely. He reflected on his parents’ experience; they had moved to a senior complex where they could transition to different buildings with higher levels of care as needed, without having to move to a new facility altogether. He could not imagine WESTHOME being able to accommodate such a progression, saying, “It doesn’t seem to lend itself to that kind of service. I don’t think it was ever intended to become a care home”. He imagined having to go to a group home in the future: “I would be very sad to leave this building. At this point I’m resigned to it”. When another focus group member suggested that WESTHOME could facilitate in-home care as needed, his main concern was whether this might be used to justify increases in rent. He was particularly conscious of not having children or grandchildren to take care of him: “So we’re kind of on our own for the most part. That has very severe economic impact, particularly for disabled people”.In contrast, an American Indian/white straight transgender woman felt differently about the future, picturing the community growing older together:It is a total gift from the universe to […] have all of my urgency taken away from me with my life. Because, as I said to my neighbors and my friends, this is the last stop for me. So I give a lot of leeway to my neighbors and my friends here, because we’re all going to be here. We’re all going to be pushing our little walkers together here.Being in an age-specific environment brought up different feelings for participants, including elements of ageism and ambivalence about living in senior housing, with some seeking to distance themselves from those they saw as “elderly” and others reporting that they drew solidarity and inspiration from their neighbors. After being bought out of her flat after living in the same area for 20 years, a mixed race straight transgender woman was relieved to have a permanent home where she did not have to worry about future rent increases. Stability was something she had tried hard to maintain through her adult life, after growing up in low-income housing and moving frequently, including living in hotels. She thought about the community in terms of two distinct groups, with about a quarter of the residents seeming “very, very elderly and in ill health” to her and the rest being “very outgoing […] out every day, doing things […] still working”. The sense of youth and energy at WESTHOME was uplifting for her:It doesn’t feel like we’re just in an elderly place, it feels like a place that’s living, growing still. That makes a big difference, because I think if it was just really sick, old, elderly people, that would zap your energy.For her, exercise was key to avoiding health problems associated with older age: “We’re not all walking around with walkers or… The way to avoid that is to have somewhere to do some kind of exercise”. She wanted WESTHOME to add a workout facility—the low-intensity options offered did not suit her: “I don’t like yoga, Tai Chi, I need stair master, honey”. Another resident felt that assumptions about older people had informed decisions about what amenities to provide:I know [LGBTQIA+ nonprofit] and [housing provider] had more of an idea that we were just going to be a lot of old people, probably not able to get out and do things, but a number of us have cars. They didn’t take that into consideration, unfortunately.While some residents sought to distance themselves from ageism and related stereotypes about aging, others described feeling inspired by the oldest members of the community:We have somebody that’s almost 100 that lives with us. We see her, and she motivates us. Every time I see her walking around this building, it encourages me to want to walk. I ain’t got to it yet but it’s good, it’s an encouragement. (African American straight cisgender woman)Several participants felt that living together with people of similar ages gave them a sense of solidarity and shared experiences, especially in terms of health challenges. As one put it:We’re all around the same age. You know what I mean? We’re all 55, 56, 57. So we’re kind of all the same. So we’re all going to be watching each other at the same rate get to the same spot.Similarly, a Mexican American transgender woman felt residents could understand each other’s needs and health experiences, unlike younger people: “Like, “Oh, this aches today”, or, “That aches today”, versus I can’t tell my little nephews or nieces or relate in that sense”.In this qualitative exploration of experiences of living in LGBTQIA+-welcoming affordable senior housing, we found that residents’ mental health and well-being was influenced by gaining housing security as well as specific features offered by WESTHOME. Once they no longer had to worry about finding or retaining stable housing, residents were able to take better care of themselves and enjoy living together with others. Living in an attractive physical environment with a strong sense of community promoted a sense of well-being and pride, and the services provided further supported residents’ health. Although most participants shared positive feelings about their surroundings, they differed in their responses to the LGBTQIA+-welcoming and senior-only nature of their new home, with some distancing themselves from these labels and others embracing them and hoping to be able to stay for the long term.We found that moving to stable, supportive, and affordable housing was associated with benefits for health and well-being, particularly for psychological health. With the relief of anxiety about finances and safety, residents could relax and take better care of themselves. Our findings buttress the existing literature on the positive relationship between housing stability and health. Although definitions of housing instability vary , there iOur study also aligns with other findings on the links between experiences of discrimination and housing instability . We founAs well as appreciating the stability and appearance of their new home, participants highlighted how community, social support, and in-house services benefitted their health. Sullivan found that acceptance, safety, and inclusivity were key reasons for choosing LGBT senior living communities, and that “created community” developed surprisingly quickly, through “shared activities, care for one another, and the shared connection of being sexual minority seniors” (p. 241) . The resThe strong link between community and psychological health for the residents of WESTHOME also echoes a qualitative study on aging preferences of older lesbians , in whicFinally, we found that the LGBTQIA+-welcoming, older adult-specific, affordable nature of this housing evoked mixed feelings. Existing evidence is inconsistent on the benefits and drawbacks associated with age-segregated housing in terms of emotional well-being ,51). In It is also important to note that the lottery was centrally administered alongside the other affordable housing available in the city, in the context of huge demand for housing and increasing rent costs. Lottery entry was open to anyone who met the age and income eligibility requirements, and participants had applied for countless housing lotteries in the past without success. For some, WESTHOME was one of many options they would have accepted, rather than an environment that they had specifically and actively sought out for its LGBTQIA+-welcoming characteristics. It is important for those developing similar housing developments around the U.S. to keep in mind these structural constraints and their potential impact on community building.This is the first study to investigate experiences of residents moving to an LGBTQIA+-welcoming affordable senior housing development. We designed and followed a robust analytic plan, and our sample included a large proportion of the total number of residents in the building. However, we also acknowledge the limitations of this study, which was undertaken at a single site, less than a year after residents moved in and perhaps during a “honeymoon” period. We conducted focus groups on site, and recruitment was facilitated by in-house staff. There is a potential for social desirability bias given that participants may have felt pressured to give positive feedback, and being among neighbors in a focus group could have made some reluctant to disagree or express dissatisfaction. Finally, not all participants identified as LGBTQIA+, although all were living in an LGBTQIA+-welcoming community. The findings of this study may not be reflective of the experiences of all residents of LGBTQIA+-welcoming housing, but they may provide important insights for those planning and evaluating similar housing across the U.S. There is also a need for future research on whether the desire and need for LGBTQIA+ senior housing is specific to certain generations and geographic regions.LGBTQIA+ older adults face unique challenges in obtaining affordable and stable housing, as well as greater health concerns compared to their cisgender heterosexual peers. Affordable, supportive, and inclusive housing for LGBTQIA+ older adults may provide benefits for physical, mental, and social health by fostering community and facilitating access to services. This research forms the basis of a larger longitudinal mixed-methods study of the effects of affordable and inclusive housing on long-term health and healthcare costs, which will enhance our understanding of the time course and trajectories of these effects. As the LGBTQIA+ older adult population continues to grow, it is essential to provide appropriate and accessible housing solutions to support health and well-being of LGBTQIA+ populations throughout older age, recognizing their unique needs and preferences. Public health implications include: informing housing agencies and advocates as well as public health and clinical professionals of the need to improve programs and services; increasing understanding of the housing and health needs of LGBTQIA+ older adults; and initial evidence on the potential benefits of LGBTQIA+ age-friendly housing on the physical and mental health of LGBTQIA+ older adults, including the role that housing can play in increasing access and utilization of healthcare and social services.