The Link between Homelessness and HIV

Homelessness exposes individuals to a wide range of health challenges, which in part explains the increase in mortality among individuals experiencing homelessness. One of the greatest challenges facing individuals in this situation is human immunodeficiency virus (HIV). Researchers in San Francisco recently noted an increase in HIV infection rates among individuals experiencing homelessness in the city, while the overall rate of new infections continued to decline. The findings pushed health officials to redouble their efforts to help individuals experiencing homelessness to connect with care and keep them engaged with their team of providers.

HIV Infection Statistics

IN 2017, 221 people in San Francisco were diagnosed with HIV, down from 233 in 2016. During the same time period, however, the number of individuals with HIV experiencing homelessness rose from 29 to 31. The numbers become unsettling when compared to 2015, when 272 HIV cases were recorded, only 27 involved individuals experiencing homelessness. National guidelines dictate that new cases of HIV associated with homelessness should account for no more than 5 percent of all new diagnoses in a given year, yet San Francisco now has a rate of 14 percent. The statistic is alarming when considering that homelessness is strongly associated with mortality among people living with HIV.

Researchers are aware that homelessness contributes significantly to the new spread of HIV because of lower rates of viral suppression in this demographic. Among all individuals with HIV, 74 percent have an undetectable viral load. Yet, when looking specifically at people experiencing homelessness and living with HIV, the rate of viral suppression plummets to 32 percent. Individuals with an undetectable viral load do not transmit the disease to other people. Public health officials recognize that achieving the goal of zero transmission will not happen until homelessness is adequately addressed. Research has shown that people experiencing homelessness are twice as likely to participate in risky behavior that could result in a new infection.

Greater Access to Care

Living with HIV often predisposes people to encounter difficulties in securing stable housing. In San Francisco, one in nine individuals living with HIV do not have suitable housing. However, the city is actively working to change this fact. Recently, the city acquired a federal grant from the Centers for Disease Control and Prevention for $2 million annually over the next four years. The grant will fund an initiative known as Project OPT-IN, which seeks to create greater access to testing and care among individuals experiencing homelessness by providing information at specialized booths in areas they frequent. Much of the project funding is for hiring new staff to undertake outreach work and build trust to encourage people to seek care.

San Francisco is concerned about people who already have an HIV diagnosis and those at risk of becoming infected with HIV, including those experiencing homelessness. For this reason, Project OPT-IN will also connect people with pre-exposure prophylaxis (PrEP), a pill designed to reduce the risk of HIV transmission by more than 90 percent. While providing individuals experiencing homelessness with greater access to PrEP may help to reduce transmission rates, it would also connect them to consistent medical care to get their prescriptions filled.

Removing Barriers to HIV Care

San Francisco officials recognize that individuals experiencing homelessness face barriers to treatment, including a lack of access to PrEP. They recently began spearheading initiatives to improve care retention rates. For example, plans are currently underway to provide lockers in which individuals could store their HIV medications. In addition, San Francisco General Hospital Ward 86 accepts patients with HIV who did not make an appointment before coming to the hospital. The option provides around-the-clock options for connecting to care.

In addition, the city has implemented a notification strategy as part of Linkage, Integration, Navigation, and Comprehensive Services (LINCS), a program to connect individuals with HIV treatment. Whenever a former LINCS client is admitted to the San Francisco General Hospital Ward 86, the program staff receive a notification so they can come out and attempt to re-engage the client.

More Housing Options

At the same time, more efforts are needed to connect people living with HIV to stable housing. The San Francisco AIDS Foundation works with individuals to connect them to care and obtain housing in the process. Stable housing makes it easier for individuals to access systems of care by removing some of the greatest barriers. For example, individuals would not have to worry about leaving their medications behind because they are forced to move, nor would they need to prioritize the search for food or shelter over their anti-virals. However, housing options are limited, and until they become more available, it will be a challenge to place vulnerable individuals in stable situations.

Rohit Varma, MD, MPH, is an internationally recognized opthalmologist and researcher who focuses on the diagnosis and treatment of glaucoma.

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