HIV and tuberculosis (TB) often go hand in hand among people experiencing homelessness (PEH) in the U.S.—a reality that gives public health officials an opportunity to utilize shelters in tackling both viruses at the same time, new research suggests.
The findings were presented by Udodirim Onwubiko, M.P.H., an epidemiologist with the Fulton County Board of Health in Georgia, at the IDWeek clinical science conference in October. The study was spurred by an outbreak of TB across several Atlanta homeless shelters in 2008.
Onwubiko and colleagues conducted a retrospective analysis on 18,605 PEH who were screened for TB between 2008 and 2018, and whose HIV status was either self-reported or laboratory-confirmed.
Of the 18,605 PEH screened for TB, 9,308 (53%) had a known HIV status. Of these, 38% (n=3,559) received a HIV test, while 62% (n=5,749) only self-reported their HIV status. The prevalence of HIV among all PEH who self-reported their status was 4.0% (296 out of 7,404) while the prevalence of laboratory-confirmed HIV infection among people receiving an HIV test was similar, at 3.6% (129 out of 3,559).
Researchers concluded that the prevalence of HIV among PEH in Atlanta was more than four times higher than the prevalence in the general Atlanta population, which currently stands at 0.86%.
This HIV prevalence rate for PEH in Atlanta is somewhat higher than the rate of HIV among PEH nationally, which is estimated to be about 3%. The overall number of PEH in the U.S. is estimated at 3.5 million, thus suggesting that roughly 105,000 of the 1.2 million Americans living with HIV are experiencing homelessness.
Homelessness is a strong risk factor for both TB and HIV in the U.S. Onwubiko said that public health programs geared towards addressing TB among PEH could be prime opportunities to also actively address HIV in that population, too. Onwubiko suggested that health officials need not wait for an outbreak, such as the one that occurred in Atlanta in 2008, to take action to control TB; instead, essential, proactive anti-TB measures are needed for people who congregate in places like homeless shelters.
Onwubiko added that increasing access to HIV prevention and care at homeless shelters “may also help reduce both HIV transmission and TB acquisition in this at-risk population in the South,” and help the U.S. South make progress toward ending both its TB and HIV epidemics.
Prioritizing Housing First Can Help Reduce Public Health Burdens
Health issues and a lack of permanent housing are tightly interwoven issues—and with HIV and homelessness, it’s not clear which is the greater risk factor for the other. Some studies have estimated that up to half of people with HIV are at risk of homelessness, due to high costs of housing and medical care.
Further, for those who lack stable housing, it’s harder for them to protect themselves from HIV—as well as TB and other communicable diseases. Even if a PEH ostensibly has health care options available, there is some evidence that stigma and trauma can be barriers to accessing it, according to Elizabeth Bowen, Ph.D., an associate professor at the University at Buffalo School of Social Work. “In addition to the other barriers to health care, many [PEH] say they did not feel safe with health care workers, before and during homelessness, and that they felt stigmatized in health care settings,” Bowen said.
Bowen is a strong advocate of the Housing First model, which prioritizes the use of federal dollars to rapidly rehouse people and to provide them with supportive housing without any preconditions (e.g., meeting certain income requirements, or abstaining from alcohol or drug use).
The federal government appeared to de-emphasize a Housing First approach in its most recent strategic plan for homelessness, according to an analysis by the Center on Budget and Policy Priorities. “This plan falls woefully short of what communities and homelessness services providers need to reduce homelessness, especially as they face some of the toughest challenges since the Great Recession of about a decade ago,” the analysis stated.
An Unexpected Opportunity Amidst the COVID-19 Crisis
Given the severity of higher unemployment during the pandemic and the present lack of a new COVID-19 relief package from the federal government, the U.S.’s homeless crisis is not likely to improve anytime soon. And with another attempt at ending the Affordable Care Act (ACA) looming—the Supreme Court is about to hear arguments as it welcomes a new, ACA-hostile justice—it’s possible that more people may lose their health coverage in the future.
That said, in an ironic twist, the COVID-19 pandemic might present some new opportunities to get PEH into housing. In California, a city-state-county collaborative called Project Roomkey, which places vulnerable PEH in secure hotel and motel rooms to prevent the spread of COVID-19, could also represent a bridge to permanent housing after the pandemic subsides.
“Once COVID feels like less of a crisis, we will still have an urgent need to get people into housing,” Bowen said, adding that Project Roomkey is a model that could be replicated in communities across the country.
Bowen added that federal funding for people living with HIV needs to be supplemented by state and local funding to prevent these individuals from becoming unhoused, and to help them protect themselves from situations that can leave them vulnerable to HIV infection. “Federal, city and state governments need to be doing more to prevent homelessness, including emergency financial assistance to prevent evection, and other programs to get people into stable housing,” she said.