Screening of homeless people during COVID-19 identifies several new cases of HIV, especially among blacks
Innovative peer-centered outreach project, testing homeless and unstably housed people in London at the height of the COVID epidemic for HIV and viral hepatitis, found a significant proportion of undiagnosed HIV positive or diagnosed but not supported.
Dr Binta Sultan, physician in inclusion health at University College Hospital, London (UCL), presented the results of the project at the joint conference of the British HIV Association and the British Association of Sexual Health and HIV.
The average age of death for homeless people is 43, with death rates 12 times that of housed people among women and eight times that of men. A previous study from London showed that one in 83 homeless people were infected with HIV, six times the prevalence in the general adult population.
Even among at-risk groups, homelessness significantly increases the risk of HIV and hepatitis: a recently published meta-analysis of studies with people who inject drugs found that being homeless increased the risk of contracting HIV by 55% and hepatitis C by 65%, with the recent epidemic in Glasgow showing how HIV can quickly establish a new foothold among the homeless.
Providing health care to the homeless is complex for many reasons. Homeless people are often passing through; health workers can only have one opportunity to test and refer them; and homelessness services are the responsibility of many different agencies that do not coordinate. An example cited by Dr Sultan was that hepatitis doctors were reluctant to offer HIV testing at the same time as hepatitis testing.
To address these needs, the UCL team worked with a consortium of seven HIV, hepatitis and homeless charities to offer integrated testing for HIV, hepatitis B, hepatitis C and syphilis as part of Find and treat, a long-established project to find and treat homeless people with tuberculosis. During the first COVID-19 lockdown in England, people sleeping rough were temporarily accommodated in hotels and other emergency accommodation, providing a new opportunity to engage the homeless.
Peer outreach workers have been trained to provide testing in homeless shelters, women’s shelters and emergency accommodation for asylum seekers. The Mortimer Market Center, UCL’s sexual health clinic, provided the medical expertise and the Fast Track Cities initiative provided the test kits.
Testing has often been carried out under difficult conditions, both in terms of maintaining COVID security and finding space for point-of-care testing (Dr Sultan showed a photo of an installed PCR machine in a hotel corridor). People tested were referred to care for both treatment and harm reduction services such as PrEP.
Between May and November 2020, 1,411 people were tested for any blood-borne virus and 1,259 for HIV. Their average age was 41 and 76% were men. A significant result was the ethnic diversity of clients: more than a quarter were of Black African, South Asian or Black Caribbean descent (13.5% alone were Black Africans) and 68% were born outside the UK. United. Fifteen percent were current or former injection drug users (6.6% currently) and 5% were identified as gay or bisexual.
Thirty-six clients, or one in 35 tested, tested positive, eight of whom were unaware of their status. Thirty of the 35 (83%) were men. They were more likely than HIV-negative people to have stayed in temporary homeless shelters before the lockdown.
They were considerably more likely to be black (36%) or Asian (31%) and 77% were born outside the UK. Thirty-nine percent had a history of injection drug use and 31% were gay or bisexual.
Of the 28 who already knew their HIV status, 20 were on antiretroviral therapy (ART), but five had been interrupted on ART during the COVID pandemic. Thirty-two of those living with HIV are currently on treatment (89%), although viral suppression data is not available. Unfortunately, an HIV-positive client died.
One hundred and thirty-eight people tested positive for anti-hepatitis C antibodies (10%), ten of whom also tested positive. Of the 138, 98 (71%) were positive for hepatitis C PCR, indicating current active infection. All 98 were referred for treatment and 79% had it approved.
Dr Sultan said the study results exposed the impact of structural inequalities among the homeless, and in particular racism and precarious immigration status. She called for better integration of HIV and hepatitis C testing, and for homeless testing and outreach care to be a separate multidisciplinary service commissioned from London, acting as a safety net to compensate the multiple exclusions experienced by the homeless. She pointed out that peer support was a very effective way to provide these services.
Sultan B et al. High HIV prevalence among homeless people in London: results of an innovative peer-based blood-borne virus testing service launched at the start of the COVID epidemic. Fifth Joint Conference of the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASSH), Abstract 10, 2021.