Homelessness, HIV testing, and the reach of public health efforts for people who inject drugs, San Francisco, California

Highlights

• Living in single-room occupancy hotels was associated with getting HIV tested.

• Living with others was associated with sharing syringes but not HIV testing.

• Living outdoors was associated with sharing syringes but not HIV testing.

• Younger people who inject drugs (PWID) were less stably housed than older PWID.

• Public health and HIV screening efforts may not be reaching unstably housed PWID.

Abstract

Background

There is a dearth of literature that explicitly examines associations between housing and HIV testing among people who inject drugs (PWID). Thus, the present study investigated the links between housing status and HIV testing for PWID.

Methods

Respondent-driven sampling recruited 382 HIV-negative PWID, who completed structured interviews in San Francisco. Logistic regression determined whether housing statuses in the past 12 months ([1] owned/rented, [2] single-room occupancy hotels [SROs], [3] living with friends/family/partners, [4] shelters, [5] outdoors) were associated with getting HIV tested in the past 12 months while adjusting for sociodemographics and receptive sharing of injection paraphernalia in the past 12 months.

Results

PWID who lived in SROs had greater odds of being tested for HIV than PWID who did not live in SROs (aOR = 1.95, CI_.95: 1.06–3.60) while adjusting for covariates. Although bivariable analyses indicated that receptively sharing syringes was more common for PWID who lived with others (χ²[3] = 7.94, p = 0.047) or lived outdoors (χ²[3] = 9.50, p = 0.023) than those who did not, respectively, PWID who lived with others (aOR = 1.72, CI_.95 = 0.95–3.14) or lived outdoors (aOR = 1.37, CI_.95 = 0.74–2.53) did not show greater odds of HIV testing in multivariable analyses.

Conclusions

PWID who lived in SROs had greater odds of HIV testing than PWID who did not live in SROs. Although PWID who lived with others or outdoors showed greater HIV risk, they did not show greater odds of HIV testing. Public health efforts may be reaching PWID in SROs, but more work is needed to reach PWID who live with other people or outdoors.

Introduction

People who inject drugs (PWID) are disproportionately affected by HIV infection. Globally, injection drug use (IDU) accounts for 10% of HIV infections, 30% outside of Africa (World Health Organization, 2020), and results in HIV outbreaks (Ball et al., 2019; Conrad et al., 2015; Golden et al., 2019). Up to 40% of PWID share injection equipment (Centers for Disease Control and Prevention [CDC], 2020). The HIV-prevention strategies comprising the Ending the HIV Epidemic (EtHE) initiative require that the risks posed to PWID are addressed (United States Department of Health and Human Services, 2020). HIV screening and treatment in PWID are critical to prevent HIV outbreaks and adverse individual and public health outcomes (Golden et al., 2019; Kamarulzaman and Altice, 2015). However, research has shown that less than half of PWID reported HIV testing in the past year in the United States (US) (Furukawa et al., 2020), and global testing data tend to be sparse (Larney et al., 2017; Metsch et al., 2015).

An estimated 50.3% of PWID have experienced homelessness in North America (Degenhardt et al., 2017). Along with IDU-specific HIV risk, homelessness contributes to HIV outbreaks among PWID internationally, including in North America and Europe (Des Jarlais et al., 2020). A few studies have examined the link between homelessness and HIV testing. For example, in the US, veterans (Noska et al., 2017) and Black sexual-minority men (Creasy et al., 2019) who were homeless had greater odds of recent HIV testing than their respective, more stably housed counterparts, and this is at least partly due to increased testing in settings where homeless persons may be more likely to present (e.g., homeless shelters, substance use treatment programs, emergency departments). Research is needed to test for a similar association among PWID.

In the present study, we tested associations between several specific housing statuses (e.g., living outdoors; living in single-room occupancy hotels, or SROs [i.e., multi-unit buildings with at least some shared accommodations for low-income individuals]) and HIV testing controlling for sociodemographics and receptively sharing injection equipment. We classified renting/owning a home or living in SROs, where residents gain tenant’s rights after 30 days under California law (Housing Rights Committee of San Francisco, 2020), as stable housing; we classified other housing statuses, including living in shelters or outdoors, as less stably housed. Studies rarely distinguish types of unstable housing. We focused on PWID in San Francisco, California, where the cost of living is the second highest in the US (Burrows, 2019) and HIV seroprevalence may be five times greater among homeless and marginally housed persons than in the general population (Robertson et al., 2004). Being more stably housed was expected to be associated with lower odds of HIV testing.