An innovative peer-centred outreach project, testing homeless and unstably housed people in London during the height of the COVID epidemic for HIV and viral hepatitis, has revealed a significant proportion with HIV who were either undiagnosed, or diagnosed but not in care.
Dr Binta Sultan, physician in Inclusion Health at University College Hospital in London (UCL), presented the project’s findings at the joint British HIV Association and British Association of Sexual Health and HIV conference yesterday.
The average age of death in people experiencing homelessness is 43, with mortality rates 12 times that of the housed in women and eight times in men. A previous London study showed that one in 83 homeless people had HIV, six times the prevalence in the general adult population.
Even among risk groups, homelessness considerably raises 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 acquiring HIV by 55% and of hepatitis C by 65%, with the recent outbreak in Glasgow showing how HIV can quickly establish a new foothold among homeless people.
Delivering healthcare to the homeless is complex for many reasons. Homeless people are often transient; health workers may only have one opportunity to test and refer them; and services for homeless people are the responsibility of many different agencies who do not co-ordinate. One example cited by Dr Sultan was that there was resistance among hepatitis physicians to offering HIV testing alongside hepatitis testing.
To meet these needs, the UCL team worked with a consortium of seven HIV, hepatitis and homeless charities to offer integrated HIV, hepatitis B, hepatitis C and syphilis testing as part of Find and Treat, a long-established project originally set up to find and treat homeless people with TB. During the first COVID-19 lockdown in England, rough sleepers were temporarily housed in hotels and other emergency accommodation, providing a new opportunity to engage homeless people.
Peer outreach workers were trained to offer the testing in homeless hostels, women’s shelters, and emergency accommodation for asylum seekers. Mortimer Market Centre, UCL’s Sexual Health Clinic, provided the medical expertise and the Fast Track Cities initiative supplied the test kits.
Testing was often done under difficult conditions, both in terms of maintaining COVID safety and finding space for point-of-care testing (Dr Sultan showed a picture of a PCR machine set up in a hotel corridor). People tested were referred to care both for treatment and for harm reduction services such as PrEP.
Results
Between May and November 2020, 1411 people were tested for any blood-borne virus and 1259 for HIV. Their average age was 41 and 76% were men. One significant finding was the ethnic diversity of the clients: over a quarter were of Black African, south Asian or Black Caribbean ethnicity (13.5% alone were black African) and 68% had been born outside the UK. Fifteen percent were current or former injecting drug users (6.6% current) and 5% identified as gay or bisexual.
Thirty-six clients, or one in 35 tested, were found to have HIV, of whom eight were unaware of their status. Thirty of the 35 (83%) were men. They were more likely than HIV-negative people to have been staying in temporary homeless hostels before lockdown.
They were considerably more likely to be Black (36%) or Asian (31%) and 77% had been born outside the UK. Thirty-nine percent had a history of injecting drugs and 31% were gay or bisexual.
Of the 28 who already knew their HIV status, 20 were on antiretroviral therapy (ART), but five had experienced ART interruption during the COVID pandemic. Thirty-two of the HIV-positive are now on treatment (89%), although viral suppression data were not available. One client with HIV unfortunately died.
One hundred and thirty-eight people tested positive for hepatitis C antibodies (10%), including ten people who also had HIV. Of the 138, 98 (71%) were hepatitis C PCR positive, indicating current active infection. All the 98 were referred for treatment and 79% had it approved.
Dr Sultan said that the study’s findings laid bare the impact of structural inequalities in homeless people, and especially of racism and insecure immigration status. She urged better integration of HIV and hepatitis C testing, and for outreach testing and care for the homeless to be a distinct commissioned multidisciplinary service in London, acting as a safety net to compensate for the multiple exclusions homeless people experience. She highlighted peer support as a highly effective way of delivering these services.
References
Sultan B et al. High prevalence of HIV among people who experience homelessness in London: results of an innovative peer-centred outreach blood-borne virus testing service initiated 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.