San Francisco health officials working to end HIV infections and deaths in The City are zeroing in on the homeless population, where there’s been an uptick in new cases.
While the number of newly diagnosed HIV infections continued to decline overall last year, there was a continued upward trend of new cases among the homeless, according to the Public Health Department’s recently issued annual HIV report.
A total of 221 people were newly diagnosed with HIV in 2017, of which 31, or 14 percent, were homeless. In 2016, 233 people were newly diagnosed, of which 29, 12 percent, were homeless. In 2015 there were 272 new HIV cases, of which 27 or 10 percent were among the homeless.
“Fourteen percent of our new diagnoses are homeless and the national guidelines say that that proportion should be no greater than 5 percent as our goal,” Dr. Susan Buchbinder, director of the Health Department’s Bridge HIV, a branch of the department dedicated to HIV prevention, told the Health Commission last week. “Homelessness is also a substantial contributor to deaths among people living with HIV.”
She continued, “We know that homelessness is a major driver of new transmissions. To get to zero HIV infections and zero HIV associated deaths we need to reach our homeless populations.”
In addition, the rate of viral suppression among the homeless is much lower, at 32 percent, than the 74 percent rate among all those diagnosed with HIV, according to Susan Scheer, director of the Public Health Department’s HIV Epidemiology Section. Viral suppression means the HIV virus has been suppressed through treatment to an undetectable level.
Since 2006, the number of new infections among homeless persons peaked at 65 in 2010. While the homeless cases declined in 2011 to 39, since then they have fluctuated each year and now appear to be increasing.
Between 2006 and 2017, there were 543 homeless cases in that time period compared to 4,838 cases among housed residents.
Scheer said that in comparison to those with housing, “Homeless cases are more likely to be women, trans-women, African-Americans, people who inject drugs, including [men who have sex with men]injectors.”
“And while there is no significant differences in age between these two groups, I do think it is interesting to note that about 34 percent of the homeless cases are diagnosed with HIV before the age of 30, so they are being diagnosed very young,” Scheer said.
Jennifer Friedenbach, executive director of the Coalition on Homelessness, told the San Francisco Examiner Monday that “we cannot get to zero transmissions and continue to have homelessness.”
“For example, people experiencing homeless instability and homelessness are less able to hold onto condoms,” Friedenbach said, adding that studies show “housing instability contributes to individuals being twice as likely to engage in behaviors that can transmit the virus.”
She added, “The big story is that … every ninth HIV positive San Franciscan does not have adequate housing.”
Of the deaths of those diagnosed with HIV between 2002 and 2016, those who were ever homeless had a higher proportion of deaths “due to viral hepatitis, accidents, mental disorders due to substance abuse, drug overdose, and assault,” the report said.
To address HIV in the homeless population, The City applied for and received a federal grant from Centers for Disease Control and Prevention to launch a new effort that began in July. The grant is $2 million annually for four years.
In its application for the funding, the department said the effort, which is called Project OPT-IN, is “critically needed.”
“Although SF has made great progress towards ‘getting to zero,’ not all populations have benefitted,” the application said, and notes “unstable housing also has a negative impact on PrEP retention.”
PrEP, or pre-exposure prophylaxis, is a pill that reduces the chances by more than 90 percent of being infected by HIV and is recommended for those who are HIV negative but at risk of contracting the disease.
The City estimates that PrEP use has grown from about 4,400 residents in 2014 to up to 20,000 in 2017. The U.S. Food and Drug Administration authorized use of the anti-HIV drug in 2012.
The Project OPT-IN effort includes better data sharing and new treatment strategies, including having more booths set up in the areas where there are homeless for testing and medical care.
Tracey Packer, director of the Health Department’s Community Health Equity and Promotion branch, told the Examiner Monday that the grant funding will help hire more staff to do outreach and work with homeless persons to encourage them to seek the care they need in follow up visits.
“It’s building trust,” Packer said. “It takes time.”
She said that they want to reduce barriers to treatment and will try allowing homeless to seek care at San Francisco General Hospital Ward 86, which has treated HIV patients since the 1980s, without having to first make appointments.
She also said they plan to roll out a program where homeless persons can store their HIV viral suppression medicines in lockers.
Another strategy includes notification. If a former HIV client of LINCS, a program that connects those with HIV with treatment, is admitted to the emergency room at the hospital, they would receive a text or email notifying them so they can re-engage with the client.
The AIDS Foundation, which runs the 6th Street Harm Reduction Center, is among the non-profit groups helping people living with HIV obtain housing and find medical care.
Joe Hollendoner, chief executive officer of the San Francisco AIDS Foundation, emphasized the importance of housing in the effort against HIV.
He said for many homeless living with HIV “it can be difficult to access systems of care because of barriers like identification, insurance, or previous trauma” and he said “you might not be able to keep possession of medications because are forced to move or flee, or maybe you have to prioritize food over medication.”
“We’ve been saying it for years: housing is health care,” Hollendoner said.