In the JournalsPerspective

Estimates show high prevalence of HIV, hepatitis among homeless veterans

Homeless veterans experience a higher prevalence of HIV, hepatitis C virus and hepatitis B virus infection compared with non-homeless veterans, according to a retrospective analysis of VA data.

Veterans are disproportionately affected by HIV, HCV and HBV compared with the general public, and homeless veterans are at a particularly high risk for infection due to overlapping risk factors such as high rates of mental health and substance use disorders, according to Amanda J. Noska, MD, MPH, infectious disease physician at the Providence VA Medical Center in Providence, Rhode Island, and colleagues.

Noska and colleagues used VA warehouse data containing records for more than 5.6 million veterans to evaluate testing and prevalence rates for HIV, HCV and HBV in 2015. They said the results of their study, published in Clinical Infectious Diseases, “reinforce the need for integrated health care services along with homeless programming.”

“While VA’s homeless services’ primary focus is on housing, a veteran’s involvement with homeless services provides a unique opportunity for engagement in other health care services, potentially using an integrated, co-located clinic model in a comprehensive approach,” Noska and colleagues wrote.

For the purposes of their study, they defined the homeless population as any veterans who used VA homeless services at least once during the year, meaning some may have been housed at the time of their testing.

“Homelessness is often a fluid state in which individuals transition between levels of housing stability,” Noska and colleagues wrote. “While the use of homeless services does not guarantee that the veteran was homeless at the time of the visit, the use of homeless services undoubtedly identifies veterans who have recently been homeless, are currently homeless, or are at substantial risk of becoming homeless.”

The VA database included information on 242,740 veterans who received homeless services in 2015 and more than 5.4 million other veterans who comprised the non-homeless population in the study. Noska and colleagues calculated both the prevalence of laboratory-confirmed infection among veterans who were tested, known as the “tested prevalence,” and the population prevalence, which includes laboratory-confirmed cases as well as the estimated number of veterans who came to the VA with established diagnoses of HIV, HCV or HBV, but who did not have laboratory evidence of infection.

Testing rates for all three infections were considerably higher in the homeless population. According to the researchers, 63.8% of homeless veterans had been tested for HIV compared with 36.8% of non-homeless veterans. The differences were 78.1% to 59.5% for HCV and 52.8% to 27.6% for HBV.

For HIV, the tested prevalence was 2.32% among homeless veterans compared with 1.15% among the non-homeless population. The population prevalence of HIV was 1.52% among homeless veterans compared with .44% among non-homeless veterans. The tested prevalence for HCV among homeless and non-homeless veterans was 15.3% and 4.5%, respectively. The population prevalence also was much higher in the homeless population, 12.1% vs. 2.7%. For HBV, the tested prevalence and population prevalence were also higher among homeless veterans compared with non-homeless veterans — 1.80% vs.1.32% and .99% vs..40%, respectively.

The tested and population prevalence rates for HIV and HCV were several times higher for homeless men compared with homeless women, but only slightly higher for men with HBV.

“These national data describe the most comprehensive estimates of HIV, HCV and HBV testing rates, tested prevalence and population prevalence in the heterogeneous population of homeless and non-homeless veterans in VA care in 2015,” Noska and colleagues concluded. “The unique structure of VA allows for the integration of health care delivery with homeless services to better meet the needs of homeless veterans living with HIV, HCV and HBV moving forward.” – by Gerard Gallagher

Disclosure: The researchers report no relevant financial disclosures.

Bar graph: National HIV, HCV and HBV population prevalence estimates among non-homeless and homless veterans, 2015

Homeless veterans experience a higher prevalence of HIV, hepatitis C virus and hepatitis B virus infection compared with non-homeless veterans, according to a retrospective analysis of VA data.

Veterans are disproportionately affected by HIV, HCV and HBV compared with the general public, and homeless veterans are at a particularly high risk for infection due to overlapping risk factors such as high rates of mental health and substance use disorders, according to Amanda J. Noska, MD, MPH, infectious disease physician at the Providence VA Medical Center in Providence, Rhode Island, and colleagues.

Noska and colleagues used VA warehouse data containing records for more than 5.6 million veterans to evaluate testing and prevalence rates for HIV, HCV and HBV in 2015. They said the results of their study, published in Clinical Infectious Diseases, “reinforce the need for integrated health care services along with homeless programming.”

“While VA’s homeless services’ primary focus is on housing, a veteran’s involvement with homeless services provides a unique opportunity for engagement in other health care services, potentially using an integrated, co-located clinic model in a comprehensive approach,” Noska and colleagues wrote.

For the purposes of their study, they defined the homeless population as any veterans who used VA homeless services at least once during the year, meaning some may have been housed at the time of their testing.

“Homelessness is often a fluid state in which individuals transition between levels of housing stability,” Noska and colleagues wrote. “While the use of homeless services does not guarantee that the veteran was homeless at the time of the visit, the use of homeless services undoubtedly identifies veterans who have recently been homeless, are currently homeless, or are at substantial risk of becoming homeless.”

The VA database included information on 242,740 veterans who received homeless services in 2015 and more than 5.4 million other veterans who comprised the non-homeless population in the study. Noska and colleagues calculated both the prevalence of laboratory-confirmed infection among veterans who were tested, known as the “tested prevalence,” and the population prevalence, which includes laboratory-confirmed cases as well as the estimated number of veterans who came to the VA with established diagnoses of HIV, HCV or HBV, but who did not have laboratory evidence of infection.

Testing rates for all three infections were considerably higher in the homeless population. According to the researchers, 63.8% of homeless veterans had been tested for HIV compared with 36.8% of non-homeless veterans. The differences were 78.1% to 59.5% for HCV and 52.8% to 27.6% for HBV.

For HIV, the tested prevalence was 2.32% among homeless veterans compared with 1.15% among the non-homeless population. The population prevalence of HIV was 1.52% among homeless veterans compared with .44% among non-homeless veterans. The tested prevalence for HCV among homeless and non-homeless veterans was 15.3% and 4.5%, respectively. The population prevalence also was much higher in the homeless population, 12.1% vs. 2.7%. For HBV, the tested prevalence and population prevalence were also higher among homeless veterans compared with non-homeless veterans — 1.80% vs.1.32% and .99% vs..40%, respectively.

The tested and population prevalence rates for HIV and HCV were several times higher for homeless men compared with homeless women, but only slightly higher for men with HBV.

“These national data describe the most comprehensive estimates of HIV, HCV and HBV testing rates, tested prevalence and population prevalence in the heterogeneous population of homeless and non-homeless veterans in VA care in 2015,” Noska and colleagues concluded. “The unique structure of VA allows for the integration of health care delivery with homeless services to better meet the needs of homeless veterans living with HIV, HCV and HBV moving forward.” – by Gerard Gallagher

Disclosure: The researchers report no relevant financial disclosures.

Bar graph: National HIV, HCV and HBV population prevalence estimates among non-homeless and homless veterans, 2015

    Perspective

    Wendy Armstrong, MD
    Wendy Armstrong
    In the paper recently published by Noska and colleagues, the investigators evaluated the prevalence of three transmissible infectious diseases — HIV, HBV and HCV — analyzed by housing status using the large Veterans Affairs database with more than 240,000 veterans in care in 2015. They found that the rates of each of these infections is higher in the VA population than the general population, with rates among homeless veterans significantly higher than those among non-homeless veterans. These results confirm reports in non-veteran populations that also show higher rates of HIV, HBV and HCV among homeless persons compared with their non-homeless comparators. Overall, however, prevalence rates in the VA population are higher than the general population, although when stratified for housing status, the non-homeless veterans have similar prevalence rates to the U.S. population as a whole.
    Overall, these findings reinforce the importance of social determinants of disease, which affect general health status as well as the risk for contracting HIV, HBV and HCV. Many risk behaviors have been associated with housing status, including increased transactional sex, increased injection drug use and needle sharing. Homelessness is also associated with poverty, stigma, lack of access to health care and preventive services, unemployment and mental health disorders. Effective HIV, HBV and HCV prevention and treatment programs require addressing these challenging social and structural issues that pose substantial barriers to care. Housing First approaches (programs that rapidly move individuals from the street into apartments) are gaining traction across the country and have been shown to be cost effective in communities where these programs have been studied. Stable housing is an important step toward participation in health care. These important results from the VA population are again a call to support our veterans as well as all our citizens to benefit from stable housing, ultimately improving individual health as well as population health by reducing transmission to others.

    Wendy Armstrong, MD, FIDSA, FACP
    Professor of medicine, Emory University
    Chair, HIV Medicine Association
    Disclosure: Armstrong reports no relevant financial disclosures.