Despite significant declines in new HIV diagnoses and improvement in HIV-related care indicators in San Francisco (SF), health disparities persist particularly among homeless persons living with HIV (PLWH). City-wide linkage and case management programs seek to improve outcomes across the continuum of HIV care. We measured HIV care indicators comparing those who were homeless to those housed in SF.
The SF HIV surveillance registry was used to determine linkage to care and viral suppression among PLWH by housing status. Homelessness was defined as a medical chart notation of homeless or living in a homeless shelter. Temporal trends from diagnosis to viral suppression by housing status for cases diagnosed in 2013-2016 were measured. Care was defined as having a CD4+ cell count or HIV viral load test. Viral suppression (VS) was defined as HIV RNA<200 c/mL.
In 2015, 29 (10%) of 296 newly HIV diagnosed cases were homeless. Linkage to care within one month and VS within 12 months of diagnosis were lower among homeless compared to housed persons; 66% vs 79% (p=.10) and 59% vs 79% (p=.02), respectively. Among 12,769 PLWH in 2015 with last known residence in SF, 301 (2%) were known to be homeless. Compared to all persons diagnosed in 2006-2016, homeless persons were more likely to be cis women (14% vs 7%, p<.0001), trans women (10% vs 3%, p<.0001), African American (27% vs 14%, p<.0001) or a person who injects drugs (58% vs 20%, p<.0001); 35% were <30 years old. In 2015, homeless PLWH were less likely than the housed to have had ≥1 care visit (52% vs 81%, p<.0001) or to have VS (31% vs 74%, p<.0001). In 2015, 30 homeless PLWH who were not-in-care enrolled in LINCS (a short-term intensive case management program); 27 (90%) were re-linked to care within 3 months and 77% were virally suppressed within 12 months. In 2013-2016, city-wide rapid linkage to care was scaled up; median days from diagnosis to viral suppression were greater for homeless than housed cases each year (Figure) but decreased significantly over time (p=.04).
Although a small proportion of all SF PLWH, homeless persons had poorest linkage to care and VS. Time from diagnosis to VS has significantly improved over time for the homeless. Scale–up of city-wide rapid linkage to care and intensive case management programs are beginning to show progress in decreasing disparities among homeless PLWH, our most vulnerable population.