The Population Impact of Eliminating Homelessness on HIV Viral Suppression among People Who Use Drugs

OBJECTIVE:

We sought to estimate the change in viral suppression prevalence if homelessness were eliminated from a population of HIV-infected people who use drugs (PWUD).

DESIGN:

Community-recruited prospective cohort of HIV-infected PWUD in Vancouver, Canada. Behavioral information was collected at baseline and linked to a province-wide HIV/AIDS treatment database. The primary outcome was viral suppression (<50 copies/mL) measured during subsequent routine clinical care.

METHODS:

We employed an imputation-based marginal modelling approach. First, we used modified Poisson regression to obtain effect estimates (adjusting for sociodemographics, substance use, addiction treatment, and other confounders). Then, we imputed an outcome probability for each individual while manipulating the exposure (homelessness). Population viral suppression prevalence under realized and "housed" scenarios were obtained by averaging these probabilities across the population. Bootstrapping was conducted to calculate 95% confidence limits.

RESULTS:

Of 706 individuals interviewed between January 2005 and December 2015, the majority was male (66.0%), of Caucasian race/ethnicity (55.1%), and had a history of injection (93.6%). At first study visit, 223 (31.6%) reported recent homelessness, and 37.8% were subsequently identified as virally suppressed. Adjusted marginal models estimated a 15.1% relative increase (95%CI: 9.0%, 21.7%) in viral suppression in the entire population-to 43.5% (95%CI: 39.4%, 48.2%)-if all homeless individuals were housed. Among those homeless, eliminating this exposure would increase viral suppression from 22.0% to 40.1% (95%CI: 35.1%, 46.1%), an 82.3% relative increase.

CONCLUSIONS:

Interventions to house homeless, HIV-positive individuals who use drugs could significantly increase population viral suppression. Such interventions should be implemented as a part of renewed HIV/AIDS prevention and treatment efforts.

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By:  Marshall BD1, Elston B, Dobrer S, Parashar S, Hogg RS, Montaner JS, Kerr T, Wood E, Milloy MJ.

• 1Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA bUrban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada cFaculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada dDepartment of Medicine, University of British Columbia, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

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