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Human Immunodeficiency Virus (HIV) has gone from a deadly infection to a manageable health condition in the last thirty years. Today, we have medications available that can treat those with HIV and prevent HIV in uninfected people. Pre-exposure prophylaxis, also known as PrEP, is a medication given to individuals without HIV to keep them from becoming infected. It can be taken as a daily pill, or an injectable drug given every two months. PrEP is highly useful in preventing new cases of HIV in high-risk groups. Unfortunately, despite the advances in preventing HIV, there were 32,100 new HIV cases in 2021 alone. Sadly, not everyone who could benefit from this critical drug is able to access it.
Increased HIV Risks in Homelessness
People experiencing homelessness face an increased risk of getting HIV compared to those in stable housing. In 2021, the CDC found that 8% of people with HIV experienced homelessness within the last 12 months. Furthermore, people experiencing homelessness may be more likely to engage in behaviors that increase their risk of developing HIV, such as substance use or risky sexual behavior. It is often harder for people experiencing homelessness to take medication every day due to both individual and structural factors. They may not be able to regularly travel to a clinic. Folks experiencing homelessness may also not be aware of medications like PrEP that can reduce their likelihood of developing HIV. Other potential problems include concerns about side effects from the medication or beliefs that they are not at risk of contracting HIV. However, programs that include patient education and support can help to address these factors.
Boston Healthcare for the Homeless Leads the Way
Organizations such as Boston Healthcare for the Homeless have been leading the charge to make PrEP more accessible to people experiencing homelessness. Programs they offer include regular check-ins with caseworkers over the phone or in person, supplying storage space at their facilities, and helping patients pick up their medication. They also provided short-interval prescriptions for 14 days, which helped to lower the risk of stolen or lost medications. These resources have made it easier for people experiencing homelessness to get PrEP in Boston.
Unfortunately, even with these benefits, only 44% of patients were still taking PrEP after 6 months. Having access to PrEP was not enough to keep people on the drug long-term. One potential reason could be that some patients went to prison or drug treatment facilities and could no longer pick up their prescriptions. It is important to do more than just improve access to PrEP. We need other solutions if we want more people to stay on PrEP long-term and remain HIV-free.
Housing First Approach
Chicago House works to provide access to housing to unstably housed people with HIV or who are at high risk of developing HIV. Not only do they provide housing, but they also connect individuals with PrEP, mental healthcare, job assistance, and case management. Access to housing plays a crucial role in supporting those at high risk for HIV. All 41 people who entered their housing services between 2019 and 2022 remained HIV-free while in the program. Additionally, 86% of those who left the program were able to secure permanent housing. Although Chicago House focuses on housing individuals with HIV, their prevention programs have done important work in improving the health outcomes of people without HIV. Approaches that integrate housing and medication are making great strides in preventing HIV in unstably housed populations.
Pre-Exposure Prophylaxis (PrEP) Works
In 2021, the FDA approved an injectable form of PrEP. Clinical trials found that the injectable drug lowered the risk of contracting HIV by 66% compared to oral PrEP. This result occurred because some trial participants did not take their oral PrEP daily, resulting in more HIV infections in that group. This new medication could help people experiencing homelessness stick with PrEP longer. Healthcare providers can give the medicine as a starter dose once every month for two months. After the second injection, patients only need one injection every two months. Not having to take a pill every day would be helpful, because folks in homelessness have reported difficulties in taking a pill at the same time each day. People on PrEP typically need to receive blood work to confirm a lack of HIV infection every three months, so an injectable medication would not necessarily result in more doctor visits compared to an oral medication.
Although HIV is currently a treatable condition, it can still result in serious health problems, especially in individuals who struggle with taking their medications. It is important to focus on preventing HIV infections in high-risk individuals, including people experiencing homelessness. We need more research to identify how injectable PrEP could improve medication adherence in populations in homelessness. We have the resources to prevent HIV in our most vulnerable community members. More must be done to make this incredible treatment available to everyone who could benefit.
Ben King is an Editor for the Medical Care Blog. He is an epidemiologist by training and an Assistant Professor at the University of Houston’s Tilman J Fertitta Family College of Medicine, in the Departments of Health Systems and Population Health Sciences & Behavioral and Social Sciences. He is also a statistician in the UH Humana Integrated Health Systems Sciences Institute at UH, a Scientific Advisor to the Environmental Protection Agency, and the President of Methods & Results, a research consulting service.
His own research is often focused on the intersection between poverty, housing, & health. Other interests include neuro-emergencies, diagnostics, and a bunch of meta-topics like measurement validation & replication studies. For what it’s worth he has degrees in neuroscience, community health management, and epidemiology.
