HIV Outbreaks Among People Experiencing Homelessness and Housing Instability

Dear Recipients

April 12, 2023

In recent years, numerous HIV outbreaks among people experiencing homelessness and housing instability have been identified¹. Housing status is a social determinant of health that has a significant impact on HIV prevention and care outcomes. The experiences of homelessness and housing instability are linked to higher viral loads and failure to attain or sustain viral suppression² among people with HIV. The Health Resources and Services Administration's (HRSA) Ryan White HIV/AIDS Program (RWHAP) clients with unstable or temporary housing have lower levels of viral suppression than those with stable housing (77.3% clients versus 90.8%) clients ³. Homelessness and housing instability are also associated with increased vulnerability for HIV acquisition. Stable housing provides a foundation from which people can participate in HIV prevention services and is associated with reductions in behaviors associated with getting or transmitting HIV⁴.

The National HIV/AIDS Strategy for the United States (2022-2025) sets a bold target to decrease homelessness and housing instability for people with HIV by 50 percent. The Strategy also calls for improved coordination among federal, state, and local governments and community-based organizations to quickly detect and respond to HIV outbreaks⁵. As such, the Centers for Disease Control and Prevention (CDC) Division of HIV Prevention, the U.S. Department of Housing and Urban Development (HUD) Office of HIV/AIDS Housing (OHH), and HRSA's HIV/AIDS Bureau (HAB) have partnered on recent responses to HIV outbreaks among people experiencing homelessness and housing instability.

Based on the lessons learned through our joint outbreak response efforts, CDC, HUD, and HRSA encourage communities to take the following actions to effectively prepare for and respond to these outbreaks:

• Health departments and housing providers should integrate and assess HIV prevention, care, and housing data on individuals impacted by outbreaks to determine the extent to which they are experiencing homelessness or housing instability and to identify gaps and coordinate service delivery to improve housing stability and health outcomes.
• Personnel involved with outbreak response should assess HIV prevention, care, and treatment needs and leverage all available resources to establish integrated models of service delivery that meet people where they are.
• Individuals engaged in local outbreak response efforts should identify and leverage housing resources to assist people experiencing homelessness and housing instability in their community in addition to those available through HUD's Housing Opportunities for Persons With AIDS (HOPWA) program. Although HOPWA is a critical housing program for people with HIV, current funding does not meet the need for housing services for this population. In addition, HOPWA is unable to serve people who do not have HIV. Information on non-HOPWA housing resources can be found in the attached APPENDIX Federal Support for Housing Services and HIV Outbreak Response.
• Housing providers should implement Housing First and other low-barrier housing models that offer flexibility, individualized support, and client choice in the provision of housing assistance and supportive services, including integration with substance use disorder services.
• Housing providers should explore shared housing arrangements to foster social connection, decrease housing costs, and expand available units to people with HIV and those without HIV who need prevention services.
• Housing providers should use grant funds for housing navigator positions to partner with HIV prevention and care outreach workers to provide linkage and referrals to housing programs and resources for people experiencing homelessness or housing instability.

These recommendations are based on experiences in communities with HIV outbreaks among people experiencing homelessness and housing instability. In these communities, people with HIV may also experience a variety of additional challenges, including substance use, mental health disorders, other infectious and non-infectious diseases, incarceration, food insecurity, unemployment, trauma and loss, and stigma⁶. Some communities experienced difficulties in responding to these outbreaks due to a lack of low-barrier or Housing First housing options, including insufficient options for people with a history of incarceration or people who actively use injection drugs. Another barrier to HIV prevention efforts was limited capacity for substance use disorder services. In addition, the jurisdictions reported a need for flexible housing assistance models to serve those at different stages of homelessness or housing instability, regardless of their HIV status, to transition to safe, stable housing with social support.

The lessons learned from these recent outbreak response efforts underscore the need for ongoing collaboration among state and local public health, healthcare, housing, and social services providers to prepare for and respond to HIV outbreaks, reduce HIV transmission, and improve HIV care and viral suppression outcomes. In at least two of these communities, Homeless Management Information System (HMIS) data provided important insights to HIV surveillance staff in identifying needs and guiding efforts to determine eligibility for and link people to appropriate housing and services as available.

In all the communities that experienced outbreaks, the assessment of service gaps played a critical role in addressing both immediate and long-term service needs. State and local health departments worked with service providers to expand service delivery, including co-location of services, training and capacity development at sites, and the establishment of new partnerships with trusted providers in the community. Many of these activities can be done before an outbreak occurs, as identifying gaps and developing new models of service delivery strengthen the overall system of care for all people regardless of HIV status.

As we work to end the HIV epidemic, collaboration among public health, healthcare, housing, and social services providers is critical for effective detection and response to outbreaks and the prevention of future outbreaks among people experiencing homelessness or housing instability. Community efforts to provide safe and stable housing, reduce new HIV infections, and increase access to care and support for people with HIV, are necessary in order to achieve the goals of the National HIV/AIDS Strategy and the Ending the HIV Epidemic in the U.S. (EHE) Initiative. We look forward to our continued federal collaboration and work with our state and local partners to take actions to end the HIV epidemic in the United States.

Sincerely,

/Jonathan Mermin/

Jonathan H. Mermin, MD, MPH
Rear Admiral and Assistant Surgeon General, USPHS
Director
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention

/Jemine A. Bryon/

Jemine A. Bryon
Deputy Assistant Secretary
Office of Special Needs
Housing and Urban Development

/Laura Cheever/

Laura Cheever, MD, ScM
Associate Administrator
HIV/AIDS Bureau
Health Resources and Services Administration

Footnotes

1. Lyss S, Buchacz K, McClung RP, Asher A, Oster AM. Responding to Clusters and Outbreaks of Human Immunodeficiency Virus Among People Who Inject Drugs: Recent Experience and Lessons Learned. J Infect Dis. 2020 Sep 2;222(Supplement_5): S239-S249.
2. Aidala, A. A., Wilson, M. G., Shubert, V., Gogolishvili, D., Globerman, J., Rueda, S., Bozack, A. K., Caban, M., & Rourke, S. B. Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review. American Journal of Public Health, 106(1), e1–e23. 2016.
3. Health Resources and Services Administration. Ryan White HIV/AIDS Program Annual Client-Level Data Report 2021. ryanwhite.hrsa.gov/data/reports. Published December 2022.
4. Aidala, et al. 2016.
5. The White House. National HIV/AIDS Strategy for the United States 2022–2025. Washington, DC. 2021.
6. Lyss, et. al. 2020

Appendix

Federal Support for Housing Services and HIV Outbreak Response

HUD

It is especially important that HUD-funded organizations engage in HIV outbreak response efforts to house and stabilize people with HIV and people who do not have HIV but would benefit from prevention services. Grant funding under HUD's Housing Opportunities for Persons With AIDS (HOPWA) program can be used to support a range of housing assistance types and supportive services for low-income people with HIV and their families. Grant funding under HUD's Continuum of Care (CoC) and Emergency Solutions Grants (ESG) programs can be used to provide emergency, transitional, and permanent housing, outreach, and supportive services to individuals and families experiencing homelessness who are either HIV-positive or those who need HIV prevention services. In addition, these programs can fund housing search activities for eligible individuals and families.

The HOPWA, CoC, and ESG programs allow for shared housing arrangements where one or more individuals or households agree to share the space and cost of a permanent rental housing unit. The benefits of shared housing models include increased social connection and decreased isolation, reduced housing costs, and opportunity to access better housing options. These programs also promote the adoption of Housing First principles by funded housing providers, which include having few programmatic prerequisites, low-barrier admission policies, quick and successful connection to permanent housing, proactively offered but voluntary supportive services, and a focus on housing stability.

HUD staff and technical assistance (TA) providers can offer guidance and support to communities encountering an HIV outbreak among people experiencing homelessness or housing instability. Individuals engaged in outbreak detection and response efforts should contact their local HUD Office of Community Planning and Development (CPD), which can provide information and facilitate connections to local housing and service providers and can coordinate with Office of HIV/AIDS Housing and other HUD staff to provide guidance and technical assistance to assist with outbreak response efforts on the HUD Exchange TA portal. HMIS Privacy and Security Standards: Emergency Data Sharing for Public Health or Disaster Purposes includes information for communities covered under HMIS Privacy and Security Standards of the capabilities and limitations of sharing client information during public health or disaster emergencies.

As people of color are overrepresented in both the HIV epidemic and in the numbers of people experiencing homelessness, HUD recognizes the need for communities to better understand and address these issues. The Racial Equity page on the HUD Exchange website includes resources, data toolkits, and research reports related to identifying disparities and implementing responses to address the overrepresentation of people of color in the homeless system.

Congress appropriated significant additional resources to HUD to help communities respond to COVID-19 and the resulting economic crisis, including funding under the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the American Rescue Plan (ARP) that are being utilized to address homelessness and housing instability. The HOPWA and ESG programs were allocated supplemental grant funds under the CARES Act that communities may use for COVID-19 preparedness and response activities, including rental assistance, homelessness prevention, and supportive services for people with HIV and people experiencing homelessness. ARP funding is being administered through HUD's HOME Investment Partnerships (HOME) program and has the purpose of assisting individuals or households who are homeless or at risk of homelessness and other vulnerable populations by providing housing, rental assistance, supportive services, and non-congregate shelter, to reduce homelessness and increase housing stability.

HRSA

RWHAP funding can be used for a variety of support services, including housing, that help people with HIV stay in HIV care and treatment. RWHAP recipients determine which services to fund depending on community needs and resources. The allowable support services, such as housing, can help bridge gaps that exist in the current services and help limited resources stretch further.

The RWHAP AIDS Education and Training Center (AETC) Program provides training that is critical to capacity development in areas experiencing an HIV outbreak or at risk for an outbreak. Available training includes HIV testing, preexposure prophylaxis (PrEP), HIV treatment, and integrating mental health and substance use treatment into HIV care, as well as other topics that can help address service needs. Communities have been able to successfully expand HIV care and treatment in non-traditional settings that have resulted in integrated models, such as one-stop shops.

In 2017, HRSA and HUD released a joint statement to funded organizations encouraging the sharing of data across systems to better coordinate and integrate medical and housing services for people with HIV. In 2019, the agencies released a toolkit for service providers with best practices for sharing data and improving service coordination.

The Bureau of Primary Health Care's (BPHC) National Health Care for the Homeless Program supports community-based organizations to provide high-quality, accessible health care, including HIV prevention services, to people experiencing homelessness.

CDC

CDC's Division of HIV Prevention provides technical assistance and support for responding to HIV clusters and outbreaks. CDC support can include assistance with epidemiologic analysis and interpretation, connection with peers across the country doing similar work, identification of promising best practices and innovative delivery of prevention activities, and assistance with planning and implementing response activities for specific clusters or outbreaks. Organizations with needs or interests related to HIV outbreak response in their community should contact their state or local health department, who can facilitate collaboration with CDC as needed.

CDC also funds a Capacity Building Assistance (CBA) Provider Network to provide free CBA services to state and local health departments, community-based organizations, and healthcare organizations to support their implementation of high-impact HIV prevention initiatives. Providers can provide support in several areas, including addressing social determinants of health, HIV services for disproportionately impacted populations, such as those experiencing homelessness or unstable housing, and cluster detection and response. More information on each organization funded can be found in the CBA Provider Service Directory. Additionally, online, virtual, and in-person trainings are available, including a training on homelessness for public health providers.

CDC funds state and local health departments to implement evidence-based, high-impact programs to improve access to HIV and other health and social services; this includes a range of activities related to detecting and responding to HIV clusters and outbreaks. CDC also prioritizes hearing from and collaborating with people with HIV through roundtables, town halls, and ongoing community listening sessions focused on issues that intersect with HIV and affect health outcomes, including housing.

Through the Ending the HIV Epidemic in the U.S. Initiative (EHE), CDC funds 32 state and local health departments to implement locally tailored and integrated solutions to meet the unique needs of their communities, including flexibilities to use funds to support housing. CDC also funds over 100 community-based organizations and their clinical partners to deliver comprehensive HIV services to communities disproportionately affected by HIV. In addition, CDC supports the Housing Learning Collaborative, a virtual learning community to build capacity of EHE jurisdictions to develop and implement innovative programs to respond to housing-related needs. CDC published an issue brief on the role of housing in Ending the HIV Epidemic and federal efforts to address housing and HIV more broadly.