Pilot Study Implements HIV Rapid-Testing in Homeless Shelters

BACKGROUND:
Veterans continue to be over-represented among the homeless: Veterans make up only 11% of the U.S. population, but comprise 26% of all homeless. The link between homelessness and HIV is widely established, with homeless individuals having infection rates at least three times higher than the general population. Given their risk, targeting homeless individuals for HIV testing is imperative. Moreover, HIV rapid testing (RT) and nurse/counselor-initiated screening can increase screening and the proportion of patients who receive screening results. Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. Prior to this initiative, there was no HIV shelter testing program in LAC. The pilot study included four elements: 1) pre-implementation planning and launch; 2) quantitative evaluation (e.g., numbers of RTs administered, positive results, and numbers linked to care; 3) qualitative evaluation of the views of key stakeholders (i.e., agency/shelter staff, testing counselors) via survey; and 4) cost analysis.

FINDINGS:

• The HIV rapid-testing/linkage-to-care initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able "to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done," showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing.
• During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were Veterans), identifying seven (0.86%) preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care.
• Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months.

LIMITATIONS:

• This project encountered implementation delays due to local requirements (e.g., safety/anonymity of testing areas, secure parking); thus, an unexpected result was spurring agency evaluations of internal systems and practices.
• Due to IRB concerns, demographic data were not collected, nor could investigators ascertain the proportion of unduplicated tests.

IMPLICATIONS:

• LAC agencies recognized the high risk among the homeless and the need for HIV testing; however, it was not until this effort that they prioritized HIV testing in homeless shelters. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a "plug and play" intervention, for the most part.

Anaya HD, Butler J, Knapp H, et al. Implementing an HIV Rapid-Testing/Linkage to Care Project among Homeless Individuals in Los Angeles County: A Collaborative Effort between Federal, County, and City Government. American Journal of Public Health. January 2015;105(1):85-90.