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

摘要

Objectives. We developed and implemented an HIV rapid testing–linkage-to-care initiative between federal and local government. Methods. We used mixed methodology; HIV testing data were collected on-site, and qualitative data were collected via telephone. We used postintervention stakeholder and staff interviews to evaluate barriers and facilitators to this initiative. Results. We tested 817 individuals. We identified and confirmed 7 preliminary HIV positive individuals (0.86% seropositivity), 5 of whom were linked to care. Mean testing cost was $48.95 per client; cost per positive result was $5714. Conclusions. This initiative can be used as a template for other health departments and research teams focusing on homelessness and mitigation of the HIV/AIDS epidemic. Homelessness continues to be a major problem in the United States. National estimates indicate that 610?000 individuals are homeless at any time. 1 Los Angeles County, California, is the nation’s homeless capital, with an estimated 58?000 homeless on any evening. 2 Compared with the general public, homeless individuals have higher rates of early mortality 3 and increased morbidity (e.g., cardiovascular and respiratory diseases, substance abuse). 4 The homeless are in particular need of access to quality health care and effective linkage to care. 4 US veterans are overrepresented among the homeless. Veterans make up only 11% of the US population but constitute 26% of all homeless people. 5 The link between homelessness and HIV is widely established. Homeless individuals have median infection rates at least 3 times higher than the US population (3.4% vs 1%). 6 In a serostudy of 6 US Department of Veterans Affairs (VA) hospitals, average seroprevalence was 3.7%. 7 The Centers for Disease Control and Prevention (CDC) recommends screening all populations with a prevalence greater than 0.1%. 8 Despite this recommendation and high group seroprevalence, many homeless people, including veterans, do not have access to HIV testing. 9 In a recent study, only 22% of high-risk veterans had been tested for HIV. 10 The failure of tested individuals to return for results is a significant contributor to the HIV epidemic. In a recent study, almost one third of individuals testing positive did not return for results. 11 This failure has staggering implications because, as CDC data suggest, those unaware of their HIV positivity are 3.5 times more likely to infect others. 12 This has additional implications for homeless individuals, who are at greater risk for not returning for results. 13 HIV rapid testing (RT) and nurse- or counselor-initiated screening can increase rates of screening and receipt of results. 14 RT is a point-of-care procedure using oral swabs, with results available in 20 minutes. RT obviates having to return for results, and nonphysician screening systematizes testing into primary prevention priorities. RT has been applied in nontraditional settings and is acceptable to patients and providers. 15,16 A collaborative involving the VA, the Los Angeles Homeless Services Authority (LAHSA), the Los Angeles County Office of AIDS Programs and Policy (OAPP), and the City of Los Angeles AIDS Coordinator’s Office was formed to provide RT in homeless shelters and to link individuals with HIV to care. Prior to commencement, there was no HIV shelter testing program in Los Angeles County. The basis of this initiative was a pilot effort by the VA. 17 The study team was composed of VA researchers responsible for the study design and implementation. City and county agencies were responsible for shelter buy - in, and OAPP provided pretrained, certified counselors to administer confidential RT. This type of multiagency effort offers certain advantages. County or city agencies could implement HIV testing initiatives; however, without the VA’s involvement, linking veterans to VA care could be costly, time-consuming, or both. Alternatively, the VA could initiate HIV testing in homeless shelters; the VA is precluded, however, from testing nonveterans. In our opinion, the strengths of this type of collaborative effort outweigh any potential barriers to participation. This effort provided a unique opportunity to design and evaluate best-practices approaches to (1) identify HIV-infected homeless individuals and (2) increase linkage to care for HIV-positive shelter residents.