Dear Colleague Letter: HIV Outbreaks Among People Experiencing Homelessness and Housing Instability

From CDC, HUD, and HRSA - Ryan White HIV/AIDS Program Colleagues,

Today, the Health Resources and Services Administration, in collaboration with the Centers for Disease Control and Prevention and the U.S. Department of Housing and Urban Development, released the following [April 12, 2023] Dear Colleague Letter on HIV outbreaks among people experiencing homelessness and housing instability: 

Dear Recipients,

In recent years, numerous HIV outbreaks among people experiencing homelessness and housing instability have been identifiedⁱ. 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 suppressionⁱⁱ 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%) clientsⁱⁱⁱ. 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 HIV^iv.

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 outbreaks^v. 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:  

1. 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.  
2. 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.   
3. 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). 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. 
4. 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.   
5. 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.  
6. 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 stigma^vi. 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) https://www.hudexchange.info/ 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 H. Mermin, MD, MPH
Rear Admiral and Assistant Surgeon General, USPHS
Director
National Center for HIV, Viral Hepatitis, STD, and TB Prevention

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

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