“Just as HIV before it, the COVID-19 pandemic is shining a spotlight on unequal access to health care and resources like housing that are essential to health and well-being,” Elise D. Riley, Ph.D., M.P.H., of the University of California-San Francisco (UCSF) explained during this month's 23rd International AIDS Conference (AIDS 2020), which was held virtually due to the pandemic.
The importance of housing as a tool for better public health outcomes was documented well before SARS-CoV-2 swept the globe. Riley’s study among women living with HIV who were in care found that every 10 nights during which a participant was unsheltered increased her odds of having detectable levels of HIV.
But there’s no one cause or solution to housing instability. People experience homelessness for a variety of reasons, and a range of programs are needed to serve their needs, Riley noted.
Such programs could include mobile health care systems and enhanced outreach, Asa Clemenzi-Allen, M.D., also with UCSF, suggested. Allen’s own study found similar results to Riley’s along a continuum of housing stability, with various stages between living outdoors and being in one’s own home.
While COVID-19 restrictions are necessary, they are also exacerbating the existing fragmentation of care systems. Patient-centered, wrap-around systems are needed to deliver multiple interventions that serve the varying needs of a heterogenous homeless population, Allen concluded.
One attempt at such integration is moving London’s fast-track HIV program into city hotels where people affected by COVID-19 are temporarily housed, Kat Smithson, M.A., of the National AIDS Trust reported. The program re-links people to HIV care if they are living with HIV, experiencing homelessness, and either have or are at risk for the novel respiratory virus.
Housing instability has been worsened by the city selling off social housing stock and the country’s welfare reform capping public support. As a result, the number of people sleeping rough has increased. “We need to address structural inequalities and the social policies that drive them,” Smithson said.
While homeless shelters are not a long-term solution to these problems, they can provide temporary indoor accommodations. However, COVID-19 has visited there, too. In one San Francisco shelter, two residents testing positive for the virus led to 255 being at risk, 68% of whom ultimately tested positive for SARS-CoV-2, Elizabeth Imbert, M.D., M.P.H., of UCSF reported. Fifty-three percent of those with the virus were asymptomatic.
The study showed that SARS-CoV-2 had been transmitted in common spaces, including through parts of the ventilation system. Imbert concluded that testing only those whose beds are within six feet of infected residents is insufficient. However, contact tracing is difficult among people without a fixed address, leading to potential infections being missed.
The shelter was closed in April. To preserve inpatient hospital capacity and prevent further spread of the virus, San Francisco used empty hotels to house people experiencing homelessness who are affected by COVID-19. Five such “shelter-in-place hotels” include around-the-clock nursing and behavioral health support, explained Jonathan Fuchs, M.D., M.P.H., of the San Francisco Department of Public Health.
“Isolation hotels” are intended for those with COVID-19, and “quarantine hotels” for people who have been exposed to the virus. Fuchs called for studies to understand why a significant portion of people left these accommodations prematurely.
Elsewhere, people in shelters are also dying from the novel respiratory virus. In New York City’s homeless shelters, 54 people died from COVID-19 alone in April 2020, compared to an average monthly shelter death rate of 21 in 2019, the Coalition for the Homeless recently reported.
The city uses empty hotels to isolate or stabilize people experiencing homelessness who are affected by COVID-19, Charles King of Housing Works explained, adding: “While housing is essential, it is not sufficient.” The organization takes a harm reduction approach, providing on-site behavioral health services and even cigarette deliveries for smokers.
“COVID housing is not only a human right, it is a public imperative,” King concluded.