HIV in "Hidden" Populations: The Unhoused and Incarcerated

In 2019, the United States government launched a campaign to end the HIV epidemic. The program focuses on proven methods to prevent new cases and provide consistent treatment to those already living with HIV. The goal is to reduce new HIV diagnoses by 90 percent by 2030.¹

Called Ending the HIV Epidemic in the U.S. (EHE), the program works to address barriers to prevention and care that some groups experience. For example, people who are unhoused or incarcerated face unique hurdles when trying to prevent HIV or get consistent treatment.2,3

HIV and unhoused populations

Stable housing is closely linked to better health for all people, including those living with HIV. Unfortunately, homelessness is much more common among those living with HIV than among the general population.⁴

For people with HIV, taking medicines as prescribed is necessary to suppress the virus. But this is hard to do when they are coping with an unstable living situation. A recent study of unhoused people living with HIV/AIDS showed they:⁴

• Were more likely to have poorer health
• Less commonly took their medicines consistently or as prescribed
• Had worse CD4 count and higher viral loads

This same study found that unhoused people living with HIV and AIDS were half as likely to reach viral suppression compared to people with stable housing.⁴

Providing stable housing to improve lives

Many studies show that unstable housing makes it harder to:^2,4

• Eat nutritious meals
• Practice personal hygiene
• Keep doctor's appointments
• Pick up prescriptions

Providing housing and support services to people has been proven to improve their overall health. It also reduces behaviors linked to getting and transmitting HIV. Housing First is a government program aimed at decreasing homelessness among people living with HIV by 50 percent by 2025.²

HIV and incarcerated populations

Like being unhoused, being incarcerated has a big impact on people living with HIV. Those living with HIV are much more likely to be or have been in jail or prison than other groups of people. One in 6 people with HIV spends some time in jail or prison.⁵

Studies show that many people living with HIV keep the virus suppressed during incarceration. However, 3 out of 4 people with HIV do not keep the virus suppressed after their release. This raises their risk of transmitting the virus to others in their community after being incarcerated.⁵

Formerly incarcerated people may face many barriers to taking daily HIV treatment after returning to their community. Barriers may include:^3,5

• Unstable housing, transportation, and nutrition
• Substance abuse disorder
• Serious mental illness
• Social stigma
• Mistrust of the healthcare system
• Lack of connection to support services

PrEP and long-acting ART could help

Doctors have several suggestions for preventing and suppressing HIV during and after incarceration. First, prisons could help reduce HIV transmission by making condoms and pre-exposure prophylaxis (PrEP) pills available. Since some transmission is linked to prison tattoos, access to clean needles could also help lower new infection rates.^3,5

Treatment for opioid use disorder is also important to keep incarcerated and recently released people healthy. Studies show that treating opioid use disorder reduces the risk of overdose after release. It also reduces injection-related behaviors that are linked to HIV transmission.³

During and after jail time, giving people long-acting antiretroviral treatments (ART) rather than daily pills would help bridge gaps in treatment. But long-acting injectables are much more expensive than daily pills, so they are not often used.^3,5

HIV specialists know the tools that help reduce transmission and keep the unhoused and incarcerated healthy. However, more state and federal funding is needed to support HIV prevention strategies that work. These tools will especially help groups who are more affected by HIV and AIDS than other groups.^3,5