Homelessness continues to be a major problem in the United States and among veterans. National estimates of the number of homeless center around 600,000 individuals at any given time in the US. Veterans are more likely to be homeless than non-veterans, with approximately 38-40% of homeless men found to be veterans in previous surveys (Rosencheck, Frisman, & Chung, 1994), yielding an estimated 200,000 homeless veterans. Homeless persons have three times the risk for HIV as the general population, and the CDC recommends annual testing to identify disease early so as to provide cost effective life-saving therapy (Sanders, 2005). Yet many homeless persons do not receive such testing (Douaihy et al., 2005; Desai & Rosenheck, 2004). One possible explanation is that the homeless (and homeless veterans) have difficulty accessing medical care (Cargill & Stone, 2005; Kushel, et al., 2001). VA outreach efforts have been shown to ameliorate this problem (McGuire et al., 2003). Another reason is the cumbersome nature and complexity of current counseling and testing. Because traditional HIV test results are unavailable on the same day, many homeless persons do not return for their results and it is difficult to reach them in follow-up. Studies have demonstrated that rapid testing (RT), which provides results in 20 minutes, increases testing rates among homeless in shelters and elsewhere (Desai & Rosenheck, 2004); however, this approach has not been attempted among homeless veterans.
The specific research aims of this project were to:
-Implement a HIV rapid test pilot project within VISN 22 which will evaluate the rates of testing and receipt of results among homeless veterans staying in designated year-round shelter sites within Los Angeles County;
-Evaluate the effectiveness of successful referral to the VA homeless services programs.
-Evaluate the costs associated with the implementation of this type of outreach HIV screening program for homeless veterans.
Depending on randomization, this study will provide either 1) HIV RT to homeless veterans; 2) referral to long-term homeless services to veterans. Veterans will be recruited from designated shelter sites as part of the Los Angeles Homeless Services Authority (LAHSA) emergency shelter program within Service Planning Area (SPA) 4. SPA 4 encompasses the area immediately surrounding downtown Los Angeles, and is also where the largest congregation of homeless individuals resides within the county. To this end, we have received the support of William Daniels, VISN 22 homelessness network director and Mitchell Netburn, Executive Director of LAHSA. The recruiter will visit one shelter per night, five nights per week, for three months. At each study site, flyers will be handed out to all clients which states that homeless veterans may be eligible for VA-sponsored homeless services, and if they are interested in learning more, to please discuss with the recruiter. A predetermined study randomization scheme will be calculated using a random number generator for those people interested in participating. Patients will be randomized using this method to one of two study conditions. Depending on randomization, this study will provide either 1) HIV RT to homeless veterans; 2) referral to long-term homeless services to veterans. Participants who agree will sign an informed consent describing their random assignment to one of two study conditions:
Model A: Study recruiter will ask patients if they would like an HIV rapid test. If they agree, the recruiter will administer the test as well as risk reduction, pre- and post-test counseling. In addition to the HIV test, participants will be referred to the VA for eligibility screening, and the possibility of extended homeless services.
Model B: Recruiter will refer participant for eligibility screening at either the WLA VA or the downtown Los Angeles VA Outpatient Center (LAOPC). Homeless services include a wide range of clinical preventive services including traditional HIV testing and counseling. Potential participants will be told that they must be deemed eligible at one of these sites before they can be linked to any services.
We will screen 300 homeless veterans for eligibility into the study at year-round homeless shelters within the Los Angeles County Homeless Services Agency (LAHSA) catchment area. Based on estimates gleaned from a previous HIV rapid testing project recently conducted at the WLA VAMC, we estimate that upon completion of eligibility requirements (and continued willingness to participate on the part of the veteran), that our final study total will be 90 eligible and willing homeless veterans. This group of 90 enrolled participants will be randomized into two study groups:
Model A--HIV rapid test + referral (60)
Model B--referral only (30)
Our rationale for a 2-1 bias in our sampling design is that we require large numbers in the RT + referral arm to properly evaluate the efficacy of offering HIV rapid testing to veterans in homeless shelters. Because we hypothesize the success of our referral only arm to be minimal, a large sample size is not required to adequately evaluate this. If they answer in the affirmative that they would be interested in participating, the recruiter will ascertain that they meet the following inclusion criteria: 1) Service in the regular military exclusive of reserve units or the National Guard continuously for at least two years with honorable discharge, 2) aged 18 to 65; 3) fluent English; 4) competent to consent; 5) no HIV test in the past year, and 6) not know themselves to be HIV+. If eligible, the recruiter will ask if they would like to participate in a study which may provide VA healthcare and other social services. The following true/false questions will be asked of all possible participants prior to final consent, to ascertain competency to consent.
1.You may receive an HIV test as part of your agreement to participate in this project.
2.After agreeing to participate in this project, you can withdraw your participation at any time.
3.You have to be able to speak English adequately in order to take part in this research project.
In the event a participant's confirmatory test yields a positive result and is subsequently found to be ineligible for VA services, we have arranged for a referral to the Los Angeles County Office of AIDS Programs and Policy for placement with a local social service agency for further care. All participants, regardless of HIV status, deemed potentially eligible for services with the VA will be referred for eligibility screening at either the West Los Angeles VA or the Greater Los Angeles Outpatient Center (LAOPC).
Recruiters approached 2664 individuals; 136 (5.1%) were eligible. Ninety-seven (71.3% of those eligible) accepted enrollment. Testing rates were 100.0% in RT arm and 3.3% in Referral arm (p<0.0001). Test result receipt rates were 98.5% in RT arm and 0.0% in Referral arm (p<0.0001). There was no increase in visits to VA homeless programs in either arm. HIV prevalence/rate of new incidence was 1.5%. While more than half admitted high-risk behaviors in the past 12 months, 78% reported chances of HIV infection as "none" or "low" rather than "moderate" or "high."
This study has the potential to increase the number of homeless veterans who:
1) receive HIV testing as well as results
2) sign up for homeless services
The findings were also recently used as the foundation of a larger multi-agency collaborative grant between the VA, and the City and County of Los Angeles.
- Knapp H, Anaya HD, Feld JE. Expanding HIV rapid testing via point-of-care paraprofessionals. International Journal of STD & AIDS. 2008 Sep 1; 19(9):629-32.
- Feld JE, Hoang T, Knapp H, Asch S, Anaya H. Implementing an HIV Rapid Testing Intervention for Homeless Veterans in Shelter Settings within Los Angeles County. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Anaya HD, Goetz MB, Asch SM, Karmarkar U. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care within the United States Department of Veterans Affairs. Paper presented at: HIV Diagnosis, Prevention, and Access to Care National Annual Summit; 2008 Nov 20; Washington, DC.