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. Author manuscript; available in PMC: 2021 Nov 5.
Published in final edited form as: J Soc Distress Homeless. 2020 Mar 6;1(9):10.1080/10530789.2021.1892931. doi: 10.1080/10530789.2021.1892931

HIV Injection Risk Behaviors among HIV-Negative People Who Inject Drugs Experiencing Homelessness, 23 U.S. Cities

Ruthanne Marcus 1, Susan Cha 1, Catlainn Sionean 1, Dafna Kanny 1; National HIV Behavioral Surveillance Study Group1
PMCID: PMC8570172  NIHMSID: NIHMS1751911  PMID: 34744406

Abstract

Despite recent declines in numbers of people who inject drugs (PWID) diagnosed with HIV, clusters of HIV among PWID are ongoing, especially among PWID experiencing homelessness. Using data from the National HIV Behavioral Surveillance in 2018, we evaluated the association between homelessness and injection risk and prevention behaviors among HIV-negative PWID who were recruited by respondent-driven sampling in 23 U.S. cities. Interviewers assessed sociodemographic characteristics, history of overdose, and behavioral risk and prevention factors for HIV. Adjusted prevalence ratios (aPR) and 95% CI were obtained using Poisson regression models. Of 10,614 HIV-negative PWID participants, 7275 (68.5%) reported experiencing homelessness. Homeless PWID were more likely than those who were not to be younger age, white, unemployed, without health insurance, in poverty, experiencing psychological distress, and incarcerated in the past 12 months. PWID experiencing homelessness were significantly more likely to report injection risk behaviors [share syringes/equipment (aPR = 1.26; 95% CI = 1.20–1.33), non-fatal opioid overdose (aPR = 1.64; 95% CI = 1.49–1.79)] and prevention behaviors [testing for HIV in past 12 months (aPR = 1.18; 95% CI = 1.12–1.24) and using syringe services programs (aPR = 1.09; 95% CI = 1.03–1.16)] than PWID not experiencing homelessness. Homelessness among PWID is associated with injection risk behaviors and non-fatal overdose.

Keywords: People who inject drugs, respondent-driven sampling, homelessness, HIV, HIV prevention, syringe services programs

Introduction

Despite the recent decline in annual diagnoses of HIV attributed to injection drug use (Centers for Disease Control and Prevention, 2019; Wejnert et al., 2016), clusters of HIV among people who inject drugs (PWID) are occurring in the U.S. due to increased opioid use and injection equipment sharing (Broz et al., 2018; Cranston et al., 2019; Peters et al., 2016). Among the most concerning issues is the risk of infection among PWID who are experiencing homelessness (Cranston et al., 2019; Golden et al., 2019). National estimates of the number of people in the U.S. experiencing homelessness showed an 8.7% increase from 2018 to 2019; driven by the number of unsheltered people who are homeless (U.S. Department of Housing and Urban Development Office of Community Planning and Development, 2020). Housing instability is associated with increased HIV morbidity and mortality, and poor health outcomes (Aidala et al., 2016; Bowen & Mitchell, 2016; Milloy et al., 2012). Moreover, there is a bidirectional relationship between homelessness and substance use disorders with disputable evidence regarding causation (Linton et al., 2013). People experiencing homelessness who inject drugs may be at greater risk for HIV than people who inject drugs who are stably housed due to higher rates of syringe and injection equipment sharing (Adams et al., 2019; Des Jarlais et al., 2007; Linton et al., 2013).

In 2015, HIV prevalence was 7% and homelessness in the past 12 months was 64% among PWID (Centers for Disease Control and Prevention, 2018). Moreover, 34% of PWID reporting receptive syringe sharing (i.e. injecting with a syringe or needle that had already been used by someone else) and 42% of PWID reporting distributive syringe sharing (i.e. passing a used syringe to another person) (Adams et al., 2019; Centers for Disease Control and Prevention, 2018). People who are unstably housed are twice as likely to report sharing injection equipment (Des Jarlais et al., 2007). Likewise, this can be seen in National HIV Behavorial Surveillance (NHBS) data in 2015 that showed distributive sharing was more frequent among people reporting homelessness in the past 12 months than among those who were not homeless (Adams et al., 2019). However, data are lacking on the association between homelessness and receptive syringe sharing among PWID at risk for HIV. These behavioral risks are also associated with non-fatal overdose, a growing concern among people with substance use disorders, particularly opioid use (Jenkins et al., 2011), yet the association between homelessness, injecting drug use, and non-fatal overdose among a large sample of HIV-negative PWID has not been explored.

Furthermore, people experiencing homelessness may lack access to essential medical care, mental health services (Kertesz et al., 2014), and substance use treatment (Palepu et al., 2013) but less is known about factors associated with homelessness among HIV-negative PWID who are at risk for HIV and who may lack access to services for HIV prevention. We used 2018 NHBS data to evaluate HIV injection risk and prevention behaviors among HIV-negative PWID participants who reported experiencing homelessness compared to those who did not. Findings may be used to identify factors that could improve recommendations for HIV prevention.

Methods

We used data from NHBS, which conducts standardized interviews and optional HIV testing to monitor prevalence of HIV infection, risk and prevention behaviors, and use of prevention services among populations at increased risk for HIV infection. In 2018, NHBS used respondent-driven sampling (RDS) (Heckathorn, 1997) to recruit a sample of PWID in 23 metropolitan statistical areas (MSAs) with high HIV prevalence (Centers for Disease Control and Prevention, 2020). Participants were eligible to participate if they reported injection drug use in the past 12 months, demonstrated physical evidence (e.g. track marks) or knowledge of injection, resided in the MSA, were aged ≥18, could provide informed consent, and could complete the interview in English or Spanish.

Trained interviewers at each site conducted standardized interviews on sexual and injection risk and prevention behaviors for HIV infection, sociodemographic characteristics, and access to care using computer-assisted personal interviews (CAPI). Interviews were conducted one-on-one in-person. Participants who consented were offered rapid HIV testing at the field site. Participants whose tests were reactive had either a second rapid test performed or an additional blood sample collected for supplemental laboratory-based testing to confirm the first rapid test result. Incentives in the form of cash or gift cards were given to participants (Centers for Disease Control and Prevention, 2020). Eligible PWID were offered up to five coupons to recruit PWID in their social network. All procedures, including HIV tests, were anonymous. Project activities were approved by the Centers for Disease Control and Prevention and by applicable institutional review boards in participating MSAs. Detailed methods are described elsewhere (Centers for Disease Control and Prevention, 2020).

Definitions/Measures

Homelessness, the exposure of interest, was measured in response to the question: “in the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, in a Single Room Occupancy hotel (SRO) or in a car.” Demographic characteristics included: gender (male, female, and transgender), age group (18–29, 30–39, 40–49, and ≥50), race/ethnicity (Black, Hispanic/Latino, White, and Other), education (<high school, high school diploma/GED, and >high school), employment status (unemployed, employed full or part-time, and not in labor force/other), disability status (no disability and has a disability), and health insurance (no insurance, private plan, public plan, public and private plans, and other health insurance). Social factors assessed included: marital status (married/living together, single [i.e. separated/divorced/widowed], and never married), poverty status (household income at or below the federal poverty level, above the federal poverty level) according to the U.S. Department of Health and Human Services guidelines in 2018 (U.S. Department of Health and Human Services, 2018), and incarceration history (never incarcerated, incarcerated but not in the past 12 months, incarcerated in the past 12 months). Psychological distress was measured by the Kessler-6 screening scale (range 0–24) categorized as having psychological distress (score of 13–24) or no psychological distress (score of 0–12)(Kessler et al., 2003). The Kessler-6 is a screening measure used in epidemiological studies to assess the prevalence of “serious mental illness,” defined as at least one disorder meeting criteria for the Diagnostic and Statistical Manual (DSM) (Kessler et al., 2003). The Kessler-6 has been shown to identify persons likely to have a psychiatric disorder with accuracy and reliability comparable to other psychological screening instruments (Choi et al., 2015; Kessler et al., 2003; Swartz & Lurigio, 2006). Age at first injection was dichotomized as less than 30 years of age versus 30 years and older with calculations for median and interquartile ranges (IQR).

If any drug other than prescribed drugs was injected in the past 12 months, the participant was asked about the drug injected most frequently (heroin by itself, speedball [heroin and cocaine together], powder or crack cocaine, methamphetamine [includes meth, crystal meth, speed, or crank], or prescription opioids [painkillers such as Oxycontin, Dilaudid, morphine, Percocet, or Demerol]). We also ascertained non-injection use of any of the following drugs during the 12 months before interview: marijuana, powder or crack cocaine, benzodiazepines, ecstasy, heroin, methamphetamine, or prescription opioids. Binge drinking in the past 30 days was defined as drinking in about two hours four or more alcoholic drinks for females, and five or more alcoholic drinks for males. Receptive syringe sharing (defined as using a needle or syringe that had been previously used by someone else in the past 12 months), shared injection equipment (including cookers, cotton, or water), and shared syringes to divide drugs, were combined to create an overall shared syringes or other equipment variable. Non-fatal opioid overdose in the past 12 months was assessed among participants who reported using opioids during that time frame. Prevention behaviors in the past 12 months included being tested for HIV, obtaining sterile syringes from a syringe services program (SSP), safe syringe disposal (only disposal methods were “put it in a medical sharps container” or “took it to a needle or syringe exchange program”), and, among PWID who used opioids in the past 12 months, use of medication-assisted treatment (MAT).

Data analysis

Analyses were limited to participants who were eligible for and completed the interview, had a negative NHBS HIV test result, self-reported as HIV-negative, and had non-missing response to the key exposure variable, homelessness in the past 12 months. We assessed correlates of homelessness in the past 12 months, and the association between homelessness and key outcomes of interest (i.e. injection risk and prevention behavior). Prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated from log-linked Poisson regression models with generalized estimation equations clustered on RDS recruitment chains and adjusted for participants’ personal network size and city. To account for confounding, models calculating adjusted prevalence ratios (aPR) additionally controlled for gender, race/ethnicity, poverty, disability status, and employment status based on the literature (Adams et al., 2019).

Results

Of the 11,437 eligible PWID who completed the interview, 10,615 agreed to an HIV test and self-reported HIV-negative status; homelessness was missing for one additional participant, resulting in an analysis sample of 10,614. Of 10,614 HIV-negative PWID who met the inclusion criteria in the 2018 NHBS, 7275 (68.5%) reported experiencing homelessness. A higher percentage of homeless PWID compared with PWID who were not homeless were 18–39 years old [18–29 years old (17.3% vs. 8.9%) and 30–39 years old (30.7% vs. 18.9%)], white (44.3% vs. 31.9%), unemployed (56.8% vs. 34.3%), without health insurance (28.9% vs. 21.0%), living in poverty (77.2% vs. 70.2%), experiencing psychological distress (44.8% vs. 26.7%), and incarcerated in the past 12 months (43.3% vs. 21.0%) (Table 1). PWID experiencing homelessness were also more likely to inject speedballs (56.3% vs. 45.6%), powder or crack cocaine (47.7% vs. 36.7%), prescription opioids (23.3% vs. 14.9%), binge drink (28.9% vs. 24.0%), and use non-injection drugs (81.8% vs. 72.4%) than PWID not reporting homelessness.

Table 1.

Characteristics of HIV-Negative persons who inject drugs by housing status, National HIV Behavioral Surveillance, 23 U.S. cities, 2018.

Housing status P valuec
Homelessa (n = 7275) Not Homeless (n = 3339) Total (n = 10,614)
No. Col. % No. Col. % No.b Col. %
Gender 0.0349
 Male 5078 69.8 2247 67.3 7325 69.0
 Female 2143 29.5 1076 32.2 3219 30.3
 Transgender 54 0.7 16 0.5 70 0.7
Age (years) <.0001
 18–29 1256 17.3 298 8.9 1554 14.6
 30–39 2231 30.7 630 18.9 2861 27.0
 40–49 1754 24.1 676 20.3 2430 22.9
 ≥50 2034 28.0 1735 52.0 3769 35.5
Race/ethnicity <.0001
 Black 1883 25.9 1527 45.8 3410 32.2
 Hispanic/Latinod 1571 21.6 599 17.9 2170 20.5
 White 3220 44.3 1065 31.9 4285 40.4
 Othere 595 8.2 147 4.4 742 7.0
Education 0.0077
 <High school 2075 28.5 923 27.6 2998 28.3
 High school diploma/GED 2980 41.0 1399 41.9 4379 41.3
 >High school 2217 30.5 1017 30.5 3234 30.5
Employment status <.0001
 Unemployed 4133 56.8 1145 34.3 5278 49.7
 Employed (full or part time) 953 13.1 677 20.3 1630 15.4
 Not in labor force/otherf 2189 30.1 1517 45.4 3706 34.9
Disability status 0.0023
 No disability 2286 31.5 1158 34.7 3444 32.5
 Has a disability 4979 68.5 2179 65.3 7158 67.5
Psychological distress <.0001
 No (0–12) 4008 55.2 2436 73.3 6444 60.9
 Yes (13–24) 3252 44.8 889 26.7 4141 39.1
Health insurance <.0001
 No insurance 2090 28.9 699 21.0 2789 26.4
 Private plan 131 1.8 156 4.7 287 2.7
 Public plan 4904 67.8 2398 72.2 7302 69.2
 Public and private plans 38 0.5 26 0.8 64 0.6
 Other health insurance 68 0.9 44 1.3 112 1.1
Marital status <.0001
 Married/living together 788 10.8 607 18.2 1395 13.1
 Single (separated, divorced, widowed) 2171 29.8 1092 32.7 3263 30.7
 Never married 4316 59.3 1640 49.1 5956 56.1
Poverty status <.0001
 At or below federal poverty level 5586 77.2 2321 70.2 7907 75.0
 Above federal poverty level 1653 22.8 984 29.8 2637 25.0
Incarceration <.0001
 Never incarcerated 786 10.8 530 15.9 1316 12.4
 Incarcerated, not in past 12 months 3339 45.9 2105 63.1 5444 51.3
 Incarcerated in past 12 months 3147 43.3 701 21.0 3848 36.3
Injection substance use past 12 months
 Heroin 6510 89.5 3061 91.7 9571 90.2 0.4261
 Speedballg 4097 56.3 1523 45.6 5620 53.0 <.0001
 Powder or Crack Cocaine 3468 47.7 1226 36.7 4694 44.2 <.0001
 Methamphetamine 3118 42.9 589 17.6 3707 34.9 <.0001
 Prescription opioidsh 1693 23.3 499 14.9 2192 20.7 <.0001
 Binge drinking (past 30 days) 2082 28.9 793 24.0 2875 27.4 <.0001
Non-injection drugi use past 12 months <.0001
 No 1323 18.2 923 27.7 2246 21.2
 Yes 5952 81.8 2415 72.4 8367 78.8
Age at first injection (years) – Median (IQR) 22 (18–28) 22 (18–30) 22 (18–29)
 11–29 years 5586 77.3 2470 74.2 8056 76.3 0.0268
 ≥30 years 1637 22.7 860 25.8 2497 23.7
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Abbreviations: GED: general educational development; IQR: interquartile range.

a

At any time during the past 12 months, lived on the street, in a shelter, a single room occupancy hotel, or in a car.

b

Variable categories may not sum to total due to missing responses.

c

P value from Wald chi-square test.

d

Hispanics/Latinos may be of any race.

e

“Other” includes American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, and multiple races.

f

Includes homemaker, full time student, retired, and other.

g

Heroin and cocaine injected together.

h

Painkillers such as Oxycontin, Dilaudid, morphine, Percocet, or Demerol.

i

Non-injection drugs include: marijuana, powder or crack cocaine, benzodiazepines, ecstasy, heroin, methamphetamine, or prescription opioids.

PWID experiencing homelessness were significantly more likely to report injection risk behaviors, including syringe and equipment sharing (aPR=1.26; 95% CI=1.20–1.33) and non-fatal overdose (aPR=1.64; 95% CI=1.49–1.79) than PWID who did not experience homelessness (Table 2). Homeless PWID were more likely to engage in HIV prevention behaviors, including testing for HIV in the past 12 months (aPR=1.18; 95% CI=1.12–1.24) and obtaining sterile syringes from an SSP (aPR=1.09; 95% CI=1.03–1.16) compared to PWID who did not experience homelessness. There was no notable difference in the proportion who reported safe syringe disposal or MAT use among opioid users experiencing homelessness compared to those who were not homeless.

Table 2.

Injection risk and prevention behaviors among HIV-Negative persons who inject drugs by housing status, National HIV Behavioral Surveillance, 23 U.S. cities, 2018.

Housing status
Homelessa Not homeless Prevalence ratios PR (95% CI)b Adjusted prevalence ratios aPR (95% CI)c
Total n % Total n %
Injection risk behaviors
Shared syringes or other equipmentd 7272 4772 65.6 3336 1576 47.2 1.35 (1.28–1.42) 1.26 (1.20–1.33)
Non-fatal opioid overdose 6962 2305 33.1 3235 573 17.7 1.77 (1.63–1.94) 1.64 (1.49–1.79)
Prevention behaviors
Tested for HIV in past 12 months 7206 4245 58.9 3301 1590 48.2 1.18 (1.12–1.24) 1.18 (1.12–1.24)
Obtained sterile syringes from an SSP 7268 4198 57.8 3337 1406 42.1 1.12 (1.06–1.19) 1.09 (1.03–1.16)
Safe syringe disposal only 7273 1537 21.1 3337 617 18.5 0.89 (0.80–1.00) 0.91 (0.80–1.01)
Medication-assisted treatmente 6965 3743 53.7 3237 1735 53.6 0.96 (0.92–1.00) 0.96 (0.92–1.00)
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Abbreviations: PR: prevalence ratios; aPR: adjusted prevalence ratios; CI: confidence intervals; SSP: syringe services program.

a

At any time during the past 12 months, lived on the street, in a shelter, a single room occupancy hotel, or in a car.

b

All models were clustered on recruitment chain and adjusted for the participant’s personal network size and city.

c

Adjusted for network size, city, gender, age, race/ethnicity, poverty, disability status, and employment status.

d

A combined variable including syringe sharing (defined as using a needle or syringe that had been previously used by someone else in the past 12 months), shared injection equipment (including cookers, cotton, or water), and shared syringes to divide drugs.

e

Only includes people who reported using opioids in the past 12 months.

Discussion

In this multi-site, cross-sectional study, we found that among HIV-negative PWID, homelessness is associated with injection risk behaviors which can increase the risk of HIV acquisition, including sharing injection equipment and non-fatal opioid overdose. These findings support previous studies (Corneil et al., 2006; Jenkins et al., 2011; Linton et al., 2013) that demonstrated an association between homelessness and injection risk behaviors. However, our sample provides more recent data from a large, geographically diverse population of PWID from the community who were actively injecting drugs, and the analysis explored receptive injection equipment sharing and the multifactorial relationship between homelessness, PWID, and non-fatal overdose. Additionally, previous studies have focused on injection risk behaviors among people with diagnosed HIV (Kidder et al., 2008) and not those at risk for infection. Overall, in 2018, almost 7 in 10 HIV-negative PWID from 23 geographically diverse U.S. cities experienced homelessness in the previous 12 months. Injection equipment sharing and non-fatal overdose were more common among homeless PWID possibly due to factors such as public injection (Hunter et al., 2018; Sutter et al., 2019; Trayner et al., 2020), which can increase risky injection practices, and fear of confiscation of injecting equipment by law enforcement or police harassment (Werb et al., 2008). Among PWID, 45% experience non-fatal overdose in their lifetime (Martins et al., 2015). The association between homelessness and non-fatal overdose was reported in previous studies (Jenkins et al., 2011a; Lyons et al., 2019), in which the relationship was compounded by a history of incarceration and sharing of injection equipment. Furthermore, the introduction of fentanyl and fentanyl analogs into the drug supply has increased the number of reported overdoses (Hedegaard et al., 2018; O’Donnell et al., 2018; Park et al., 2018). We also found a higher percentage of PWID experiencing homelessness compared with PWID who were not homeless were injecting multiple types of substances and using non-injecting drugs. Polysubstance use has previously been identified among people experiencing homelessness (Bhalla et al., 2017) and is associated with overdose (Barocas et al., 2019; Schneider et al., 2019).

Our study also found an association between homelessness and certain sociodemographic factors and social determinants of health. These findings support earlier studies that show housing instability provides an increased risk environment for PWID (Padgett et al., 2015; Rhodes et al., 2005). We found demographic factors, such as younger age, were associated with PWID experiencing homelessness with almost half of homeless PWID in our analysis being aged 18–39 years compared with nearly 28% of those not experiencing homelessness. Furthermore, we identified psychosocial and structural factors associated with homelessness among PWID including psychological distress, poverty, lack of health insurance, and incarceration. These social factors have frequently been shown to influence housing stability among PWID (Degenhardt et al., 2017; Fryling et al., 2015; Padgett et al., 2011; Thompson et al., 2013).

Homelessness was associated with HIV prevention behaviors among HIV-negative PWID. Early diagnosis and prevention of HIV acquisition are two of four primary goals of the federal campaign designed to End the HIV Epidemic (Fauci et al., 2019) in the United States. Testing all vulnerable populations including PWID, is an essential component of this initiative. We found encouraging evidence that HIV-negative PWID experiencing homelessness are engaging in preventive behaviors against HIV acquisition, specifically, testing for HIV in the past 12 months and obtaining sterile syringes from an SSP. Reasons for higher rates of HIV testing among PWID experiencing homelessness may be due to the high rates of incarceration (Courtenay-Quirk et al., 2008) and use of emergency departments for medical care (Fazel et al., 2014), which can be venues for routine HIV testing. Routine HIV testing is also often available through harm reduction programs such as comprehensive SSPs that integrate syringe services and primary medical care (Rich et al., 2018), and SSPs can serve as a gateway into integrated medical care for HIV for people who test positive, and HCV testing, abscess and wound care, evaluation for endocarditis, and importantly, integration with behavioral health addressing co-occurring mental health needs and substance use referral and treatment (Rich et al., 2018). Unfortunately, SSPs are not available in all jurisdictions (Centers for Disease Control and Prevention, 2020; Des Jarlais et al., 2015) despite their proven benefits in: reducing risky injection behaviors (injection drug use, injection equipment sharing, and non-fatal overdose) (Dasgupta et al., 2019; Des Jarlais et al., 2015; Huo & Ouellet, 2007), improving access to drug treatment programs, including medication-assisted treatment (Kidorf et al., 2009), and safe syringe disposal (Dasgupta et al., 2019; Tookes et al., 2012), and providing naloxone for overdose prevention (Clark et al., 2014). Introduction of SSPs after the HIV outbreak in Scott County, Indiana (Peters et al., 2016) resulted in a reduction in syringe sharing from 75% before the outbreak to 21% (Dasgupta et al., 2019). Prevention behaviors that reduce HIV risk, such as proper disposal of used syringes increased after the introduction of the SSP from 17% to 82% (Dasgupta et al., 2019), although safe syringe disposal did not differ by homeless status in our analysis.

Increasing availability of SSPs is one prevention intervention for reducing HIV transmission, however, the high prevalence of homelessness among HIV-negative PWID underscores the urgency of addressing housing issues to alleviate multimorbidity and poor health outcomes, including substance use and HIV. People who are stably housed decrease their drug use (Des Jarlais et al., 2007), seek treatment for substance use (Padgett et al., 2011), and reduce HIV risks (Aidala et al., 2016) more often than people experiencing homelessness. Intervention models, such as “Housing First,” provide a comprehensive system of services that encourage permanent supportive housing with wrap-around services (Padgett et al., 2015). This successful model addresses the syndemic of HIV, substance use and homelessness, and is far less penalizing than the traditional “treatment first” models that emphasize housing in temporary shelters where residents are first required to maintain sobriety (Padgett et al., 2015). Those limited models do not address multimorbidity and are not sustainable for people with opioid use disorders who require long-term and comprehensive solutions.

Conducting analysis of data from a national surveillance system is not without limitations. NHBS is a geographically diverse sample, however, it may not be representative of all PWID and the findings may not be generalizable to other geographic locations. Due to the cross-sectional nature of the survey, we could not capture the dynamic changes in homelessness status in which people may be homeless at one point in their lives and stably housed at another point. Furthermore, the definition of homelessness used in this survey does not differentiate between people experiencing current or chronic homelessness and those who are temporarily or unstably housed. However, we asked about housing in the past 12 months, which may over- or under-estimate experiences associated with homelessness. Except for the Kessler-6 scale, our data do not comprehensively capture psychiatric diagnoses or mental health symptoms that may be prevalent among PWID and people experiencing homelessness. Further characterization of these comorbidities may be useful for understanding injection risk behaviors. Finally, these data are self-reported and are, therefore, subject to recall error and social desirability bias.

Conclusions

Homelessness is highly prevalent among HIV-negative PWID and is associated with injection risk behaviors and non-fatal overdose. Evidence-based interventions and linkage efforts to support access to HIV and substance use disorder services and treatment among PWID is essential. Access to prevention services such as SSPs that provide overdose prevention (e.g. naloxone), integrated with comprehensive medical and behavioral health care, including medical care, HIV and HCV testing, and housing services, can reduce HIV transmission risk.

Acknowledgements

The authors thank National HIV Behavioral Surveillance (NHBS) staff and participants. We also acknowledge the contributions of the Behavioral Surveillance Team and the Behavioral and Clinical Surveillance Branch at CDC and the NHBS Study Group Members. NHBS Study Group Members include: Atlanta, GA: Pascale Wortley, Jeff Todd, David Melton; Baltimore, MD: Colin Flynn, Danielle German; Boston, MA: Monina Klevens, Rose Doherty, Conall O’Cleirigh; Chicago, IL: Antonio D. Jimenez, Thomas Clyde; Dallas, TX: Jonathon Poe, Margaret Vaaler, Jie Deng; Denver, CO: Alia Al-Tayyib, Daniel Shodell; Detroit, MI: Emily Higgins, Vivian Griffin, Corrine Sanger; Houston, TX: Salma Khuwaja, Zaida Lopez, Paige Padgett; Los Angeles, CA: Ekow Kwa Sey, Yingbo Ma, Hugo Santacruz; Memphis, TN: Meredith Brantley, Christopher Mathews, Jack Marr; Miami, FL: Emma Spencer, Willie Nixon, David Forrest; Nassau-Suffolk, NY: Bridget Anderson, Ashley Tate, Meaghan Abrego; New Orleans, LA: William T. Robinson, Narquis Barak, Jeremy M. Beckford; New York City, NY: Sarah Braunstein, Alexis Rivera, Sidney Carrillo Newark, NJ: Abdel R. Ibrahim, Afework Wogayehu, Luis Moraga; Philadelphia, PA: Kathleen A. Brady, Jennifer Shinefeld, Chrysanthus Nnumolu,; Portland, OR: Timothy W. Menza, E. Roberto Orellana, Amisha Bhattari; San Diego, CA: Anna Flynn, Onika Chambers, Marisa Ramos; San Francisco, CA: Willi McFarland, Jessica Lin, Desmond Miller; San Juan, PR: Sandra Miranda De León, Yadira Rolón-Colón, María Pabón Martínez; Seattle, WA: Tom Jaenicke, Sara Glick; Virginia Beach, VA: Jennifer Kienzle, Brandie Smith, Toyah Reid; Washington, DC: Jenevieve Opoku, Irene Kuo; CDC: Monica Adams, Christine Agnew Brune, Amy Baugher, Dita Broz, Janet Burnett, Susan Cha, Johanna Chapin-Bardales, Paul Denning, Dafna Kanny, Teresa Finlayson, Senad Handanagic, Terence Hickey, Kathryn Lee, Rashunda Lewis, Elana Morris, Evelyn Olansky, Taylor Robbins, Catlainn Sionean, Amanda Smith, Anna Teplinskaya, Lindsay Trujillo, Cyprian Wejnert, Ari Whiteman, Mingjing Xia.

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Publisher's Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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