Experiencing homelessness and progression through the HIV cascade of care among people who use drugs

Objective:To investigate the longitudinal association between periods of homelessness and progression through the HIV cascade of care among people who use drugs (PWUD) with universal access to no-cost HIV treatment and care.Design:Prospective cohort study.Methods:Data were analysed from the ACCESS study, including systematic HIV clinical monitoring and a confidential linkage to comprehensive antiretroviral therapy (ART) dispensation records. We used cumulative link mixed-effects models to estimate the longitudinal relationship between periods of homelessness and progression though the HIV cascade of care.Results:Between 2005 and 2019, 947 people living with HIV were enrolled in the ACCESS study and 304 (32.1%) reported being homeless at baseline. Homelessness was negatively associated with overall progression through the HIV cascade of care [adjusted partial proportional odds ratio (APPO) = 0.56, 95% confidence interval (CI): 0.49-0.63]. Homelessness was significantly associated with lower odds of progressing to each subsequent stage of the HIV care cascade, with the exception of initial linkage to care.Conclusions:Homelessness was associated with a 44% decrease in the odds of overall progression through the HIV cascade of care, and a 41-54% decrease in the odds of receiving ART, being adherent to ART and achieving viral load suppression. These findings support calls for the integration of services to address intersecting challenges of HIV, substance use and homelessness among marginalized populations such as PWUD.