Population-Level Health Effects of Involuntary Displacement of People Experiencing Unsheltered Homelessness Who Inject Drugs in US Cities

Abstract

ImportanceAt least 500 000 people in the US experience homelessness nightly. More than 30% of people experiencing homelessness also have a substance use disorder. Involuntary displacement is a common practice in responding to unsheltered people experiencing homelessness. Understanding the health implications of displacement (eg, “sweeps,” “clearings,” “cleanups”) is important, especially as they relate to key substance use disorder outcomes.ObjectiveTo estimate the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in 23 US cities.Design, Setting, and ParticipantsA closed cohort microsimulation model that simulates the natural history of injection drug use and health outcomes among people experiencing homelessness who inject drugs in 23 US cities. The model was populated with city-level data from the Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance system and published data to make representative cohorts of people experiencing homelessness who inject drugs in those cities.Main Outcomes and MeasuresProjected outcomes included overdose mortality, serious injection–related infections and mortality related to serious injection–related infections, hospitalizations, initiations of medications for opioid use disorder, and life-years lived over a 10-year period for 2 scenarios: “no displacement” and “continual involuntary displacement.” The population-attributable fraction of continual displacement to mortality was estimated among this population.ResultsModels estimated between 974 and 2175 additional overdose deaths per 10 000 people experiencing homelessness at 10 years in scenarios in which people experiencing homelessness who inject drugs were continually involuntarily displaced compared with no displacement. Between 611 and 1360 additional people experiencing homelessness who inject drugs per 10 000 people were estimated to be hospitalized with continual involuntary displacement, and there will be an estimated 3140 to 8812 fewer initiations of medications for opioid use disorder per 10 000 people. Continual involuntary displacement may contribute to between 15.6% and 24.4% of additional deaths among unsheltered people experiencing homelessness who inject drugs over a 10-year period.Conclusion and RelevanceInvoluntary displacement of people experiencing homelessness may substantially increase drug-related morbidity and mortality. These findings have implications for the practice of involuntary displacement, as well as policies such as access to housing and supportive services, that could mitigate these harms.

Health, harm reduction, and social service providers’ perspectives on the appropriateness and feasibility of peer distribution of HIV self-test kits among people who use drugs

“…First, we recruited service providers in one specific geographic region and socio-political context. However, regarding the transferability (i.e., transportability) of our findings [ 39 ], it is important to note that San Diego County shares many characteristics with other jurisdictions across the United States that are impacted by drug use-related HIV transmission (e.g., a geographically-dispersed population and limited public transportation infrastructure, a large and growing population of individuals experiencing unsheltered homelessness who are subjected to frequent, health-harming “street sweeps” and displacement [ 72 ], and a rapidly expanding harm reduction service delivery landscape). Second, our relatively brief (~ 45 min) interviews were initially designed to explore service providers’ perspectives on long-acting injectable PrEP delivery to PWUD [ 33 ], and we may have missed opportunities to systematically probe about delivering information and supported referrals to local HIV services (for prevention and treatment), which will be critical to maximizing the individual and public health impacts of this approach.…”

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

“…Many factors contribute to the likelihood of survival after a cancer diagnosis, including biological, environmental, behavioral, health care, economic, political, and social determinants . Lack of housing is a critical factor that interacts across many of these domains with consequences on health outcomes—ranging from poor access to ambulatory care, to bias and stigma, to difficulty navigating complex health care systems due to competing priorities, and to vulnerability to external forces such as law enforcement or shelter requirements . However, this individual-level social determinant of health has been understudied, particularly in cancer, in part because of the lack of systematic documentation of housing status.…”

“…Our evaluation of surgical outcomes is limited to only a subset of procedures performed at the VA. However, the VASQIP tends to report more complex surgeries, especially those that require inpatient admission, so we anticipate that many of the complications in both groups are accounted for in our analysis …”

Involuntary displacement and self-reported health in a cross-sectional survey of people experiencing homelessness in Denver, Colorado, 2018–2019

“…As an illustration, in Denver, Colorado – where 30% of the people experiencing homelessness are unsheltered [ 13 ] – city officials enacted a “camping ban” in 2012, which allows involuntary displacement of people experiencing unsheltered homelessness [ 14 ]. However, scientific literature on the health impacts of involuntary displacement is limited [ 12 , 15 , 16 ].…”

“…The health impacts of involuntary displacement have been largely explored in the context of substance use; in previous studies, people experiencing displacement had lower odds of being in substance use treatment, may be more likely to share injection drug use equipment, and are likely to experience increased morbidity and mortality due to injection drug use [ 15 , 16 ]. However, existing research on involuntary displacement also shows that people who are displaced lose medications and survival necessities (including identification cards and telephones), are disconnected from social support networks, and may be pushed further into covert locations [ 12 , 17 ].…”