What are homeless persons’ HIV prevention needs?
who are the homeless?
Homelessness is a growing problem in the US.1 It is estimated that on any given day there are more than 800,000 homeless individuals in the US, while over the course of a year there are 2.3 to 3.5 million individuals who experience a period of homelessness.2 In the 2004 Mayors’ report on homelessness 70% of cities surveyed registered an increase in the number of requests for emergency shelter during the preceding year.3
The US homeless population is typically divided into three major groups: single adults, members of homeless families and youth. It is estimated that single adults make up 54% of the population, families 40% and unaccompanied youth 5%.3
do homeless populations have a high prevalence of HIV infection?
People who are homeless have poorer health and higher mortality than the general population.4 The prevalence of HIV/AIDS varies widely among homeless subgroups, but generally exceeds that of the non-homeless population. The elevated prevalence of infection combined with limited access to treatment and poor living conditions have contributed to HIV/AIDS becoming a leading cause of death in this population.5
A study in San Francisco, CA, reported an overall HIV prevalence of 10.5% for currently homeless and marginally housed adults, which is five times higher than that of the general San Francisco population. The same study reported an HIV prevalence of 30% among homeless men who have sex with men (MSM) and 8% among homeless injection drug users (IDUs).6
The association between homelessness and HIV appears to be a two-way street. HIV+ persons are at greater risk of homelessness due to discrimination and the high costs of housing and medical care. At the same time, homeless people have an elevated risk of contracting HIV.
what puts a homeless person at risk?
Homeless persons are in transient living situations, typically in impoverished communities with high HIV prevalence. Thus, risky behaviors they may engage in are more likely to result in infection.
Homeless persons are also more likely to evidence drug, alcohol, and mental disorders than the general population. By one estimate in 2000, 88% of homeless single men and 69% of homeless single women had one of these three disorders.7 Overall, almost one-fourth of the single adult homeless population suffers from severe and persistent mental illness.2 The impulsivity and impaired judgment often associated with severe mental illness or substance abuse contribute to risky behaviors such as unprotected sex, multiple partners, sharing needles or exchanging sex for drugs.
The conditions of homelessness and extreme poverty also contribute to risky behaviors. For example, most homeless shelters provide communal sleeping and bathing, are single sex, and offer limited privacy. Under these restrictions, it is more difficult to have stable sexual relationships.
Other characteristics that are common among homeless persons and associated with HIV risk behaviors include: adverse childhood experiences such as physical and sexual abuse,2,8 sexual assault, partner violence and other traumatic histories and poor social support.9
what are barriers to prevention?
A common misconception is that the greatest barrier to delivering prevention services to homeless persons is finding them. The reality, however, is that homeless people are often visible by living or working in the streets or readily accessible in shelters. Forming trusting relationships, making consistent contact over time, and working through already existing social networks can help find and retain homeless persons for follow-up and services. In one HIV testing program for homeless persons with severe mental illness, 90% of those tested returned to receive their results.10
Institutional barriers and settings can restrict HIV prevention activities. Staffing at shelters is often only adequate to provide basic needs, and shelters may be reluctant to allow outside HIV prevention programs to talk explicitly about sex and drugs or to distribute condoms because those activities are forbidden in most shelters. A lack of private space for counseling and education around sensitive topics can also be a barrier.
what’s being done?
The quantity and quality of services available to homeless individuals varies greatly across the nation. Historically, services have concentrated on serving single male clients and few have formed coordinated networks of care to facilitate comprehensive on-going services.2 Here we provide just a few examples of effective interventions designed specifically to serve homeless individuals at risk for or living with HIV.
Sex, Games and Videotapes is a program for homeless mentally ill men in a New York City, NY shelter that is built around activities central to shelter life: competitive games, storytelling and watching videos. For many men sex is conducted in public spaces, revolves around drug use, and must be done quickly. The program allows for sex issues to be brought up in a nonjudgmental way. One component is a competition to see who can put a condom (without tearing it) on a banana fastest–this teaches important skills for using a condom quickly. The program reduced sexual risk behavior threefold.11
Boston HAPPENS provides health education, case management, basic medical care, HIV testing, counseling and mental health care for HIV+, at-risk youth, many of whom are homeless. Boston HAPPENS’ collaborators run drop-in services and storefront clinics in places where young people hang out. Through persistent outreach and individualized case management, HAPPENS retains homeless at-risk youth in care.12
Providing homeless individuals with housing and cash benefits has been shown to reduce risk taking behaviors such as unprotected sex, drug use and needle sharing.13,14
Housing Works is an AIDS service organization that specializes in providing comprehensive care to HIV+ homeless persons in New York City. Their services include housing, healthcare, job training and placement, as well as a variety of other advocacy services for homeless HIV+ persons.15
what needs to be done?
There is an ongoing need to deliver effective prevention activities in culturally appropriate service settings that homeless persons use, such as soup kitchens, shelters, residential hotels and clinics. Staff of these organizations should be trained in HIV prevention education methods that recognize specific risk factors related to homelessness, employ realistic expectations for change and give homeless people concrete goals that they can accomplish.
Coordinated care networks need to be developed so that staff can link individuals quickly and easily to the services they need.16 Group interventions that have worked in certain settings need to be broadly disseminated and adapted for use in other locations.
Efforts to prevent HIV transmission among homeless persons will flounder without a concerted effort to better address their survival needs including long term housing, jobs, income, adequate nutrition, substance abuse treatment, and regular medical and mental health services. Unfortunately, despite the announcement of new initiatives to help the homeless,1 recent trends in government support in these areas are discouraging and the growing federal budget deficit does not bode well for increases in the near future. As one of the most vulnerable populations in our society, homeless persons need support, respect, protection and continued prevention efforts.
Prepared by Naomi Adler BA*, Dan Herman Phd**, Ezra Susser MD DrPh***
*CAPS, **NY State Psychiatric Inst., *** Columbia U Mailman School of Public Health
1. Burt M, Laudan Y, Lee E, et al. Helping America’s homeless: emergency shelter or affordable housing? Washington, D.C.: Urban Institute Press. 2001.
2. U.S. Conference of Mayors. A status report on hunger and homelessness inAmerica’s cities: 2004.www.usmayors.org/uscm/hungersurvey/2004/onlinereport/HungerAndHomelessnessReport2004.pdf(Accessed 4/20/06)
3. Burt, MR, Laudan, AY, Douglas T, et. al. 1999 Homelessness: Programs and the People They Serve – Summary Report. Washington, DC: DHUD/DHHS.http://www.huduser.org/publications/homeless/homelessness/contents.php(Accessed 4/20/06)
4. Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. Canadian Medical Association Journal. 2004;170:1243.
5. Robertson MJ, Clark RA, Charlebois ED, et al. HIV seroprevalence among homeless and marginally housed adults in San Francisco. American Journal of Public Health. 2004;94:1207-1217.
6. North CS, Eyrich KM, Pollio DE, et al. Are rates of psychiatric disorders in the homeless population changing? American Journal of Public Health. 2004;94:103-108.
7. Herman DB, Susser ES, Struening EL, et al. Adverse childhood experiences: are they risk factors for adult homelessness? American Journal of Public Health. 1997;87:249-255.
8. Zlotnick C, Tam T, Robertson MJ. Adverse childhood events, substance abuse, and measures of affiliation. Addiction and Behavior. 2004;29:1177-1181.
9. Desai MM, Rosenheck RA. HIV testing and receipt of test results among homeless persons with severe mental illness. American Journal of Psychiatry. 2004;161:2287-2294.
10. Susser E, Valencia E, Berkman A, et al. Human immunodeficiency virus sexual risk reduction in homeless men with mental illness. Archives of General Psychiatry. 1998;55:266-272.
11. Harris SK, Samples CL, Keenan PM, et al. Outreach, mental health, and case management services: can they help to retain HIV-positive and at-risk youth and young adults in care? Maternal and Child Health Journal. 2003;7:205-218.
12. Aidala A, Cross JE, Stall R, Harre D, et. al. Housing status and HIV risk behaviors: implications for prevention and policy. AIDS and Behavior. 2005;9:1-15.
13. Riley ED, Moss AR, Clark RA, et. al. Cash benefits are associated with lower risk behavior among the homeless and marginally housed in San Francisco. Journal of Urban Health. 2005;82:142-150.
14. Housing Works www.housingworks.org (Accessed 4/20/06)
15. Woods ER, Samples CL, Melchiono MW, et. al. Initiation of services in the Boston HAPPENS Program: human immunodeficiency virus-positive, homeless, and at-risk youth can access services. AIDS Patient Care STDs. 2002;16:497-510.
September 2005. Fact Sheet #16ER
Special thanks to the following reviewers of this Fact Sheet: Martha Burt, Carol Caton, Travis Emery, Lillian Gelberg, Sion Harris, Daniel Kidder, Steven Metraux, Carol North, Thomas Painter, Jamie Van Leeuwen, Harris Sion, Suzanne Wenzel, Elizabeth Woods, Cheryl Zlotnick.
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.firstname.lastname@example.org. ©Sepetmber 2005, University of California