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American Indian/ Alaskan Natives (AI/AN)
What are American Indian/ Alaskan Natives’ (AI/AN) HIV prevention needs?
Are AI/AN at risk for HIV?
Yes. American Indians and Alaskan Natives (AI/AN) represent a unique population within the US, not only because of their oppression suffered in the development of this country but also because of their ongoing struggle to gain recognition in the HIV/AIDS epidemic. AI/ANs are not so unique, however, that they are protected from the same behaviors that put all people at risk for HIV infection. The long history of oppression of AI/AN in the US has had a devastating effect on the health and well-being of Native Peoples. This history, including colonization, outlawing Native languages and spiritual practices, and centuries of forced relocation, has created justified mistrust of US government programs and health institutions.1 This legacy continues to shape the experience of AI/AN as they are disproportionately impacted by poverty, ill health, family violence and drug and alcohol abuse. All of these factors are associated with HIV risk.2 Through the end of 2000, AI/ANs comprised 2,337 AIDS cases and 871 HIV cases3. AI/AN constitute approximately 1% of the total US population, and just under 1% of reported AIDS and HIV cases3. Although these numbers appear small relative to other populations, the impact is considerable. Underreporting and the lack of detailed HIV surveillance of AI/AN may result in significant undercounting of HIV infections. Further, AI/AN are often misclassified in terms of race/ethnicity on data collection forms, due to assumptions about names, skin color, residence and even intentionally misleading self reporting.4 A study of STD data in Oklahoma found that 35% of chlamydia and over 60% of gonorrhea cases among AI/AN had been incorrectly attributed as Hispanic or white.5
What puts AI/ANs at risk?
HIV research among AI/AN has a short history starting in the early 1990s, with few studies on risk behavior. According to the CDC, for AI/AN men, the leading exposure category for HIV is men who have sex with men (MSM) at 51%, MSM and injection drug use (IDU) 13% and heterosexual IDU 12%. Among women, the primary exposure risk is heterosexual contacts at 41%, followed by IDU at 32%. However, this data does not include data from California, which has the largest Native population of all 50 states.6 AI/AN populations are disproportionately impacted by social, behavioral and economic factors that are associated with HIV risk. AI/AN suffer high rates of poverty and unemployment, with 32% living below poverty level, compared to 13% of the general US population. Native Americans also experience high rates of drug and alcohol use, STDs and violence. Alcohol use in the AI/AN population has resulted in the highest alcohol-related mortality rates for all US populations.9 One study of AN drug users found that alcohol use was the factor that put them at greatest risk for HIV. Many individuals reported blacking out while drinking, and later learned that they had unprotected sex with complete strangers or persons they would not otherwise accept as partners.10 This same study showed that drug using Alaskan Native women are at high risk for gonorrhea infection and HIV infection. AN women were more likely to inject drugs than any other ethnic group among women, and they were more likely to have white male injectors as sex partners. Sex pairs composed of AN women and white men were the least likely of any ethnic pair combinations to use condoms.11 In states with AI/AN populations over 20,000, gonnorhea and syphilis rates are twice as high as among other ethnic groups.7 Persons with STDs are more likely both to transmit HIV and become infected with HIV if exposed. A study of American Indian youth in over 200 reservation-based schools across the US showed that youth engaged in several risk behaviors: the use of alcohol, tobacco and other drugs, risky sexual behavior and suicidal behaviors. Drug use was most commonly associated with other risky behaviors.12
What are barriers to prevention?
HIV is often rendered invisible within AI/AN communities that are facing many other severe and more visible health and social problems such as alcoholism, diabetes and unemployment. As a result, there is often great denial about HIV as a problem in AI/AN communities. Like in many other tight-knit communities, confidentiality can be difficult to maintain in AI/AN communities, especially in rural areas. This can be a barrier to important prevention activities such as testing for HIV, discussing sexual practices with health care providers, obtaining drug treatment, or buying condoms in local stores. Prevention services for AI/AN MSM are severely underfunded, and those that exist may not reach MSM at risk. AI/AN MSM have a wide range of identities, from “gay” to “two-spirit” and may not access services addressed to urban gay men.13 AI/AN MSM may feel isolated and not seek out needed services because of stigma and denial about homosexuality in some AI/AN communities. The AI/AN population is highly diverse, with over 550 federally-recognized tribes. AI/AN consider themselves to belong to Indian nations that are sovereign, with complex relationships between tribal, state and federal governments. Many state and local governments erroneously assume that the IHS is solely responsible for the health- related needs of AI/AN. Less than 1% of IHS budget goes to urban populations, yet more than half of all AI/AN in the US live in urban areas. As a result, AI/AN tribes and organizations are often denied funding opportunities available to other citizens.
What’s being done?
To address the rising rates of STDs and HIV among adolescents in a rural Arizona Indian tribe, tribal health educators, school officials and public health officials collaborated to establish several programs including school health clinics, Native American HIV+ speakers, peer-produced educational dramas, community educational meetings and radio and newspaper ads. Cases of STDs and HIV peaked in 1990 and slowly declined over the next six years, for a 69% overall reduction in STDs.14 The Indigenous People’s Task Force (IPTF) in Minneapolis, MN, promotes health and education for Native persons. Their Ogitchidag Gikinooamaagad (warrior/teachers) peer education/theater program provides youth with a comprehensive HIV/AIDS prevention curriculum, theater instruction and traditional teachings. IPTF’s programs have been acknowledged by the US Surgeon General.15 The Indian Health Care Resource Center (IHCRC) of Tulsa, OK provides a biweekly social group for two-spirit Native American men to help build a sense of community, self-esteem and reduce risk behaviors. IHCRC also hosts a relationship skills-building workshop which focuses on helping the participants determine what they want out of relationships, managing triggers to risk behavior and increasing negotiating skills. Each year, IHCRC offers a 4-day retreat with social, cultural and educational activities including traditional meals, a Powwow and stomp dancing.16
What still needs to be done?
AI/AN communities, although diverse in many ways, share a sense of pride, self- determination, spirituality, and resiliency which have helped them fight HIV infection in their communities. These efforts need to be encouraged to ensure sustained HIV prevention. This can only occur with cooperation and collaboration between the many agencies who work with AI/AN, including tribal health care systems, federal, state and local health departments and non-profit agencies. For example, complex funding streams need to be simplified to allow AI/AN communities greater access to prevention resources. HIV/AIDS must be made visible in AI/AN communities to prevent the spread of HIV. Visibility can be increased by collecting reliable HIV/AIDS data, including AI/AN in the design and delivery of HIV prevention programs, addressing AI/AN stigma about homosexuality and drug use, and linking to STD, violence, unintended pregnancy, and alcohol and drug abuse prevention programs.
Says who?
1. National Institutes of Health. Women of color health data book: adolescents to seniors. 1999. NIH publication #99-4247.www4.od.nih.gov/orwh/WOCEnglish.pdf (accessed January 2002). 2. Vernon I. Killing Us Quietly: Native Americans and HIV/AIDS. University of Nebraska Press, 2001. 3. Centers for Disease Control and Prevention. U.S. HIV and AIDS cases reported through December 2001, Year-end edition. HIV/AIDS Surveillance Report. 2001;13 (2). (accessed April 2006). 4. Rowell RM, Bouey PD. Update on HIV/AIDS among American Indians and Alaska Natives. The IHS Primary Care Provider. 1997;22:49-53. (accessed April 2006). 5. Thoroughman DA, Frederickson D, Cameron HD, et al. Racial Misclassification of American Indians in Oklahoma state surveillance data for sexually transmitted diseases. American Journal of Epidemiology. 2002;155(12): 1137-41. 6. Smith AS, Ahmed B, Sink L. US Census Bureau. An Analysis of State and County Population Changes by Characteristics: 1990-1999. Working Paper Series No. 45. (accessed April 2006). 7. Centers for Disease Control and Prevention. HIV/AIDS among American Indians and Alaskan Natives – United States, 1981-1997. Morbidity and Mortality Weekly Report. 1998;47:154-160. (accessed April 2006). 8. Morrison-Beedy D, Carey MP, Lewis BP, et al. HIV risk behavior and psychological correlates among Native American women: an exploratory investigation. Journal of Women’s Health and Gender-Based Medicine. 2001:10;487-494. 9. Indian Health Service. Trends in Indian Health–1997. U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Office of Planning, Education, and Legislation, Division of Program Statistics. 1998. 10. Baldwin JA, Maxwell CJ, Fenaughty AM, et al. Alcohol as a risk factor for HIV transmission among American Indian and Alaska Native drug users. American Indian and Alaska Native Mental Health Research. 2000;9:1-16. 11. Fisher DG, Fenaughty AM, Paschane DM, et al. Alaska Native drug users and sexually transmitted disease: results of a five-year study. American Indian Alaska Native Mental Health Research. 2000;9:47-57. 12. Potthoff SJ, Bearinger LH, Skay CL, et al. Dimensions of risk behaviors among American Indian youth. Archives of Pediatric and Adolescent Medicine. 1998;152:157-163. 13. National Native American AIDS Prevention Center. HIV Prevention for gay/bisexual/two-spirit Native American men. 1996. https://www.nnaapc.net/ (accessed April 2006). 14. Yost D, Hamstra S, Roosevelt L. HIV/AIDS and STD prevention in a rural Arizona Indian tribe. Presented at the International Conference on AIDS, Geneva, Switzerland. 1998. Abst #43162. 15. Indigenous People’s Task Force, 1433 East Franklin Ave. Suite 18A, Minneapolis, MN 55404. Contact Sharon Day 612/870-1723.www.indigenouspeoplestf.org (accessed January 2002). 16. Indian Healthcare Resource Center of Tulsa, 550 South Peoria, Tulsa, OK 74120. https://www.ihcrc.org/ (accessed January 2002).
Prepared by Ron Rowell MPH*, Paul Bouey PhD MPH** *San Francisco Foundation, **Pangaea Global AIDS Foundation January 2002. Fact Sheet #43E Special thanks to the following reviewers of this Fact Sheet: Joan Benoit, Lucy Bradley-Springer, Yvonne Davis, Sharon Day, Thomas Lee Eades, Sheila Fitzgibbons, Diane Morrison-Beady, Billy Rogers, Chris Sandoval, Delight E. Satter, Irene Vernon, Diane Williams, Charlton Wilson.
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 [email protected]. © January 2002, University of California
Asian and Pacific Islanders (APIs)
What are Asian and Pacific Islanders’ HIV prevention needs?
revised 5/07
are APIs at risk?
Asians and Pacific Islanders (APIs) are one of the fastest growing ethnic populations in the United States.1 It is projected that by 2050, APIs together will comprise 8% of the total US population, or 34 million persons.1,2 Asians and Pacific Islanders are extremely diverse and represent 49 different ethnic groups and over 100 languages. APIs include Chinese, Filipinos, Koreans, Hawaiians, Indians, Japanese, Samoans and Vietnamese, among other groups. Most APIs live in concentrated metropolitan areas such as Honolulu, HI; San Francisco, CA; New York City, NY and Los Angeles, CA.2 Between 2001 and 2004, APIs represented less than 1% of all US HIV/AIDS cases, yet APIs had the highest estimated annual percentage increase in HIV/AIDS diagnosis rates of all race/ethnicities (8.1% for males and 14.3% for females).3 When populations such as APIs show low prevalence (overall numbers) but high increases in incidence (new diagnoses), prevention efforts are crucial to keep future HIV/AIDS cases low. Underreporting and a lack of detailed HIV surveillance mask the true nature of the epidemic among APIs. One study found that API AIDS diagnoses may be underreported by as much as 33%.4 This may in part be due to the misclassification of race and ethnicity in medical records, the source of information for case reports.2,5 For example, persons with Filipino surnames may be mistakenly recorded as Latino. In addition, the lack of detailed demographic information on specific ethnicity and place of birth makes it difficult to track differences in the AIDS epidemic for API subpopulations and develop ethnically-targeted public health measures.2
who are APIs at risk?
HIV transmission in API men occurs mostly between men who have sex with men (MSM), followed by men who have high-risk heterosexual contact or are injection drug users (IDUs). In 2005, MSM transmission accounted for 71% of all API AIDS diagnoses to date.6 Among API women, HIV transmission occurs mostly when a woman has sex with a man who is at increased risk, followed by women who are IDUs.6 While API MSM are most affected by HIV/AIDS, diagnosis rates among API women have increased (14.3%), as noted above.3 The CDC does not categorize transgendered women (persons born as men but who identify and live as women), but one study showed a 13% HIV prevalence among API transgendered women in San Francisco, CA.7
what puts APIs at risk?
Among API MSM, social discrimination and the lack of family, peer and community support for sexual and racial diversity can negatively impact self-esteem and positive self-identity, thereby increasing their HIV risk. In one study, 57% of gay API men in San Francisco, CA, used alcohol prior to engaging in anal intercourse; approximately 24% reported unprotected anal intercourse. However, 85% believed they were unlikely to contract HIV.:9 APIs have significantly lower rates of HIV testing than the rest of the US population, despite reporting similar rates of risk behavior2, and often delay seeking HIV services. In one study of young API MSM in San Francisco, CA, 24.4% of participants had never tested for HIV. Additionally, 2.6% tested HIV+, of whom 61.5% were unaware they were positive, and 38.5% reported recent unprotected sex10. Untested HIV+ APIs are more likely to engage in high-risk behaviors and unknowingly infect other persons.11 Those that delay seeking services are at greater risk of presenting with advanced AIDS at diagnosis and acquiring co-infections like hepatitis B, tuberculosis and PCP.5,12 Immigrant API women employed in massage parlors often engage in activities that put them at risk for HIV infection. However, for many of these women, immediate survival needs take priority over HIV prevention. Problems with the police, sex work, immigration, family planning, language barriers, and a lack of condom use policies in parlors all constitute risk factors for this population.13
what are barriers to prevention?
Although APIs are often stereotyped as the “model minority,” 17% of APIs lack health insurance and cannot receive adequate medical treatment and healthcare services.14 Because of limited API health and behavioral risk data, resources are often channeled to other populations, without assessing or acknowledging API healthcare needs.14 Among APIs, the cultural avoidance of issues such as sexual behavior, illness and death creates barriers to HIV prevention, breeds stigmatization and negatively impacts the psychological and mental health of those living with the illness.15 Approximately 40% of APIs are limited English proficient (low or no English skills)14, and few culturally competent intervention programs exist for ethnically, culturally and linguistically diverse API populations. One study found that language is the most common barrier to receiving healthcare services for APIs with HIV/AIDS.12
what’s being done?
There are many national and local programs that provide HIV prevention and education services for APIs, as well as capacity building and technical assistance efforts for agencies serving APIs.17 For example: The Asian and Pacific Islander Coalition on HIV/AIDS (APICHA) developed the Bridges Project, a community-based intervention to reduce disparities in care for HIV+ APIs in New York. It created linkages with hospitals and medical providers, provided case management and advocacy services and offered cultural competency training for providers. It was effective in improving service use and reducing barriers for non-English speaking, Asian-primary-language and undocumented participants.12 Life Foundation, in Honolulu, HI, has been running community-level programs for Pacific Islander MSM and transgenders since 1999. “UTOPIA Hawai’i” is based on the Mpowerment model and has been very successful in reaching high risk Pacific Islanders that would have never accessed HIV services before.18 The Health Project for Asian Women (HPAW) addressed Asian female sex workers at massage parlors in San Francisco, CA, with two interventions: Massage Parlor Owner Education Program and Health Educator Masseuse Counseling Program. HPAW staff escorted masseuses to health clinics, handed out safer sex kits and provided translation, referrals and advocacy services. Masseuses participated in a 3-session counseling intervention and massage parlor owners received an education session.13 Asian & Pacific Islander Wellness Center conducted an anti-stigma HIV media campaign targeting Chinese communities of San Francisco, CA, using bus shelter posters, newspaper advertisements and a documentary featuring local community leaders, people living with HIV and their families. They also lead the annual National Asian & Pacific Islander HIV/AIDS Awareness Day with over fifteen events across the US to increase acceptance of HIV among families and A&PI communities.19
what needs to be done?
We have a golden opportunity to keep numbers low among APIs, but that opportunity may be disappearing quickly as APIs have the highest increases in HIV/AIDS diagnosis rates of any racial group in the US. HIV prevention programs for APIs should focus on those at greatest risk, including MSM, women, transgenders and substance users. Programs can help APIs develop and strengthen support systems, as well as focus on prevention and healthcare needs, such as early testing for HIV, hepatitis B and TB. More culturally and linguistically-appropriate prevention and healthcare services for APIs need to be developed and evaluated. Stigma around HIV, homosexuality, sex work and drug use should be addressed with anti-stigma campaigns that increase discussions on HIV/AIDS prevention and lead to greater acceptance of APIs living with HIV. Collaborating with policymakers and new partners such as faith-based organizations can help to address stigma among APIs. Given the enormous diversity among APIs in the US, it is important to improve surveillance systems and quality of data and consistently collect information on subpopulation ethnicity and birthplace.3 Research is needed on HIV and co-infections (hepatitis B and tuberculosis) and on acculturation and its relationship to HIV.
Says who?
1. Choi KH, Wong F, Sy FS. HIV/ AIDS among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:iii-v. 2. Zaidi IF, Crepaz N, Song R, et al. Epidemiology of HIV/AIDS Among Asians and Pacific Islanders in the United States. AIDS Education and Prevention. 2005;17:405-417. 3. Racial/ethnic disparities in diagnoses of HIV/AIDS33 states, 2001-2004. Morbidity and Mortality Weekly Report. 2006;55:121-125. 4. Kelly JJ, Chu SY, Diaz T, et al. Race/ethnicity misclassification of persons reported with AIDS. Ethnicity & Health. 1996;1:87-94. 5. Wortley PM, Metler RP, Hu DJ, et al. AIDS among Asians and Pacific Islanders in the United States. American Journal of Preventative Medicine. 2000;18:208-214. 6. Cases of HIV infection and AIDS in the United States and dependent areas, 2005. HIV/AIDS Surveillance Report. 2006;17:37. 7. Operario D, Nemoto T. Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women. AIDS Education and Prevention. 2005;17:430-443. 8. Wilson PA, Yoshikawa H. Experiences of and responses to social discrimination among Asian and Pacific Islander gay men: Their relationship to HIV risk. AIDS Education and Prevention. 2004;16:68-83. 9. Choi KH, Operario D, Gregorich SE, et al. Substance use, substance choice, and unprotected anal intercourse among young Asian American and Pacific Islander men who have sex with men. AIDS Education and Prevention. 2005;17:418-429. 10. Do TD, Chen S, McFarland W, et al. HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco. AIDS Education and Prevention. 2005;17:540-554. 11. Wong F, Campsmith ML, Nakamura GV, et al. HIV testing and awareness of care-related services among a group of HIV-positive Asian Americans and Pacific Islanders in the United States: Findings from a supplemental HIV/AIDS surveillance project. AIDS Education and Prevention. 2004;16:440-447. 12. Chin JJ, Kang E, Haejin Kim J, et al. Serving Asians and Pacific Islanders with HIV/AIDS: Challenges and lessons learned. Journal of Health Care for the Poor and Underserved. 2006;17:910-927. 13. Nemoto T, Iwamoto M, Oh HJ, et al. Risk behaviors among Asian women who work at massage parlors in San Francisco: Perspectives from masseuses and owners/managers. AIDS Education and Prevention. 2005;17:444-456. 14. Ghosh C. Healthy People 2010 and Asian Americans/Pacific Islanders: Defining a baseline of information. American Journal of Public Health. 2003;93:2093-2098. 15. Kang E, Rapkin BD, Remien RH, et al. Multiple dimensions of HIV stigma and psychological distress among Asians and Pacific Islanders living with HIV illness.AIDS and Behavior. 2005;9:145-154. 16. API Capacity Building programs 17. Takahashi LM, Candelario J, Young T, et al. Building capacity for HIV/AIDS prevention among Asian and Pacific Islander organizations: The experience of a culturally appropriate capacity-building program in southern California. Journal of Public Health Management and Practice. 2007:S55-S63. 18. Utopia Hawai’i 19. API Wellness antistigma campaign
Prepared by Roshan Rahnama, Nina Agbayani, Stacy Lavilla,* John Chin, PhD** *Association of Asian Pacific Community Health Organizations (AAPCHO), **NY Academy of Medicine May 2007. Fact Sheet #33ER Special thanks to the following reviewers of this fact sheet: Vince Crisostomo, Chandak Ghosh, Erin Kahle, Saori Miyazaki, Lina Sheth, Lois Takahashi, Ed Tepporn, Peter Tuiolosega Silva. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©May 2007, University of CA.
Homeless persons
What are homeless persons’ HIV prevention needs?
revised 9/05
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
Says who?
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: https://endhomelessness.atavist.com/mayorsreport2016 ) 3. Burt, MR, Laudan, AY, Douglas T, et. al. 1999 Homelessness: Programs and the People They Serve – Summary Report. Washington, DC: DHUD/DHHS. 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 [email protected]. ©Sepetmber 2005, University of California
Sex Workers
are sex workers at risk for HIV?
Sex workers in the US may be at risk for HIV depending on the conditions of their workplace. Male, female and transgender sex workers who are most vulnerable to HIV are street-based workers, most of whom are poor or homeless, and likely to have had a history of sexual or physical abuse.1 Street-based sex workers are also commonly dependent on drugs or alcohol, and at a greater risk for violence from clients and police.2 Sex work off the street (in brothels, massage parlors, private homes or escort services) is less likely to result in HIV infection for the workers because they may exercise greater control over their working conditions and sexual transactions, including condom use. Little research has been done on rates of HIV infection among street-based sex workers across the US. In one study of drug-using female sex workers in Miami, FL, 22.4% of the women tested HIV+.3 In a study of male sex workers in Houston, TX, 26% reported testing HIV+.4
what places sex workers at risk?
Sex workers who are injection drug users (IDUs) are more likely to be HIV+ than those who do not inject drugs.2 Injection risks include sharing needles and injection equipment and being injected by someone else. IDU and other substance use (crack cocaine, methamphetamine, alcohol) can also impact sexual risks by compromising safe sexual behavior and communication.5 Persons who use crack cocaine are more likely to enter sex work and have large numbers of partners.6 The decision and ability to use condoms is a complex one that depends on many factors.7,8 Negotiating safer sex can be affected by money, if business is slow or clients offer more money for unprotected sex. Clients may use violence to enforce unsafe sex. Sex workers may use drugs before or with clients, which affects decision making and ability to use condoms. Sex workers may also be targeted by police if they are carrying condoms.5 In addition, sex workers, like many people, may choose not to use condoms with their boyfriends/girlfriends/spouses. Sex workers have elevated rates of sexually transmitted diseases (STDs), including HIV.1 One study of female, male and transgender sex workers in San Francisco, CA, reported high rates of gonorrhoea (12.4%), chlamydia (6.8%), syphilis (1.8%) and herpes (34.3%).9 Active STDs increase the likelihood of acquiring HIV. Genital trauma caused by frequent or forced intercourse also increases HIV risk.1 Violence, and the trauma associated with it, is a concern for many sex workers. Violence can include physical, sexual and verbal abuse that sex workers experienced as children, and as adults from their clients and intimate partners. It can also include the violence many street-based sex workers witness daily. This history of violence leaves many sex workers with emotional trauma, and many may turn to drug use to deal with the harsh realities of their daily lives.10
what are barriers to prevention?
The illegality of sex work in the US drives the industry underground and leads to a strong distrust of both police and public health authorities among sex workers. To avoid arrest, street-based sex workers are often forced to change how they work to avoid police.11 For example, sex workers may take less time to negotiate sexual transactions prior to getting into a client’s car, and may even agree to engage in riskier sexual activities. Conducting HIV prevention outreach or education in this environment can be difficult. Desperation and poverty can often override HIV prevention concerns. Drug-addicted persons may turn to prostitution to earn money to pay for the high cost of illegal drugs. Transgender persons may use sex work to make money for hormones or surgery. Many homeless youth have no training or means of support, and rely on prostitution for survival. Attention to the more immediate concerns of food, housing, and addiction often takes priority over concerns of HIV infection.12
what is being done?
JEWEL (Jewelry Education for Women Empowering their Lives), was an economic empowerment and HIV prevention project for drug-using women involved in prostitution in Baltimore, MD. The JEWEL intervention used six 2-hour sessions that taught HIV prevention and the making, marketing and selling of jewelry. Women participants significantly reduced trading drugs or money for sex, the number of sex trade partners, and drug use, including daily crack use.13 The Health Project for Asian Women (HPAW) addressed Asian female sex workers at massage parlors in San Francisco, CA, with two interventions: Massage Parlor Owner Education Program and Health Educator Masseuse Counseling Program. HPAW staff escorted masseuses to health clinics, handed out safer sex kits and provided translation, referrals and advocacy services. Masseuses participated in a 3-session counseling intervention and massage parlor owners received an education session.14 A brief intervention for male sex workers in Houston, TX, consisted of two 1-hour sessions held a week apart. Almost two-thirds (63%) of the men who began the intervention completed it, and those that completed the intervention increased their condom use during paid anal sex.15 Breaking Free in St Paul, MN, helps primarily African American girls and women leave sex work. The program helps women in crisis stabilize, then begin an intense program of counseling and education to address the traumas associated with sex work. Breaking Free offers transitional and permanent housing, as well as an internship program to help women who may have never held a real job become employable.16 The St. James Infirmary in San Francisco, CA, a peer-based clinic for sex workers by sex workers, provides male, female and transgender sex workers with free medical services. They also offer HIV/STD screening and treatment, transgender health, harm reduction and peer counseling, psychiatric services, acupuncture, massage, support groups, food, clothing, and needle exchange. Staff conducts street and venue-based outreach to distribute safer sex supplies and offers HIV testing.9
what still needs to be done?
In the US over the past decade, there has been very little research conducted on HIV/AIDS in the sex worker population. Furthermore, past research focused largely on the role of sex workers as vectors of HIV/STDs for the general public. To prevent HIV among sex workers, it is essential not only to increase overall research efforts in this population, but to also acknowledge the greater context in which sex work is transacted, as well as the specific practice of sex workers. Researchers, public health and law enforcement officials need to hear from sex workers what they need to keep themselves safe, and work together to achieve those goals. Laws and police attitudes towards carrying condoms must be eased to allow sex workers to protect themselves. Violence against sex workers by clients, police, and other neighborhood community members must be criminalized, while sex workers should be encouraged and supported to report violent incidents. Street-based sex workers face a multitude of needs, from immediate concerns of housing, food and medical attention, to longer-range concerns such as mental health services, substance abuse treatment, violence prevention, job training and employment, HIV/STD prevention, quality health care, improved relationships with law enforcement and help leaving sex work. Increased funding and awareness is needed for public health programs that address this full range of issues sex workers face. PREPARED BY ROSHAN RAHNAMA, CAPS