HIV, homelessness, and public health: critical issues and a call for increased action

"Death Is a Possibility for Those without Shelter": A Thematic Analysis of News Coverage on Homelessness and the 2021 Heat Dome in Canada

Among the most vulnerable to the health-harming effects of heat are people experiencing homelessness. However, during the 2021 Heat Dome, the deadliest extreme heat event (EHE) recorded in Canada to date, people experiencing homelessness represented the smallest proportion of decedents (n = 3, 0.5%)-despite the impacted region (British Columbia) having some of the highest rates of homelessness in the country. Thus, we sought to explore the 2021 Heat Dome as a media-based case study to identify potential actions or targeted strategies that were initiated by community support agencies, individuals and groups, and communicated in the news during this EHE that may have aided in the protection of this group or helped minimize the mortality impacts. Using media articles collated for a more extensive investigation into the effects of the 2021 Heat Dome (n = 2909), we identified a subset which included content on people experiencing homelessness in Canada (n = 274, 9%). These articles were thematically analysed using NVivo. Three main themes were identified: (i) public warnings issued during the 2021 Heat Dome directly addressed people experiencing homelessness, (ii) community support services explicitly targeting this population were activated during the heat event, and (iii) challenges and barriers faced by people experiencing homelessness during extreme heat were communicated. These findings suggest that mass-media messaging and dedicated on-the-ground initiatives led by various organizations explicitly initiated to support individuals experiencing homelessness during the 2021 Heat Dome may have assisted in limiting the harmful impacts of the heat on this community.

Sheltered from the heat? How tents and shade covers may unintentionally increase air temperature exposures to unsheltered communities

Objective

Heat vulnerability and homelessness are central public health concerns in cities globally, and public health implementation should address these two challenges in tandem to minimize preventable heat-related morbidity and mortality. Populations facing unsheltered homelessness use tents (or similar shelters) with shading features to minimize sun and heat exposure. This study evaluates the efficacy of different tent cover (shading) materials and how they moderate the in-tent air temperature (Tair) exposures of tent users during extreme summer conditions.

Study design

Within-tent Tair monitoring using Kestrel Drop devices occurred across three full typical summer days in Phoenix, Arizona in July 2022.

Methods

In-tent Tair were statistically compared between six small side-by-side identical tents with different cover materials (control (no cover), mylar, white bedsheet, tarp, sunbrella fabric, aluminum foil), as well as with ambient Tair.

Results

Using any tent resulted in higher daytime in-tent Tair than ambient Tair. Further, compared to a control tent, the Tair within tents shaded with sunbrella, tarp, and white bedsheet had significantly higher Tair at all times (2.36 °C, 2.46 °C, and 1.11 °C higher Tair, respectively), controlling for Tair and day/night.

Conclusion

Adding cover materials over tents may increase heat risk to an already vulnerable population at certain times of the day. Higher in-tent Tair is attributable to the reduced ability for heat and vapor to escape, largely due to reduced ventilation (mixing). Local authorities and welfare associations should reconsider using unventilated tents for shading and promote more widespread, ventilated tents and shade to ensure that prevention efforts do not further marginalize the most vulnerable. Future work should incorporate more comprehensive measurements of solar radiation to quantify overall heat stress for exposure reduction techniques.

Human Immunodeficiency Virus (HIV) Treatment With Antiretroviral Therapy Mitigates the High Risk of Mental Health Disorders Associated With HIV Infection in the US Population

Background

Whether treatment of human immunodeficiency virus (HIV) with antiretroviral therapy (ART) is associated with lower risk of mental health disorders (MHDs) among people with HIV (PWH) remains unknown. We aim to determine the association between HIV and MHDs and whether ART alters the risk of MHDs among PWH in the US adult population.

Methods

We conducted a real-world study using the Merative MarketScan claims database (2016-2020), identifying individuals with HIV (diagnosed using International Classification of Diseases, Tenth Revision, Clinical Modification codes) and those without HIV. A multivariable stratified Cox proportional hazard regression model was conducted to examine the association of HIV treatment status with MHDs, adjusting for potential confounders. Additionally, we sought to determine the effect modification of ART on the relationship between living with HIV and MHDs.

Results

A total of 313 539 individuals, with a mean age of 44.2 (standard deviation, 11.4) years, predominantly males (81.2%), residing in the South region of the US (50.9%) were included in the present analysis. During 671 880 person-years of follow-up, 46 235 incident MHD cases occurred. In the multivariable Cox proportional hazard model, living with HIV was associated with higher risk of incident MHDs. Relative to those without HIV, the adjusted hazard ratio was 1.85 (95% confidence interval [CI], 1.79-1.92; P < .001) for those with HIV on treatment, and 2.70 (95% CI, 2.59-2.82; P < .001) for those with HIV without any treatment. Stronger associations between HIV and MHDs were observed in men relative to women, among those aged 18-34 years relative to those aged 55-63 years, and among those with no overweight/obesity relative to obese individuals (Pinteraction < .001 for all).

Conclusions

HIV was associated with an increased risk of developing MHDs. However, HIV treatment mitigated the risk.

The microbiota in feces of domestic pigeons in Seoul, Korea

In Korea, feral pigeons pose significant public health risks because they carry various zoonotic pathogens. Human population density is a significant factor in zoonotic disease events. Seoul is one of the largest cities by population density among developed countries and where most of the homeless population in Korea exists. We designed this study to compare the microbiota of pigeon feces by regional characteristics and the presence of homeless individuals. Therefore, this study used 16S rRNA amplicon sequencing to detect possible pathogenic microbes and assess the current risk of zoonosis in Seoul, South Korea. Pigeon fecal samples (n = 144) obtained from 19 public sites (86 and 58 fecal samples from regions in and outside Seoul, respectively) were examined. Potentially pathogenic bacteria were also detected in the fecal samples; Campylobacter spp. was found in 19 samples from 13 regions, Listeriaceae was found in seven samples, and Chlamydia spp. was found in three samples from two regions. Principal coordinates analysis and permutational multivariate analysis of variance revealed a significant difference in bacterial composition between the regions in Seoul (n = 86) and outside Seoul (n = 58) and between the regions with (n = 81) and without (n = 63) homeless individuals. Overall, this study identified various potentially pathogenic microorganisms in pigeon feces at public sites in South Korea. Moreover, this study demonstrates that the microbial composition was influenced by regional characteristics and homelessness. Taken together, this study provides important information for public health strategic planning and disease control.

Multipronged Approach to Controlling a Tuberculosis Outbreak Among Persons Experiencing Homelessness

In May 2009, the Marion County Public Health Department in Indiana declared a tuberculosis (TB) outbreak among persons experiencing homelessness in Marion County, began active case finding to detect additional cases, and formed a TB outbreak response team to plan and coordinate outbreak activities. Outbreak-associated cases had 1 of 2 outbreak genotypes and either reported experiencing homelessness themselves or had an epidemiologic link to a shelter or a person experiencing homelessness. The last of 53 outbreak-associated cases was detected in 2019 after more than 2 years without a case. The Marion County Public Health Department continues to address TB-related issues and implement prevention measures at homeless shelters and among persons experiencing homelessness in 2019. This example, in addition to other published guidance, can be used by jurisdictions to plan and implement their own TB outbreak prevention and response activities among persons experiencing homelessness.

Restructuring personal networks with a Motivational Interviewing social network intervention to assist the transition out of homelessness: A randomized control pilot study

BACKGROUND

Social relationships play a key role in both substance use and homelessness. Transitioning out of homelessness often requires reduction in substance use as well as changes in social networks. A social network-based behavior change intervention that targets changes personal social networks may assist the transition out of homelessness. Most behavior change interventions that incorporate social networks assume a static network. However, people experiencing homelessness who transition into housing programs that use a harm reduction approach experience many changes in their social networks during this transition. Changes may include disconnecting from street-based network contacts, re-connecting with former network contacts, and exposure to new network members who actively engage in substance use. An intervention that helps people transitioning out of homelessness make positive alterations to their social networks may compliment traditional harm reduction housing program services.

METHODS

We conducted a pilot randomized controlled trial (RCT) of an innovative Social Network Intervention (MI-SNI), which combines network visualization and Motivational Interviewing to assist adults transitioning out of homelessness. The MI-SNI provides feedback to new residents about their social environments and is designed to motivate residents to make positive changes in both their individual behavior and their personal network. In a sample of 41 adult housing program residents with past year risky substance use, we examined whether participants randomized to receive a MI-SNI showed greater changes in their personal networks over 3 months compared to those receiving usual care.

RESULTS

There were significant differences in the networks of the MI-SNI group compared to the group receiving usual care at follow-up, controlling for baseline network characteristics. The MI-SNI group had greater reductions in the proportion of their network members who influenced alcohol or other drug use (AOD) use, such as drinking partners, and more frequently changed their relationships in the direction of lower AOD risk with network members who were retained in their networks across waves.

CONCLUSIONS

This study is the first pilot test of a MI-SNI customized for assisting the transition out of homelessness to test for personal network changes. Results indicate that MI-SNIs can have a positive impact on short-term network changes and thus may serve as a useful adjunct to behavioral change interventions. These findings suggest that a MI-SNI approach may help individuals experiencing homelessness and risky AOD use positively restructure their social networks while transitioning into supportive housing. These promising results suggest the need for a larger RCT test of this innovative intervention approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02140359.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

Understanding disparities in viral suppression among Black MSM living with HIV in Atlanta Georgia

INTRODUCTION

Due to factors associated with structural racism, Black men who have sex with men (MSM) living with HIV are less likely to be virally suppressed compared to white MSM. Most of these data come from clinical cohorts and modifiable reasons for these racial disparities need to be defined in order to intervene on these inequities. Therefore, we examined factors associated with racial disparities in baseline viral suppression in a community-based cohort of Black and white MSM living with HIV in Atlanta, GA.

METHODS

We conducted an observational cohort of Black and white MSM living with HIV infection in Atlanta. Enrolment occurred from June 2016 to June 2017 and men were followed for 24 months; laboratory and behavioural survey data were collected at 12 and 24 months after enrolment. Explanatory factors for racial disparities in viral suppression included sociodemographics and psychosocial variables. Poisson regression models with robust error variance were used to estimate prevalence ratios (PR) for Black/white differences in viral suppression. Factors that diminished the PR for race by ≥5% were considered to meaningfully attenuate the racial disparity and were included in a multivariable model.

RESULTS

Overall, 26% (104/398) of participants were not virally suppressed at baseline. Lack of viral suppression was significantly more prevalent among Black MSM (33%; 69/206) than white MSM (19%; 36/192) (crude Prevalence Ratio (PR) = 1.6; 95% CI: 1.1 to 2.5). The age-adjusted Black/white PR was diminished by controlling for: ART coverage (12% decrease), housing stability (7%), higher income (6%) and marijuana use (6%). In a multivariable model, these factors cumulatively mitigated the PR for race by 21% (adjusted PR = 1.1 [95% CI: 0.8 to 1.6]).

CONCLUSIONS

Relative to white MSM, Black MSM living with HIV in Atlanta were less likely to be virally suppressed. This disparity was explained by several factors, many of which should be targeted for structural, policy and individual-level interventions to reduce racial disparities.

Impact of Targeted Local Interventions on Tuberculosis Awareness and Screening Among Persons Experiencing Homelessness During a Large Tuberculosis Outbreak in Atlanta, Georgia, 2015-2016

OBJECTIVES

Tuberculosis (TB) outbreaks disproportionately affect persons experiencing homelessness (PEH) in the United States. During 2014-2016, a resurgent TB outbreak occurred among PEH in Atlanta, Georgia. To control the outbreak, citywide policies and educational interventions were implemented in January 2015. Policy changes standardized and enforced TB screening requirements for PEH in homeless shelters. Educational campaigns informed PEH of the outbreak and encouraged TB screening. We evaluated factors associated with, and the effect policy changes and educational interventions had on, TB screening and awareness among PEH in Atlanta.

METHODS

Questions related to TB screening and awareness of the outbreak were added to an annual US Department of Housing and Urban Development survey of PEH in Atlanta in 2015 (n = 296 respondents) and 2016 (n = 1325 respondents). We analyzed the 2016 survey data to determine characteristics associated with outcomes.

RESULTS

From 2015 to 2016, reported TB screening increased from 81% to 86%, and awareness of the TB outbreak increased from 68% to 75%. In 2016, sheltered PEH were significantly more likely than unsheltered PEH to report being evaluated for TB in the previous 6 months (prevalence odds ratio [pOR] = 3.18; 95% confidence interval [CI], 2.28-4.47) and to report being aware of the TB outbreak (pOR = 4.00; 95% CI, 2.89-5.55).

CONCLUSIONS

Implementation of required TB screening and educational interventions may reduce the incidence and severity of TB outbreaks among PEH in other communities. Furthermore, the annual survey of PEH offers an opportunity to collect data to better inform practices and policies.

The Importance of Context: Linking Veteran Outpatients Screening Positive for Housing Instability with Responsive Interventions

This study aims to explore the relationship between the context of screening for housing instability and Veterans' access to services, with the goal of ensuring effective processes to address housing instability among Veterans. This study used administrative data from 100,022 Veterans' electronic medical records and qualitative data collected during in-depth interviews with 22 health care providers and six Homeless Program staff. A mixed effects logistic regression assessed the relationship between Veterans' screening experiences and connection with services; qualitative data were analyzed using a grounded theory approach to present providers' reflections on administering screening for housing instability and responding to Veterans' positive screens with needed resources. We observed a significant relationship between providers' roles and location of screening with patients' timely linkage with services. Providing additional training related to how to conduct the screen and provide required resources, shifting screening responsibilities to providers with more flexibility to address these needs, and embedding supportive services in the care team may improve post-screening linkage with services.

Developing a triage tool for use in identifying people living with HIV who are at risk for non-retention in HIV care

Introduction:

Identifying PLHIV in HIV care who are at particular risk of non-retention in care is an important element in improving their HIV care outcomes. The purpose of this study was to develop a risk prediction tool to identify PLHIV at risk of non-retention in care over the course of the next year.

Method:

We used stepwise logistic regression to assess sociodemographic, clinical and behavioral predictors of non-retention in HIV care. Retention in care was defined as having evidence of at least two encounters with an HIV care provider (or CD4 or viral load lab tests as a proxy measure for the encounter), at least 3 months apart within a year. We validated the risk prediction tool internally using the bootstrap method.

Results:

The risk prediction tool included a total of six factors: age group, race, poverty level, homelessness, problematic alcohol/drug use and viral suppression status. The total risk score ranged from 0 to 17. Compared to those in the lowest quartile (0 risk score), those who were in the middle two quartiles (score 1–4) and those in the upper quartile (>4 risk score) were more likely not to be retained in care (odds ratio [OR] 1.63 [CI; 1.39–1.92] and OR 4.82 [CI; 4.04–5.78] respectively). The discrimination ability for the prediction model was 0.651.

Conclusion:

We found that increased risk for non-retention in care can be predicted with routinely available variables. Since the discrimination of the tool was low, future studies may need to include more prognostic factors in the risk prediction tool.

Homelessness and HIV: A Combination Predictive of Poor Tuberculosis Treatment Outcomes and in Need of Innovative Strategies to Improve Treatment Completion

Antioquia Department is the state with the highest burden of tuberculosis (TB) in Colombia. Our aim was to determine the risk factors associated with unsuccessful TB treatment in HIV-seropositive and homeless persons, compared with non-HIV-infected and non-homeless persons with TB. We conducted a retrospective cohort study using observational, routinely collected health data from all drug-susceptible TB cases in homeless and/or HIV-seropositive individuals in Antioquia from 2014 to 2016. Unsuccessful TB treatment was defined as individuals having been lost to follow-up, having died, or treatment failure occurrence during the study period. Successful treatment was defined as cure of TB or treatment completion according to the WHO definitions. We identified 544 homeless persons with TB (432 HIV- and 112 HIV+), 835 HIV+ persons with TB and non-homeless, and 5,086 HIV-/non-homeless people with TB. Unsuccessful treatment rates were 19.3% in HIV-/non-homeless persons, 37.4% in non-homeless HIV+ patients, 61.5% in homeless HIV- patients, and 70.3% in homeless HIV+ patients; all rates fall below End TB strategy targets. More than 50% of homeless patients were lost to follow-up. Risk factors associated with unsuccessful treatment were HIV seropositivity, homelessness, male gender, age ≥ 25 years, noncontributory-type health insurance, TB diagnosis made during hospitalization, and previous treatment for TB. These results highlight the challenge of treating TB in the homeless population. These findings should put an onus on TB programs, governments, clinicians, and others involved in the collaborative care of TB patients to pursue innovative strategies to improve treatment success in this population.

Mental health, substance use and HIV risk behaviors among HIV-positive adults who experienced homelessness in the United States - Medical Monitoring Project, 2009-2015

Homelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.

Comparison of Two Distinct House Ball Communities Involved in an HIV Prevention Study: Baseline Data from the POSSE Project

For many Black/African American gay, bisexual, and other young men who have sex with men (B-GBMSM), the House/Ball Community (HBC) offers a social network where they can be free to express diverse sexual and gender identities, but HIV prevalence and stigma are high. The POSSE project is an effectiveness-implementation trial of a popular opinion leader intervention designed to address HIV prevention in the Chicago and Philadelphia HBCs. In June 2016 baseline behavioral data were collected along with HIV, gonorrhea and Chlamydia testing. Eligible participants were sexually-active YMSM or transgender women (TGW), between the ages of 15-24, who self-identified as Black. One-third participants (32.5%) met or exceeded the clinical cut-off for depressive symptoms. Approximately 18% of the participants across both cities reported that they were HIV-positive. Overall, the baseline data establishes the need for HIV and STI prevention interventions across both cities, as well as interventions to address other co-occurring epidemics.

Sexual Partner Characteristics, Relationship Type, and HIV Risk Among a Community Venue-based Sample of Urban Adolescent and Young Adult Men Who Have Sex with Men

Few studies have examined sexual partnerships and HIV risk in diverse samples of African American/black and Hispanic/Latino adolescent and young adult men who have sex with men (YMSM), a group that have a high burden of HIV in the U.S. A community-venue recruitment approach was used, which identified significant differences in HIV risk by sexual partner type among 1215 YMSM. Those with casual partners had a higher number of sexual partners, had more STIs, and were more likely to engage in transactional sex, to use alcohol, marijuana, or other substances compared with those with main partners only. Among those with female sexual partners, many used condoms "every time" when engaging in vaginal sex with casual partners, but a sizeable proportion "never/rarely" used condoms with their main partners. Our findings demonstrate a need for tailored HIV prevention education and counseling with necessary skills regarding consistent and correct condom use with all sexual partnerships.

HIV Treatment Cascade by Housing Status at Enrollment: Results from a Retention in Care Cohort

Though housing instability is linked to poor HIV health outcomes, studies that assess the HIV treatment cascade by housing status are limited. Using data from a multi-site Retention in Care initiative we constructed HIV treatment cascades for participants (n = 463) of five grantee sites. We found no significant differences in viral suppression at follow-up among participants who were unstably housed at enrollment (49%) as compared to those who were stably housed at enrollment (54%). Among participants with available data at 6- or 12-month follow-up, 94% were engaged in care, 90% were retained in, 94% were on ART, and 71% had suppressed viral load. Some site-level differences were noted; at two of the sites participants who were stably housed were more likely to be retained in care and on ART. Overall, findings demonstrated that participants moved successfully through the HIV treatment cascade regardless of housing status at enrollment, suggesting that evidence-based support and services to help people living with HIV/AIDS can help mitigate barriers to engagement in care associated with lack of stable housing.

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

Can TasP Approaches Be Implemented in Correctional Settings?: A review of HIV testing and linkage to community HIV treatment programs

High rates of HIV in correctional populations makes evaluation of programs that increase HIV testing in correctional settings and linkage to HIV treatment upon release, and understanding key implementation issues of these programs, essential to reducing new HIV infection. We conducted a systematic search for studies of outcomes or implementation issues of programs that promote HIV testing or that promote linkage to community HIV treatment post-release. Thirty-five articles met inclusion criteria: nine HIV testing initiatives and four linkage programs. HIV testing uptake rates were between 22% and 98% and rates of linkage to community treatment were between 79% and 84%. Findings suggest that some programs may be effective at reducing HIV transmission within the communities to which inmates return. However, attention to implementation factors, such as organizational culture and staff collaborations, appears critical to the success of these programs. Future research using rigorous design and adequate comparison groups is needed.

Exchange of Sex for Drugs or Money in Adolescents and Young Adults: An Examination of Sociodemographic Factors, HIV-Related Risk, and Community Context

The goal of this research was to examine associations among sociodemographic factors, HIV risk, and community context (e.g., economic insecurity, job training, housing instability, crime victimization, and perceived community norms) in adolescents and young adults who ever exchanged sex for drugs or money. Anonymous survey data were collected using ACASIs at community venues where adolescents and young adults congregate in resource-challenged, STI prevalent, urban, US neighborhoods. Conventional descriptive statistics, Fisher's exact tests, and generalized estimating equations approaches were used to examine associations. Participants (1818, 95.5 % of those screened eligible) were, on average, aged 21.0 years; 42.2 % were males, and 4.6 % were transgender. Almost one-third (32.1 %) identified as gay or lesbian, 18.1 % identified as bisexual; 66.2 % were Black and 21.0 % were Hispanic; 1.3 % was 'living on the street'. A sizeable proportion reported HIV-related risk: 16.3 % exchanged sex, 12.6 % had sex with someone they knew to be HIV-infected, 7.8 % had sex with someone who injected drugs, and 1.3 % injected drugs. Multivariate comparisons identified a number of variables (e.g., being male or transgender, homelessness, sex with a partner who has HIV, STI history, unemployment, job training access, housing instability, crime victimization, perceived community norms) that were significantly associated with exchange of sex (p < 0.05). This research contributes to the knowledge-base regarding exchange of sex among adolescents and young adults, particularly as it relates to community context. Longitudinal studies to describe the trajectory of social, health, and physical risks and consequences are needed for development of effective evidence-based prevention strategies.

Rapid organizational network analysis to assess coordination of services for HIV testing clients: an exploratory study

Recognizing that HIV testing provides a gateway opportunity to connect with at-risk populations, we explored an approach to collect, analyze and present data on the network of connections between HIV testing organizations and other health and social service agencies operating in Durham County, NC. We surveyed 26 health and social service organizations, including 6 providing HIV testing services, and presented the results including frequency tabulations, network visualizations and metrics, and GIS maps to the participating organizations. Mapping the landscape of organizational relationships was seen as a practical and expedient approach to facilitating cross-sector collaborative efforts to improve community health.

A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents

This article presents findings of a pilot test of a Motivational Interviewing social network intervention (MI-SNI) to enhance motivation to reduce high risk alcohol and other drug (AOD) use among formerly homeless individuals transitioning to housing. Delivered in-person by a facilitator trained in MI, this four-session computer-assisted intervention provides personalized social network visualization feedback to help participants understand the people in their network who trigger their alcohol and other drug (AOD) use and those who support abstinence. If ready, participants are encouraged to make changes to their social network to help reduce their own high-risk behavior. Participants were 41 individuals (33 male, 7 female, 1 other; 23 African-American, 5 non-Latino White, 6 Latino, 7 other, mean age 48) who were transitioning from homelessness to permanent supportive housing. They were randomly assigned to either the MI-SNI condition or usual care. Readiness to change AOD use, AOD abstinence self-efficacy, and AOD use were assessed at baseline and shortly after the final intervention session for the MI-SNI arm and around 3-months after baseline for the control arm. Acceptability of the intervention was also evaluated. MI-SNI participants reported increased readiness to change AOD use compared to control participants. We also conducted a subsample analysis for participants at one housing program and found a significant intervention effect on readiness to change AOD use, AOD abstinence self-efficacy, and alcohol use compared to control participants. Participants rated the intervention as highly acceptable. We conclude that a brief computer-assisted Motivational Interviewing social network intervention has potential to efficaciously impact readiness to change AOD use, AOD abstinence self-efficacy, and AOD use among formerly homeless individuals transitioning to permanent supportive housing, and warrants future study in larger clinical trials.

Exploring the Healthcare Environment and Associations with Clinical Outcomes of People Living with HIV/AIDS

Despite three decades of dramatic treatment breakthroughs in antiretroviral regimens, clinical outcomes for people living with HIV vary greatly. The HIV treatment cascade models the stages of care that people living with HIV go through toward the goal of viral suppression and demonstrates that <30% of those living with HIV/AIDS in the United States have met this goal. Although some research has focused on the ways that patient characteristics and patient-provider relationships contribute to clinical adherence and treatment success, few studies to date have examined the ways that contextual factors of care and the healthcare environment contribute to patient outcomes. Here, we present qualitative findings from a mixed-methods study to describe contextual and healthcare environment factors in a Ryan White Part C clinic that are associated with patients' abilities to achieve viral suppression. We propose a modification of Andersen's Behavioral Model of Health Services Utilization, and its more recent adaptation developed by Ulett et al., to describe the ways that clinic, system, and provider factors merge to create a system of care in which more than 86% of the patient population is virally suppressed.

Assessment of Capacity to Consent by Nurses Who Deliver Health Care to Patients Who Misuse Substances

This qualitative study explored the current practice that nurses use to assess capacity to consent to health care (CTC-HC) in street outreach settings. Key informant interviews were conducted with a purposive sample of nurses from each of British Columbia’s five regional health authorities, allowing nurses to describe their lived experiences with assessing CTC-HC. Content analysis was used to summarize information captured in the data. A total of 19 nurses participated in the study. Five themes emerged from the data: (a) internal guiding forces that contribute to the nurses’ assessment, (b) external influences that contribute to the nurses’ assessment, (c) measures that are important for assessing CTC-HC, (d) threshold setting, and (e) context (physical and interpersonal) within which assessment of capacity takes place. These elements will be incorporated into a capacity assessment tool that can be used in nursing best practices.

A computer-assisted motivational social network intervention to reduce alcohol, drug and HIV risk behaviors among Housing First residents

BACKGROUND

Individuals transitioning from homelessness to housing face challenges to reducing alcohol, drug and HIV risk behaviors. To aid in this transition, this study developed and will test a computer-assisted intervention that delivers personalized social network feedback by an intervention facilitator trained in motivational interviewing (MI). The intervention goal is to enhance motivation to reduce high risk alcohol and other drug (AOD) use and reduce HIV risk behaviors.

METHODS/DESIGN

In this Stage 1b pilot trial, 60 individuals that are transitioning from homelessness to housing will be randomly assigned to the intervention or control condition. The intervention condition consists of four biweekly social network sessions conducted using MI. AOD use and HIV risk behaviors will be monitored prior to and immediately following the intervention and compared to control participants' behaviors to explore whether the intervention was associated with any systematic changes in AOD use or HIV risk behaviors.

DISCUSSION

Social network health interventions are an innovative approach for reducing future AOD use and HIV risk problems, but little is known about their feasibility, acceptability, and efficacy. The current study develops and pilot-tests a computer-assisted intervention that incorporates social network visualizations and MI techniques to reduce high risk AOD use and HIV behaviors among the formerly homeless. CLINICALTRIALS.

GOV IDENTIFIER

NCT02140359.

State variation in HIV/AIDS health outcomes: the effect of spending on social services and public health

Objective:

Despite considerable advances in the prevention and treatment of HIV/AIDS, the burden of new infections of HIV and AIDS varies substantially across the country. Previous studies have demonstrated associations between increased healthcare spending and better HIV/AIDS outcomes; however, less is known about the association between spending on social services and public health spending and HIV/AIDS outcomes. We sought to examine the association between state-level spending on social services and public health and HIV/AIDS case rates and AIDS deaths across the United States.

Design:

We conducted a retrospective, longitudinal study of the 50 U.S. states over 2000–2009 using a dataset of HIV/AIDS case rates and AIDS deaths per 100 000 people matched with a unique dataset of state-level spending on social services and public health per person in poverty.

Methods:

We estimated multivariable regression models for each HIV/AIDS outcome as a function of the social service and public health spending 1 and 5 years earlier in the state, adjusted for the log of state GDP per capita, regional and time fixed effects, Medicaid spending as % of GDP, and socio-demographic, economic, and health resource factors.

Results:

States with higher spending on social services and public health per person in poverty had significantly lower HIV and AIDS case rates and fewer AIDS deaths, both 1 and 5 years post expenditure (P ≤ 0.05).

Conclusion:

Our findings suggest that spending on social services and public health may provide a leverage point for state policymakers to reduce HIV/AIDS case rates and AIDS deaths in their state.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

BACKGROUND

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.

OBJECTIVES

We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.

SEARCH METHODS

We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.

SELECTION CRITERIA

We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.

RESULTS

Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.

CONCLUSIONS

Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Differences in housing, health, and well-being among HIV-positive women living in poverty

The social context of living in poverty has a direct and indirect impact on a woman's health and well-being. This cross-sectional study investigates the relationship between housing and adherence to treatment, emotional wellness, environmental safety, physical health status, and risk behaviors among HIV-positive women receiving services from an AIDS service organization in the mid-South. Significant differences were found between stably housed and unstably housed women on the dependent outcome variables. Results suggest that housing services for HIV-positive women may be an effective way to increase their health and well-being as well as prevent transmission to others.

Moving toward a holistic conceptual framework for understanding healthy aging among gay men

In the last four decades, we have witnessed vast and important transitions in the social, economic, political, and health contexts of the lived experiences of gay men in the United States. This dynamic period, as evidenced most prominently by the transition of the gay rights movement to a civil rights movement, has shifted the exploration of gay men's health from one focusing primarily on HIV/AIDS into a mainstream consideration of the overall health and wellbeing of gay men. Against this backdrop, aging gay men in the United States constitute a growing population, for whom further investigations of health states and health-related disparities are warranted. In order to advance our understanding of the health and wellbeing of aging gay men, we outline here a multilevel, ecosocial conceptual framework that integrates salient environmental, social, psychosocial, and sociodeomgraphic factors into sets of macro-, meso-, and micro-level constructs that can be applied to comprehensively study health states and health care utilization in older gay men.

Contingency management facilitates the use of postexposure prophylaxis among stimulant-using men who have sex with men

Compared to a control behavioral intervention, Contingency Management, an escalating voucher-based incentive system to reinforce stimulant abstinence, better supported MSM stimulant users in PEP course completion, decreased stimulant use, and a trend toward fewer condomless sexual acts.

Background. Stimulant-using men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) acquisition. Contingency Management (CM) is a robust substance abuse intervention that provides voucher-based incentives for stimulant-use abstinence.

Methods. We conducted a randomized controlled trial of CM with postexposure prophylaxis (PEP) among stimulant-using MSM. Participants were randomized to CM or a noncontingent “yoked” control (NCYC) intervention and observed prospectively. Generalized linear models were used to estimate the effect of CM on PEP course completion, medication adherence, stimulant use, and sexual risk behaviors.

Results. At a single site in Los Angeles, 140 MSM were randomized to CM (n = 70) or NCYC (n = 70). Participants were 37% Caucasian, 37% African American, and 18% Latino. Mean age was 36.8 (standard deviation = 10.2) years. Forty participants (29%) initiated PEP after a high-risk sexual exposure, with a mean exposure-to-PEP time of 32.9 hours. PEP course completion was greater in the CM group vs the NCYC group (adjusted odds ratio [AOR] 7.2; 95% confidence interval {CI}, 1.1–47.9), with a trend towards improved medication adherence in the CM group (AOR, 4.3; 95% CI, 0.9–21.9).

Conclusions. CM facilitated reduced stimulant use and increased rates of PEP course completion, and we observed a trend toward improved adherence. Participants in the CM group reported greater reductions in stimulant use and fewer acts of condomless anal intercourse than the control group. This novel application of CM indicated the usefulness of combining a CM intervention with PEP to produce a synergistic HIV prevention strategy that may reduce substance use and sexual risk behaviors while improving PEP parameters.

The effects of homelessness on Veterans' health care service use: an evaluation of independence from comorbidities

OBJECTIVES

This study evaluates the prevalence of Multiple Comorbid Chronic Disease (MCCD) within homeless and non-homeless Veterans and the association between MCCD and inpatient medical care.

METHODS

All individuals seen in the VA North Texas Health Care System between October 1, 2009 and September 30, 2010 (n = 102,034) were evaluated. Homelessness during the year and the number of common chronic diseases were evaluated for an association with likelihood of medical and psychiatric hospitalizations, bed days of care, inpatient substance treatment, rehabilitation admissions, and emergency department visits.

RESULTS

Homeless Veterans had higher all-cause mortality rates and rates of use of almost all resources after controlling for chronic disease burden using the Charlson Comorbidity Index, psychiatric illnesses, substance use disorders, and demographic variables.

CONCLUSIONS

Homelessness Veterans are vulnerable to a high use of resources and mortality, independent of medical and psychiatric conditions. This finding should focus additional attention on reducing homelessness.

Desire across borders: markets, migration, and marital HIV risk in rural Mexico

This paper presents five concepts that articulate specific processes through which political and economic factors shape sexuality, drawing on ethnographic research on changing notions of marriage, love, and sexuality conducted in migrant-exporting rural Mexico and with Mexican migrants in Atlanta and New York. The first section describes how changing beliefs about love, marriage, sexual intimacy and fidelity constitute a cultural terrain which facilitates 'vaginal marital barebacking' in rural Mexico. The paper details sexual opportunity structures; sexual geographies; the multi-sectoral production of risk (including the ways in which housing, transportation, and other policy sectors together create the 'recreation-deserts' in which many migrants live); sexual projects, and externalities as conceptual tools that articulate how political and economic factors from the meso- to the macro-level shape sexuality.

Is there life after DEBI? Examining health behavior maintenance in the diffusion of effective behavioral interventions initiative

The evidence-based interventions that are identified, packaged, and disseminated by the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention as part of the Diffusion of Effective Behavioral Interventions (DEBI) initiative-commonly referred to the "DEBIs"-currently represent a primary source of HIV prevention interventions for community-based providers. To date, little attention has focused on whether the intended outcomes of the DEBIs, i.e., reductions in HIV-related risk behaviors, are maintained over time. This review summarized evidence for the sustainability of the effects of the DEBIs on HIV sexual risk behavior and intravenous drug use from studies of original and adapted DEBIs. Evidence of intervention decay or a lack of any intervention effect was identified in several original and adapted versions of the DEBIs included in this review. Recommendations include modifications to current criteria for inclusion in the DEBI portfolio, in addition to the development of remediation strategies to address intervention decay. Further, theoretical models that specify the processes that underlie the maintenance of health behaviors over time should be used in developing HIV prevention interventions.

Tuberculosis among the homeless, United States, 1994-2010

OBJECTIVES

1) To describe homeless persons diagnosed with tuberculosis (TB) during the period 1994-2010, and 2) to estimate a TB incidence rate among homeless persons in the United States.

METHODS

TB cases reported to the National Tuberculosis Surveillance System were analyzed by origin of birth. Incidence rates were calculated using the US Department of Housing and Urban Development homeless population estimates. Analysis of genotyping results identified clustering as a marker for transmission among homeless TB patients.

RESULTS

Of 270,948 reported TB cases, 16,527 (6%) were homeless. The TB incidence rate among homeless persons ranged from 36 to 47 cases per 100,000 population in 2006-2010. Homeless TB patients had over twice the odds of not completing treatment and of belonging to a genotype cluster. US- and foreign-born homeless TB patients had respectively 8 and 12 times the odds of substance abuse.

CONCLUSIONS

Compared to the general population, homeless persons had an approximately 10-fold increase in TB incidence, were less likely to complete treatment and more likely to abuse substances. Public health outreach should target homeless populations to reduce the excess burden of TB in this population.

EXPLORING MULTIPLE LEVELS of ACCESS to RENTAL SUBSIDIES and SUPPORTIVE HOUSING

Despite the well-documented benefits of stable housing, there are myriad barriers that preclude low-income and homeless individuals from accessing housing support. This paper examines which individual characteristics predict greater or more limited access to supportive housing and rental subsidy programs in Hartford, Connecticut. Although individuals with HIV/AIDS are most likely to access housing, limited options remain for other vulnerable populations, including those with substance use disorders and mental illness.

Relationship among adverse childhood experiences, history of active military service, and adult outcomes: homelessness, mental health, and physical health

OBJECTIVES

We determined whether a report of adverse childhood experiences predicts adult outcomes related to homelessness, mental health, and physical health and whether participation in active military service influences the relationship between childhood and adult adversity.

METHODS

Using data from the 2010 Washington State Behavioral Risk Factor Surveillance System, we tested by means of logistic regression the relationship between adverse childhood experiences and 3 adult outcomes--homelessness, mental health, and physical health--as well as differences among those with a history of active military service.

RESULTS

Adverse childhood experiences separately predicted increased odds of experiencing homelessness as an adult and mental health and physical health problems. Childhood adversity increased the likelihood of adult homelessness and poor physical health among individuals with no history of active military service and the likelihood of mental health problems among individuals with a history of active military service.

CONCLUSIONS

The relationship between childhood adversity and adult adversity changes in degree when history of active military service is controlled, which has implications for Armed Forces recruitment strategies and postmilitary service risk assessment.

To use or not to use: a stage-based approach to understanding condom use among homeless youth

This study used a stage-based approach to understand condom use behavior in a representative sample of 309 sexually active homeless youth recruited from shelters, drop-in centers, and street sites in Los Angeles County. Focusing on the youth's most recent sexual event, the three stages of condom use examined were: (1) whether the partners decided prior to the event about using condoms; (2) whether a condom was available at the event; and (3) whether a condom was used at the event. Logistic regression analysis was used to identify attitudinal, relationship, and contextual correlates of each of these three stages. Deciding ahead of time about condom use was associated with being Hispanic, level of education, condom attitudes, and various relationship characteristics (e.g., partner type, monogamy, relationship abuse), with the nature of these associations varying depending on the type of decision (i.e., deciding to use, deciding to not use). Condom availability was more likely to be reported by males, if the event was described as being special in some way, or if the event lacked privacy. Condom use was more likely among youth with more positive condom attitudes and among youth who decide ahead of time to use a condom, but less likely among those in monogamous relationships or when hard drugs were used prior to sex. Whether sexual intercourse is protected or unprotected is the end result of a series of decisions and actions by sexual partners. Results from this study illustrate how condom use can be better understood by unpacking the stages and identifying influential factors at each stage. Each stage may, in and of itself, be an important target for intervention with homeless youth.

A cross-sectional evaluation of the prevalence and associations of HIV among female sex workers in the Gambia

To determine HIV prevalence among female sex workers in the Gambia and HIV risk factors, we accrued participants (n = 251) through peer-referral and venue-based recruitment. Blood samples were screened for HIV and participants were administered a questionnaire. Bivariate and multivariate logistic regression identified factors associated with HIV status. Forty respondents (15.9%) were HIV-positive: 20 (8.0%) were infected with HIV-1 only, 10 (4.0%) with HIV-2 only, and 10 (4.0%) with both HIV-1 and HIV-2; 12.5% (n = 5/40) knew their status. Condom usage at last sex was 97.1% (n = 170/175) with new clients and 44.2% (n = 53/120) with non-paying partners. Having a non-paying partner, living with relatives or friends, having felt scared to walk in public, selling sex in multiple locations, and recent depressive symptoms were positively associated with HIV under multivariate regression. Female sex workers have a higher prevalence of HIV compared to the general Gambian population. Interventions should be rights-based, promote safer sex practices and regular testing for female sex workers and linkage to HIV treatment and care with adherence support for those living with HIV. In addition, service providers should consider non-paying partners of female sex workers, improve knowledge and availability of condoms and lubricant, and address safety and mental health needs.

Understanding heterosexual condom use among homeless men

This study uses an event-based approach to examine individual, relationship, and contextual correlates of heterosexual condom use among homeless men. Structured interviews were conducted with a predominantly African American sample of 305 men recruited from meal lines in the Skid Row area of Los Angeles. Men reported on their most recent heterosexual event involving vaginal or anal intercourse. Adjusting for demographic characteristics only, condom use was more likely when men had higher condom use self-efficacy, greater HIV knowledge, or talked to their partner about condoms prior to sex. Condom use was less likely when men held more negative attitudes towards condoms, the partner was considered to be a primary/serious partner, hard drug use preceded sex, or sex occurred in a public setting. Condom attitudes, self-efficacy, partner type, and communication were the strongest predictors of condom use in a multivariate model that included all of the above-mentioned factors. Associations of unprotected sex with hard drug use prior to sex and having sex in public settings could be accounted for by lower condom self-efficacy and/or less positive condom attitudes among men having sex under these conditions. Results suggest that it may be promising to adapt existing, evidence-based IMB interventions for delivery in non-traditional settings that are frequented by men experiencing homelessness to achieve HIV risk reduction and thus reduce a significant point of disparity for the largely African American population of homeless men.

Unprotected sex among heterosexually active homeless men: results from a multi-level dyadic analysis

HIV is a serious public health problem for homeless populations. Homeless men who have sex with women have received less attention in the HIV risk literature than other homeless populations. This research uses multi-level modeling to investigate the context of unprotected sex among heterosexually active homeless men in the Skid Row area of Los Angeles. Based on interviews with 305 randomly selected men who discussed 665 of their recent female sexual relationships, this project investigates the correlates of unprotected sex during the past 6 months at the partnership, individual, and social network levels. Several different measures of relationship closeness and lack of communication about HIV/condoms were associated with unprotected sex. Controlling for relationship factors, men's negative attitudes towards condoms, mental health, and higher number of male sex partners also were associated with having unprotected sex with female partners. We discuss the implications of these findings for health interventions.

Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV

We present a cost-utility analysis based on data from the Housing and Health (H&H) Study of rental assistance for homeless and unstably housed persons living with HIV in Baltimore, Chicago and Los Angeles. As-treated analyses found favorable associations of housing with HIV viral load, emergency room use, and perceived stress (an outcome that can be quantitatively linked to quality of life). We combined these outcome data with information on intervention costs to estimate the cost-per-quality-adjusted-life-year (QALY) saved. We estimate that the cost-per-QALY-saved by the HIV-related housing services is $62,493. These services compare favorably (in terms of cost-effectiveness) to other well-accepted medical and public health services.

Neighborhoods and HIV: a social ecological approach to prevention and care

Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

Developing effective health interventions for women who inject drugs: key areas and recommendations for program development and policy

Women who inject drugs face multiple gender-specific health risks and barriers to healthcare access. These gendered factors may contribute to elevated rates of HIV for this population. Though few countries systematically collect gender-disaggregated data related to injecting drug use, evidence indicates that there are large populations of women who inject drugs and who are in need of improved health services, including HIV prevention. Research on the effectiveness of interventions specifically tailored for women who inject drugs, along with the experience of programs working with this subpopulation, suggests that HIV risk practices need to be addressed within the larger context of women's lives. Multifaceted interventions that address relationship dynamics, housing, employment, and the needs of children may have more success in reducing risky practices than interventions that focus exclusively on injecting practices and condom use. Improved sexual and reproductive healthcare for women who use drugs is an area in need of development and should be better integrated into basic harm reduction programs.

Social network and individual correlates of sexual risk behavior among homeless young men who have sex with men

PURPOSE

There is growing interest in network-based interventions to reduce HIV sexual risk behavior among both homeless youth and men who have sex with men. The goal of this study was to better understand the social network and individual correlates of sexual risk behavior among homeless young men who have sex with men (YMSM) to inform these HIV prevention efforts.

METHODS

A multistage sampling design was used to recruit a probability sample of 121 homeless YMSM (ages: 16-24 years) from shelters, drop-in centers, and street venues in Los Angeles County. Face-to-face interviews were conducted. Because of the different distributions of the three outcome variables, three distinct regression models were needed: ordinal logistic regression for unprotected sex, zero-truncated Poisson regression for number of sex partners, and logistic regression for any sex trade.

RESULTS

Homeless YMSM were less likely to engage in unprotected sex and had fewer sex partners if their networks included platonic ties to peers who regularly attended school, and had fewer sex partners if most of their network members were not heavy drinkers. Most other aspects of network composition were unrelated to sexual risk behavior. Individual predictors of sexual risk behavior included older age, Hispanic ethnicity, lower education, depressive symptoms, less positive condom attitudes, and sleeping outdoors because of nowhere else to stay.

CONCLUSIONS

HIV prevention programs for homeless YMSM may warrant a multipronged approach that helps these youth strengthen their ties to prosocial peers, develop more positive condom attitudes, and access needed mental health and housing services.

Quality of life themes in Canadian adults and street youth who are homeless or hard-to-house: a multi-site focus group study

BACKGROUND

The aim of this study was to identify what is most important to the quality of life (QoL) of those who experience homelessness by directly soliciting the views of homeless and hard-to-house Canadians themselves. These individuals live within a unique social context that differs considerably from that of the general population. To understand the life areas that are most important to them, it is critical to have direct input from target populations of homeless and hard-to-house persons.

METHODS

Focus groups were conducted with 140 individuals aged 15 to 73 years who were homeless or hard-to-house to explore the circumstances in which they were living and to capture what they find to be important and relevant domains of QoL. Participants were recruited in Toronto, Ottawa, Montreal, and Vancouver. Content analysis was used to analyze the data.

RESULTS

Six major content themes emerged: Health/health care; Living conditions; Financial situation; Employment situation; Relationships; and Recreational and leisure activities. These themes were linked to broader concepts that included having choices, stability, respect, and the same rights as other members of society.

CONCLUSIONS

These findings not only aid our understanding of QoL in this group, but may be used to develop measures that capture QoL in this population and help programs and policies become more effective in improving the life situation for persons who are homeless and hard-to-house. Quality of life themes in Canadian adults and street youth who are homeless or hard-to-house: A multi-site focus group study.

Prevalência e vulnerabilidade à infecção pelo HIV de moradores de rua em São Paulo, SP

OBJETIVO: Analisar a prevalência e o perfil de vulnerabilidade ao HIV de moradores de rua. MÉTODOS: Estudo transversal com amostra não probabilística de 1.405 moradores de rua usuários de instituições de acolhimento de São Paulo, SP, de 2006 a 2007. Foi realizado teste anti-HIV e aplicado questionário estruturado. O perfil de vulnerabilidade foi analisado pela frequência do uso do preservativo, considerando mais vulneráveis os que referiram o uso nunca ou às vezes. Foram utilizadas regressões logística e multinomial para estimar as medidas de efeito e intervalos de 95% de confiança. RESULTADOS: Houve predominância do sexo masculino (85,6%), média de 40,9 anos, ter cursado o ensino fundamental (72,0%) e cor não branca (71,5%). A prática homo/bissexual foi referida por 15,7% e a parceria ocasional por 62,0%. O número médio de parcerias em um ano foi de 5,4 e mais da metade (55,7%) referiu uso de drogas na vida, dos quais 25,7% relataram uso frequente. No total, 39,6% mencionaram ter tido uma doença sexualmente transmissível e 38,3% relataram o uso do preservativo em todas as relações sexuais. A prevalência do HIV foi de 4,9% (17,4% dos quais apresentaram também sorologia positiva para sífilis). Pouco mais da metade (55,4%) tinha acesso a ações de prevenção. A maior prevalência do HIV esteve associada a ser mais jovem (OR 18 a 29 anos = 4,0 [IC95% 1,54;10,46]), história de doença sexualmente transmissível (OR = 3,3 [IC95% 1,87;5,73]); prática homossexual (OR = 3,0 [IC95% 1,28;6,92]) e à presença de sífilis (OR = 2,4 [IC95% 1,13;4,93]). O grupo de maior vulnerabilidade foi caracterizado por ser mulher, jovem, ter prática homossexual, número reduzido de parcerias, parceria fixa, uso de drogas e álcool e não ter acesso a ações de prevenção e apoio social. CONCLUSÕES: O impacto da epidemia entre moradores de rua é elevado, refletindo um ciclo que conjuga exclusão, vulnerabilidade social e acesso limitado à prevenção.