HIV/AIDS & HOMELESSNESS

Recommendations for Clinical Practice

and Public Policy

Developed for

The Bureau of Primary Health Care and

The HIV/AIDS Bureau

Health Resources and Services Administration

John Song, M.D., M.P.H., M.A.T.

November 1999

Financial and other support for the development and distribution of this paper were provided by the
Bureau of Primary Health Care and the HIV/AIDS Bureau, Health Resources Services Administra-
tion, United States Department of Health and Human Services, to the National Health Care for the
Homeless Council, Inc., and its subsidiary, the Health Care for the Homeless Clinicians Network.

The views presented in this paper are those of the author and do not necessarily represent those of
the United States government or of the National Health Care for the Homeless Council.

Nothing in this paper should be construed as providing authoritative guidelines for the practice of
medicine or for treatment of medical conditions.

This paper may be reproduced in whole or in part with appropriate recognition to the author, John Y.
Song, MD, and the publisher, the Health Care for the Homeless Clinicians Network, National
Health Care for the Homeless Council, Inc.

Second Printing
February, 2000

National Health Care for the Homeless Council

Health Care for the Homeless Clinicians Network

Post Office Box 60427

Nashville TN 37206-0427

Phone 615/226-2292

Fax 615/226-1656

council@nhchc.org or network@nhchc.org

http://www.nhchc.org

iii

PREFACE

HIV/AIDS and homelessness are twin plagues that take a staggering toll. Each condition complicates
the other, and lives hang in the balance as health care providers and their patients try to sort through
the complications and assure critical services. This paper is dedicated to the improvement of
HIV/AIDS care for homeless people, and to the end of both of these plagues.

In considering HIV/AIDS and homelessness together, this paper explores largely uncharted territory.

Its principle author, Dr. John Y. Song, brought to the task his insight from treating HIV-infected peo-
ple as a volunteer with Health Care for the Homeless, Inc., of Maryland, and writing skills honed in
part through his experience as a leader of a homeless writers group in Baltimore. He also brought a
kind and generous heart. We are grateful that Dr. Song chose to devote part of his dual fellowship in
General Internal Medicine and in Ethics and Public Policy to this project. The Johns Hopkins School
of Medicine and Georgetown University deserve appreciation for the support they provided for his
endeavor.

In defining the parameters of the paper, Dr. Song consulted with an HIV/AIDS Advisory Committee
of the Health Care for the Homeless Clinicians Network, whose members also reviewed various
drafts as the work progressed. Advisory Committee members are listed in Appendix IV. Brenda J.
Proffitt, MHA, ably staffed and guided the Committee in her role as Project Director for the HCH
Clinicians Network.

A Symposium on HIV/AIDS and Homelessness convened by two agencies of the Health Re-

sources Services Administration, the Bureau of Primary Health Care and the HIV/AIDS Bureau
brought together researchers, HIV-infected homeless people, health care providers, HIV/AIDS spe-
cialists and homeless advocates to contribute further advice to the project. Many of the recommen-
dations in this paper emerged from that very productive Symposium. Participants are listed in
Appendix V.

Special thanks is due to Jean L. Hochron, MPH, and Lori S. Marks, BA, of the Bureau of Primary
Health Cares Division of Programs for Special Populations, for understanding the need for this publi-
cation and for guiding its development. Equally valuable were the support and resources provided by
HRSA's HIV/AIDS Bureau staff, particularly Magda L. Barini-Garcia, MD, MPH, and Kim Y. Evans,
MHS. Patricia A. Post, MPA, Communications Manager for the National Health Care for the Home-
less Council, edited this paper into its final form with remarkable skill. Carlos Velez also provided
editorial assistance.

Thank you to all who contributed to the work represented here, and to the many others who struggle
against HIV/AIDS and homelessness each day.

John N. Lozier, MSSW
Executive Director
National Health Care for the Homeless Council

TABLE OF CONTENTS

EXECUTIVE SUMMARY

1 5

II. INTRODUCTION

7 8

III. HIV PREVENTION

9 11

A. Background

1. Substance Abuse Treatment

2. Mental Health Care

3. Targeted Prevention

4. Harm Reduction

B. Recommendations

1. Clinical Recommendations

2. Public Policy Recommendations

IV. ACCESS TO CARE

13 19

A. Background

1. Barriers to Health Care

2. HIV Counseling and Testing

3. Continuity of Care

4. Appropriate and Proficient Care

B. Recommendations

1. Clinical Recommendations

2. Public Policy Recommendations

V. GENERAL HIV CARE

21 27

A. Background

1. Immunizations and Testing

2. Tuberculosis

3. Homeless Women

4. Rural Areas

B. Recommendations

1. Clinical Recommendations

2. Public Policy Recommendations

vii

VI. ANTIRETROVIRAL TREATMENT

29 33

A. Background

1. Treatment Failure

2. Resistance

3. Combinations without Protease Inhibitors

4. Access

B. Recommendations

1. Clinical Recommendations

2. Public Policy Recommendations

VII.

ADHERENCE

35 38

A. Background

1. Adherence Assessment

2. Reasons for Non-Adherence

3. Maximizing Adherence

4. Public Health Considerations

B. Recommendations

1. Clinical Recommendations

2. Public Policy Recommendations

VIII. RESEARCH

39 40

A. Background

1. Needs Assessment

2. Priorities

B. Recommendations

1. Epidemiology

2. Behavioral Research

3. Clinical Research

4. Policy Research

Appendix I - REFERENCES

43 58

Appendix II - CASE HISTORIES

59 68

Appendix III - GLOSSARY

Appendix IV - HCH CLINICIANS' NETWORK HIV/AIDS ADVISORY COMMITTEE

Appendix V - SYMPOSIUM ON HIV/AIDS AND HOMELESSNESS PARTICIPANTS

73 75

EXECUTIVE SUMMARY

This document is intended for clinicians and other service providers, health care policy makers and

advocates. It was developed by the National Health Care for the Homeless Council in collaboration

with the Bureaus of Primary Health Care and HIV/AIDS, Health Resources and Services Admini-

stration, Department of Health and Human Services, in response to the following concerns:

The prevalence of HIV/AIDS is dramatically higher among homeless people

than in the general population.

Homelessness and HIV/AIDS are widespread and intersecting problems that

occur in both urban and rural populations throughout the United States.

Conditions associated with homelessness make HIV prevention and control

especially difficult.

Limited access to medical care severely restricts HIV/AIDS prevention, risk

reduction and treatment for homeless persons.

Adherence to complex HIV treatment regimens presents special challenges

for homeless patients and their caregivers.

Of the 400,000 to 600,000 individuals currently estimated to be living with AIDS in the United

States (CDC), approximately one-third to one-half are either homeless or at imminent risk of home-

lessness (Goldfinger, as cited in ACLU). Median prevalence rates of the human immunodeficiency

virus (HIV) that causes AIDS have been found to be at least three times higher 3.4% versus un-

der 1% in homeless populations than in the general population (Allen). Even higher prevalence

rates (8.5% 62%) have been reported in various homeless subpopulations, including adults with

severe mental illness (Zolopa; Paris; Susser; Fournier; Torres).

Neither HIV nor homelessness is limited to urban populations. Both problems are widespread, inter-

secting in rural and urban areas across the United States. Although the prevalence of HIV is likely

to be highest in large metropolitan areas, there is evidence that the AIDS case rate is increasing

more in non-metropolitan areas (CDC). Among persons known to be at highest risk for HIV infec-

tion, including intravenous drug users and persons engaging in high-risk sexual behaviors, those

without a stable home are even more likely to be HIV-positive, wherever they may live (Wiebel;

Smereck).

Although new medications have reduced the number of HIV cases that progress to full-blown

AIDS, antiretroviral therapy is not universally available. Despite their disproportionately high risk

for HIV infection and transmission, homeless individuals have limited access to preventive and

therapeutic HIV/AIDS care. Moreover, their limited access to comprehensive health care delays the

identification of HIV, accelerates the onset of AIDS, and impedes the resolution of behavioral dis-

orders that interfere with HIV risk reduction and treatment. Restricted access to health care is also

a contributing factor in the increased prevalence of opportunistic infections and other medical con-

ditions, including tuberculosis, that are more common among homeless people than among other

groups.

To address these critical public health issues, access to health care for homeless individuals must be

increased through expanded health coverage. Better coordination of care must be achieved among

providers of clinical and social services, which must include behavioral health care and housing. In

addition, continuity of care must be improved, especially following admission to and discharge from

inpatient and criminal justice facilities.

HIV/AIDS Prevention

Preventive measures commonly used in other populations at increased risk for HIV infection are of-

ten unavailable to homeless men and women. Although homeless shelters, food kitchens and clinics

are ideal settings for primary HIV prevention, insufficient resources limit the health education and

risk reduction interventions these organizations can provide.

Nor are HIV testing and counseling generally available to homeless individuals, who experience

unique barriers even when these services are available. Travel to clinics for testing or to obtain test

results is often difficult for people experiencing homelessness, and mobile testing is not provided

with sufficient frequency. Homeless persons testing positive for HIV who seek care are often unable

to obtain referrals to HIV/AIDS specialty clinics. Compounding these barriers is the lack of routine

screening of homeless individuals for sexually transmitted disease, psychoactive substance abuse and

mental illness. Early identification and treatment of these conditions would assist in HIV and AIDS

prevention.

A number of strategies shown to reduce HIV risks in the homeless population, including substance

abuse treatment, needle exchange programs, safe injection education and the provision of condoms,

are not routinely available. Linkages among primary care, HIV treatment and behavioral health

services, though effective where they exist, are also limited. Similarly, some clinical and social ser-

vice providers lack sufficient training to engage homeless clients active participation in HIV risk

reduction.

To address these limitations, policy makers, community planning groups and health care providers

must assure that HIV prevention programs are made available to all homeless individuals, and that

preventive interventions are culturally, developmentally and linguistically appropriate for the indi-

viduals they are intended to influence. In addition, harm reduction initiatives should be adequately

funded to reduce known risks of HIV infection for homeless individuals. Finally, treatment for HIV,

substance abuse and mental illness should be linked to primary care services and coordinated by ex-

perienced homeless providers.

Access to Comprehensive Health Care

Although many Americans have limited access to comprehensive and well-coordinated health care,

individuals who experience homelessness are particularly vulnerable to increased morbidity and

mortality when excluded from integrated medical and behavioral health services. Among the most

significant health care access barriers are lack of health insurance and financial resources, difficulty

managing entitlement processes, lack of transportation, and a limited number of culturally and lin-

guistically competent caregivers who are willing and able to serve poor and homeless people. Be-

cause subsistence needs take most of their time and energy, most homeless people relegate preven-

tive and primary health care to a lower priority in their lives. Lack of provider flexibility (e.g., office

hours limited to times when homeless patients are unable to keep appointments) makes needed care

even harder to obtain.

Influenza and other respiratory infections, diabetes, anemia and liver disease are among the condi-

tions that tend to be more serious and complex for homeless individuals, primarily because they do

not obtain care early. Lack of adequate food and financial resources exacerbates medical problems.

All medical conditions are made more complex by HIV, which disrupts the bodys natural response

to disease. Thus it is essential for health care providers to screen and treat homeless clients for a

wide variety of common medical conditions.

Access to HIV Care

While traditional homeless service providers and other community-based clinics can provide neces-

sary primary care services, they often lack the resources and expertise to provide sufficient HIV care.

Homeless individuals who receive health care services from safety net providers may have limited

access to HIV testing and specialty care. Restricted access to mental health and addictions treat-

ment can further delay and compromise the efficacy of HIV therapy.

Treatment should be made available for all conditions that impact on HIV care, including other

sexually transmitted diseases, hepatitis, substance abuse and mental illness. Goods and resources

that make care more effective, such as food, shelter and bathroom facilities, should be provided

where necessary as an integral part of HIV care.

Prophylactic antibiotic therapy for opportunistic infections (OIs) is relatively inexpensive and can

reduce morbidity and mortality in HIV-infected persons. Treatment of these conditions can also

prepare homeless clients to adhere to more complex treatment regimens. Nevertheless, not all

homeless people who need OI prophylaxis receive it. Whether clinicians are not offering homeless

clients treatment, or whether they are refusing it (or both) is unclear. In any case, clinicians should

be persistent and creative in their efforts to make OI prophylaxis available to homeless clients, and

encourage adherence to antibiotic therapy.

Antiretroviral Therapy

During the last several years, biomedical research has produced a variety of antiretroviral therapeu-

tic agents that have proven effective in suppressing HIV in infected persons. Tests used to measure

HIV progression have also improved substantially with the calculation of HIV viral loads in blood

plasma. The level of HIV in the blood can be seen as a predictor of disease progression. Combina-

tions of various antiretroviral agents, when taken as prescribed, can reduce viral loads to undetect-

able levels in relatively short periods of time.

To be successful, antiretroviral therapy requires diligent patient adherence to complicated treatment

regimens. Patients may have to take more than twenty pills in several doses daily, following strict

dietary instructions. In addition, some individuals experience severe side effects. Antiretroviral

therapy does not work for everyone, especially for individuals who do not take their medications as

prescribed. They risk treatment failure and the development of drug resistance. When a particular

treatment fails, the patient may not be able to resume it, as the medication may no longer be effec-

tive in suppressing the virus in that individual. In some instances, failure of a particular medication

may mean that other medications are not effective either, due to a phenomenon called cross-

resistance.

Prescribing antiretroviral therapy requires a detailed assessment of the individuals health status and

lifestyle to assure that medications can be taken as prescribed, with adjustments in therapy where

possible to maximize adherence. Especially promising for some individuals are simpler protease-

sparing treatment regimens that achieve viral suppression while reducing the risk of drug resistance.

An individuals viral load must be monitored closely in case it does not respond to treatment or re-

bounds after decreasing initially. If a patient fails a particular drug combination, other combinations

may be prescribed.

Because antiretroviral therapy is expensive, it is not always available to individuals who are poor and

homeless. Although antiretroviral medications are becoming more affordable through government

programs and charitable sources, not all homeless individuals have access to them or to clinicians

who are familiar with antiretroviral therapy. Additional steps should be taken to make antiretroviral

therapy more accessible to homeless persons and to provide them and their clinical providers with

the education and resources needed to make treatment successful.

Adherence

It is generally believed that failure of antiretroviral therapy is most often due to lack of patient ad-

herence to the prescribed treatment regimen. Prior to prescribing antiretroviral medications, physi-

cians determine whether a particular individual can or will adhere to the therapy. Many homeless

persons are excluded from treatment because they lack stability, housing, regular access to food, wa-

ter and other resources needed to ensure adherence to antiretroviral therapy. In addition, substance

abuse disorders, which affect significant numbers of homeless individuals, are generally considered to

be grounds for withholding antiretroviral therapy because they can undermine patients capacity to

adhere reliably to any treatment regimen.

Nevertheless, there are no absolute contraindications to antiretroviral therapy. While it is impor-

tant to prescribe complex treatment regimens, where appropriate, to individuals who can adhere to

them, it is also essential to assist others to obtain the most effective alternative treatment available.

Clinicians and service providers should make an in-depth assessment of the impediments their pa-

tients may face in adhering to therapy. Rather than using the assessment as a basis for denial of

treatment, physicians should respond to identified barriers by working with their patients to over-

come them or prescribe regimens that are easier to follow. Where possible, clinicians should pre-

scribe medications that can suppress HIV in simple combinations a rational strategy for all pa-

tients, whether or not they have stable housing.

Patient adherence can also be facilitated through co-management of care by clinicians, non-clinical

service providers and other individuals who are in regular contact with homeless individuals. With

the exception of some case managers, non-clinical service providers tend to be poorly informed

about antiretroviral therapy. It is essential, therefore, that all homeless service providers obtain ba-

sic information about antiretroviral therapy, including how it works and how to manage side effects.

In this way, a variety of trained service providers and support personnel can assist homeless patients

in maintaining appropriate adherence to HIV treatment.

Research

The research literature on HIV/AIDS and homelessness, though sparse, clearly identifies barriers to

prevention, health care access and treatment faced by homeless people living with HIV, and points

to a number of areas where more investigation is needed. More targeted studies employing standard-

ized methodologies are needed to form a scientific basis for the development of successful

HIV/AIDS prevention and treatment strategies for people who lack stable housing.

Such research is warranted by the preliminary evidence, reported here, that HIV/AIDS has a dis-

proportionate effect on particular homeless subpopulations, and that HIV-infected, housed persons

are at increased risk of becoming homeless. Failure to measure the scope of HIV/AIDS within the

homeless population and to develop effective prevention and treatment strategies is likely to exacer-

bate the serious public health problem which the human immunodeficiency virus and its devastating

sequelae already present.

Epidemiological studies are needed to better characterize the extent of HIV/AIDS among homeless

people and the extent of homelessness among persons with HIV/AIDS. These include focused stud-

ies on homeless subpopulations for whom HIV prevention and care are known to be especially prob-

lematic e.g., rural populations, homeless women and transgendered individuals. Behavioral re-

search is required to develop successful strategies for decreasing HIV transmission among homeless

persons, and to identify individual characteristics that may increase treatment adherence.

Clinical research is needed to measure the impact of co-morbidities and nutritional deficiences on

HIV/AIDS progression, to quantify immunization rates and determine outcomes of antiretroviral

therapy in the homeless population. Finally, policy research is needed to document the impact of

health coverage on HIV-infected homeless persons health and access to care, and to develop strate-

gies to increase access to comprehensive health care for all homeless people.

II.

INTRODUCTION

L. T. started antiretroviral medications in 1997, taking them for six months with dili-

gence. During that time, he was housed in a single residence hotel. When he became

homeless again, however, he told me that he knew that he would not be able to take

his medications as prescribed, and he did not want to take them for fear of resistance.

For the last year, L. T. has been homeless and not taking medication. His CD4 count

fell to 250 and his viral load climbed to over 300,000. He is aware that he may be in

trouble medically.

Barry Zevin, M.D., San Francisco

Between 1981 and 1999, the United States Public Health Service reported 688,200 cases of ac-

quired immunodeficiency syndrome (AIDS). Currently, 400,000 600,000 U.S. residents are esti-

mated to be living with the human immunodeficiency virus (HIV) that causes AIDS, and about

40,000 new cases of HIV are reported each year (CDC). An estimated one-third to one-half of peo-

ple living with AIDS in the United States are either homeless or at imminent risk of homelessness

(Goldfinger, as cited in ACLU).

A large, multi-site housing needs assessment survey found that 41% of respondents with HIV/AIDS

had been homeless sometime in their lives (Lieberman), and local needs assessments from Los An-

geles and Philadelphia portray similar housing instability among those with HIV/AIDS (Low;

Aquaviva). Given that homeless people in general are less likely to be counted (Link) and are less

likely to be tested for HIV than housed individuals (Rockwell), these figures probably underestimate

the scope of the problem.

The prevalence of HIV infection in homeless populations studied is at least three times higher than

in the general population. A multi-site study tracking the spread of HIV in 16 U.S. cities between

1989 and 1992 reported a median HIV seroprevalence of 3.4% among homeless adults, compared to

less than 1% in the general population (Allen). Local studies conducted during the 1990s in urban

areas with high HIV prevalence rates have reported even higher rates of HIV infection in homeless

subgroups, ranging from 8.5% to 62% (Zolopa; Paris; Susser; Fournier; Torres). Although the range

is broad because of different study protocols, locales, subpopulations and definitions of homelessness,

these figures are significantly higher than the estimated prevalence in the general population.

Among persons known to be at highest risk for HIV infection intravenous drug users and persons

engaging in high-risk sexual behaviors those who do not have a stable home are even more likely

to be HIV-positive (Wiebel; Smereck). A 1995 study found that 69% of homeless adults surveyed

were at risk for HIV infection from unprotected sex with multiple partners, injection drug use

(IDU), sex with IDU partners, or exchanging unprotected sex for money or drugs (St. Lawrence;

ACLU). Homeless persons with severe mental illness and/or chemical dependencies are especially

vulnerable to the disease because of their impaired capacity to learn and practice risk reduction be-

haviors (Susser).

Homeless people have alarmingly high HIV infection rates for a variety of reasons, including en-

gagement in high-risk behaviors and the lack of resources to prevent HIV transmission. For those

already infected, HIV antiretroviral therapy (ART) is often delayed or never begun. Even when ini-

tiated, treatment regimens are so complex that they pose adherence difficulties that may result in

the development of drug-resistant strains of the virus. Lack of health insurance, transportation,

housing and other subsistence needs make health care extremely difficult for homeless individuals to

obtain, resulting in poorer health and diminished capacity to resolve problems that led to their

homelessness in the first place. When these problems are compounded by HIV/AIDS, they are be-

yond the capacity of homeless individuals to solve alone.

In response to these issues, the National Health Care for the Homeless Council initiated a project in

1998 to gather more detailed information about HIV and homelessness in the United States. Inter-

mediate goals were to explore problems encountered by clinicians serving homeless people who are

engaged in HIV prevention and treatment, and to derive from their experience recommendations

for clinical practice and public policy. The ultimate goal of this project is to improve HIV prevention

and care for all people who are homeless.

John Song, M.D., M.P.H., M.A.T., volunteered to spearhead this effort while completing dual fel-

lowships in General Internal Medicine at The Johns Hopkins University School of Medicine, Balti-

more, Maryland, and in Ethics and Public Policy at Georgetown University, Washington, DC. Dr.

Song conducted a comprehensive literature review, interviewed HIV specialists and other clinicians

experienced in treating homeless persons with HIV/AIDS, and conducted a survey of homeless ser-

vice providers through the Health Care for the Homeless Clinicians Network. On March 1920,

1999, the Bureaus of Primary Health Care and HIV/AIDS of the Health Resources and Services

Administration hosted a symposium to discuss HIV/AIDS and Homelessness, involving HIV-

infected homeless people, health care providers, researchers, advocates and policy makers. Dr. Song

summarized these discussions and information gathered from other sources to develop this docu-

ment, in collaboration with the National Health Care for the Homeless Council.

The document is intended for clinicians and other service providers, policy makers and advocates,

and contains information that should help all of these parties to better understand and address a va-

riety of issues faced by persons living with HIV. The document explores current practices of clini-

cians who provide HIV care to homeless patients, including factors they should take into account

when prescribing highly active antiretroviral therapy (HAART). It also identifies deterrents to

HIV/AIDS prevention and optimal care for homeless individuals, and suggests directions for further

discussions among clinicians and policy makers to help overcome these barriers.

III.

HIV PREVENTION

S. A. was 21 years old when I met her in March 1997. She was brought to our urgent

care clinic by an outreach worker who told me that S. A. only spoke Spanish and was

recently released from jail for prostitution. She was at the time in one of the city shel-

ters, where our medical and social services staff had established a satellite clinic. S.A. is

a transgender male to female, who tested HIV-positive a year before. She was rejected

by her family in Mexico and came to the U. S. two years ago with a boyfriend. Shortly

after arriving in the States, S. A. was alone and depending on sex work for an income.

She had multiple sexual encounters without protection, at her clients requests. She

was smoking methamphetamines and using injectable estrogens as frequently as she

could to keep her feminine characteristics.

Linette Martinez, M.D., San Francisco

Background

Homeless individuals engage in behaviors that place them at high risk for HIV infection, and do so

at alarming rates. These behaviors include injection drug use (Rekart; Erickson; Lieberman), high-

risk sexual behavior (Johnson; Hudson; Kouzi), needle-sharing (Williams; Rekart; Beardsley; Blu-

thenthal), shooting gallery use (Celentano; Beardsley), and exchange of sex for money or drugs

(Schilling; Corby). High-risk behaviors are motivated by the need to subsist on the streets, by co-

occurring mental illness and substance abuse, and by a peer culture that encourages these behaviors.

Data regarding the prevalence of addictive disorders among homeless people are varied. Studies

conducted in the 1980s, from which high prevalence rates are often quoted, over-represented long-

term shelter users and single males, among whom rates of substance abuse are known to be espe-

cially high. Moreover, these studies reported lifetime substance use rather than current addiction

(NCH). It is estimated that the prevalence of drug use among homeless people is 3040% (Koegel),

although some studies have demonstrated even higher proportions (Susser; Spinner; Robertson).

Substance Abuse Treatment

Although there are no generally accepted prevalence rates that accurately describe the proportion of

all homeless adults engaging in substance abuse, addictions are generally acknowledged to be more

prevalent in homeless than in domiciled populations. Nevertheless, treatment for substance abuse

and dependence is not usually available to homeless men and women, who are sometimes denied

treatment because they are homeless. Active substance abuse is associated with lack of access to

HIV care and poor adherence to antiretroviral therapy (Samet; Eldred; Ohmit).

In a study conducted by the HCH Clinicians Network, 78% of homeless health care providers sur-

veyed found it difficult to obtain substance abuse treatment for their HIV/AIDS patients

(HCHCN). Other studies found that less than half of homeless individuals in need of addiction

treatment obtained it (NCH), and that patients were excluded from treatment because they were

homeless (Oakley). Although estimates of the prevalence of alcohol and other drug use among

homeless individuals vary, alcohol use and alcohol use disorder are acknowledged to be more com-

mon among homeless than domiciled individuals (Robertson; Susser; Breakey; Wright).

Mental Health Care

High-risk behaviors are practiced regardless of a co-occurring mental illness (Valencia; Susser; Gold-

finger; Fischer), but mental illness is both an impetus and a consequence of substance abuse in many

homeless people, and can exacerbate high-risk behavior. Mental illness also complicates HIV pre-

vention and care (Ferrando; Singh; Chesney). Like addiction treatment, mental health services for

homeless people are often inadequate (Oakley). The HCHCN survey found that 69% of providers

had difficulty obtaining mental health services for their homeless patients.

Targeted Prevention

Homeless men and women engage in the exchange of sex for money or drugs, but lack the resources

to engage in safer sexual or other practices. Homeless women with children may place themselves at

increased risk for HIV transmission in response to the economic pressure of having to provide for

their families with few marketable skills. Individuals identified as homeless are more likely to engage

in high-risk behavior during periods of homelessness compared to periods of relative stability (Celen-

tano).

Few prevention programs are designed for people without stable housing, and studies demonstrate

that existing risk reduction interventions may not be as effective for homeless individuals as for their

domiciled counterparts (Clatts; Abdul-Quader). Nevertheless, successful risk reduction has been

demonstrated in homeless populations as a result of targeted prevention programs (Nyamathi;

Susser; Goulart).

Harm Reduction

Harm reduction refers to activities that are designed to reduce or minimize the damage caused by

high-risk behaviors such as injection drug use and prostitution (McMurray-Avila), with the ultimate

goal of eliminating these behaviors. Essential to the process of harm reduction is engagement, with

the realization that elimination of high-risk behavior may take time and small steps. Harm reduc-

tion techniques include needle exchange programs, safe injection education (such as sterilizing nee-

dles with bleach), safer sex negotiation, and relapse policies which recognize that treatment success

is often preceded by multiple episodes of failure.

Recommendations

Clinical Recommendations
HIV prevention and risk reduction should be an integral part of any program serving homeless peo-

ple. To be successful, prevention initiatives should include the following elements:

Provider training. All service providers who work with homeless people on a regular basis, both

clinical and non-clinical, should be trained in HIV prevention.

Engagement. Primary care providers should inquire tactfully but persistently about high-risk be-

haviors as a routine part of clinical assessments. Clinicians should provide HIV prevention and

risk reduction information and resources to their homeless clients, and should actively engage

them in preventing risky behaviors.

Cultural sensitivity. Information about HIV prevention and risk reduction should be culturally

and linguistically appropriate for the people expected to benefit from it. More educational mate-

rials targeted to particular homeless populations should be developed and made available.

Outreach. Street-based outreach is needed to convey HIV prevention information and re-

sources to unsheltered homeless persons. Targeted outreach to special populations women,

transgendered individuals, persons with chemical dependencies and rural populations is par-

ticularly needed. Prevention strategies should include providing access to condoms and clean

needles. Outreach services must be linked to HIV counseling and testing and to primary care

services.

Multidisciplinary linkages. Because many homeless people have multiple and complex health

conditions that heighten their risk for HIV infection, risk reduction interventions should involve

clinicians from multiple disciplines. All programs serving homeless individuals should establish

linkages with and provide referrals for primary care, substance abuse treatment and mental

health services.

HIV screening and testing. Access to HIV screening and provision of HIV prevention informa-

tion in shelters and mobile units are essential parts of risk reduction. Incentives should be pro-

vided to encourage patients to return for test results. Testing and treatment for sexually trans-

mitted diseases should also be provided, when necessary.

Substance abuse treatment. Substance abuse treatment providers should assess their clients

living conditions prior to beginning