HIV/AIDS and Homelessness
Published by the National Coalition for the Homeless, July 2009
The Human Immunodeficiency Virus (HIV), which is found in bodily fluids such as blood, semen, vaginal secretions, and breast milk, destroys the immune system by inserting its own genetic material into white blood cells called T cells. Over time, T cells are killed and HIV replicates. As the concentration of T cells falls, the immune system weakens, leaving the body open to opportunistic infections. The disease progresses through four stages, the last of which is full-blown AIDS, when the body has little natural immunity left. The average time from HIV infection to AIDS is 10 years, and a person may live for several months to five years after the AIDS diagnosis (Straub, 2007).
At the end of 2006, 1,106,400 people were estimated to have HIV/AIDS in the United States (Centers for Disease Control and Prevention). By the end of 2007, 455,636 of these people had progressed to AIDS, including 889 children under the age of 13. In 2007, 14,110 people died of AIDS-related causes. In the homeless population, HIV/AIDS is even more prevalent. The National Alliance to End Homelessness estimates that 3.4% of homeless people were HIV-positive in 2006, compared to 0.4% of adults and adolescents in the general population (Centers for Disease Control and Prevention, 2008).
RELATIONSHIP TO HOMELESSNESS
HIV/AIDS and homelessness are intricately related. The costs of health care and medications for people living with HIV/AIDS (PLWHA) are often too high for people to keep up with. In addition, PLWHA are in danger of losing their jobs due to discrimination or as a result of frequent health-related absences. As a result, up to 50% of PLWHA in the United States are at risk of becoming homeless (National Alliance to End Homelessness, 2006).
In addition, the conditions of homelessness may increase the risk of contracting HIV. A disproportionately large number of homeless people suffer from substance abuse disorders. Many homeless people inject drugs intravenously, and may share or reuse needles. This practice is responsible for 13% of HIV/AIDS diagnoses in the United States. An additional 50% of cases are a result of male-to-male sexual contact, and 33% are due to heterosexual sex (Centers for Disease Control and Prevention). Unfortunately, the conditions of homelessness may lead to sexual behaviors that increase the risk of contracting HIV. For example, many shelters are single sex, and most offer limited privacy, including communal sleeping and bathing. These circumstances make it difficult for shelter residents to form stable sexual relationships (University of California San Francisco Center for AIDS Prevention Studies, 2005).
Homeless people with HIV/AIDS encounter many challenges to their health. Due to factors such as poor hygiene, malnutrition, and exposure to cold and rainy weather, homeless people are already three to six times more likely than housed people to become ill (National Health Care for the Homeless Council, 2008). Since HIV targets the immune system, PLWHA do not have the ability to fight off disease, and their risk of illness is even higher. Additionally, crowded shelters with poor ventilation can endanger people with HIV/AIDS by exposing them to infections such as hepatitis A, pneumonia, tuberculosis, and skin infections. One study shows that people who sleep in a shelter are twice as likely to have tuberculosis if they are HIV-positive (National Alliance to End Homelessness, 2006).
Psychological factors play an additional role in the progression of HIV/AIDS. Psychological distress has been shown to increase the severity of the disease (Greeson et al., 2008). People who are homeless experience a great deal of stress on a daily basis, which exacerbates the progression of HIV/AIDS. Additionally, stress, depression, and other psychosocial factors that are common in homeless people affect behaviors, which in turn affect the progression of HIV/AIDS. For example, depression decreases a person’s likelihood to adhere to medication, which is necessary to treat HIV/AIDS (Gore-Felton and Koopman, 2008).
It is very difficult for homeless PLWHA to adequately treat their disease. For example, homelessness makes it more difficult to obtain and use antiretroviral treatments (ARTs), the medication for HIV/AIDS medications. ARTs have complex regimens, and adherence is very difficult for people who don’t have access to stable housing, clean water, bathrooms, refrigeration, and food (National Alliance to End Homelessness, 2006). Many homeless people also do not have health insurance and cannot pay for the medications and health services that are necessary to treat HIV/AIDS.
Homeless PLWHA need to be placed in supportive housing tailored to their needs. The experience of homelessness exacerbates the disease and hinders treatment. According to a New York study, formerly homeless people were four times more likely to get medical care once they had been placed in supportive housing than when they were in case management. Housing also increases the likelihood of receiving and adhering to ARTs (National Alliance to End Homelessness, 2006). The United States Department of Housing and Urban Development addresses this problem with the Housing Opportunities for Persons With AIDS (HOPWA) Program, but this program only serves 79 cities and 38 states (National Alliance to End Homelessness, 2006). More funding needs to be allocated to providing PLWHA with supportive housing.
Preventative and educational programs need to be provided at shelters, soup kitchens, and other locations that are easily accessible and comfortable for homeless people. Currently, many shelters only minimally address HIV/AIDS. Sex and drug use are strictly forbidden at most shelters, so many shelters do not allow outside HIV/AIDS education and prevention programs to openly discuss those topics or to distribute condoms. A few education programs, such as “Sex, Games, and Videotapes,” have been effective in shelters. Programs such as these need to become federally funded and widespread (University of California San Francisco Center for AIDS Prevention Studies, 2005).
Comprehensive services such as health education, HIV testing, case management, mental health services, and basic health care also need to be provided to homeless PLWHA. Group interventions have been effective in some situations and should be replicated. Coordinated care networks need to be organized so that homeless PLWHA can receive the care that they need in a timely manner (University of California San Francisco Center for AIDS Prevention Studies, 2005).
REFERENCES AND ADDITIONAL RESOURCES
- Centers for Disease Control and Prevention. “HIV Prevalence Estimates – United States, 2006.” Morbidity and Mortality Weekly Report. Oct. 2008. Available from http://www.cdc.gov/mmwr/.
- Centers for Disease Control and Prevention. “HIV/AIDS in the United States.” Aug. 2008. Available from http://www.cdc.gov.
- Centers for Disease Control and Prevention. “HIV/AIDS Statistics and Surveillance: Basic Statistics.” 2007. Available from http://www.cdc.gov.
- Gore-Felton, C. and Koopman, C. “Behavioral Mediation of the Relationship Between Psychosocial Factors and HIV Disease Progression.” 2008. Psychosomatic Medicine, 70(5), 569-574.
- Greeson, J.M., Hurwitz, B.E., Llabre, M.M., Schneiderman, N., Penedo, F.J., and Klimas, N.G. “Psychological distress, killer lymphocytes and disease severity in HIV/AIDS.” 2008. Brain, Behavior, and Immunity, 22(6), 901-911.
- National Alliance to End Homelessness. “Homelessness and HIV/AIDS.” Aug. 2006. Available from http://www.endhomelessness.org.
- National Health Care for the Homeless Council. “Health Care for the Homeless: Comprehensive Services to Meet Complex Needs.” Dec. 2008. Available from http://www.nhchc.org.
- Straub, R.O. Health Psychology: A Biopsychosocial Approach. 2007. New York: Worth Publishers.
- University of California San Francisco Center for AIDS Prevention Studies. “What are Homeless Persons’ HIV Prevention Needs?” Sept. 2005. Available from www.caps.ucsf.edu.