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HIV/AIDS and Homelessness

NCH Fact Sheet #9
Published by the National Coalition for the Homeless, August 2007

Lack of affordable housing is a critical problem facing a growing number of people living with Acquired Immunodeficiency Syndrome (AIDS) and other illnesses caused by the Human Immunodeficiency Virus (HIV). People with HIV/AIDS may lose their jobs because of discrimination or because of the fatigue and periodic hospitalization caused by HIV-related illness. They may also find their incomes drained by the costs of health care.
Tragically, individuals with HIV/AIDS may die before they are able to receive housing assistance. Efforts to build HIV/AIDS housing often encounter chronic funding shortfalls, bureaucratic indifference, and the stigma and fear of AIDS. Projects to create HIV/AIDS housing may fail because of local opposition by neighborhood or community groups.

PREVALENCE

  • Studies indicate that the prevalence of HIV among homeless people is between 3%-20%, with some subgroups having much higher burdens of disease.
  • In general, people who are homeless have higher rates of chronic diseases than people who are housed, due in part to the effects of lifestyle factors (such as drug, alcohol, or tobacco use), exposure to extreme weather, nutritional deficiencies, and being victimized by violence (Zerger, 2003).
  • An estimated 3.5 million people are homeless in the United States every year (National Coalition for the Homeless, 2005).
  • People living with HIV/AIDS are at higher risk of becoming homeless. A Los Angeles study found that 50% of domiciled people living with HIV/AIDS felt they were at risk of becoming homeless, while a Philadelphia study found that 44% of persons living with HIV/AIDS were unable to afford their housing, a risk factor for homelessness (Song, 1999).
  • Of nearly 12,000 people living with HIV/AIDS surveyed by AIDS Housing of Washington, 40% report having been homeless at least once in the past (AHW, 2003).
  • The homeless population has a median rate of HIV prevalence at least three times higher—3.4% versus 1%—than the general population. Even higher rates (8.5 to 62%) have been found in various subpopulations (Song, 2003).
  • A 1995 survey of homeless adults found that 69% 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 (Adams, 2003).
  • Homeless women and adolescents are particularly at risk (Adams, 2003).  Single homeless women are more likely to be victims of domestic violence and sexual abuse, both of which have been linked to HIV infection (Song, 2003).  Homeless adolescents are at risk due to higher rates of sexual abuse and exploitation. It has been estimated that 70 to 85% of homeless adolescents abuse substances (Adams, 2003).
  • Homeless women have special barriers to health care. Homeless mothers, in particular, have been found to subordinate their own health care needs for the needs of their children (Song, 2003).
  • Many homeless adolescents find that exchanging sex for food, clothing, and shelter is their only chance of survival on the streets. In turn, homeless youth are at a greater risk of contracting AIDS or HIV-related illnesses. HIV prevalence studies anonymously performed in four cities found a median HIV-positive rate of 2.3% for homeless persons under age 25 (Robertson, 1996).
  • People living with HIV/AIDS are at higher risk of becoming homeless. A Los Angeles study found that 50% of domiciled people living with HIV/AIDS felt they were at risk of becoming homeless, while a Philadelphia study found that 44% of persons living with HIV/AIDS were unable to afford their housing, a risk factor for homelessness (AIDS Housing of Washington, 2003).

ISSUES

A 2000 study by Columbia University showed that the greatest need for HIV or AIDS treatment after medication was stable housing. As a direct result of the lack of housing, many homeless people with HIV or AIDS are unable to receive adequate health care, treatment, and education about the disease. Therefore, there are special considerations and challenges when caring for homeless individuals with HIV or AIDS.

To address the special considerations and challenges that primary care providers may face in caring for homeless individuals with HIV, the Health Care for the Homeless Clinicians' Network is undertaking a project focusing on HIV and homelessness. The following information is taken from the Network's September 1999 newsletter, Healing Hands.

HIV infection exacerbated by homelessness deserves special attention for the following reasons:

High morbidity and mortality: HIV-infected homeless persons are believed to be sicker than their domiciled counterparts. For example, they tend to have higher rates and more advanced forms of TB, and higher incidence of other illnesses such as Bartonella. Another study has demonstrated that more homeless people die of AIDS than other HIV-infected populations.

Barriers to care: Homeless people with HIV may face many barriers to optimal care. Injection drug use and lack of insurance, common among homeless people, have been shown to negatively affect health care utilization, level of medical care, and health status.

Challenges to adherence: Adherence to complex medical regimens may be more difficult if one does not have stable housing or access to basic subsistence needs such as food. As it is believed that decreased adherence is the single best predictor of protease inhibitor failure and the primary cause of medication resistance, this problem has grave personal and public health implications.

POLICY RECOMMENDATIONS

Homeless persons with HIV/AIDS need safe, affordable housing and supportive, appropriate health care. Emergency housing grants should be available for persons with HIV-related illnesses who are in danger of losing their homes, and housing assistance should be available for those already on the streets. Federal assistance must be provided through adequate funding of targeted housing and health programs, and through the enforcement of anti-discrimination laws.

RESOURCES

Adams, Michael. HIV and Homeless Shelters: Policy and Practice, American Civil Liberties Union AIDS Project. Available online: archive.aclu.org/issues/gay/hiv_homeless.html (Accessed: June 20, 2003).
AIDS Housing of Washington. Second National HIV/AIDS Housing Conference, 1996. Available for $5.00 from AIDS Housing of Washington, 2025 First Ave., Marketplace Towers, Suite 420, Seattle, WA 98121-2145; 206/448-5242.
AIDS Housing of Washington, AIDS Housing Survey, Spring 2003.
AIDS National Interfaith Network. The HIV/AIDS Housing Handbook, 1993. Available for $5.00 from AIDS Housing of Washington, 2025 First Ave., Marketplace Towers, Suite 420, Seattle, WA 98121-2145; 206/448-5242.
Health Care for the Homeless Information Resource Center. Annotated Bibliography: AIDS/HIV Among the Homeless Population, 1998. Available, for free, from the Health Care for the Homeless Information Resource Center, Policy Research Associates, 262 Delaware Avenue, Delmar, NY 12054-1123; 888/439-3300, ext. 246.
Leiberman, Betsy and Donald P. Chamberlain. Breaking New Ground: Developing Innovative AIDS Care Residences, 1993. Available for $44.95 from AIDS Housing of Washington, 2025 First Ave., Marketplace Towers, Suite 420, Seattle, WA 98121-2145; 206/448-5242.
National Coalition for the Homeless, “How Many People Are Homeless?” June 2005. Available online: www.nationalhomeless.org/numbers.html (Accessed: June 20, 2005).
 National Commission on AIDS. Housing and the HIV/AIDS Epidemic: Recommendations for Action, 1992. (Order No. D-209). Available for $7.50 prepaid from CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; 800/458-5231. National AIDS Hotline: 800/342-AIDS.
O'Connell, J., Lozier, J., and Gingles, K. Increased Demand and Decreased Capacity: Challenges to the McKinney Act's Health Care for the Homeless Program, 1997. Available from the National Health Care for the Homeless Council, P.O. Box 60427, Nashville, TN 37206-0427; 615/226-2292.
Robertson, Marjorie. Homeless Youth on Their Own, 1996. Alcohol Research Group, 2000 Hearst Avenue, Berkeley, CA 94709; 510-642-5208. Available from author.
Robbins, Greg and Fraser Nelson. Looking for a Place to Be: A Report on AIDS Housing in America, 1996. Available from AIDS Housing of Washington, 2025 First Ave., Marketplace Towers, Suite 420, Seattle WA 98121-2145; 206/448-5242.
Shelter Partnership, Inc. A Report on Housing for Persons Living with HIV/AIDS in the City and the County of Los Angeles, 1999. Available, for free, from the Los Angeles City Housing Department. Fax request: 213.367.9157.
Song, John. AIDS Housing of Washington, AIDS Housing Survey, p. 1, Spring 2003.
Song, John, MD, MPH, MAT, “HIV/AIDS & Homelessness: Recommendations for Clinical Practice and Public Policy,” November 1999. National Health Care for the Homeless Council, Health Care for the Homeless Clinician’s Network, p. 14. Available online: www.nhchc.org/Publications/HIV.pdf (Accessed: June 20, 2005).
Weisfeld, Victoria D., ed. AIDS Health Services at the Crossroads: Lessons for Community Care, 1991. Available, for free, from the Robert Wood Johnson Foundation, Communications Office, College Road, P.O. Box 2316, Princeton, NJ 08543-2316; 609/452-8701.
Zerger, Susan. Healthcare for the Homeless, A Preliminary Review of Literature: Chronic Medical Illness and Homeless Individuals, April 2002,
pp. 5-6. Available online: www.nhchc.org/Publications/literaturereview_chronicillness.pdf (Accessed: February 6, 2003).