HIV/AIDS Among the Homeless
Jacqueline Maus Feldman
Stephen Mark Goldfinger
Approaches to the treatment of people with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), homelessness, and mental illness is constantly evolving. The incidence of HIV infection and AIDS is increasing in the United States, affecting a variety of demographics differently. Many of those with HIV disease or AIDS are living longer, although their lives are often fraught with multiple challenges. Recipients and providers of care must address a multitude of issues: stigma, adherence, physical and psychiatric complications, limited resources, and competing political agendas. A variety of strategies have proven effective in people with HIV infection and AIDS, homelessness, and mental illness; these include education; advocacy; federal, state, and local involvement and funding of research and services; utilization of evidence-based practice and translational research; cultural sensitivity; collaboration and partnerships; integration of services; inclusion of family and significant others; aggressive outreach; provision of a spectrum of housing solutions; and movement to person-centered treatment. Although significant gains have been achieved, further challenges exist for those committed to quality care.
HIV/AIDS, Homelessness, and Poverty
The lives of those with HIV disease or AIDS become much more complicated if they are also affected by homelessness and poverty; the process of treatment becomes exponentially more difficult, and the quality of life diminishes. Of those living with HIV disease or AIDS, 65% report that housing stability is their second largest need, behind health care.1 In 2004, sero- prevalence in urban indigent adults in San Francisco was reported as 10.5%, five times greater than in the San Francisco general population. Of these, almost 30% were men who have sex with men (MSM), over 7% were non-MSM injection drug users (IDUs), and 5% were non-MSM non-IDU. For those MSM with HIV disease or AIDS, risk factors include sex trade among Whites, non-White race, recent receptive anal sex, and syphilis. For non-MSM IDUs with HIV disease or AIDS, risk factors included syphilis, lower education, prison, syringe sharing, and transfusions. For non-MSM, non-IDUs with HIV disease or AIDS, risk factors included having had five recent sexual partners and female crack users who exchanged sex for drugs.2
One third to half of all people living with AIDS are “either homeless or in imminent danger of losing their homes.” Of those who are homeless, 15% are infected with HIV.3 The
Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH) reported that of those who are HIV-positive, 5% are homeless.4 Of those diagnosed with AIDS, 18% were homeless in 2003. Urban settings with inordinately high housing prices are particularly difficult housing environments for those who are HIV-positive. Their average income is $575 per month, only 21% are employed, 32% receive public assistance, and only 13% have private health insurance. Of those in the CARES program, 50% lived below the federal poverty level, less than 10% had private health insurance, and only slightly more than 25% had Medicaid. The poverty level in 2002 was $18,100 for a family of four, and treatment and cost of antiretroviral medication was approximately $14,000.4 Those with HIV disease or AIDS are not only at risk for poverty and homelessness, but death as well. “HIV disease is the most predictive condition for mortality among all homeless people.”5
Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the National Institutes of Health (NIH) reported that of those who are HIV-positive, 5% are homeless.4 Of those diagnosed with AIDS, 18% were homeless in 2003. Urban settings with inordinately high housing prices are particularly difficult housing environments for those who are HIV-positive. Their average income is $575 per month, only 21% are employed, 32% receive public assistance, and only 13% have private health insurance. Of those in the CARES program, 50% lived below the federal poverty level, less than 10% had private health insurance, and only slightly more than 25% had Medicaid. The poverty level in 2002 was $18,100 for a family of four, and treatment and cost of antiretroviral medication was approximately $14,000.4 Those with HIV disease or AIDS are not only at risk for poverty and homelessness, but death as well. “HIV disease is the most predictive condition for mortality among all homeless people.”5
HIV/AIDS and Mental Illness
The rate of HIV infection appears elevated in those with serious mental illness. A 2002 report reflected that patients with schizophrenia spectrum disorder were 1.5 as likely to have a diagnosis of HIV infection, and those with a diagnosis of affective disorder were 3.8 times as likely to have a diagnosis of HIV infection.6 Sexually transmitted infections (STIs) are common among psychiatric patients who are homeless,7 which might reflect a variety of challenges within those settings.
HIV/AIDS, Homelessness, and Mental Illness
The combination of homelessness and mental illness increase the risk for becoming HIV- positive. One third of those with mental illness are homeless; they often struggle with nonadherence, are frequently sexually active, and appear particularly vulnerable to physical and sexual violence.8 A study in 2001 of homeless shelters in Philadelphia reflected a rate of HIV-positive status nine times that of the general population, with increased risk correlated to substance abuse in males and a history of serious mental illness.9 Of those occupying homeless shelters, about 20% have psychiatric problems.7 It has been noted that those who are homeless and have mental illness are particularly vulnerable to HIV infection because of cognitive deficits, vulnerability to coercion by others, and desperate need for money. Those with mental illness and who are homeless often belong to high-risk groups engaging in intravenous (IV) drug abuse, with histories of incarceration, other substance abuse, and involvement in sex trade.10
A review of these demographics highlights that the incidence of HIV infection and AIDS continues to increase, especially across ethnic/racial minorities; women in particular bear an increasing burden in terms of mortality. The interface between HIV disease, homelessness, and mental illness has been demonstrated to produce particularly vulnerable populations. The challenges then are identification, education, prevention, treatment, and support.
Challenges
Those struggling with HIV disease and AIDS, homelessness, and mental illness, along with those who provide their care and those who create and fund policy and health care systems must grapple with a particularly burdensome set of challenges.11 They are as follows:
Identification and Acceptance of Illness
As noted earlier, perhaps 20% of those who are HIV-positive are unaware of their status, and another 20% do not receive any medical care. Susser et al.7 noted that patients with serious mental illness were reluctant to admit their sexual activity, much less demonstrate willingness
to be tested. Acceptance of the illness and need for treatment are often closely tied to perceptions of stigma (see “e” below) and fear of being diagnosed with at best a chronic medical illness or at worst a potentially fatal disease.
Complicated Medical Problems
Complicated medical problems necessitate rapid and consistent access to medical care, medication, and nutrition. According to a study reported by the Department of Housing and Urban Development (HUD), two thirds of those who are homeless suffer from a chronic illness; nearly 25% of the study participants indicated that they needed to see a doctor within the last year but could not.12 It has also been reported that homeless people with HIV disease or AIDS are less likely than HIV-infected populations on the whole to receive antiretroviral medications.12 By 2002 the CARES program was funding or providing enormous amounts of medical care; access to medical care was four times greater than any service besides case management.3,13 Increased rates of immunosuppression, opportunistic infections such as tuberculosis (TB), Hepatitis B and C [HBV, HCV], Bartonella quintana (the bacterium that causes bacillary angiomatosis peliosis)5 pneumonia, and influenza, along with cancer, malnutrition, infestations, neurologic problems, and dental problems plague those with HIV disease and homelessness.1 Homeless people with HIV infection who sleep in a shelter are twice as likely to have TB as the general shelter population. Injection drug use and lack of insurance can affect health care use as well.14 Klinkenberg et al.15 studied a population of whom 6% were HIV-positive, 33% of whom were HBV-positive, and 30% of whom were HCV-positive. These illnesses were often thought to be the result of substance abuse, especially intravenous drug abuse (IVDA).15 Homeless persons with HIV disease or AIDS are believed to be more ill than those with stable housing. One study notes location of services and inclusion of aggressive outreach and minimization of barriers to access to care in treatment planning.12Related posts:
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