Homeless youth are 7 times more likely to die from AIDS, and 16 times more likely to be diagnosed with HIV.
The homeless, especially homeless youth, are exceptionally vulnerable to HIV/AIDS. Homeless people commonly participate in high-risk behaviors, such as injecting drugs and unprotected sex. They are also common victims of sexual exploitation, sexual abuse, and survival sex.
An estimated 16,859 to 27,600 runaway and homeless youth in the United States are currently HIV positive.
Homelessness in the United States
Total people experiencing homelessness on a given night in 2011
Total people experiencing homelessness on a given night in 2016
As cuts to housing and social services deepened in the 1980s, the number of homeless people grew in the United States, prompting President Reagan to sign the McKinney-Vento Homeless Assistance Act. This act remains the only piece of federal legislation that apportions funding for the sole purpose of homeless assistance. Despite the housing crisis and recession that began in 2007, America’s homeless population has declined within the last decade, partially due to government programs such as the Earned Income Tax Credit, Bush’s “housing first” program, and the Homeless Prevention and Rapid Re-Housing Program.
The causes of homelessness are numerous, and often interact with one another. Lack of affordable housing, the decline in the real value of the minimum wage, and discrimination are examples of structural factors that can cause homelessness, and are largely beyond individual control. Individual and relational factors also play a role in causing homelessness, and include traumatic events, personal crises, and mental health and addiction challenges.
Most of the homeless population is made up of single adults, however, the experience of homelessness for this demographic is typically brief and a singular event. Families that experience homelessness are typically headed by a single woman with limited education, and include young children. Homelessness impacts children in various and lasting ways, as children experiencing or who have experienced homelessness are more likely to exhibit emotional and behavioral problems than their housed peers, and are also more likely to have serious physical health problems. In addition, homeless children are more likely to experience greater school mobility, and to perform worse academically.
Homelessness and HIV
Fast Facts on HIV and Homelessness
In the United States, 3.4% of all homeless people are HIV positive, which is 3 times the rate among the general population.
Up to 70% of people in certain communities in the U.S. living with HIV/AIDS report a lifetime experience of homelessness or housing instability.
Approximately 553,742 people were experiencing homelessness in the United States on a single night in January 2017.
Organizations Combating Homelessness
Larkin Street Youth Services Agency Video
Mike had been raped by a family member for years before he went to his parents for help. Unfortunately, they did not believe Mike. He began using drugs and acting out. He then came out to his parents as gay. They were not accepting and ultimately kicked him out. Without anywhere to sleep, Mike spiraled into despair. He would sometimes go home with strangers and have sex in order to have a place to spend the night. Mike qualified for benefits to help get him on his feet, and into supportive housing. Unfortunately, Mike was evicted from his supportive housing unit, and discovered that he was HIV positive.
How to Address the Issue of Homelessness and HIV:
An important step in helping the homeless living with HIV/AIDS would be to make subsidized, affordable housing available to this population. Housing assistance allows low-income people with HIV/AIDS to have better access to health care services, and improves their physical and mental health.
Additionally, preventative steps can be taken to decrease the amount of homeless people who contract HIV, such as educational programs that are provided at shelters, soup kitchens, and other easily accessible locations.
Health and Homelessness
Health and homelessness are deeply interwoven issues. Chronic illness and/or disabling conditions, including HIV/AIDS, are more prevalent in the homeless populations. Of the estimated 3.5 million people who are homeless every year in the U.S. as many as 3.4 percent are HIV positive. This represents a rate 3 times higher than that of the general population. In specific homeless sub-populations, the rate is estimated to be even higher.
In general people living with HIV/AIDS are at a higher risk of homelessness than the general population. Some studies have indicated as many as half of individuals with HIV/AIDS are at risk of homelessness due to unaffordable housing costs and the high cost of medical care.
For homeless individuals living with HIV/AIDS the conditions of homelessness are even more dire. The impact of HIV/AIDS on a person’s immune system makes homelessness a serious health risk. Homeless shelters, while they provide respite from the elements are often a significant threat to people with HIV/AIDS. Shelter conditions can expose people with HIV/AIDS to dangerous and even life threatening infections such as hepatitis A, pneumonia, tuberculosis, and skin infections. One study shows that homeless people with HIV who sleep in a shelter are twice as likely to have tuberculosis as the general shelter population.
Homelessness not only puts individuals with HIV/AIDS at a high risk of contracting infections, it also makes obtaining and using common HIV/AIDS medications more difficult. Antiretroviral medications used to treat HIV come with demanding and rigorous regimens. Without stable housing, access to clean water, bathrooms, refrigeration, and food the likelihood of taking the medication on a regular schedule, which is vital for proper treatment, is severely impaired.
Homelessness and unstable housing are risk factors for low engagement in HIV care and inability to maintain undetectable viral load. People living with HIV in San Francisco have good treatment outcomes overall, with 74% of all HIV-positive individuals and 91% of those who received at least one lab test achieving viral suppression, but this fell to just 33% among people experiencing homelessness. Moreover, unhoused individuals had a 27-fold higher risk of death than those with stable housing.
Participants were asked to choose between two hypothetical clinics in which the services varied on five attributes:
Patient-centred care (providers “get to know me as a person”)
Drop-in versus scheduled visits
Direct phone communication with the care team, versus dealing with front-desk staff
Distance from where they usually stay (two versus 20 blocks away)
Provision of gift cards as an incentive for clinic visits.
Participants expressed the strongest preference for patient-centred providers, for which they would trade $32.79, and drop-in clinic visits, for which they would trade $11.45 in gift card value per visit.
"Homeless and unstably housed people living with HIV, who live on the economic margins and who often lack basic subsistence, were nevertheless willing to trade significant financial gain…to have a personal relationship with and immediate access to the primary care team," the researchers concluded.
Stable housing is closely linked to successful HIV outcomes. With safe, decent, and affordable housing, people with HIV are better able to access medical care and supportive services, get on HIV treatment, take their HIV medication consistently, and see their health care provider regularly. In short: the more stable your living situation, the better you do in care.
Individuals with HIV who are homeless or lack stable housing, on the other hand, are more likely to delay HIV care and less likely to access care consistently or to adhere to their HIV treatment.
Throughout many communities, people with HIV risk losing their housing due to such factors as stigma and discrimination, increased medical costs and limited incomes or reduced ability to keep working due to HIV-related illnesses.
To help take care of the housing needs of low-income people living with HIV and their families, the U.S. Department of Housing and Urban Development’s (HUD) Office of HIV/AIDS Housing manages the Housing Opportunities for Persons With AIDS (HOPWA) program. The HOPWA program is the only Federal program dedicated to addressing the housing needs of people living with HIV. Under the HOPWA Program, HUD makes grants to local communities, States, and nonprofit organizations for projects that benefit low-income people living with HIV and their families.
The abstract authors also focused on a program initiated by the San Francisco Department of Public Health. These health officials provide community-delivered street and shelter pre-exposure prophylaxis, post-exposure prophylaxis, and treatment as prevention services for people experiencing homeless. Abstract authors highlighted that these services provide care for the most vulnerable “beyond the traditional 4-wall clinic.”
Additionally, the San Francisco Department of Health is also implementing a US Centers for Disease Control and Prevention-funded public health-level demonstration project known as Outreach, Prevention, Treatment – Integration (OPT-IN). OPT-IN seeks to increase viral suppression rates and decrease new HIV cases for people experiencing homelessness through cross-sector collaboration.
(Stricof, R.., Kennedy, J., Natell, T., Weisfuse, I., and Novick, L. (1991). HIV Seroprevalence in a facility for runaway and homeless adolescents. American Journal of Public Health, 81, 50-53.
Rotheram-Borus, Song, Gwadz, Lee, Van Rossem, & Koopman, 2004
All graphics by Jaclyn Saik