Abstract
Homelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.
Keywords: Homeless, HIV, HIV risk behaviors, substance use, depression
Introduction
In 2012, 8.3% of HIV-positive adults in HIV care were homeless (White House Office of National AIDS Policy [ONAP], 2015). Homelessness is a barrier to HIV care engagement, adherence to antiretroviral therapy (ART) and viral suppression, which is key to individual health and the prevention of onward HIV transmission (Aidala, Lee, Abramson, Messeri, & Siegler, 2007; Aidala et al., 2016; Clemenzi-Allen et al., 2018; Chen et al., 2013; Harris, Xue, & Selwyn, 2016; Kidder, Wolitski, Campsmith, & Nakamura, 2007; Milloy, Marshall, Montaner, & Wood, 2012; Thakarar, Morgan, Gaeta, Hohl, & Drainoni, 2016). Furthermore, homeless persons report a high burden of mental health problems, substance use, and HIV risk behaviors, such as engaging in condomless sex (Aidala, Cross, Stall, Harre, & Sumartojo, 2005; Chen et al., 2013; Hsu et al., 2015; Kidder et al., 2007; Kidder, Wolitski, Pals, & Campsmith, 2008; Santa Maria, Padhye, Yang, Gallardo, & Businelle, 2018).
Homelessness is a stressor with serious implications for mental health, and homeless persons may use substances to cope with mental illness, suppress hunger, stay warm, or remain awake to reduce the risk of violence or victimization (Christiani, Hudson, Nyamathi, Mutere, & Sweat, 2008; Kelly & Caputo, 2007; Klee & Reid, 1998). Condomless sex more likely occurs when drug use precedes sex or when sex occurs in a non-private setting (Tucker et al., 2012). Additionally, studies have shown that homeless persons have low condom use self-efficacy, which is also associated with condomless sex (Hsu et al., 2015; Tucker et al., 2013). For HIV-positive homeless persons, mental health problems, substance use, and HIV risk behaviors are added challenges to successful HIV care engagement, ART adherence, and viral suppression (Aidala et al., 2005; Chen et al., 2013; Friedman et al., 2009; Riley et al., 2003; Weiser et al., 2006; Wolitski, Kidder, & Fenton, 2007).
In an effort to inform national and local policy makers and HIV prevention programs, and to assess progress towards the national HIV prevention goal of reducing the percentage of homeless persons in HIV care to no more than 5%, we present the only nationally representative estimates of the sociodemographic and behavioral characteristics of HIV-positive adults receiving medical care who reported recent homelessness.
Materials and Methods
The Medical Monitoring Project (MMP) is an annual cross-sectional survey designed to produce nationally representative estimates of behavioral and clinical characteristics of persons with diagnosed HIV in medical care in the United States. Briefly, MMP used a three-stage, complex sampling design in which U.S. states, Washington, D.C. and Puerto Rico were sampled; followed by facilities providing outpatient HIV clinical care in those jurisdictions; then HIV-positive adults, aged 18≥ years, receiving care in those facilities. Data were weighted based on known probabilities of selection at each jurisdiction, facility, and patient levels, and then weighted to adjust for non-response. MMP methods, including response rates, have been described in detail elsewhere (Bradley et al., 2010; Frankel et al., 2012; Iachan et al., 2016). Data were combined from matched interviews and medical record abstractions collected from June 2009–May 2015.
Ethics Statement
In accordance with guidelines for defining public health research, CDC determined MMP was public health surveillance used for disease control, program, or policy purposes (Centers for Disease Control and Prevention). Local institutional review board approval was obtained at participating states, territory, and facilities when required. Informed consent was obtained from all participants.
Measures
Patients were asked if they lived on the street, in a shelter, in a single room occupancy hotel, or in a car during the past 12 months. If they responded yes to any of these questions, they were categorized as homeless (n=2,386). If they responded no to all questions, they were categorized as housed (n=25,889).
Socio-demographic variables collected included gender, race/ethnicity, age, education attainment, sexual orientation, and health insurance type. Behavioral variables collected and reported by respondents based on the 12 months before being interviewed included drug use, alcohol or drug use before or during sex, condomless sex with an HIV-negative or unknown status partner, and condomless sex while not virally suppressed. Viral load was abstracted from patients’ medical records for the year before the interview. Viral suppression was defined as the most recent viral load documented as undetectable or <200 copies/mL. Durable viral suppression was defined as all viral loads during the past 12 months as undetectable or <200 copies/mL.
Binge drinking in the 30 days before being interviewed was defined as having ≥5 alcoholic drinks for men and 4≥ alcoholic drinks for women in one sitting on at least one day. Depression during the past two weeks was based on the patient health questionnaire depression scale (PHQ-8) (Kroenke et al., 2009). Poverty guidelines were determined using the U.S. Department of Health and Human Services poverty guidelines corresponding to the calendar year about which the combined household income was asked (U.S. Department of Health and Human Services).
Statistical Analysis
We calculated unweighted sample sizes and estimated weighted percentages, with associated 95% confidence intervals for homeless and housed adults during the 12 months before their interview for each of the years. We performed bivariate analysis using the Rao-Scott chi-square test to compare the percentage of homeless and housed adults by key socio-demographic and behavioral characteristics (Rao & Scott, 1992). All analyses were performed using SAS 9.3 (SAS Institute, Cary, NC) and accounted for clustering, unequal selection probabilities, and non-response.
Results
From 2009 to 2015, 8.3% of HIV-positive adults receiving HIV care experienced homelessness during the year before interview. Homeless adults were significantly (p<.01) more likely than housed adults to be transgender (3.7% vs. 1.2%), non-Hispanic black (53.2% vs. 40.7%), ≤29 years (12.1% vs. 7.6%), be incarcerated (19.6% vs. 3.6%), have public insurance only (66.2% vs. 49.4%), and have major (20.2% vs 10.0%) or other depression (15.1% vs. 10.8%) (Table 1).
Table 1.
Selected characteristics of HIV-positive homeless adults receiving medical care in the United States --- Medical Monitoring Project, 2009 – 2015
| Total | Homeless | Housed | p- value |
||||
|---|---|---|---|---|---|---|---|
| Characteristics | n | %†(95% CI) | n | %†(95% CI) | n | %†(95% CI) | |
| Total | 28275 | 100% | 2386 | 8.3 (7.8-8.9) | 25886 | 91.7 (91.1-92.2) | |
| Gender | <.0001 | ||||||
| Male | 20307 | 72.6 (70.8-74.3) | 1690 | 71.9 (69.6-74.2) | 18617 | 72.6 (70.8-74.5) | |
| Female | 7545 | 26.0 (24.2-27.8) | 614 | 24.4 (22.2-26.6) | 6931 | 26.1 (24.3-27.9) | |
| Transgender | 408 | 1.4 (1.3-1.6) | 80 | 3.7 (2.8-4.5) | 328 | 1.2 (1.1-1.4) | |
| Race/Ethnicity | <.0001 | ||||||
| White, non-Hispanic | 8945 | 33.2 (29.2-37.3) | 509 | 20.7 (17.0-24.4) | 8436 | 34.4 (30.2-38.5) | |
| Black, non-Hispanic | 11785 | 41.7 (36.5-47.0) | 1262 | 53.2 (48.0-58.3) | 10523 | 40.7 (35.3-46.0) | |
| Hispanic or Latino | 6287 | 20.4 (16.9-23.9) | 468 | 19.7 (16.6-22.9) | 5819 | 20.5 (16.9-24.0) | |
| Other | 1258 | 4.7 (4.1-5.2) | 147 | 6.4 (5.0-7.8) | 1111 | 4.5 (4.0-5.0) | |
| Age Groups (in years) | <.0001 | ||||||
| 18-29 | 2156 | 8.0 ( 7.3- 8.6) | 263 | 12.1 (10.3-14.0) | 1893 | 7.6 (6.9-8.2) | |
| 30-39 | 4332 | 15.7 (15.1-16.3) | 426 | 18.4 (16.5-20.2) | 3906 | 15.5 (14.9-16.0) | |
| 40-49 | 9369 | 33.0 (32.3-33.6) | 873 | 36.0 (33.7-38.3) | 8496 | 32.7 (32.0-33.4) | |
| 50-59 | 8967 | 31.3 (30.6-32.0) | 671 | 27.5 (25.4-29.6) | 8296 | 31.6 (30.9-32.4) | |
| >=60 | 3451 | 12.1 (11.6-12.6) | 153 | 6.0 (5.0-6.9) | 3298 | 12.6 (12.1-13.2) | |
| Education attainment | <.0001 | ||||||
| <High School | 6085 | 20.9 (19.4-22.3) | 805 | 33.6 (30.8-36.3) | 5280 | 19.7 (18.3-21.1) | |
| High School diploma | 7745 | 27.1 (25.9-28.3) | 738 | 31.3 (29.2-33.4) | 7007 | 26.7 (25.5-28.0) | |
| >High School | 14434 | 52.0 (49.7-54.4) | 841 | 35.1 (32.2-38.1) | 13593 | 53.6 (51.2-55.9) | |
| Poverty level | <.0001 | ||||||
| Above poverty level | 14215 | 53.9 (51.6-56.2) | 613 | 26.2 (23.7-28.7) | 13602 | 56.4 (53.9-58.8) | |
| At or below poverty level | 12974 | 46.1 (43.8-48.4) | 1684 | 73.8 (71.3-76.3) | 11290 | 43.6 (41.2-46.1) | |
| Incarceration | <.0001 | ||||||
| No | 26899 | 95.1 (94.7-95.4) | 1926 | 80.4 (78.4-82.4) | 24973 | 96.4 (96.1-96.7) | |
| Yes | 1366 | 4.9 (4.6-5.3) | 456 | 19.6 (17.6-21.6) | 910 | 3.6 (3.3-3.9) | |
| Type of health insurance | <.0001 | ||||||
| Any private insurance | 8164 | 30.3 (28.0-32.6) | 239 | 10.5 (8.4-12.6) | 7925 | 32.1 (29.7-34.5) | |
| Public insurance only | 14976 | 50.8 (48.7-53.0) | 1635 | 66.2 (62.5-69.8) | 13341 | 49.4 (47.3-51.6) | |
| Ryan White coverage only or Uninsured | 4524 | 16.9 (14.9-19.0) | 439 | 21.0 (17.3-24.8) | 4085 | 16.5 (14.6-18.5) | |
| Unspecified | 534 | 1.9 (1.6-2.3) | 58 | 2.3 (1.6-3.0) | 476 | 1.9 (1.5-2.3) | |
| Length of time since HIV diagnosis (in years) | <.0001 | ||||||
| <5 | 5703 | 21.3 (20.5-22.2) | 628 | 27.6 (25.1-30.1) | 5075 | 20.8 (19.9-21.7) | |
| 5-9 | 5875 | 20.7 (20.1-21.4) | 471 | 19.2 (17.4-20.9) | 5404 | 20.9 (20.2-21.5) | |
| >=10 | 16685 | 57.9 (56.7-59.2) | 1287 | 53.2 (50.4-56.0) | 15398 | 58.4 (57.1-59.7) | |
| Sexual Orientation | <.0001 | ||||||
| Homosexual | 9478 | 41.8 (38.6-45.0) | 548 | 28.6 (26.0-31.1) | 8930 | 43.0 (39.6-46.3) | |
| Heterosexual | 11429 | 48.5 (45.4-51.7) | 1130 | 58.3 (54.9-61.8) | 10299 | 47.7 (44.4-51.0) | |
| Bisexual | 1893 | 8.2 (7.7-8.6) | 226 | 11.4 (9.4-13.3) | 1667 | 7.9 (7.4-8.3) | |
| Other/unclassified | 322 | 1.5 (1.3-1.7) | 31 | 1.8 (1.1-2.4) | 291 | 1.5 (1.3-1.7) | |
| Depression in past 2 weeks | <.0001 | ||||||
| No depression | 21843 | 78.0 (77.0-79.0) | 1516 | 64.7 (62.1-67.2) | 20327 | 79.2 (78.2-80.2) | |
| Other depression | 3100 | 11.2 (10.7-11.7) | 356 | 15.1 (13.4-16.8) | 2744 | 10.8 (10.4-11.3) | |
| Major depression | 2996 | 10.8 (10.1-11.5) | 475 | 20.2 (18.2-22.2) | 2521 | 10.0 (9.3-10.7) | |
Abbreviations: n = unweighted sample size; CI = Confidence interval;
Time period: During 12 months, unless otherwise noted. All measures are self-reported unless otherwise noted.
Race/ethnicity are mutually exclusive. Hispanic/Latinos could be of any race.
weighted column percentage
Undetectable or < 200 copies/ml based on medical record abstraction data in the 12 months prior to interview.
Over 60% of homeless adults were sexually active during the past year. Homeless adults were significantly (p<.01) more likely than housed adults to have condomless sex with an HIV-negative or unknown status partner (29.6% vs. 24.0%) and have condomless sex with an HIV-negative or unknown status partner while not being recently virally suppressed (5.8% vs. 2.7%) or durably suppressed (8.8% vs. 4.2%) (Table 2).
Table 2.
Selected behaviors among HIV-positive homeless adults receiving medical care in the United States --- Medical Monitoring Project, 2009 – 2015
| Total | Homeless | Housed | p value | ||||
|---|---|---|---|---|---|---|---|
| Characteristics | n | %† (95% CI) | N | %† (95% CI) | n | %† (95% CI) | |
| Total | 28275 | 100% | 2386 | 8.3 (7.8-8.9) | 25886 | 91.7 (91.1-92.2) | |
| Had any sex | 0.002 | ||||||
| No | 10682 | 38.4 (37.3-39.6) | 847 | 35.4 (33.1-37.7) | 9835 | 38.7 (37.6-39.8) | |
| Yes | 17307 | 61.6 (60.4-62.7) | 1501 | 64.6 (62.3-66.9) | 15806 | 61.3 (60.2-62.4) | |
| Had condomless sex‡ | <.0001 | ||||||
| No | 20628 | 75.6 (74.1-77.0) | 1606 | 70.4 (68.0-72.7) | 19022 | 76.0 (74.6-77.5) | |
| Yes | 6727 | 24.4 (23.0-25.9) | 679 | 29.6 (27.3-32.0) | 6048 | 24.0 (22.5-25.4) | |
| Had condomless sex‡ and not recently virally suppressed †† | <.0001 | ||||||
| No | 26479 | 97.0 (96.8-97.3) | 2148 | 94.2 (93.2-95.1) | 24331 | 97.3 (97.0-97.6) | |
| Yes | 813 | 3.0 (2.7-3.2) | 129 | 5.8 (4.9-6.8) | 684 | 2.7 (2.4-3.0) | |
| Had condomless sex‡ and not durably suppressed ‡‡ | <.0001 | ||||||
| No | 26027 | 95.4 (95.1-95.7) | 2082 | 91.2 (90.0-92.5) | 23945 | 95.8 (95.4-96.1) | |
| Yes | 1265 | 4.6 (4.3-4.9) | 195 | 8.8 (7.5-10.0) | 1070 | 4.2 (3.9-4.6) | |
| Binge drinker in past 30 days | <.0001 | ||||||
| No | 23645 | 84.6 (84.1-85.1) | 1896 | 80.4 (78.3-82.6) | 21749 | 85.0 (84.4-85.5) | |
| Yes | 4392 | 15.4 (14.9-15.9) | 453 | 19.6 (17.4-21.7) | 3939 | 15.0 (14.5-15.6) | |
| Alcohol use before or during sex | <.0001 | ||||||
| No | 10961 | 62.6 (61.4-63.9) | 854 | 56.3 (53.3-59.4) | 10107 | 63.2 (61.9-64.5) | |
| Yes | 6346 | 37.4 (36.1-38.6) | 643 | 43.7 (40.6-46.7) | 5703 | 36.8 (35.5-38.1) | |
| Any drug use | <.0001 | ||||||
| No | 20815 | 73.8 (72.7-74.8) | 1341 | 56.8 (54.4-59.2) | 19474 | 75.3 (74.2-76.3) | |
| Yes | 7346 | 26.2 (25.2-27.3) | 1032 | 43.2 (40.8-45.6) | 6314 | 24.7 (23.7-25.8) | |
| Use of any non-injection drugs | <.0001 | ||||||
| No | 20977 | 74.3 (73.2-75.3) | 1387 | 58.5 (56.1-60.8) | 19590 | 75.7 (74.7-76.7) | |
| Yes | 7189 | 25.7 (24.7-26.8) | 987 | 41.5 (39.2-43.9) | 6202 | 24.3 (23.3-25.3) | |
| Use of any injection drugs | <.0001 | ||||||
| No | 27494 | 97.8 (97.3-98.3) | 2150 | 92.0 (90.0-94.1) | 25344 | 98.3 (97.9-98.7) | |
| Yes | 682 | 2.2 (1.7-2.7) | 223 | 8.0 (5.9-10.0) | 459 | 1.7 (1.3-2.1) | |
| Use of any drugs before or during sex | <.0001 | ||||||
| No | 13937 | 80.3 (79.1-81.6) | 978 | 65.3 (62.4-68.2) | 12959 | 81.8 (80.5-83.0) | |
| Yes | 3411 | 19.7 (18.4-20.9) | 518 | 34.7 (31.8-37.6) | 2893 | 18.2 (17.0-19.5) | |
| Current smoker | <.0001 | ||||||
| No | 17010 | 60.2 (58.9-61.5) | 885 | 36.9 (34.3-39.5) | 16125 | 62.3 (61.0-63.6) | |
| Yes | 11154 | 39.8 (38.5-41.1) | 1487 | 63.1 (60.5-65.7) | 9667 | 37.7 (36.4-39.0) | |
Abbreviations: n = unweighted sample size; CI = Confidence interval; ART = Antiretroviral medications;
Time period: Twelve months prior to interview unless otherwise noted. All measures are self-reported unless otherwise noted.
weighted column percentage
Had condomless sex with a negative or unknown partner
Undetectable or < 200 copies/ml based on medical record abstraction data in the 12 months prior to interview.
Undetectable or < 200 copies/ml at all viral load tests based on medical record abstraction data in the 12 months prior to interview.
Homeless adults were significantly (p<.01) more likely than housed adults to binge drink (19.6% vs 15.0%), use alcohol before or during sex (43.7% vs 36.8%), use non-injection drugs (41.5% vs 24.3%), use injection drugs (8.0% vs 1.7%), use drugs before or during sex (34.7% vs. 18.2%) and smoke (63.1% vs. 37.7%) (Table 2).
Discussion
Approximately 8% of HIV-positive adults in HIV care experienced recent homelessness—higher than the national HIV prevention goal of 5% (ONAP, 2015). Like previous studies, we found that HIV-positive homeless adults were more likely than housed adults to report major depression and substance use (Aidala et al., 2005; Chen et al., 2013; Kidder et al., 2007; Kidder et al., 2008). Among homeless persons, depression has been associated with poor HIV treatment outcomes and drug use has been associated with poor medication adherence and reduced access to care (Chen et al., 2013; Friedman et al., 2009; Riley et al., 2003; Weiser et al., 2006). Thus, homelessness, depression and substance use challenge HIV care engagement, ART adherence, and viral suppression. Homeless adults in HIV care were more likely than housed adults to have condomless sex with an HIV-negative or unknown status partner, which aligns with a study indicating that homeless persons were more likely to have condomless sex with an unknown status partner than housed persons (Kidder et al., 2008).
Several studies have demonstrated the importance of housing on an HIV-positive person’s health and the public’s health more broadly (Aidala et al., 2007; Leaver, Bargh, Dunn, & Hwang, 2007; Wolitski et al., 2007). Housing assistance has been shown to increase retention in HIV care and adherence to ART, and has been associated with reduced drug use and condomless sex (Aidala et al., 2005; Aidala et al., 2007). Thus, housing may reduce ongoing transmission of HIV and may improve co-morbidities like depression and substance use. Policies and programs that promote access to housing and other basic needs for HIV-positive persons are needed (ONAP, 2015). The Housing Opportunity for Persons with AIDS (HOPWA) program is a Federal program dedicated to the housing needs of HIV-positive persons that has been associated with improved housing, mental health, and retention in HIV care for homeless or unstably housed persons (Terzian et al., 2015; U.S. Department of Housing and Urban Development; Wolitski et al., 2010). Continued funding for HOPWA may contribute to further success in HIV care and treatment for HIV-positive homeless persons. However, housing alone might not be enough. Retaining persons in housing may be time consuming—taking time away from providing important health and HIV prevention services (Henwood et al., 2018). In a longitudinal study, condomless sex remained high and exposure to HIV prevention programming decreased significantly even after homeless persons transitioned into housing (Wenzel et al., 2019).
Studies have shown that receipt of mental health services and drug treatment improves re-engagement in, and access to HIV care, respectively (Knowlton et al., 2001). Integrating ancillary services such as substance abuse treatment and mental health counseling with HIV care may improve health outcomes for this key population already engaged in HIV care and experiencing several co-morbidities. The National Health Care for the Homeless Council’s clinicians’ network recommends that HIV care be flexible, holistic and client-centered, and provided by an interdisciplinary team of providers (Audain et al., 2013).
There are some limitations of this study. The behavioral data collected were self-reported and subject to social desirability and recall bias. Our data are cross-sectional, and causality cannot be inferred. Our measure of homelessness does not measure chronic homelessness or capture less extreme aspects of housing instability, such as doubling up or moving frequently; thus, our prevalence estimate may be lower than what might be found among persons experiencing any kind of housing instability and it is unclear how sociodemographic and behavioral characteristics might differ by disparate living arrangements. Additionally, our analysis only includes homeless adults who are receiving HIV care and aware of their HIV infection; therefore, our estimates of homelessness may be lower than what might be found among all homeless adults with diagnosed HIV. However, understanding the sociodemographic and behavioral characteristics of homeless adults receiving HIV care is still important since homeless persons tend to be at greatest risk of engaging in HIV risk behaviors compared to housed and unstably housed persons (Aidala et al., 2005). For HIV-positive homeless persons, improving health outcomes and reducing HIV risk behaviors requires that HIV care focus on addressing basic needs, such as housing, and integrating ancillary services with HIV care.
Acknowledgements:
We thank participating Medical Monitoring Project patients, facilities, project areas, and Provider and Community Advisory Board members. We also acknowledge the contributions of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC and the MMP 2009-2014 project areas (http://www.cdc.gov/hiv/statistics/systems/mmp/resources.html)
Source of funding: Funding for the Medical Monitoring Project is provided by a cooperative agreement (PS09-937) from the Centers for Disease Control and Prevention.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
Footnotes
Conflicts of interest: The authors declare no conflicts of interest.
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