1. Housing Status and HIV Risk Behaviors Among Homeless and Housed Persons with HIV in the United States The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy. Daniel P. Kidder, PhD, 1 Richard J. Wolitski, PhD, 2 Sherri L. Pals, PhD, 2 & Michael L. Campsmith, DDS, MPH 2 U.S. Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 1 Global AIDS Program 2 Division of HIV/AIDS Prevention XVII International AIDS Conference, Mexico City 6 August 2008

2. Background: Homelessness in the U.S.  Determining numbers of homeless persons in U.S. is difficult –Often episodic: People cycle in and out –Chronically homeless persons: Difficult to locate  Social and economic factors associated with HIV in the U.S. are also associated with homelessness –Male, black, substance use, mental health, lack of education, history of physical & sexual abuse  Homeless persons: More chronic diseases and physical health problems than general population.

3. Background  Homeless persons are more likely than stably housed people to engage in HIV risk behaviors –Injection drug use –Risky sexual practices –Exchanging sex for money, drugs, or a place to stay  HIV/AIDS diagnosis rates are 3 to 9 times higher among homeless persons compared with those in stable housing in U.S.  Yet few studies conducted among homeless people living with HIV/AIDS –Most studies have been single site, small scale

4. Study Goals  Examine differences between homeless and housed people living with HIV/AIDS on: –HIV sexual transmission risk behaviors –Substance use (drug and alcohol) risk behaviors  Examine independent effects of homelessness on sex and substance use risk, controlling for potentially confounding factors

5. Methods U.S. CDC’s Supplement to HIV/AIDS Surveillance (SHAS) project  Behavioral survey of adults  All participants recently (past 2 years) diagnosed with HIV or AIDS in U.S.  Extends information routinely collected in AIDS surveillance  Cross-sectional  Multi-site

6. DE Hartford, CT New Haven, CT Jersey City, NJ Population-Based AZ WA NM Denver Facility-Based Los Angeles County, CA KS Edisto Health District, SC Charleston County, SC Richland County (Columbia), SC Atlanta Tampa Miami Detroit Austin/Travis County MN Baltimore, MD Jacksonville Houston Chicago Philadelphia Paterson, NJ Participating SHAS Sites

7. Methods (continued)  Questionnaire modules: Sociodemographics Drug use Sexual behavior HIV testing and medications Health and social services use  Data collected from 1990 – 2003  Current study includes data from May 2000 – December 2003 –n = 8075

8. Housing Status  At time of interview  Homeless –Living in shelter or on streets –n = 310 (4%)  Housed –Living in house, apartment, medical care facility, or correctional institution –n = 7765 (96%)

9. Sociodemographic Characteristics HomelessHoused p Age (average)40 NS Gender (% male)7872<0.05 Race (%)NS Black6055 Hispanic2019 White1822 Other34 < High School Education (%)4631<0.001 Unemployed (%)9063<0.001 Annual household income <$10,000 (%)8749<0.001 Marital status (% married)511<0.001 Bivariate analyses

10. Sexual Behavior HomelessHousedp Sexually Active, past 12 months (%)6369<0.05 Sex Partners (%) >9, ever8473<0.001 >1, past 12 months4231<0.001 Sex Exchange for Money/Drugs (%) Ever4621<0.001 Past 12 months154<0.001 Unprotected Sex at Last Sex with an Unknown Serostatus Partner (%) 1610<0.05 Bivariate analyses

11. Substance Use HomelessHousedp Possible Alcohol Abuse (%)5535<0.001 Drug Use, past 12 months (%)5934<0.001 Injection Drug Use (IDU), ever (%)3719<0.001 Injection Drug Use, past 12 months (%) (among those who had ever injected) 4631<0.001 Bivariate analyses

12. Multivariate Logistic Regression Analyses  Dependent variables: –Sexual risk behaviors Sexually active, # sex partners, sex exchange, unprotected sex with unknown status partner –Substance use Alcohol abuse, drug use, injection drug use  Controlling for sociodemographic, HIV risk group factors often associated with homelessness –Age, gender, race/ethnicity, marital status, education, income, employment –Men who have sex with men (MSM), IDU, MSM/IDU, high risk heterosexual

13. Sexual Behavior Regression Analyses Reference Group: Housed Participants Adjusted OR95% CI Sexually Active, past 12 months0.970.75, 1.26 Sex Partners >9, ever1.591.11, 2.27 >1, past 12 months1.671.29, 2.15 Sex Exchange (money/drugs) Ever2.481.89, 3.25 Past 12 months2.911.99, 4.25 Unprotected Sex at Last Sex with an Unknown Serostatus Partner 1.991.29, 3.07

14. Substance Use Regression Analyses Reference Group: Housed Participants Adj. OR95% CI Possible Alcohol Abuse1.631.26, 2.10 Drug Use, past 12 months2.311.77, 3.00 Injection Drug Use Ever1.901.46, 2.47 Past 12 months2.751.87, 4.06

15. Summary of Results Compared to housed respondents, homeless had greater odds of having…  more sex partners  exchanged sex for money or drugs  unprotected sex with unknown status partner  possible alcohol abuse  used drugs  injected drugs …even after controlling for possible confounding factors

16. Limitations  SHAS not representative of all people living with HIV/AIDS in the U.S.  Some sites only interviewed people with AIDS  Not a study of homeless people  Self-report data  Cross-sectional

17. Conclusions  Little research has been reported on homeless people living with HIV/AIDS in the U.S.  Results indicate importance of screening for housing status and behavioral interventions for PLWHA  Homeless PLWHA should be a special priority for substance abuse and HIV prevention programs