Condomless Sex Among Homeless Youth: The Role of Multidimensional Social Norms and Gender

Sociodemographic and Behavioral Risk Correlates of PrEP Interest and Use Among Young Adults Experiencing Homelessness in Los Angeles

Young adults experiencing homelessness (YAEH) are at elevated risk for HIV compared to their stably housed peers. Preexposure prophylaxis (PrEP) is highly effective at preventing HIV infection, yet YAEH have been largely overlooked in PrEP efforts to date despite YAEH reporting high overall interest in PrEP. We assessed individual, social, and structural variables associated with PrEP interest and use among a sample of 195 YAEH (ages 18-25) recruited from drop-in centers across Los Angeles County who met criteria for HIV risk. In the current sample, though most had heard of PrEP (81.0%), the majority were not interested in taking PrEP (68.2%) and only a minority had used/were using PrEP (11.8%). YAEH who identified as sexual and/or gender minority, reported knowing someone who had used PrEP, or recently accessed sexual health services were more likely to have used and/or reported interest in using PrEP. Those who reported more episodes of heavy drinking were less likely to report having used PrEP. Suggestions are provided for better integrating PrEP-related services into existing behavioral and health service programs for YAEH, as well as leveraging peers and fostering positive social norms to reduce PrEP-related stigma and increase interest and use of PrEP among YAEH.

Reproductive justice for unhoused women: An integrative review of the literature

This review examines the reproductive health experiences of unhoused women and youth. Guided by the reproductive justice framework, this review examines barriers to accessing contraception, medical abortion, and prenatal care while homeless. Twenty-one articles were identified through keyword searches in Google Scholar, Ebscohost Academic Search Premier, and PsycINFO. In included articles, barriers were identified at the individual, relational, and contextual levels. Findings from this scoping review illustrate the need to examine multiple levels of analysis when seeking to improve access to family planning services for individuals experiencing homelessness. Included literature suggests an overabundance of research documenting barriers to contraceptive care relative to the literature examining abortion and prenatal care experiences and a scarcity of research examining barriers to reproductive justice among unhoused individuals who do not identify as women.

'I told him I'm gonna get it': intimate partner birth control communication among homeless young women

Homeless youth have disproportionately high rates of unintended pregnancy and STIs. Enhancing communication between sexual partners can improve sexual health outcomes, yet little is known about this topic among homeless youth; therefore, this study aimed to examine how homeless youth communicate with their partners about birth control. In-depth semi-structured interviews regarding intimate partner birth control communication were conducted with 10 homeless young women aged 14-22 years following their completion of a comprehensive sexual health program (Wahine Talk). We transcribed the interviews verbatim and used a structured, inductive analytic approach to identify themes. Analysis identified three themes: Getting the Conversation Started, Conversation Content, and Impact of Conversation. Birth control conversations were prompted by programme participation, birth control side effects, and family members' interest in homeless youth becoming pregnant. Barriers to communication included fear and mistimed conversations (e.g. during the initiation of sex). Homeless young people shared simultaneous desires to delay pregnancy and concerns about side effects of birth control use. Discussions about birth control with their partners may demonstrably improve homeless youth's intimate relationships and family planning efforts. Providers can support homeless young women by helping them plan conversation timing and addressing fear, including the risk of violence.

Counter-Narratives of Structural Oppressions, Stigma and Resistance, and Reproductive and Sexual Health Among Youth Experiencing Homelessness

Youth experiencing homelessness (YEH) face myriad injustices regarding their reproductive and sexual health and rights. Reproductive and sexual health research with YEH often explores condom-use and sexually transmitted infections, potentially contributing to narrow conceptualizations of YEH as "unclean" or in need of disease-screening. A narrative theory perspective was applied to this study, which allowed for the emergence of alternative storylines, or counter-narratives, which attend to manifestations of power and oppression within the lives of marginalized individuals. Qualitative interviews engaged 30 young people (ages 18-21) accessing shelter services. Narrative analyses identified YEHs' documentations of dominant narratives related to structural oppressions, stigma, and numerous dimensions of reproductive and sexual health including how they create, through their resistance, counter-narratives that include their preferred futures. YEH emphasized systemic sources of stigma and outlined their criticisms of the state. Within-group stigma emerged as a noteworthy theme, with YEH showing both empathy and ambivalence towards other YEH, along with internalization of stigmatizing narratives about pregnancy and homelessness. Approaches to service provision that further amplify youths' voices in naming and challenging the many oppressions and stigmas they face should be prioritized. Moreover, policies should be implemented to dismantle the actual root causes of challenges faced by YEH, rather than perpetuating them through measures rooted in interlocking oppressions of discrimination, inequity, and judgment.

Relationship Between Sexual Activity, Contraceptive Utilization and Biopsychosocial Characteristics Among Homeless Shelter Adolescents

Objective: To determine whether biopsychosocial factors are associated with sexual activity and contraceptive utilization among homeless shelter adolescents.

Methods: A retrospective study of 440 adolescents at a shelter in Pennsylvania between February 2015 and September 2019 was conducted. The cohort was evaluated to determine what relationship age, gender identity, substance use, and trauma history have with sexual activity and contraceptive utilization.

Results: Sexual activity was significantly related to age (mean 15.8+1.4 years in sexually active vs. 14.7+1.6 years in abstinent youth, p<0.001); remote history of self-harm behavior (relative risk ratio (RR) 1.23 [95% CI 1.03-1.46]; p=0.02), history of aggressive behavior (RR 1.21 [95% CI 1.01-1.46]; p=0.04), history of trauma (RR 1.24 [95% CI 1.04-1.48]; p=0.03), and substance use (RR 2.27 [95%CI 1.86-2.77]; p<0.001). There were 55.7% sexually active females vs. 42.50% males reporting contraception use (p=0.01). After adjustment, older age and substance use remained significantly associated with sexual activity (adjusted odds ratio (AOR) 1.58 [95% CI 1.36-1.83]; p<0.001 and AOR 5.18 [95% CI 3.28-8.18]; p<0.001, respectively).

Conclusions: Females self-reported sexual activity using contraception more than males. After adjustment, older age and substance use were associated with sexual activity. By better understanding the impact these factors can have on contraceptive utilization, informed policy and practice interventions can be developed and implemented to help increase safe sex practices in spaces where homeless adolescents access healthcare.

Risky Sexual Behavior Among Street Children, Adolescents, and Young People Living on the street in southern Brazil

Although adolescents living on the street tend to have unprotected sex with many partners and substance abuse, little is known about this reality in Brazil. To estimate the prevalence and factors associated with risky sexual behavior among children and adolescents living on the street in Porto Alegre and Rio Grande. A cross-sectional study was carried out using the Respondent-Driven Sampling (RDS) sampling method to quickly and efficiently access populations of difficult access. Poisson regression with robust adjustment of variance was used in the multivariate analysis. The sample consisted of 231 participants aged 10-21 years. Most were male and aged 16- 21 years. More than half (66.7%) of the respondents did not have a school bond, and 64.5% did not live with the family. Half of the sample had been living on the street for at least four years, spending 15 h or more on the street. Most (86.6%) responded that they had already used illicit drugs in their lives, and unprotected sex prevalence was 61.9%. The variables independently associated with unprotected sex were years living on the street, hours spent on the street, having a steady partner, illicit drug use, and sexual intercourse without a condom under the influence of drugs. The high prevalence of unprotected sex points to the need for intervention policies for this population to prevent the main risk factors.

Profiles of HIV Risk, Sexual Power, and Decision-Making among Sexual Minority Men of Color Who Engage in Transactional Sex: A Latent Profile Analysis

Though the transmission of HIV is preventable, there were still 37,968 new documented cases in the United States in 2018. HIV incidence is disproportionate in sexual minority men of color. The purpose of this study was to examine sexual relationship power risk profiles to identify distinct subgroups within the profiles who carry the highest HIV risk. Latent class profile analysis was used to identify subgroups of sexual minority men of color at the highest risk for contracting HIV based on their sexual power profiles. Among 322 sexual minority men, we identified four latent profiles. Profile 1: Low transactional sex and high power (n = 133; 14.3%); Profile 2: Transactional sex, high decision-making in sexual relationships, and low control in sexual relationship (n = 99; 30.7%); Profile 3: Low transactional sex, low decision-making, and moderate control (n = 43; 13.4%); Profile 4: High transactional sex and low power (n = 47; 14.6%). LPA was useful to identify distinct subgroups based on measures of sexual risk and relationship sexual power. Findings carry significant implications for developing tailored strategies to increase HIV knowledge and related HIV prevention and risk reduction services for sexual minority men of color who engage in transactional sex.

Wohn- und Obdachlosigkeit

Der Beitrag beginnt mit einer Diskussion der aktuellen Theorie und Forschung

zum Problembereich Obdachlosigkeit. Anschließend werden die verschiedenen Aspekte der Nutzerbeteiligung im Lichte dieser unterschiedlichen Dimensionen von Wohnungslosigkeit und Wohnungsprekarität untersucht. Er schließt mit einem Überblick über die aktuelle Forschung auf diesem Gebiet.

Risk behaviour and access to HIV/AIDS prevention services among formerly homeless young adults living in housing programmes

Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn't know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services.

The influence of peer relationships on young people's sexual health in Sub-Saharan African street contexts

This paper explores the interaction between peer relationships and sexual health among street youth in three Sub-Saharan African cities: Accra (Ghana), Bukavu (Democratic Republic of Congo), and Harare (Zimbabwe). It begins by conceptualising peer relationships for youth globally and considers why these are pivotal for young people living in street settings. The paper reconceptualizes street peer relationships not as replacement families, but as sharing ‘social anchorage’ in the street space. It draws on qualitative ethnographic data from Growing up on the Streets, a longitudinal research project with a participatory methodology undertaken between 2012 and 2016 and engaging street youth (aged 14–20 at project outset) trained in ethnographic observations as research assistants (n = 18), following a network of ten peers (n = 229 by 2016), reporting their experiences in weekly interviews with facilitators. A wider network attended focus groups (n = 399). The project engaged a ‘capability’ approach, with ten capabilities defined by street youth as key to their daily lives. Empirical evidence is from a subset of data qualitatively coded (using NVivo) against capabilities ‘Health and Wellbeing’ and ‘Friendship’, across all interviews, focus groups and cities (n = 212 sources). In exploring this intersection, the paper demonstrates beneficial and adverse impacts of peer influence on sexual health, including misinformation about contraceptives and death from an informal sector abortion; highlighting findings from across the three cities around primacy of same-sex peer relations, mistrust between genders and in healthcare providers. The paper finds that while street youth remain subject to cultural norms around gender identities, street peer relationships hold a persuasive power; contributing to both everyday survival and moments of acute need. It concludes that recognising the right of young people to live and seek livelihoods in urban settings, and adopting the social networks they create to advance street youth's sexual health has become even more relevant in a (post)pandemic world.

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Young people are the majority living in new urban informality.

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A new conceptualization positions street peer relations as socio-spatially anchored.

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Peers can play a critical role in the sexual wellbeing of young street people.

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Policy, practice and peer social networks can advance sexual health of street youth.

Study protocol for a group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among young adults experiencing homelessness

BACKGROUND

Young people experiencing homelessness have alarmingly high rates of alcohol and other drug (AOD) use, which is associated with sexual risk behaviors such as unprotected sex, trading sex, and sex with multiple casual partners. Few risk reduction programs for this population have been developed and rigorously evaluated, particularly those that address both of these interrelated behaviors, use a collaborative and non-judgmental approach, and are feasible to deliver in settings where homeless young people seek services. This paper describes the protocol of a study evaluating a four-session Motivational Interviewing (MI)-based group risk reduction intervention for this population. The protocol has been shown to be efficacious in pilot work over 3 months with 200 homeless young adults [1]. The current study seeks to refine the intervention protocol and evaluate the program on a larger scale.

METHODS/DESIGN

In a cluster-cross-over randomized controlled trial, 18-25 year olds will receive the AWARE risk reduction program (n = 200) or standard care (n = 200) at one of three drop-in centers serving homeless youth in the Los Angeles area. We will evaluate intervention effects on primary outcomes of AOD use and sexual risk behavior, as well as secondary outcomes of health-related quality of life and social stability, over a 12-month period.

DISCUSSION

This project has the potential to fill a significant gap in prevention services by demonstrating that a brief intervention, feasible to deliver within settings where young people experiencing homelessness typically seeks services, can significantly reduce the interrelated problems of AOD use and sexual risk behavior. Trial registration ClinicalTrials.gov Identifier: NCT03735784. Registered November 18, 2018, https://clinicaltrials.gov/ct2/show/record/NCT03735784 (retrospectively registered).

Safer Sex Communication and Sexual Health Behaviors Among a Representative Statewide Sample of Homeless Adolescents

Homeless adolescents are at substantial risk of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and unplanned pregnancy; however, little research has assessed factors, such as safer sex communication, that may protect homeless adolescents against these negative outcomes. Using the 2015 North Carolina Youth Risk Behavior Survey (YRBS; unweighted N = 5,486; ages 12 to 18; 5% homeless), we compared homeless adolescents' primary safer sex communication sources (i.e., health care providers, parents, teachers, peers, religious leaders) to housed adolescents' communication sources and assessed how these sources relate to sexual health behaviors, including condom use, HIV testing, and number of sexual partners. Most homeless adolescents (61%), and 46% of housed adolescents reported having questions about sex. Further, twice as many homeless adolescents communicated primarily with health care providers compared to housed adolescents. Importantly, among homeless adolescents, communicating primarily with health care providers or teachers was related to greater likelihood of condom use and communicating primarily with religious leaders was related to greater likelihood of HIV testing. Parent communication was unrelated to homeless adolescents' sexual health behaviors. Last, communicating primarily with peers was associated with reduced likelihood of HIV testing. Having nonparental adult communication sources, including health care providers, teachers, and religious leaders, may be critical for encouraging safer sex behaviors among homeless adolescents.

Individual and Social Network Correlates of Sexual Health Communication Among Youth Experiencing Homelessness

Despite the potential for sexual health communication to be leveraged for HIV prevention among youth experiencing homelessness (YEH), there has yet to be a rigorous examination of individual and network or relational characteristics associated with sexual health communication in this group of young people. Cross-sectional survey and social network data from 1014 YEH aged 14-25 recruited in Los Angeles, California, were utilized to assess individual and network or relational characteristics associated with communication regarding condom use and HIV testing among YEH. Results suggest that social networks are key to understanding sexual health communication; YEH's engagement in sexual health communication was significantly related to the composition of their networks. To increase testing and decrease new HIV cases, a prudent strategy would be to train existing social network members (e.g., staff members, home-based peers, or partners) as agents of change in naturally occurring social networks of YEH.

"It seems kinda like a different language to us": Homeless youths' attitudes and experiences pertaining to condoms and contraceptives

Homeless youth become pregnant or involved in pregnancies at high rates. There are many ways by which unintended pregnancies may be prevented, including the use of condoms and other contraceptives. However, there is a dearth of research regarding contraceptive use among this vulnerable youth population, and especially through lenses that consider homeless youths' diverse gender identities, expressions, and sexualities. This study qualitatively explores homeless youths' attitudes and experiences regarding condom and other contraceptive use. Data were obtained from interviews with 30 youth experiencing homelessness, ages 18-21. Youth reported inconsistent use of condoms and other contraceptives, which youth often attributed to their perceptions of contraceptive inaccessibility and exorbitant cost. Most youth also did not know where to obtain contraceptive information and services, and reported transportation barriers and fear of being stigmatized in health care settings, particularly in relation to their gender identities and sexualities. Findings suggest that reproductive and sexual health information and services are urgently needed by all homeless young people, and from low-barrier, non-judgmental, and empathetic sources.

Exploring the Relationship Between Foster Care Experiences and HIV Risk Behaviors Among a Sample of Homeless Former Foster Youth

Recent research shows high rates of poor behavioral health outcomes among homeless former foster youth, including increased risk for HIV-risk behaviors. In the current study, data were collected from 184 youth at drop-in centers in Los Angeles using behavioral health questionnaires to explore the relationships between specific aspects of foster care experiences and engagement in HIV-risk behaviors. Results indicated that youth whose first homelessness experience occurred before leaving foster care were significantly more likely to engage in drug use with sex and exchange sex than those whose first homelessness experience occurred after leaving foster care. Intervention services targeting HIV-risk behaviors should consider the aspects of foster care placements that may increase the risk of these behaviors, such as long periods of placement or experiencing homelessness before exiting foster care, as well as those that may decrease the risk of these behaviors, such as exiting placement at an older age.

Implications for PrEP Uptake in Young Adults Experiencing Homelessness: A Mixed Methods Study

Youth experiencing homelessness (YEH) have a high risk of contracting HIV; however, they remain relatively unreached by pre-exposure prophylaxis (PrEP)-based HIV prevention initiatives. We used a cross-sectional mixed-methods study to explore PrEP knowledge, interest, facilitators, and barriers among YEH. Young adults were recruited from agencies serving YEH in Houston, TX (n = 30) and Los Angeles, CA (n = 15) to participate in an electronic self-report survey and a semistructured interview. Survey results indicate that 68.2% of YEH had low or no prior knowledge of PrEP, though 63.7% reported interest in taking PrEP. Qualitative results revealed facilitators of PrEP use, including high PrEP acceptability and awareness, and supportive social networks. Several barriers emerged, including medication-related barriers, adherence, cost, access barriers, low perceived HIV risk, perceived stigma of PrEP use, and low PrEP awareness. Despite high PrEP acceptability, PrEP use among YEH remains low partly due to low PrEP awareness, low perceived HIV risk, and medical mistrust.

Social networks and substance use after transitioning into permanentsupportive housing

BACKGROUND

Substance use disorders are common among persons experiencing homelessness, and research has identified social networks as important correlates of substance use in this population. Permanent supportive housing (PSH), particularly Housing First, which uses a harm reduction model not requiring substance abstinence, is a key solution for ending homelessness. However, conflicting evidence exists regarding the associations between moving into PSH and changes in substance use, and there is limited understanding of how networks may influence such changes.

METHODS

Using observational, longitudinal data from 421 persons before they moved in and over their first year in PSH (collected as part of a HIV-risk study), this paper assesses substance use change (alcohol, marijuana, and illicit drugs) and associations between perceived network characteristics and individual substance use.

RESULTS

Substance use remained relatively stable among participants over their first year living in PSH, although illicit substance use reduced somewhat at six months compared to baseline levels (from 18.5%-14.5%) and marijuana use increased slightly at 12 months (from 26.6% at baseline to 32.9%). Substance use among social network members was consistently associated with individual-level substance use, both cross-sectionally and longitudinally. Specific network substance use characteristics, such as proximity, location met, and social support, had differential relationships with particular substance types.

CONCLUSIONS

These findings provide longitudinal evidence that changes within substance-using social networks are associated with subsequent changes in individual use and underscore the importance of interventions aimed at promoting positive social relationships for formerly homeless persons and improving PSH's social environments.

A Youth Participatory Project to Address STIs and HIV among Homeless Youth

The purpose of this study was to conduct a youth participatory action research project to address the disparities in sexually transmitted infection (STI) and HIV rates among homeless youth. Four youth served as co-investigators and cultural informants for the project. The team conducted focus groups (N = 22; ages 16-22) and in-depth interviews (N = 20; ages 18-24) with homeless youth to explore decisions about condomless sex, knowledge of STIs and HIV, health-care access for STI-related services, and perceptions about STI testing. Findings revealed that homeless youth have good general knowledge about STIs, are receptive to STI testing for themselves and their sexual partners, and have heightened concerns about being HIV positive and peers knowing their STI status. Results from the current study could contribute to the development of youth-informed tailored interventions to increase protective sexual behavior, reduce health disparities, and improve access to and the quality of health-care services for homeless youth.

The Relative Influence of Injunctive and Descriptive Social Norms on Methamphetamine, Heroin, and Injection Drug Use Among Homeless Youths: The Impact of Different Referent Groups

The current study assessed the relative influence of both injunctive and descriptive norms in the context of different referent groups (i.e., family, street peers, home-based peers, and staff members) on past 30-day methamphetamine, heroin, and injection drug use behaviors of homeless youth. Cross-sectional data ( N = 911) were collected from three drop-in centers in Los Angeles, California. The study consisted of two parts: a social network interview and a computerized self-administered survey. Multivariate logistic regression models examined the association of objection to drug use from referent groups (injunctive norms; that is, street-based peers, home-based peers, relatives, staff members) and drug use of referent groups (descriptive norms) with youths’ substance use behaviors. Multivariate results indicated that the role of injunctive and descriptive norms varied across the three substance use behaviors and by referent group. Findings indicate the need to carefully consider the diversity of homeless youths’ networks in designing substance use interventions.