Reducing Homelessness among Persons with HIV: An Ecological Case Study in Delaware

INTRODUCTION

Among persons with HIV (PWH), homelessness is associated with poorer health. From 2009-2014, national HIV prevention goals included a reduction in homelessness among PWH. We sought to examine social ecological factors associated with homelessness among PWH at a sub-national level during that period.

METHODS

National data were used to identify Delaware as the only jurisdiction where homelessness among PWH declined from 2009-2014. We analyzed population-level indicators and conducted telephone interviews with 6 key stakeholders to further examine this trend.

RESULTS

Overall homelessness, household poverty, and median housing price were associated with homelessness among PWH in Delaware. Key stakeholders indicated that centralized intake processes improved screening, referral, and linkages of clients to housing units.

DISCUSSION

In addition to social and economic factors, collaborative program strategies may improve housing outcomes for PWH. Monitoring trends at sub-national levels can help identify successful approaches as well as needed services or policy change.

Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness

Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.

Psychosocial Risk Factors for Transitions Into Housing Instability Among Women Veterans

INTRODUCTION

Preventing and ending homelessness for women veterans, a priority of the Department of Veterans Affairs (VA), can be aided by identifying factors that increase their risk for housing instability.

METHODS

This study relied on data from the Veterans Health Administration's universal screen for housing instability from Fiscal Year 2013 to 2016, and administrative data from electronic medical records. Using logistic regression, we compared 2 groups of women veterans: those who consistently had stable housing and those who transitioned to unstable housing after a period of housing stability.

RESULTS

We found that a history of military sexual trauma, lack of access to VA benefits and other financial resources, and single or divorced marital status were significant risk factors for women veterans' housing instability. These findings are consistent with an existing theoretical model of housing instability and homelessness among women veterans, which highlights the importance of traumatic and adverse events and isolation as risk factors.

CONCLUSIONS

These risk factors and their effect on women veterans' housing instability can be mitigated by new and increased supportive interventions, targeted to those at highest risk.

A Sector Wheel Approach to Understanding the Needs and Barriers to Services among Homeless-Experienced Veteran Families

BACKGROUND

Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform providers for this important population.

METHODS

Twenty-five semi-structured interviews were conducted from February through September 2016 with 18 veteran parents with a recent history of homelessness (9 mothers, 9 fathers), and 7 homeless service providers throughout Los Angeles County. The "Sector Wheel for Under-Resourced Populations" data elicitation approach was used to conduct the interviews, which allowed the participant to guide the interview by discussing different sectors of a family's life affected by homelessness. The interviews were audio-recorded, transcribed, and themes were coded with Atlas.ti.

RESULTS

Interviews revealed parenting stress and worsening family mental health during homelessness. Participants described barriers to navigating housing, social, and health services with children, including not knowing where to seek help, difficulty connecting to health and social services in the community, and a lack of family-focused services. Parents encountered discrimination by landlords and lack of access to permanent housing in safe neighborhoods.

CONCLUSIONS

Findings demonstrate a need for delivering family-centered and comprehensive services to homeless-experienced veteran families that recognize the multifaceted needs of this population. Advocacy initiatives are needed to address discrimination against veterans experiencing family homelessness and increase access to affordable permanent housing in safe neighborhoods for families.

[Ways of governing street life during the pandemic: discourses, technologies, and practices]

Drawing on multiple sources, this article presents an analysis of a national survey implemented by Street Clinic teams in Brazil on the homeless population and the COVID-19 pandemic. Through the lens of certain ethical-political principles and methodological decisions, we focus our analysis on discourses about who lives and works on the streets during the pandemic, connecting discourse with experience. From the perspective of governmentality and biopolitics, we seek to shed light on power relations that reveal modes of government embodied at the street level - mainly related to isolation measures and social distancing - to create tensions surrounding the emergence of the notion of the homeless population in the midst of the pandemic. We conclude with a discussion of the precariousness that circumscribes life on the streets as a shared condition, and search for ways to comprehend forms of resistance and the right to exist.

Health status, diseases and vaccinations of the homeless in the city of Palermo, Italy

INTRODUCTION

In Italy, as in the rest of the world, the number of homeless people is increasing considerably. Many of them suffer from chronic conditions, mental health problems and addiction to alcohol, drugs or smoking, and need complex medical care. Their health status is often exacerbated by greater difficulty in accessing primary care. The aim of the present study was to assess health conditions of homeless people living in Palermo, Southern Italy, and to find ways to limit the spread of common infectious diseases that can be prevented by vaccination.

MATERIAL AND METHODS

A self-administered questionnaire was distributed. The questionnaire was structured into two parts including an introduction with socio-demographic information, and a second part investigating health status, chronic diseases and vaccinations. A multivariable logistic regression model was used and adjusted Odds Ratios (aOR) are presented.

RESULTS

The sample consisted of 52 homeless, 35 (67.3%) of whom were male and the most represented age class (55.8%) was < 50 years of age. The average age of the sample was 49.6 years (SD ± 15.2) and 88.5% were born in Italy. A multivariable logistic regression model based on 52 observations was used. The analysis showed that the female gender was significantly associated with: not performing regular physical activity (aOR 4.14, 95% C.I. 1.20 - 14.32, p = 0.025), suffering from chronic diseases (aOR 3.52, 95% C.I. 1.02 - 12.11, p = 0.046) and taking medicines (aOR 3.95, 95% C.I. 1.14 - 13.64, p = 0.030).

CONCLUSIONS

This particularly fragile population is exposed to diseases that are largely preventable or curable through a wider and more early access to care by local health facilities with a subsequent reduction in the worsening of clinical outcomes and related social costs.

Barriers to End-of-Life Services for Persons Experiencing Homelessness as Perceived by Health and Social Service Providers

BACKGROUND

People experiencing homelessness have significantly shorter life expectancies and higher rates of morbidity and mortality than the general population. Many barriers have been identified to providing palliative care to this population. This study examines health and social service providers' experiences providing end-of-life care to people experiencing homelessness, seeking recommendations to improve both patient and provider experience.

METHODS

Qualitative study using phenomenological approach. Qualitative and quantitative surveys with 136 health and social service providers in Ontario's South East Local Health Integration Network, in-depth interview with 10 key informants.

FINDINGS

Participants approached the end-of-life care of people experiencing homelessness from a framework of dignity and respect. Themes included barriers to end-of-life care internal to the health care system; care avoidance; the experience of stigma for this population when accessing end-of-life care; lack of provider information and awareness on how to provide care for marginalized groups, how to provide care in the context of substance use, and how to assist clients in accessing the formal palliative care system; and the need for harm reduction approaches to end-of-life care for persons experiencing homelessness.

DISCUSSION

Focusing on harm reduction, and using the framework of Equity-Oriented Health Care to make systemic, cultural, and policy changes to develop a palliative-care system for persons experiencing homelessness may improve care experience for both patients and providers.

Experiences of Palliative Health Care for Homeless and Vulnerably Housed Individuals

BACKGROUND

Thirty-five thousand Canadians are homeless on any given night, and mortality rates are much higher than for the general population. Studies have identified barriers to accessing end-of-life care among the homeless, including logistic barriers and experiences of stigma. This study seeks to explore the experience, goals, fears, and hopes surrounding death in the setting of homelessness or vulnerable housing.

METHODS

Qualitative phenomenological study involving focus groups and in-depth interviews with 31 people with lived experience of homelessness. Additional sociodemographic data collected from participants.

FINDINGS

Themes included extensive experience with death and dying, relationship with mortality, ideas for a good death, and desires for end-of-life care. Participants presented suggestions for improving end-of-life care including care that was delivered by people with lived experience of homelessness and substance use; care that was provided either as outreach or in a welcoming, flexible institutional environment; care that minimized stigma and enhanced dignity; and care that respected people's desires to use substances at the end of life.

DISCUSSION

Participants with lived experience of homelessness were articulate in their desires and needs for end-of-life care. They have extensive exposure to mortality and feel that their needs are not met by the current palliative care system. Recommendations for system change that include harm reduction and equity-oriented health care, as well as a combination of outreach and inpatient services, are necessary before palliative care services will be accessible for this population.

Adults with Housing Insecurity Have Worse Access to Primary and Preventive Care

OBJECTIVE

Housing insecurity has been linked to high-risk behaviors and chronic disease, although less is known about the pathways leading to poor health. We sought to determine whether housing insecurity is associated with access to preventive and primary care.

METHODS

We conducted weighted univariate, bivariate, and multivariate analyses by using 2011 to 2015 Behavioral Risk factor Surveillance Survey data (N = 228,131 adults). The independent variable was housing insecurity derived from the question on worry about paying rent or mortgage. The outcome measures were health services utilization (no usual source of care, no routine checkup in the past 1 year, and delayed medical care due to cost), self-rated health (number of days reported physical, mental health not good, and poor overall health), and number of chronic diseases (0, 1, 2 or more). The covariates included age, sex, race/ethnicity, income, level of education, marital status, and number of children in the family. We also adjusted for state fixed effects and survey year. We performed χ² tests and binary logistic regressions on categorical variables and ran t tests and estimated linear regression models on continuous variables. Multinomial logistic regressions were estimated for the number of chronic diseases.

RESULTS

Of the 228,131 adults in the study sample, 28,704 adults reported housing insecurity. We found that those with housing insecurity were more likely to forgo routine check-ups and lack usual sources of care. Low-income individuals, minorities, the unmarried, and middle-aged adults were more likely to report housing insecurity.

CONCLUSION

Housing insecurity is associated with worse access to preventive and primary care. Interventions to enhance access for these patients should be developed and studied.

Identifying the barriers and facilitators for homeless people to achieve good oral health

OBJECTIVE

A qualitative exploration of the barriers and facilitators for people experiencing homelessness achieving good oral health.

PARTICIPANTS

Adults using two homeless centres in Leeds.

METHODS

Focus group discussions were convened with homeless people using support services. Both an inductive and deductive approach to data analysis was taken. Themes were identified and then a framework applied to analysis using Nvivo software.

RESULTS

Three focus group discussions with 16 participants were conducted with people experiencing homelessness. The barriers identified were insufficient information on local dental services, negative attitudes of oral health professionals, low priority of dental care, anxiety and cost of dental treatments. Facilitators included single dental appointments, accessible dental locations and being treated with respect.

CONCLUSIONS

Despite the barriers that prevent people experiencing homelessness from maintaining and improving their oral health, the participants were aware that they needed oral healthcare and requested that dental services were made available to them and were accessible in line with their socioeconomic status and needs.

Chronic Pain Among Homeless Persons with Mental Illness

Objective

Chronic pain is an important public health issue. However, characteristics and needs of marginalized populations have received limited attention. Studies on prevalence and correlates of chronic pain among homeless persons are lacking. We assessed chronic pain among homeless persons with mental illness in the At Home/Chez Soi study.

Design

Cross-sectional data from a randomized controlled trial on homelessness and mental health.

Setting

Data collected between 2009 and 2013 in three Canadian cities.

Subjects

One thousand two hundred eighty-seven homeless persons with mental illness.

Methods

Data on chronic pain and utilization of prescribed and nonprescribed interventions was assessed using a chronic pain screening instrument. Mental illness was diagnosed with the Mini-International Neuropsychiatric Interview.

Results

Forty-three percent reported moderate to severe chronic pain, interfering with general daily activities (80%), sleep (78%), and social interactions (61%). Multivariate analysis indicated that increasing age and diagnoses of major depressive disorder, mood disorder with psychotic features, panic disorder, and post-traumatic stress disorder (PTSD) were independent predictors of chronic pain. Chronic pain was further associated with increased suicidality. Among participants reporting chronic pain, 64% had sought medical treatment and 56% treated pain with prescribed drugs, while 38% used illicit drugs for pain relief.

Conclusions

Chronic pain is very common among homeless persons with mental illness and affects activities of daily living. Clinicians treating this population should be aware of the common connections between chronic pain, depression, panic disorder, PTSD, and substance use. While the data indicate the contribution of chronic pain to complex treatment needs, they also indicate a clear treatment gap.

Evaluating the impact of pharmacist health education on the perceptions of the pharmacist's role among women living in a homeless shelter

Objectives:

To determine the impact of pharmacist-provided educational seminars on the participant’s perception of the pharmacist’s role in providing women’s health education. Secondary objectives include the participant’s level of perceived benefit from the information provided during each presentation, as well as determining characteristics of participants who are interested in attending seminars.

Methods:

This is a prospective study conducted within a homeless women’s shelter in Phoenix, Arizona. Pharmacists and pharmacy students provided 10 monthly educational seminars on topics related to women’s health. Participants completed a pre- and post-seminar survey regarding their perceptions of the presentations and pharmacists.

Results:

Fifty-six participants attended at least one of 10 seminars from January to November 2014. The average age was 46 years old, taking approximately 3 medications, and 66% completed a high school degree or lower. Prior to the presentations, 30% of participants agreed or strongly agreed that they would seek advice from a pharmacist on the topic presented, which increased significantly to 82% of participants after the presentation (p<0.001). Similarly, 55% of participants rated themselves as agreeing or strongly agreeing with being knowledgeable on the topic presented prior to the presentation, and this increased significantly to 77% after the presentation (p=0.001). After attending the educational session, 70% of participants agreed or strongly agreed that they would make changes to their health, and that they would attend an additional session. The participants noted their increased learning about the topic, the clarity of visual aids and presentation, and knowledge of the presenters as the best parts of the presentation.

Conclusion:

Pharmacist’s participation in providing educational seminars in the homeless women’s population increases the participant’s knowledge and perception of the pharmacist’s role within the population. Future studies can further investigate an evolving role of pharmacists in optimizing healthcare in the homeless population.

Vitamin C Deficiency of Korean Homeless Patients Visiting to Emergency Department with Acute Alcohol Intoxication

Vitamins are essential micronutrients for maintenance of tissue functions. Vitamin deficiency is one of the most serious and common health problems among both chronic alcoholics and the homeless. However, the vitamin-level statuses of such people have been little studied. We evaluated the actual vitamin statuses of alcoholic homeless patients who visited an emergency department (ED). In this study the blood levels of vitamins B1, B12, B6, and C of 217 alcoholic homeless patients were evaluated retrospectively in a single urban teaching hospital ED. Vitamin C deficiency was observed in 84.3% of the patients. The vitamin B1, B12, and B6 deficiency rates, meanwhile, were 2.3%, 2.3%, and 23.5%, respectively. Comparing the admitted patients with those who were discharged, only the vitamin C level was lower. (P=0.003) In fact, the patients' vitamin C levels were markedly diminished, vitamin C replacement therapy for homeless patients should be considered in EDs.

A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities

BACKGROUND

People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports.

METHODS

The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the "10 Essential Public Health Services."

RESULTS

Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system.

CONCLUSION

The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the "grand challenges" of integrated community health services.

The clinical characteristics and predictors of treatment success of pulmonary tuberculosis in homeless persons at a public hospital in busan

BACKGROUND

Homelessness is associated with an increased risk of exposure to Mycobacterium tuberculosis. Several factors, including alcoholism, malnutrition, lack of stable housing, combine to make tuberculosis more prevalent in the homeless. The aims of this study were to determine the factors associated with increasing success rate of tuberculosis treatment in the homeless.

METHODS

A cross-sectional analysis of the clinical features in 142 pulmonary tuberculosis-positive homeless patients admitted to the Busan Medical Center from January 2001 to December 2010 was carried out. These results were compared with a successful treatment group and incomplete treatment group. We also evaluated the risk factors of treatment non-completion. Statistical analysis for the comparisons was performed using a χ(2) test, independent samples t-test, and multiple logistic regression.

RESULTS

Comparison of clinical characteristics showed significant differences between the two groups in the type of residence (P < 0.001), diseases with risk factors (P = 0.003), and history of tuberculosis treatment (P = 0.009). Multiple regression analysis revealed the residence (odds ratio [OR], 4.77; 95% confidence interval [CI], 2.05 to 11.10; P < 0.001) and comorbidity with risk factor (OR, 2.72; 95% CI, 1.13 to 6.53; P = 0.025) to be independently associated with treatment success.

CONCLUSION

To improve the success rate of tuberculosis treatment in the homeless person, anti tuberculosis medication should be taken until the end of treatment and a management system for the homeless person is required. Further social and medical concerns for stable housing and management of comorbidity may lead to an improvement in the successful tuberculosis treatment of homeless person.

Provision of clinical pharmacy services in two safety net provider settings

OBJECTIVE

The purpose of this report is to characterize the patient population served by the Grace Lamsam Pharmacy Program and to describe program outcomes.

METHODS

A chart review was conducted for all patients (n=100) participating in the Grace Lamsam Pharmacy Program from January 1, 2007 to February 6, 2008. The primary outcome data collected were the medication related problems (unnecessary drug therapy, needs additional drug therapy, ineffective drug therapy, dosage too low, dosage too high, adverse drug reaction, noncompliance, and needs different drug product) identified by pharmacists, the number and type of pharmacist interventions made, estimated cost savings from perspective of the patient and clinical data (hemoglobin A1C, blood pressure measurements, and LDL-C) for patients with diabetes, hypertension, and hyperlipidemia, respectively. Basic demographic data was collected, including: patient gender, age, education level, race/ethnicity, marital status, and income. Patients' smoking status, type and number of medical conditions, medications being used at baseline, and number of pharmacist visits per patient during the study review period were also recorded.

RESULTS

The majority of patients cared for were male, middle-aged, and African-American. The majority (90%) of patients had an income below 150% of the 2007 Federal poverty level. Patients were most commonly treated for diabetes, hypertension, and hyperlipidemia. During the period of review, 188 medication related problems were identified and documented with noncompliance being the most common medication related problem identified. Pharmacists completed 477 Pharmaceutical Manufacturer Assistance Program applications for 68 patients. These interventions represented a cost savings from the patients' perspective of approximately 243 USD per month during the review period. Blood pressure, A1C, and LDL-C readings improved in patients enrolled in the clinical pharmacy program at the free clinic and the community health center.

CONCLUSION

A clinical pharmacy services model provides a role for the pharmacist in an interdisciplinary team (beyond the traditional dispensing role) to identify medication related problems in the drug therapy of patients who utilize safety-net provider health care services.

Mortality among homeless shelter residents in New York City

OBJECTIVES

This study examined the rates and predictors of mortality among sheltered homeless men and women in New York City.

METHODS

Identifying data on a representative sample of shelter residents surveyed in 1987 were matched against national mortality records for 1987 through 1994. Standardized mortality ratios were computed to compare death rates among homeless people with those of the general US and New York City populations. Logistic regression analysis was used to examine predictors of mortality within the homeless sample.

RESULTS

Age-adjusted death rates of homeless men and women were 4 times those of the general US population and 2 to 3 times those of the general population of New York City. Among homeless men, prior use of injectable drugs, incarceration, and chronic homelessness increased the likelihood of death.

CONCLUSIONS

For homeless shelter users, chronic homelessness itself compounds the high risk of death associated with disease/disability and intravenous drug use. Interventions must address not only the health conditions of the homeless but also the societal conditions that perpetuate homelessness.

Nutritional status of pavement dweller children of Calcutta City

Pavement dwelling is likely to aggravate malnutrition among its residents due to extreme poverty, lack of dwelling and access to food and their exposure to polluted environment. Paucity of information about nutritional status of street children compared to that among urban slum dwellers, squatters or rural/tribal population is quite evident. The present study revealed the magnitude of Protein Energy Malnutrition (PEM) and few associated factors among a sample of 435 underfives belonging to pavement dweller families and selected randomly from clusters of such families, from each of the five geographical sectors of Calcutta city. Overall prevalence of PEM was found almost similar (about 70%) to that among other 'urban poor' children viz. slum dwellers etc., but about 16% of them were found severely undernourished (Grade III & V of IAP classification of PEM). About 35% and 70% of street dweller children had wasting and stunting respectively. Severe PEM (Grade III & IV) was more prevalent among 12-23 months old, girl child, those belonged to illiterate parents and housewife mothers rather than wage earners. It also did increase with increase of birth rate of decrease of birth interval.

Pregnancy among three national samples of runaway and homeless youth

PURPOSE

To compare estimates of the prevalence of pregnancy among runaway and homeless youth between the ages of 14 and 17 years in various settings with each other and with youth in the general population.

METHODS

Comparisons used three surveys of youth: (a) the first nationally representative survey of runaway and homeless youth residing in federally and nonfederally funded shelters, (b) a multicity survey of street youth, and (c) a nationally representative household survey of youth with and without recent runaway and homeless experiences.

RESULTS

Youth living on the streets had the highest lifetime rates of pregnancy (48%), followed by youth residing in shelters (33%) and household youth (<10%).

CONCLUSIONS

Shelter and street youth were at much greater risk of having ever been pregnant than were youth in households, regardless of whether they had recent runaway or homeless experiences. Such youth need comprehensive services, including pregnancy prevention, family planning, and prenatal and parenting services.

Pregnancy among three national samples of runaway and homeless youth

PURPOSE

To compare estimates of the prevalence of pregnancy among runaway and homeless youth between the ages of 14 and 17 years in various settings with each other and with youth in the general population.

METHODS

Comparisons used three surveys of youth: (a) the first nationally representative survey of runaway and homeless youth residing in federally and nonfederally funded shelters, (b) a multicity survey of street youth, and (c) a nationally representative household survey of youth with and without recent runaway and homeless experiences.

RESULTS

Youth living on the streets had the highest lifetime rates of pregnancy (48%), followed by youth residing in shelters (33%) and household youth (<10%).

CONCLUSIONS

Shelter and street youth were at much greater risk of having ever been pregnant than were youth in households, regardless of whether they had recent runaway or homeless experiences. Such youth need comprehensive services, including pregnancy prevention, family planning, and prenatal and parenting services.

Substance use and risky sexual behavior among homeless and runaway youth

PURPOSE

To (a) characterize human immunodeficiency virus (HIV)-related risk behaviors of homeless youth; (b) determine whether substance use is associated with risky sexual behavior in this population; and, if so, (c) explore explanations for this relationship.

METHODS

A purposive sample of 327 homeless youth (ages 14-21 years) in Washington, DC, were surveyed in 1995 and 1996. Survey items were adapted from items used in a national study of adult substance use and sexual behavior and measured global (lifetime) and event-specific (most recent sexual encounter) behaviors.

RESULTS

Sexual activity with many partners, "survival" sex, and substance use were common. However, needle use was rare, and consistent condom use was evident in half the sample. Nearly all correlations between global measures of substance use and risky sex were statistically significant, but only a few of the event-specific correlations were significant. Marijuana use during the most recent sexual encounter was associated with nonuse of condoms, but this relationship disappeared in the multivariate model. However, crack use during the last encounter was associated with condom use; this relationship remained significant in the multivariate model. Lack of motivation to use condoms, longer histories of sexual activity and homelessness, symptoms of drug dependency, not discussing HIV risks with partner, and being female were also associated with nonuse of condoms.

CONCLUSIONS

Homeless youth do use condoms, even within the context of substance use and casual sex. Results suggest that prevention and targeted intervention efforts have had some positive effect on this population, but young homeless women are in need of targeted prevention. Finally, additional research is needed to investigate the observed relationship between crack use and condom use in this sample.

Projection of HIV infection in Calcutta

Starting with the base year of 1991, the HIV infection projection for 1992-99 for the total, as well as various high-risk sub-populations of Calcutta, the first of its kind is provided. These projections are based on statistical methodology developed in this paper. Our methodology for spread of HIV infection takes into account various social interactions and practices and also uses available data. Rates of these interactions and practices and estimates of demographic parameters used in making projections were obtained primarily from surveys and census data. Since one of these estimated rates, that of HIV transmission rate through heterosexual encounters between an infected and an uninfected had a large range, we have provided two sets of projections based on the largest of these rates (worst-case scenario) and another that is consistent with the available data. The total projection of the number of HIV infected cases in Calcutta for 1999 is between 49,000 and 1,26,000. Separate projections are also provided for high-risk sub-groups. Among these, the sex workers expectedly will continue to manifest the highest numbers of newly infected cases. The temporal rate of increase in prevalence is projected to be alarmingly higher in the general population than even among sex workers, although the actual prevalence will continue to be the lowest in the general population compared to all other sub-groups of the population.

Prevalence of sexual risk behaviour and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City

We aim to assess the prevalence of HIV sexual risk behaviours and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City. Survey data were examined from 775 runaway and homeless adolescents recruited from street settings and youth agencies during 1992/1993. Nearly all (98%) reported having engaged in sexual intercourse, of whom 49% first had intercourse by the age of 13. Condom use during all vaginal intercourse in the previous 3 months was reported by 42%. Among males, 23% indicated that they had exchanged sex for money, as did 14% of the females. Ninety-seven per cent had used alcohol or drugs and 21% had injected drugs. Overall, 75% reported having had sex while under the influence of alcohol or drugs. Systematic epidemiological studies of this population and the development of innovative interventions are essential to reduce the threat of HIV among runaway and homeless youth.

Self-reported risk factors for AIDS among homeless youth

This study assessed HIV risk behaviors in a sample of homeless youth in a large urban area and examined factors associated with these behaviors. Self-reported behaviors were assessed via interviews with 196 homeless youth in Chicago in all 10 urban shelters serving this group and in 5 street locations. Overall, 83.7% reported at least one of these risk factors: multiple sex partners; high-risk partners; inconsistent condom use; history of sexually transmitted disease; anal sex; prostitution; and/or intravenous drug use. An index of these behaviors was associated with being male, having unmet personal needs, being interviewed in street locations, and having a history of sexual abuse. Findings suggest that strategies that may decrease risk behaviors among homeless youth include the elimination of their need to rely on illicit activities for income, provision of basic needs, education regarding existing services, increased outreach efforts, and early identification of and protection from childhood sexual abuse.

Sexual abuse history and associated multiple risk behavior in adolescent runaways

Relationships between sexual abuse and sexual risk, substance use, emotional distress, and conduct problems were examined among 190 runaways. Those who had been abused were significantly more likely than nonabused peers to engage in unprotected sex, have more sexual partners, and use alcohol and drugs, but did not differ in emotional distress. Those abused after age 13 were more often engaged in sex work than nonabused peers. Males abused before age 13 had more sexual partners than those not abused, and runaway males were significantly more likely to have been sexually abused than has been reported in prior research.

Prevalence and risk factors for HBV infection among street youth in central Brazil

PURPOSE

A seroprevalence survey was carried out among 496 street adolescents from 9 to 20 years old in central Brazil to determine the prevalence of hepatitis B (HBV) markers, as well as to assess the role of potential risk factors.

RESULTS

The findings reveal that 20.4% of the participants were homeless adolescents without family links, living and/or working on the streets. The age at first sexual intercourse was as low as 9 years old, and approximately 60% of this population had had at least one sexual relationship by the age of thirteen, indicating prepubertal initiation of sexual experiences among street adolescents. 13.5% were HBV marker-positive (anti-HBc) and 2.0% had antigenemia. Street-based youth had a higher HBV marker-positive rate when compared to home-based teens (OR = 4.1, 95% CI: 2.1-8.5) and, similarly, higher HBV prevalence was obtained for those reporting sexual activity versus the group without sexual activity (OR = 2.1, 95% CI: 1.1-3.9), even after adjusting for potential confounders.

CONCLUSIONS

We have found that street youth, particularly street-based adolescents, should be considered at-risk group for hepatitis B infection in our region. These findings may be used as a baseline information for policy changes not only in hepatitis B prevention but also to reverse the scenario of adolescents sexual abuse.

Mortality in a cohort of homeless adults in Philadelphia

BACKGROUND

Homeless people are at high risk for death from many causes, but age-adjusted death rates for well-defined homeless populations have not been determined.

METHODS

We identified 6308 homeless persons 15 to 74 years of age who were served by one or both of two agencies for the homeless in Philadelphia between January 1, 1985, and December 31, 1988. Using a data base that contained all deaths in Philadelphia and listings of all Philadelphia residents during the same period, we compared the mortality rate for this homeless population with the rate in the general population of Philadelphia.

RESULTS

The age-adjusted mortality rate among the homeless was 3.5 times that of Philadelphia's general population (95 percent confidence interval, 2.8 to 4.5). The age-adjusted number of years of potential life lost before the age of 75 years was 3.6 times higher for the homeless people than for the general population (345 vs. 97 years lost per 1000 person-years of observation). Fifty-one of the 96 deaths of homeless persons (53 percent) occurred during the summer months. Mortality rates were higher among the homeless than in the general population for nonwhites, whites, women, and men. Within the homeless cohort, white men and substance abusers had higher mortality rates than other subgroups, but even homeless people not known to be substance abusers had a threefold higher risk of death than members of the general population. Injuries, heart disease, liver disease, poisoning, and ill-defined conditions accounted for 73 percent of all the deaths among the homeless.

CONCLUSIONS

Homeless adults in Philadelphia have an age-adjusted mortality rate nearly four times that of Philadelphia's general population. White men and substance abusers are at particularly high risk. Matching cohorts of homeless people to death records is a useful way to monitor mortality rates over time, evaluate interventions, and identify subgroups with an increased risk of death.

An investigation to determine the health status of institutionalised street children in a place of safety in Durban

This study determines the health profile of institutionalized street children in a Place of Safety in Durban. Fifty black street children who had been institutionalized for a period of not more than fourteen days were interviewed and health assessments were carried out. The children's weights and heights were recorded on growth charts and structured interviews were held. Generally the children were found to be deprived, both socially and physically. Minor health problems were common and some had more serious problems. Recommendations for effective primary health care are put forward.