Current HIV/AIDS Reports

, Volume 4, Issue 4, pp 181–186 | Cite as

Poverty, unstable housing, and HIV infection among women living in the United States

  • Elise D. RileyEmail author
  • Monica Gandhi
  • C. Bradley Hare
  • Jennifer Cohen
  • Stephen W. Hwang


Women who are HIV positive incur a higher risk of mortality than men who are HIV positive, a difference which is primarily based in the social context of poverty. Economic crises that lead to homelessness, unmet subsistence needs, and sex exchange often reorder priorities among women with HIV infection, de-emphasizing consistent medical care or the use of antiretroviral therapy. High rates of mental illness, drug use, and victimization further increase health and safety risks. HIV prevention messages highlighting education and behavior change insufficiently address the predicament of indigent women where constrained survival choices in the context of poverty may take precedence over safe behaviors. In this article, we highlight the risks of poor and unstably housed women to clarify the context in which risks occur. Suggestions for service provision are offered with the understanding that providers may have limited time and expertise to meet the entire array of needs for impoverished women.


Local Syringe Exchange Program 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Ojikutu BO, Stone VE: Women, inequality, and the burden of HIV. N Engl J Med 2005, 352:649–652.PubMedCrossRefGoogle Scholar
  2. 2.
    Wenzel SL, Tucker JS: Reemphasizing the context of women’s risk for HIV/AIDS in the United States. Womens Health Issues 2005, 15:154–156.PubMedCrossRefGoogle Scholar
  3. 3.
    Olges JR, Murphy BS, Caldwell GG, Thornton AC: Testing practices and knowledge of HIV among prenatal care providers in a low seroprevalence state. AIDS Patient Care STDS 2007, 21:187–194.PubMedCrossRefGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention: HIV/AIDS Surveillance by Race/ethnicity (through 2005). Accessed August 2, 2007.
  5. 5.
    Twenty-five years of HIV/AIDS—United States, 1981–2006. MMWR Morb Mortal Wkly Rep 2006, 55:585–589.Google Scholar
  6. 6.
    Melnick SL, Sherer R, Louis TA, et al.: Survival and disease progression according to gender of patients with HIV infection. The Terry Beirn Community Programs for Clinical Research on AIDS. JAMA 1994, 272:1915–1921.PubMedCrossRefGoogle Scholar
  7. 7.
    Lemp GF, Hirozawa AM, Cohen JB, et al.: Survival for women and men with AIDS. J Infect Dis 1992, 166:74–79.PubMedGoogle Scholar
  8. 8.
    Palella FJ Jr, Delaney KM, Moorman AC, et al.: Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998, 338:853–860.PubMedCrossRefGoogle Scholar
  9. 9.
    Riley ED, Bangsberg DR, Guzman D, et al.: Antiretroviral therapy, hepatitis C virus, and AIDS mortality among San Francisco’s homeless and marginally housed. J Acquir Immune Defic Syndr 2005, 38:191–195.PubMedCrossRefGoogle Scholar
  10. 10.
    Cunningham WE, Markson LE, Andersen RM, et al.: Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the united states. HCSUS Consortium. HIV Cost and Services Utilization. J Acquir Immune Defic Syndr 2000, 25:115–123.PubMedCrossRefGoogle Scholar
  11. 11.
    Moore RD, Fortgang I, Keruly J, Chaisson RE: Adverse events from drug therapy for human immunodeficiency virus disease. Am J Med 1996, 101:34–40.PubMedCrossRefGoogle Scholar
  12. 12.
    Spire B, Carrieri P, Garzot MA, et al.: Factors associated with efavirenz discontinuation in a large community-based sample of patients. AIDS Care 2004, 16:558–564.PubMedCrossRefGoogle Scholar
  13. 13.
    Chaisson RE, Keruly JC, Moore RD: Race, sex, drug use, and progression of human immunodeficiency virus disease. N Engl J Med 1995, 333:751–756.PubMedCrossRefGoogle Scholar
  14. 14.
    Bouvet E, Casalino E, Mendoza-Sassi G, et al.: A nosocomial outbreak of multidrug-resistant Mycobacterium bovis among HIV-infected patients. A case-control study. AIDS 1993, 7:1453–1460.PubMedCrossRefGoogle Scholar
  15. 15.
    Golden S: The Women on the Outside: Meaning and Myths of Homelessness. Berkeley, CA: University of California Press; 1992.Google Scholar
  16. 16.
    Hwang SW: Mortality among men using homeless shelters in Toronto, Ontario. JAMA 2000, 283:2152–2157.PubMedCrossRefGoogle Scholar
  17. 17.
    Bachrach LL: Homeless women: a context for health planning. Milbank Q 1987, 65:371–396.PubMedCrossRefGoogle Scholar
  18. 18.
    Riley ED, Weiser SD, Sorensen JL, et al.: Housing patterns and correlates of homelessness differ by gender among individuals using San Francisco free food programs. J Urban Health 2007, 84:415–422.PubMedCrossRefGoogle Scholar
  19. 19.
    Riley ED, Moss AR, Clark RA, et al.: Cash benefits are associated with lower risk behavior among the homeless and marginally housed in San Francisco. J Urban Health 2005, 82:142–150.PubMedGoogle Scholar
  20. 20.
    Foley D: Single-room occupancy hotels: possible solutions and alternatives. Body Posit 1998, 11:35–39 concl.PubMedGoogle Scholar
  21. 21.
    San Francisco Observes World TB Day in Mission: Focus on Families in SRO (Single Room Occupancy) Hotels. San Francisco: Department of Public Health; 2002.Google Scholar
  22. 22.
    Surratt HL, Inciardi JA: HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA. AIDS Care 2004, 16:594–604.PubMedCrossRefGoogle Scholar
  23. 23.
    Gelberg L, Linn LS: Demographic differences in health status of homeless adults. J Gen Intern Med 1992, 7:601–608.PubMedCrossRefGoogle Scholar
  24. 24.
    Russell JM, Smith K: HIV infected women and women’s services. Health Care Women Int 1998, 19:131–139.PubMedCrossRefGoogle Scholar
  25. 25.
    Montoya ID: Infectious diseases and anemia in a sample of out-of-treatment drug users. Am J Manag Care 1998, 4:1257–1264.PubMedGoogle Scholar
  26. 26.
    Lum PJ, Sears C, Guydish J: Injection risk behavior among women syringe exchangers in San Francisco. Subst Use Misuse 2005, 40:1681–1696.PubMedCrossRefGoogle Scholar
  27. 27.
    Nyamathi AM, Leake B, Gelberg L: Sheltered versus non-sheltered homeless women differences in health, behavior, victimization, and utilization of care. J Gen Intern Med 2000, 15:565–572.PubMedCrossRefGoogle Scholar
  28. 28.
    Riley ED, Wu AW, Perry S, et al.: Depression and drug use impact health status among marginally housed HIV-infected individuals. AIDS Patient Care STDS 2003, 17:401–406.PubMedCrossRefGoogle Scholar
  29. 29.
    McCoy CB, Metsch LR, Comerford M, et al.: Trends of HIV risk behaviors in a cohort of injecting drug users and their sex partners in Miami, Florida, 1988–1998. AIDS Behav 2005, 9:187–199.PubMedCrossRefGoogle Scholar
  30. 30.
    Vlahov D, Safaien M, Lai S, et al.: Sexual and drug risk-related behaviours after initiating highly active antiretroviral therapy among injection drug users. AIDS 2001, 15:2311–2316.PubMedCrossRefGoogle Scholar
  31. 31.
    Latkin CA, Sherman S, Knowlton A: HIV prevention among drug users: outcome of a network-oriented peer outreach intervention. Health Psychol 2003, 22:332–339.PubMedCrossRefGoogle Scholar
  32. 32.
    Inciardi JA, Surratt HL, Kurtz SP, Weaver JC: The effect of serostatus on HIV risk behaviour change among women sex workers in Miami, Florida. AIDS Care 2005, 17(Suppl 1):S88–S101.PubMedCrossRefGoogle Scholar
  33. 33.
    McGowan JP, Shah SS, Ganea CE, et al.: Risk behavior for transmission of human immunodeficiency virus (HIV) among HIV-seropositive individuals in an urban setting. Clin Infect Dis 2004, 38:122–127.PubMedCrossRefGoogle Scholar
  34. 34.
    Tyler KA, Hoyt DR, Whitbeck LB, Cauce AM: The effects of a high-risk environment on the sexual victimization of homeless and runaway youth. Violence Vict 2001, 16:441–455.PubMedGoogle Scholar
  35. 35.
    Mallory C, Stern PN: Awakening as a change process among women at risk for HIV who engage in survival sex. Qual Health Res 2000, 10:581–594.PubMedCrossRefGoogle Scholar
  36. 36.
    Sanders-Phillips K: Factors influencing HIV/AIDS in women of color. Public Health Rep 2002, 117(Suppl 1):S151–S156.PubMedGoogle Scholar
  37. 37.
    Weiser SD, Dilworth SE, Neilands TB, et al.: Gender-specific correlates of sex trade among homeless and marginally housed individuals in San Francisco. J Urban Health 2006, 83:736–740.PubMedCrossRefGoogle Scholar
  38. 38.
    Romans SE, Potter K, Martin J, Herbison P: The mental and physical health of female sex workers: a comparative study. Aust N Z J Psychiatry 2001, 35:75–80.PubMedCrossRefGoogle Scholar
  39. 39.
    Stoskopf CH, Kim YK, Glover SH: Dual diagnosis: HIV and mental illness, a population-based study. Community Ment Health J 2001; 37:469–479.PubMedCrossRefGoogle Scholar
  40. 40.
    Meade CS, Sikkema KJ: HIV risk behavior among adults with severe mental illness: a systematic review. Clin Psychol Rev 2005; 25:433–457.PubMedCrossRefGoogle Scholar
  41. 41.
    Morrison MF, Petitto JM, Ten Have T, et al.: Depressive and anxiety disorders in women with HIV infection. Am J Psychiatry 2002, 159:789–796.PubMedCrossRefGoogle Scholar
  42. 42.
    Carrieri MP, Leport C, Protopopescu C, et al.: Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase. J Acquir Immune Defic Syndr 2006, 41:477–485.PubMedCrossRefGoogle Scholar
  43. 43.
    Kimerling R, Armistead L, Forehand R: Victimization experiences and HIV infection in women: associations with serostatus, psychological symptoms, and health status. J Trauma Stress 1999, 12:41–58.PubMedCrossRefGoogle Scholar
  44. 44.
    Staton M, Leukefeld C, Logan TK: Health service utilization and victimization among incarcerated female substance users. Subst Use Misuse 2001, 36:701–716.PubMedCrossRefGoogle Scholar
  45. 45.
    Barkan SE, Melnick SL, Preston-Martin S, et al.: The Women’s Interagency HIV Study. WIHS Collaborative Study Group. Epidemiology 1998, 9:117–125.PubMedCrossRefGoogle Scholar
  46. 46.
    El-Bassel N, Witte SS, Wada T, et al.: Correlates of partner violence among female street-based sex workers: substance abuse, history of childhood abuse, and HIV risks. AIDS Patient Care STDS 2001, 15:41–51.PubMedCrossRefGoogle Scholar
  47. 47.
    Wu E, El-Bassel N, Witte SS, et al.: Intimate partner violence and HIV risk among urban minority women in primary health care settings. AIDS Behav 2003, 7:291–301.PubMedCrossRefGoogle Scholar
  48. 48.
    Klinkenberg WD, Caslyn RJ, Morse GA, et al.: Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders. Compr Psychiatry 2003, 44:293–302.PubMedCrossRefGoogle Scholar
  49. 49.
    Hwang SW, Orav EJ, O’Connell JJ, et al.: Causes of death in homeless adults in Boston. Ann Intern Med 1997, 126:625–628.PubMedGoogle Scholar
  50. 50.
    Cheung AM, Hwang SW: Risk of death among homeless women: a cohort study and review of the literature. CMAJ 2004, 170:1243–1247.PubMedGoogle Scholar
  51. 51.
    Hwang SW, O’Connell JJ, Lebow JM, et al.: Health care utilization among homeless adults prior to death. J Health Care Poor Underserved 2001, 12:50–58.PubMedGoogle Scholar
  52. 52.
    Smith MY, Rapkin BD, Winkel G, et al.: Housing status and health care service utilization among low-income persons with HIV/AIDS. J Gen Intern Med 2000, 15:731–738.PubMedCrossRefGoogle Scholar
  53. 53.
    Gelberg L, Browner CH, Lejano E, Arangua L: Access to women’s health care: a qualitative study of barriers perceived by homeless women. Women Health 2004, 40:87–100.PubMedGoogle Scholar
  54. 54.
    Shapiro MF, Morton SC, McCaffrey DF, et al.: Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA 1999, 281:2305–2315.PubMedCrossRefGoogle Scholar
  55. 55.
    Stewart KE, Cianfrini LR, Walker JF: Stress, social support and housing are related to health status among HIV-positive persons in the deep south of the United States. AIDS Care 2005, 17:350–358.PubMedCrossRefGoogle Scholar
  56. 56.
    Byrd W, Clayton L: An American Health Dilemma: A Medical History of African Americans and the Problem of Race: Beginnings to 1900. New York: Routledge; 2000.Google Scholar
  57. 57.
    Gelberg L, Doblin BH, Leake BD: Ambulatory health services provided to low-income and homeless adult patients in a major community health center. J Gen Intern Med 1996, 11:156–162.PubMedCrossRefGoogle Scholar
  58. 58.
    Bradford DW, Gaynes BN, Kim MM, et al.: Can shelter-based interventions improve treatment engagement in homeless individuals with psychiatric and/or substance misuse disorders?: a randomized controlled trial. Med Care 2005, 43:763–768.PubMedCrossRefGoogle Scholar
  59. 59.
    Bourgois P: Anthropology and epidemiology on drugs: the challenges of cross-methodological and theoretical dialogue. Int J Drug Policy 2002, 13:259–269.CrossRefGoogle Scholar
  60. 60.
    Rhodes T, Singer M, Bourgois P, et al.: The social structural production of HIV risk among injecting drug users. Soc Sci Med 2005, 61:1026–1044.PubMedCrossRefGoogle Scholar
  61. 61.
    Link BG, Phelan JC: Understanding sociodemographic differences in health—the role of fundamental social causes. Am J Public Health 1996, 86:471–472.PubMedGoogle Scholar
  62. 62.
    Weeks MR, Grier M, Romero-Daza N, et al.: Streets, drugs, and the economy of sex in the age of AIDS. Women Health 1998, 27:205–229.PubMedCrossRefGoogle Scholar
  63. 63.
    Lichtenstein B: Domestic violence, sexual ownership, and HIV risk in women in the American Deep South. Soc Sci Med 2005, 60:701–714.PubMedCrossRefGoogle Scholar
  64. 64.
    Wolfson M, Kaplan G, Lynch J, et al.: Relation between income inequality and mortality: empirical demonstration. BMJ 1999, 319:953–955.PubMedGoogle Scholar
  65. 65.
    Cohen DA, Mason K, Bedimo A, et al.: Neighborhood physical conditions and health. Am J Public Health 2003, 93:467–471.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group LLC 2007

Authors and Affiliations

  • Elise D. Riley
    • 1
    Email author
  • Monica Gandhi
  • C. Bradley Hare
  • Jennifer Cohen
  • Stephen W. Hwang
  1. 1.Epidemiology and Prevention Interventions CenterUniversity of California at San FranciscoSan FranciscoUSA

Personalised recommendations