This paper examines housing as a contextual factor affecting drug and sexual risk behaviors among HIV positive people using pooled interview data from 2149 clients presenting for services at 16 medical and social service agencies participating in a multi-site evaluation study. The odds of recent drug use, needle use or sex exchange at the baseline interview was 2–4 times as high among the homeless and unstably housed compared to persons with stable housing. Follow-up data collected 6–9 months after baseline showed that change in housing status was associated with change in risk behaviors. Persons whose housing status improved between baseline and follow-up significantly reduced their risks of drug use, needle use, needle sharing and unprotected sex by half in comparison to individuals whose housing status did not change. In addition, for clients whose housing status worsened between baseline and follow-up, their odds of recently exchanging sex was over five times higher than for clients whose housing status did not change. The provision of housing is a promising structural intervention to reduce the spread of HIV.
Similar content being viewed by others
Notes
The demonstration projects were selected by separate HRSA or HUD national competitions in 1996–97. Projects included in the present analysis were located in Anchorage, AK, Baltimore, MD, Bridgeport, CT, Boston, MA, Chicago, IL, Durham, NC, Houston, TX, Jersey City, NJ, Long Beach, CA, Miami, FL, Newark, NJ, New York, NY, Oakland, CA, Pine Bluff, AK, Providence, RI, San Antonio, TX, Santa Cruz, CA, and Seattle WA. The number of clients enrolled at each site for which data were contributed to the multi-site data set ranged from 12 to 535 (median 75).
For example, the most comprehensive, longitudinal study of HIV positive individuals in the United States, the National HIV Cost and Services Utilization Study (HCSUS), sampled HIV-infected adults who had visited a private doctor's office, community clinic, or hospital-based clinic within an 8 week recruitment period (See Frankel et al.,1999). Persons receiving HIV care from emergency departments and medical providers in military, prison, drug treatment, or homeless service settings were excluded. Thus, persons living with HIV who were not in medical care or receiving care in non-traditional settings were not represented; those making infrequent or irregular visits were likely under represented.
Multilevel logistic regression modeling is an appropriate analysis for clustered data of the sort collected for the multi-site evaluation database (level 1: clients, level 2: projects). Unfortunately, however, a number of projects restricted their samples to individuals who were unstably housed or homeless or who had used hard drugs in the past 6 months. Restrictions of this sort, possibly unique to the demonstration projects, create invariance in the dependent variable or key independent variables and will force a significant number of projects to literally drop out of both fixed or random effects model estimation. In addition to practical issues in working with agency data, we also had concerns about the validity of the standard errors that we would obtain from a multilevel modeling approach as our data did not meet suggested minimal requirements (See Hox, 1998).
REFERENCES
Aidala, A., Havens, J., Mellins, C. A., Dodds, S., Whetten, K., Martin, D., Gillis, L., and Ko, P. (2004). The Client Diagnostic Questionnaire (CDQ): A mental health screening tool for use in AIDS service settings. Psychology, Health and Medicine, 9, 362–380.
Albert, A. E., Warner, D. L., Hatcher, R. A., Trussel, J., and Bennett, C. (1995). Condom use among female commercial sex workers in Nevada's legal brothels. American Journal of Public Health, 85, 1514–1520.
Allen, D. M., Lehman, J. S., Green, T. A., Lindegren, M. L., Onorato, I. M., and Forrester, W. (1994). HIV infection among homeless adults and runaway youth, United States, 1989–1992. AIDS, 8, 1593–1598.
Andia, J. F., Deren, S., Kang, S., Robles, R. R., Colon, H. M., Oliver-Valez, D., Finlinson, A., Beardsley, M., and Friedman, S. R. (2001). Residential status and HIV risk behaviors among Puerto Rican drug injectors in New York and Puerto Rico. American Journal of Drug and Alcohol Abuse, 27, 719–735.
Auerbach, J. D., and Coates, T. J. (2000). HIV prevention research: Accomplishments and challenges for the third decade of AIDS. American Journal of Public Health, 90, 1029–1032.
Bailey, S. L., Camlin, C. S., and Ennett, S. T. (1998). Substance use and risky sexual behavior among homeless and runaway youth. Journal of Adolescent Health, 23, 378–388.
Bangsberg, D., Tulsky, J. P., Hecht, F. M., and Moss, A. R. (1997). Protease inhibitors in the homeless. Journal of the American Medical Association, 278, 63–65.
Bourgois, P. (1998). The moral economies of homeless heroin addicts: Confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments. Substance Use and Misuse, 33, 2323–2351.
Braitman, L. E., and Rosenbaum, P. R. (2002). Rare outcomes, common treatments: Analytic strategies using propensity scores. Annals of Internal Medicine, 137, 693–696.
Browning, C. R., and Olinger-Wilbon, M. (2003). Neighborhood structure, social organization, and number of short-term sexual partnerships. Journal of Marriage and Family, 65, 730–745.
Burt, M. R., Laudan, Y. A., Douglas, T.,Valente, J., Lee, E., and Iwen, B. (1999). Homelessness: Programs and the people they serve. Findings of the national survey of homeless assistance providers and clients. Washington, DC: Urban Institute Press.
Castel, R. (2000). The roads to disaffiliation: Insecure work and vulnerable relationships. International Journal of Urban and Regional Research, 24, 519–535.
Centers for Disease Control and Prevention (CDC). (2003). Incorporating HIV prevention into the medical care of persons living with HIV. Morbidity and Mortality Weekly Report, 52, 1–24.
Clatts, M. C., Davis, W. R., Sotheran, J. L., and Atillasoy, A. (1998). Correlates and distribution of HIV risk behaviors among homeless youths in New York City: Implications for prevention and policy. Child Welfare, 77, 195–207.
Clements, K., Gleghorn, A., Garcia, D., Katz, M., and Marx, R. (1997). A risk profile of street youth in Northern California: Implications for gender-specific human immunodeficiency virus prevention. Journal of Adolescent Health, 20, 343–353.
Conviser, R. (1997). Evaluating how housing contributes to health for people with HIV. Innovations, Winter, 13–17.
Crepaz, N., and Marks, G. (2002). Towards an understanding of sexual risk behavior in people living with HIV: A review of social, psychological, and medical findings. AIDS, 16, 135–149.
Culhane, D. P., Lee, C. M., and Wachter, S. M. (1996). Where the homeless come from: A study of prior address distribution of families admitted to public shelters in New York City and Philadelphia. Housing Policy Debate, 7, 327–365.
Culhane, D. P., Gollub, E., Kuhn, R., and Shpaner, M. (2001). The co-occurrence of AIDS and homelessness: Results from the integration of administrative databases for AIDS surveillance and public shelter utilization in Philadelphia. Journal of Epidemiology and Community Health, 55, 515–520.
Des Jarlais, D. C. (2000). Structural interventions to reduce HIV transmission among injecting drug users. AIDS, 14(Suppl 1), S41–S46.
Dunn, J. R., and Hayes, M. V. (1999). Identifying social pathways for health inequalities: The role of housing. Annals of the New York Academy of Science, 896, 399–402.
Estebanez, P. E., Russell, N. K., Aguilar, M. D., Beland, F., and Zunzunegui, M. V. (2000). Women drugs and HIV/AIDS: Results of a multi-centre European study. International Journal of Epidemiology, 29, 734–743.
Evans, G. W., and Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 303–331.
Fishbein, M., Hennessy, M., Yzer, M., and Douglas, J. (2003). Can we explain why some people do and some people do not act on their intentions? Psychology, Health and Medicine, 8, 3–18.
Fisher, B., Hovell, M., Hofstetter, C. R., and Hough, R. (1995). Risks associated with long-term homelessness among women: Battery, rape, and HIV infection. International Journal of Health Services, 25, 351–369.
Foley, D. L. (1980). The sociology of housing. Annual Review of Sociology, 6, 457–478.
Fournier, A. M., Tyler, R., Iwasko, N., LaLota, M., Shultz, J., and Greer, P. J. (1996). Human immunodeficiency virus among the homeless in Miami: A new direction for the HIV epidemic. American Journal of Medicine, 100, 582–584.
Frankel, M. R., Shapiro, M. F., Duan, N., Morton, S. C., Berry, S. H., Brown, J. A., Burnam, M. A., Cohn, S. E., Goldman, D. P., McCaffrey, D. F., Smith, S. M., St.Clair, P. A., Tebow, J. F., and Bozzette, S. A. (1999). National probability samples in studies of low-prevalence diseases, Part II: Designing and implementing the HIV Cost and Services Utilization Study sample. Health Services Research, 34, 969–992.
Goode, W. J. (1963). World revolutions and family patterns. New York, NY: The Free Press.
Green, J. M., Ennett, S. T., and Ringwalt, C. L. (1999). Prevalence and correlates of survival sex among runaway and homeless youth. American Journal of Public Health, 89(9), 1406–1409.
Hirano, K., and Imbens, G. W. (2001). Estimation of causal effects using propensity score weighting: An application to data on right heart catheterization. Health Services and Outcomes Research Methodology, 2, 259–278.
Holtgrave, D. R., and Pinkerton, S. D. (1997). Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 16, 54–62.
Hox, J. (1998). Multilevel modeling: When and why. In I. Balderjahn, R. Mathar, and M. Schader (Eds.), Classification, data analysis, and data highways (pp. 147–154). New York, NY: Springer Verlag.
Huston, T. L. (2000). The social ecology of marriage and other intimate unions. Journal of Marriage and the Family, 62, 298–320.
Janssen, R. S., Holtgrave, D. R., Valdiserri, R. O., Shepherd, M., Gayle, H. D., and De Cock, K. M. (2001). The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. American Journal of Public Health, 91, 1019–1024.
Joseph, H., and Roman-Nay, H. (1990). The homeless intravenous drug abuser and the AIDS epidemic. NIDA Research Monograph, 93, 210–253.
Joyce, G. F., Goldman, D. P., Leibowitz, A., Carlisle, D., Duran, N., Shapiro, M. F., and Bozzette, S. A. (1999). Variation in inpatient resource use in the treatment of HIV: Do the privately insured receive more care? Medical Care, 37, 220–227.
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231–244.
Kilbourne, A. M., Herndon, B., Andersen, R. M., Wenzel, S. L., and Gelberg, L. (2002). Psychiatric symptoms, health services, and HIV risk factors among homeless women. Journal of Health Care for the Poor and Underserved, 13, 49–65.
Klein, C., Easton, D., and Parker, R. (2002). Structural barriers and facilitators in HIV Prevention: A review of international research. In A. O'Leary (Ed.), Beyond condoms: Alternative approaches to HIV prevention (pp. 17–46). New York, NY: Kluwer Academic Publishers.
Klinkenberg, W. D., Caslyn, R. J., Morse, G. A., Yonker, R. D., McCudden, S., Ketema, F., and Constantine, N. T. (2003). Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders. Comprehensive Psychiatry, 44, 293–302.
Kral, A. H., Molnar, B. E., Booth, R. E., and Watters, J. K. (1997). Prevalence of sexual risk behaviour and substance use among runaway and homeless adolescents in San Francisco, Denver and New York City. International Journal of STD and AIDS, 8, 109–117.
Kushel, M. B., Evans, J. L., Perry, S., Robertson, M. J., and Moss, A. R. (2003). No door to lock: Victimization among homeless and marginally housed persons. Archives of Internal Medicine, 163, 2492–2499.
Latkin, C. A. (1998). Comments on “The moral economies of homeless heroin addicts: Confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments,” by Phillippe Bourgois. Substance Use and Misuse, 33, 2375–2382.
Malmstrom, M., Johansson, S. E., and Sundquist, J. (2001). A hierarchical analysis of long-term illness and mortality in socially deprived areas. Social Science and Medicine, 53, 265–275.
McEwen, B. S. (2001). From molecules to mind. Stress, individual differences, and the social environment. Annals of the New York Academy of Sciences, 935, 42–49.
McGowan, J. P., Shah, S. S., Ganea, C. E., Blum, S., Ernst, J. A., Irwin, K. L., Olive, N., and Weidle, P. J. (2004). Risk behavior for transmission of human immunodeficiency virus (HIV) among HIV-seropositive individuals in an urban setting. Clinical Infectious Diseases, 38, 122–127.
McKirnan, D. J., Vanable, P. A., Ostrow, D. G., and Hope, B. (2001). Expectancies of sexual “escape” and sexual risk among drug and alcohol-involved gay and bisexual men. Journal of Substance Abuse, 13, 137–154.
Messeri, P. A., Abramson, D. M., Aidala, A. A., Lee, F., and Lee, G. (2002). The impact of ancillary HIV services on engagement in medical care in New York City. AIDS Care, 14(Suppl 1), S15–S30.
Messeri, P. A., Kim, S., and Whetten, K. (2003). Measuring HIV services integration activities. Journal of HIV/AIDS and Social Services, 2, 19–44.
Metzger, D. S., and Navaline, H. (2003). Human immunodeficiency virus prevention and the potential of drug abuse treatment. Clinical Infectious Diseases, 37(Suppl 5), S451–S456.
Metzger, D. S., Navaline, H., and Woody, G. E. (1998). Drug abuse treatment as AIDS prevention. Public Health Reports, 113(Suppl 1), 97–106.
Mizuno, Y., Purcell, D., Borkowski, T. M., Knight, K., and the SUDIS Team. (2003). The life priorities of HIV-seropositive injection drug users: Findings from a community-based sample. AIDS and Behavior, 7, 395–403.
Moon, M. W., Binson, D., Page-Shafer, K., and Diaz, R. (2001). Correlates of HIV risk in a random sample of street youths in San Francisco. Journal of the Association of Nurses in AIDS Care, 12, 18–27.
National Institute on Drug Abuse (NIDA). (2002). Stress and substance abuse: A special report. NIDA Community Drug Alert Bulletin. NCADI # PHD914. Rockville, MD: National Institute on Drug Abuse.
Nwakeze, P. C., Magura, S., Rosenblum, A., and Joseph, H. (2003). Homelessness, substance misuse, and access to public entitlements in a soup kitchen population. Substance Use and Misuse, 38, 645–668.
Nyamathi, A., Flaskerud, J., and Leake, B. (1997). HIV-risk behaviors and mental health characteristics among homeless or drug-recovering women and their closest sources of social support. Nursing Research, 46, 133–137.
Paris, N. M., East, R. T., and Toomey, K. E. (1996). HIV Seroprevalence among Atlanta's homeless. Journal of Health Care for the Poor and Underserved, 7, 83–93.
Pfeifer, R. W., and Oliver, J. (1997). A study of HIV seroprevalence in a group of homeless youth in Hollywood, California. Journal of Adolescent Health, 20, 339–342.
Popkin, S. J., Johnson, W. A., Clatts, M. C., Wiebel, W. W., and Deren, S. (1993). Homelessness and risk behaviors among intravenous drug users in Chicago and New York City. In B. S. Brown and G. M. Beschner (Eds.), Handbook on risk of AIDS: Injection drug users and sexual partners (pp. 313–327). Westport, CT: Greenwood Press.
Posner, M. A., Ash, A. S., Freund, K. M., Moskowitz, M. A., and Shwartz, M. (2001). Comparing standard regression, propensity score matching, and instrumental variables for determining the influence of mammography on stage of diagnosis. Health Services and Outcomes Research Methodology, 2, 279–290.
Reilly, T., and Woo, G. (2003). Access to services and maintenance of safer sex practices among people living with HIV/AIDS. Social Work in Health Care, 36, 81–95.
Robert, S. A. (1999). Socioeconomic position and health: The independent contribution of community socioeconomic context. Annual Review of Sociology, 25, 489–516.
Rosenbaum, P., and Rubin, D. B. (1983). The central role of the propensity score in observational studies for causal effects. Biometrika, 70, 41–55.
Rubin, D. B. (1987). Multiple imputation for non-response in surveys. New York, NY: Wiley.
Rutter, M., Pickles, A., Murry, R., and Eaves, L. (2001). Testing hypotheses on specific environmental casual effects on behavior. Psychological Bulletin, 127, 291–324.
Saegert, S., and Evans, G. W. (2003). Poverty, housing niches, and health in the United States. Journal of Social Issues, 59, 569–589.
Samet, J. H., Freedberg, K. A., Savetsky, J. B., Sullivan, L. M., Padmanabhan, L., and Stein, M. D. (2003). Discontinuation from HIV medical care: Squandering treatment opportunities. Journal of Health Care for the Poor and Underserved, 14, 244–255.
Sampson, R. J. (2003). The neighborhood context of well-being. Perspectives in Biology and Medicine, 46(Suppl. 3), S53–S64.
Schafer, J. L. (1997). Analysis of incomplete multivariate data. London: Chapman and Hall.
Schafer, J. L., and Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147–177.
Shlay, J. C., Blackburn, D., O'Keefe, K., Raevsky, C., Evans, M., and Cohn, D. L. (1996). Human immunodeficiency virus seroprevalence and risk assessment of a homeless population in Denver. Sexually Transmitted Diseases, 23, 304–311.
Shaw, M. (2004). Housing and public health. Annual Review of Public Health, 25, 397–418.
Shoptaw, S., and Frosch, D. (2000). Substance abuse treatment as HIV prevention for men who have sex with men. AIDS and Behavior, 4, 193–203.
Smereck, G. A., and Hockman, E. M. (1998). Prevalence of HIV infection and HIV risk behaviors associated with living place: On-the-street homeless drug users as a special target population for public health intervention. American Journal of Drug and Alcohol Abuse, 24, 299–319.
Smith, M. Y., Rapkin, B. D., Winkel, G., Springer, C., Chhabra, R., and Feldman, I. S. (2000). Housing status and health care service utilization among low-income persons with HIV/AIDS. Journal General Internal Medicine, 15, 731–738.
Sohler, N., Colson, P. W., Meyer-Bahlburg, H. F., and Susser, E. (2000). Reliability of self-reports about sexual risk behavior for HIV among homeless men with severe mental illness. Psychiatric Services, 51, 814–816.
Somlai, A. M., Kelly, J. A., Wagstaff, D. A., and Whitson, D. P. (1998). Patterns, predictors, and situational contexts of HIV risk behaviors among homeless men and women. Social Work, 43, 7–20.
Song, J. Y. (1999). HIV/AIDS and homelessness: Recommendations for clinical practice and public policy. Nashville, TN: National Health Care for the Homeless Council/HRSA.
Song, J. Y., Safaeian, M., Strathdee, S. A., Vlahov, D., and Celentano, D. (2000). The prevalence of homelessness among injection drug users with and without HIV infection. Journal of Urban Health, 77, 678–687.
Sumartojo, E. (2000). Structural and environmental factors in HIV prevention: Concepts, examples, and implications for research. AIDS, 14(Suppl. 1), S3–S10.
Sumartojo, E., and Laga, M. (Eds.) (2000). Structural factors in HIV prevention. AIDS, 14(Suppl. 1).
Surratt, H. L., and Inciardi, J. A. (2004). HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA. AIDS Care, 16(5), 594–604.
Susser, E., Valencia, E., and Conover, S. (1993). Prevalence of HIV infection among psychiatric patients in a New York City men's shelter. American Journal of Public Health, 83, 568–570.
Susser, E., Miller, M., Valencia, E., Colson, P., Roche, B., and Conover, S. (1996). Injection drug use and risk of HIV transmission among homeless men with mental illness. American Journal of Psychiatry, 153, 794–798.
Torres, R. A., Mani, S., Altholz, J., and Brickner, P. W. (1990). Human immunodeficiency virus infection among homeless men in a New York City shelter. Association with Mycobacterium tuberculosis infection. Archives of Internal Medicine, 150, 2030–2036.
U.S. Department of Housing and Urban Development (HUD). (2000). National evaluation of the housing opportunities for persons with AIDS Program (HOPWA). Washington, DC: HUD Office of Policy Development and Research.
Walters, A. S. (1999). HIV prevention in street youth. Journal of Adolescent Health, 25, 187–198.
Wechsberg, W. M., Lam, W. K., Zule, W., Hall, G., Middlesteadt, R., and Edwards, J. (2003). Violence, homelessness and HIV risk among crack-using African-American women. Substance Use and Misuse, 38, 669–700.
Wenzel, S. L., Tucker, J. S., Elliot, M. N., Hambarsoomians, K., Perman, J., Becker, K., Kollross, C., and Golinelli, D. (2004). Prevalence and co-occurrence of violence, substance abuse and disorder, and HIV risk behavior: A comparison of sheltered and low-income housed women in Los Angeles County. Preventive Medicine, 39, 617–624.
Wong, Y. L., and Piliavin, I. (2001). Stressors, resources, and distress among homeless persons: A longitudinal analysis. Social Science and Medicine, 52, 1029–1042.
Zanis, D. A., Cohen, E., Meyers, K., and Cnaan, R. A. (1997). HIV risks among homeless men differentiated by cocaine use and psychiatric distress. Addictive Behaviors, 22, 287–292.
Zolopa, A. R., Hahn, J. A., Gorter, R., Miranda, R. J., Wlodarczyk, D., Peterson, J., Pilote, L., and Moss, A. R. (1994). HIV and tuberculosis infection in San Francisco's homeless adults: Prevalence and risk factors in a representative sample. Journal of the American Medical Association, 272, 455–461.
ACKNOWLEDGMENTS
Funding for this analysis was provided by the Centers for Disease Control and Prevention (CDC), Divisions of HIV/AIDS Prevention. The multi-site research project is an inter-agency collaboration between the U.S. Health Resources and Services Administration (HRSA), Special Projects of National Significance (SPNS) Program, and the U.S. Department of Housing and Urban Development (HUD), Housing Opportunities for Persons with AIDS (HOPWA) Program. Special thanks is due to the 34 agencies and the thousands of individual persons living with HIV who have participated in the multi-site project and shared their experiences with us. This paper draws upon “The Impact of Housing on HIV Risk Behavior,” presented at the 2001 National HIV Prevention Conference, Atlanta, GA, and portions were also presented at the XIV International AIDS Conference, Barcelona, Spain, 2002, the Prevention 2003 Conference, Atlanta, GA, and the AIDS Housing Conference, Washington, DC, 2003.
This work is dedicated to the memory of Keith Cylar. Keith was co-founder and co-president of Housing Works and a tireless leader for activism and advocacy by people with HIV and AIDS in America and around the world.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Aidala, A., Cross, J.E., Stall, R. et al. Housing Status and HIV Risk Behaviors: Implications for Prevention and Policy. AIDS Behav 9, 251–265 (2005). https://doi.org/10.1007/s10461-005-9000-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-005-9000-7