The New York City Association of
Homeless and Street-Involved Youth Organizations’

State of the City’s
Homeless Youth Report 2003

HIV/AIDS

Jason is a 20 year old young man who entered an emergency room last fall because he was having trouble breathing.  After hearing that he was homeless, and briefly reviewing his history, the attending physician suggested that he be tested for HIV, and Jason agreed. 

Jason was quite concerned about his risk for HIV.  He told the doctor that the past few years had been rocky for him, and the past six months, even more difficult than usual.  Jason had not lived with a family member in over twelve years.  At that time his grandmother had died and his mother, who had serious mental health problems, was unable to care for him.  He was placed in numerous facilities and foster homes around New York City, and spent some time on the streets in between placements.

Six months ago Jason was ejected from a group home after getting in an argument with a staff person.  He began staying with various friends for short periods.  To support himself, and to save money to get his own apartment, he began selling stolen goods, and sometimes dealing drugs.  Over time, his own drug use, which had been minimal up to this point, increased, and, occasionally, when he saw no other option, he traded sex for money.  He became increasingly run down and began to experience shortness of breath.  He entered the emergency room one cold night, where he was diagnosed with bronchitis.

The next few days were a blur for him.  He remembered being told his HIV test was positive, but not much else that was said.  He was discharged with a supply of antibiotics and the name of a doctor to follow up with.  The paper with the doctor’s name, and other important papers, were left at a friend’s house and accidentally thrown out.  Jason said he “couldn’t deal” with the concept that he was HIV-positive and “went on with life.”

Over the next few months, Jason was approached by outreach workers when he was hanging out in Midtown.  One in particular was nice and seemed knowledgeable.  She often asked him if he needed condoms or information about preventing HIV, which served as a reminder to him that he needed to deal with his HIV-positive diagnosis.  One night, he confided in her that he had tested HIV-positive. 

They discussed his options and he decided to attend a medical clinic at a mobile van the next day.  He also began working with a social worker at a community-based organization, because he didn’t think he could make any serious treatment decisions until he had a stable place to live. 

STATEMENT OF THE PROBLEM

            Homeless youth are at greater risk for contracting HIV than any other subgroup of young people in the United States (Kipke, et al., 1995; Stricof 1991). Furthermore, while the development of new treatments for HIV has created a great deal of hope; homeless youth who contract HIV experience significant barriers to treatment benefits.   

            There are many service challenges associated with HIV, and housing is a critical issue in all of them:  First, homeless youth who are HIV-negative require on-going prevention efforts.  It is more difficult for youth to maintain sexual and drug safety when their lives are unstable.  And yet, youth whose HIV-status is unknown may consider HIV testing.  But because testing youth in unstable situations may have negative clinical and public health consequences, service providers work with youth to prepare them for the potential consequences beforehand.  Finally, HIV-positive homeless youth require medical care, case management, secondary prevention, and mental health care.  However, youth with unstable living situations have marked difficulty adhering to complex medical regimens and making medical appointments.

CURRENT STATE

            Based on available research data, it is estimated that 10-30% of homeless youth in New York City are HIV-positive (Allen, et al., 1994; Clatts, et al., 1998; Pfeifer & Oliver, 1997).  Data from homeless youth in other cities and of rates of sexually transmitted diseases in New York City indicate that the prevalence may be even higher, particularly for older youth and those who have been homeless longer.  Within the homeless population, sexual minority youth experience the greatest vulnerability to HIV.

             The factors that place homeless youth at risk for HIV are complex, and can be traced to their early family backgrounds.  Youth become homeless in response to long-standing family instability, parental mental health and substance use problems, and typically, serious abuse and neglect.  Many are thrown out because of their sexual orientations, or because they are transgender.  Over time, these issues contribute to a range of challenges, including limited education, lack of marketable job skills, and general emotional and cognitive instability. 

             Homeless youth must support themselves, and typically perceive no choice but to turn to the “street economy” for survival.  Some shoplift and others sell drugs, which can contribute to their own substance use problems.  About a third engage in “sex work;” that is, they exchange sex for money, drugs or a place to stay.  Some use drugs intravenously, an activity that places them at great risk for contracting HIV.   Sex work and drug use are inextricably linked.  In a typical scenario, a youth is exposed to drugs and sex work when he or she becomes homeless.  He or she may then begin to use drugs, in large measure as an attempt to cope with homelessness. Sex work is then a means of paying for drugs, and drugs are then a way of dealing with the psychological consequences of the sex work experience.  As drug use escalates, so does sex work, and so on.  Drug use, an attempt to cope with a problem, may become a problem in itself. 

             Sex work, sexual risk behavior with non-paying partners, and drug use, combined with malnutrition and exposure to the street environment itself creates exceptional vulnerability to a number of poor health outcomes, including HIV, as well as other sexually transmitted diseases, Hepatitis B, Hepatitis C, and mental health problems.   

             For these reasons service providers build relationships with youth and connect them with services before recommending HIV-testing.  While HIV testing is an essential component of the public health plan to address HIV, there is a consensus that testing a youth who is in crisis or acutely unstable results in little benefit for the individual or the public health.  Instead, homeless youth must first be assisted to reduce risk behavior and increase stability prior to HIV testing, and prepare for the consequences of either a negative or positive result.  However, it is difficult for a youth to attain stability without a permanent place to live.

             Adherence to medical treatment is a challenge for any individual, regardless of housing status, and homelessness complicates adherence efforts substantially – and in some cases makes it quite unrealistic.  Anti-HIV regimens, referred to as Highly Active Anti-Retroviral Therapy [HAART], are complex.  A typical routine consists of two to three doses a day of multiple medications. Some must be taken with food and others without; some need to be kept refrigerated and others do not.  Side effects can be debilitating, particularly when the medications are first introduced.  A youth without a stable place to live will experience significant barriers to adherence; for example, no place where he or she can store medications, take them in privacy (in case confidentiality is an issue), no means of preparing the appropriate complimentary foods, and no comfortable place to lie low when side effects are serious. 

EXISTING SERVICES

           Service providers in New York City are engaged in a multifaceted effort to prevent the transmission of HIV and ameliorate its consequences.  Multiple strategies are used for HIV prevention efforts.  Some agencies employ outreach workers, both adult/professional and peers, to meet homeless youth on the street and address risk reduction with them.  Outreach workers provide information, support, condoms and referrals, ideally bringing the homeless youth back to the host agency for more intensive services.  Most importantly, they know where and how to contact this hidden population.  Research has shown that outreach efforts successfully bring homeless youth to treatment (Anderson, et al., 1996; Huba, & Melchior, 1998; Johnson, et al., 2001; Wright-DeAgueero, Gorsky, & Seeman, 1996). In addition, HIV prevention is addressed in individual and group sessions in community-based organizations, and by health care providers, some of whom reach youth in mobile vans.  Preparation for HIV testing, including counseling, and the testing itself, is also conducted in community-based organizations.  Because, as research has shown, a negative HIV test result does not automatically translate into reduced risk behavior, newly-tested HIV-negative youth are linked to prevention services.   The medical and mental health consequences of HIV are treated in a number of facilities in New York City, including on mobile medical vans that bring state-of-the-art services to homeless youth.

SERVICE GAPS

            The greatest barrier that service providers face in combating the HIV epidemic in the homeless population is housing.  As noted above, homelessness creates marked vulnerability to HIV-infection, through the stress of the street environment, malnutrition, and sex and drug risk behavior.  It also complicates prevention, testing and treatment efforts.

RECOMMENDATIONS FOR HIV/AID SERVICES

·  Increase number of emergency shelter beds, as well as transitional living and independent living arrangements specifically for youth.

·  Fund intervention and treatment programs to assist homeless youth with making the transition to a stable living situation, including attending school and holding jobs. 

·  Continue to fund outreach efforts, as well as the community-based organizations to which they are linked, so that at-risk youth can be served.

REFERENCES

Allen DM; Lehman JS; Green TA; Lindegren ML; Onorato IM; Forrester W (1994).  HIV infection among homeless adults and runaway youth, United States, 1989-1992. Field Services Branch. AIDS, 8 (11), 1593-8.  

Anderson JE; Cheney R; Clatts M; Faruque S; Kipke M; Long A; Mills S; Toomey K; Wiebel W.  (1996). HIV risk behavior, street outreach, and condom use in eight high-risk populations.  AIDS Educ Prev, 8 (3), 191-204.

Clatts, M.C., W. R. Davis, J.L. Sotheran, and A. Atillasoy. (1998).  The correlates and distribution of HIV risk behaviors among homeless youth in New York City: Implications for prevention services and policies.  Child Welfare  LXXVII(2):  195-207.

Huba, G.J., &  Melchior, L.A.  (1998).   A model for adolescent-targeted HIV/AIDS services: conclusions from 10 adolescent-targeted projects funded by the Special Projects of National Significance Program of the Health Resources and Services Administration.   J Adolesc Health, 23 (2 Suppl), 11-27.   

Johnson, R. L., Stanford, P. D., Douglas, W., Botwinick, G., & Marino, E.  (2001).  High-risk sexual behaviors among adolescents engaged through a street-based peer outreach program--(the Adolescent HIV Project).  J Natl Med Assoc, 93 (5), 170-7.   

Kipke, M.D., S. O’Connor, R. Palmer, R. MacKenzie. (1995).  Street youth in Los Angeles:  Profile of a group at high risk for Human Immunodeficiency Virus infection.  Archives of Pediatric and Adolescent Medicine 149 (5): 513-519.

Pfeifer,  R.W. & Oliver, J.  (1997)  A study of HIV seroprevalence in a group of homeless youth in Hollywood, California.  J Adolesc Health, 20 (5), 339-42.

Stricof, R., J. Kennedy, T. Natell, I. Weisfuse, L. Novick.  (1991).  HIV seroprevalence in a facility for runaway and homeless adolescents.  AJPH, 81 (supplement), 50-53.

Wright-DeAgueero, L. K., Gorsky, R. D., & Seeman, M. G. (1996).  Cost of outreach for HIV prevention among drug users and youth at risk. Drugs & Society, 9 (1-2), 185-197.

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