Byline: Antoine B. Douaihy, MD; Keith R. Stowell, MD, MSPH; Thuy Bui, MD; Dennis Daley, PhD; Ihsan Salloum, MD, MPH
Co-occurrence of homelessness and HIV/AIDS poses a complex and multidimensional challenge to the health care provider's clinical and system integration skills. Existing data support the high prevalence of HIV/AIDS among homeless persons and a high percentage of persons living with HIV/AIDS being either homeless or at imminent risk for homelessness. There are special considerations and challenges health care providers may face in caring for homeless persons with HIV/AIDS. An integrated, flexible, interdisciplinary, community-based system of care addressing the full array of medical, psychiatric/substance abuse, and housing services would optimize clinical care for this population. Areas that deserve particular attention include HIV/AIDS prevention, access to comprehensive HIV and health care, use of antiretroviral therapy, and adherence to treatment. Research is needed to better understand the multifaceted needs of this population and to develop prevention and treatment strategies applicable to daily clinical care. [AIDS Reader. 2005;15:516-520, 527]
Key words: HIV/AIDS - Homelessness - Adherence - Integrated care - Substance abuse
Approximately one third to one half of persons living with HIV/AIDS in the United States are either homeless or at imminent risk for homelessness.1 The prevalence of HIV infection in homeless populations is at least 3 times as high as it is in the general population. Rather than existing independently of each other, homelessness and HIV/AIDS are inextricably interwoven and widespread among both rural and urban populations in the United States.
Homelessness frequently occurs in combination with substance use disorders, unsafe sexual behaviors, past incarceration, or chronic psychiatric illness-factors all associated with a heightened risk of HIV infection. Furthermore, HIV-infected homeless persons are particularly susceptible to opportunistic infections and other medical comorbidities, which if untreated, may exacerbate their illness and even lead to higher risk of mortality. HIV/AIDS, which is associated with poorer health care access than are other chronic conditions, exacerbates the problem of access to care that is already seen among the homeless population.2 Moreover, adherence to complex HIV treatment regimens presents unique challenges for homeless patients and for their caregivers.
This article provides an overview of the interfaces between HIV/AIDS and homelessness, identifies deterrents to the optimal care of HIV-infected homeless persons, explores current clinical practice guidelines in this population, and outlines directions for future research. Here the term "homeless" will be used to refer to persons without stable or permanent housing, who may live on the streets; in a shelter, mission, single-room occupancy facility, abandoned building, or vehicle; or "doubled up" with friends or family members.
SCOPE AND PREVALENCE
Owing to the numerous methodological difficulties that arise when conducting studies involving homeless persons, representative information has been somewhat elusive and estimates of HIV seroprevalence among this group vary widely, from less than 1% to more than 60%, depending on location, study design, and period.3-9
In the United States, there is a 7.4% lifetime prevalence of homelessness, with the homeless population estimated to be between 4 million and 11...
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