HIV and Substance Use Prevention Needs of Homeless Individuals: An Analysis of Program Evaluation Data from Samhsa's Minority AIDS Initiative

Background: Homelessness increases the likelihood of infectious diseases such as HIV/AIDS, hepatitis, and tuberculosis (Notaro et al., 2013), due to a variety of factors such as exposure to unsanitary environments, poor nutrition, prevalence of unprotected sex, and injected drug use. The stress and trauma of homelessness is also associated with substance use disorders (SUD) which constitute further risk factors for disease transmission (Medlow, Klineberg, & Steinbeck, 2014). Conversely, chronic illness and SUD are among the leading causes of chronic homelessness (U.S. Conference of Mayors, 2016). There is an urgent need to break this vicious cycle through tailored prevention programs. Homelessness implies distinct behavioral health and prevention service needs, especially for homeless individuals from racial/ethnic minority groups. This study aims to focus on these needs through in-depth analysis of data on risk and protective factors (RPF) associated with SUD and HIV transmission, collected from a predominantly minority adult sample. Methods: The sample consists of 27,000 participants of direct-service SUD and HIV prevention programs funded by SAMHSA’s Minority AIDS Initiative, and includes about 1,500 homeless individuals. Data were collected at program entry and exit, providing an opportunity to assess program effects on attitudes and behaviors. We compared homeless and stably-housed participants’ baseline characteristics to identify differences in prevention needs, taking into consideration factors such as age, gender, and sexual orientation. We then compared their program outcomes using multivariate logistic models, controlling for demographics and baseline levels. Results: Preliminary analysis revealed a complex pattern of baseline differences by housing status. The homeless subsample had higher baseline levels of substance use. However, contrary to expectations, they were more likely to report using protection during sex, and had better knowledge of healthcare resources in their communities. Furthermore, the homeless subsample had larger gains than the stably-housed in some behavioral outcomes (e.g., reduced binge drinking) but smaller gains in others (reduced marijuana use and reduced unprotected sex). Conclusions: The results highlight the distinct HIV and SUD prevention needs of homeless individuals, and suggest guidelines for customized risk-reduction interventions that are tailored to their age, gender, and sexual orientation. The results also underscore the importance of wraparound services such as housing, prevention, and recovery support for individuals at high risk of, or diagnosed with, HIV and SUD. Future research should also incorporate the effects of population-based strategies implemented by MAI grantees that are expected to have longer-term effects than could be fully captured by the current analysis.