HIV Risk Behavior and HIV Testing Among Heterosexually-Active Homeless Men in Skid Row

Transcription

1 HIV Risk Behavior and HIV Testing Among Heterosexually-Active Homeless Men in Skid Row Harmony Rhoades, Ph.D. Research supported by Grant R01HD from the National Institute of Child Health & Human Development; PI: Suzanne Wenzel, PhD

2 Presenter Disclosures Harmony Rhoades No relationships to disclose

3 HIV & Homeless Populations Rates of HIV among homeless persons are estimated at 3X those in the general population 1 HIV/AIDS is increasingly a disease of impoverished persons Why? Subsistence living Reduced access to services Homeless persons have higher rates of alcohol and drug use 2,3 May increase HIV risk Heterosexual risk behavior & HIV: 4 (Credit: istockphoto) Men account for 76% of new infections 80% of women with HIV/AIDS were infected through sex with men Heterosexual sex is the second leading cause of infection among men

4 HIV Testing as Prevention HIV testing reduces HIV transmission 5 1/5 of HIV is undiagnosed in the U.S. 6 Likely even higher among homeless populations 7 Testing can combat poor HIV/AIDS health outcomes 4 Late diagnosis disproportionately common among homeless persons with HIV/AIDS 8 Why study heterosexually-active homeless men? Very little research on this population to date Homelessness and transience = severe social marginalization Cannot assume that the predictors of testing among non-homeless persons would apply equally well to this population

5 Correlates of HIV Testing in Homeless Populations Substance abuse and perceived susceptibility to HIV 9-11 Having a regular source of medical care or more encounters with medical service providers 9,12-14 Homeless men may access health services via non-traditional avenues Contact with shelters or other service providers in the immediate area Incarceration ¾ of inmates report having been tested for HIV in prison 15 Important venue for testing in vulnerable populations 9,13,16 Veteran status Homeless veterans report more medical service encounters than their non-homeless counterparts 17

6 Skid Row 50 square block area of downtown Los Angeles Has the highest concentration of homeless persons in the city 10% of the homeless population The homelessness capital of the U.S. since /in/set

7 Participants Eligibility criteria: Men aged 18 or older Homeless past 12 months (i.e., stayed at least one night in a place like a shelter, abandoned building, vehicle, or outdoors because they didn t have a home to stay in) Vaginal or anal sex with a woman in past 6 months Recruited from 13 meal lines Each line had a quota approximately proportional to size Sample size = 305 homeless men 338 eligibles out of 670 men screened (50.4% eligible) 320 eligibles agreed to be interviewed: 7 left before the interview was completed or refused to complete 4 could not complete network portion of interview 4 were later found to be repeaters 6 additional men were excluded from multivariate analyses Diagnosed with HIV more than 1 year ago

8 Structured Interviews IRB approved -- USC and RAND Conducted July through October 2010 Computer-assisted personal interviews; EgoWeb software Interviews lasted 83 minutes on average Men were paid $30 for participation

9 Structured Interviews: Components Demographics Severity of homelessness Sexual partnering and risk/protective behaviors Substance use Mental health Social networks HIV testing and HIV status (self-report)

10 Demographic Characteristics (N=305) Age (mean, sd) 45.6 (10.3) Race/ethnicity (%) African American 71.7 Hispanic 10.4 White 11.5 Other or multi-racial 6.3 Education (at least HS or GED) (%) 73.3 Employed full or part-time (%) 18.0 Currently married (%) 6.1

11 Homelessness (N=305) Months homeless in lifetime (m, sd) 64.6 (72.6) Percent of the lifetime spent homeless (m, sd) 11.1 (11.3) Ever spent night in street, abandoned building, garage, etc. (%) 94.5

12 56% Substance Use Prevalence (past 6 months) 40% 38% 17% 12% 11% 7% 5% Marijuana Crack Binge drinking Rx Cocaine Meth Heroin Other

13 HIV Testing/Risk Measures Outcome: Past 12 months HIV testing CDC recommends yearly testing for high risk individuals 18 Better measure of effective early detection than lifetime testing HIV risk behavior (past six months) Includes IDU Service Access Services use in the past 30 days in the Skid Row area Incarceration (jail, prison or parole in past 6 months) Being a military veteran

14 HIV Risk Behavior (past 6 months) 100% 90% 80% 70% 60% 50% 40% 30% 63% 57% 20% 10% 0% Any unprotected sex 7% Any male partners Any sex trade 20% IDU (lifetime)

15 HIV Testing & Service Access 100% 90% 80% 70% 60% 50% 40% 30% 20% 57% 46% 19% 72% 67% 22% 26% 34% 10% 0%

16 Analysis Bivariate logistic regression All measures theoretically associated with HIV testing were assessed for statistically significant bivariate relationships Variables associated at p<=0.10 were included in the multivariate model Individual demographic characteristics retained as controls All models were weighted to account for differential probability of being included in the study Based on meal line usage and homelessness duration

17 Table 2. Binary logistic regression models predicting HIV testing utilization in past 12 months (weighted), N=299. Bivariate Results Multivariate Model Variables Odds Ratio (95% CI) Odds Ratio (95% CI) Demographic characteristics Age 1.01 ( ) 1.01 ( ) Race/ethnicity (white is omitted) African American 1.09 ( ) 0.84 ( ) Hispanic 1.16 ( ) 0.93 ( ) Other or multiracial 2.91 ( ) 2.57 ( ) High school or more (vs. <HS) 0.72 ( ) 0.63 ( ) Married 1.11 ( ) 1.51 ( ) HIV Risk Sexual Risk Behavior (past 6 months) Any unprotected sex 0.98 ( ) --- Any male partners 2.65 ( ) z 1.99 ( ) Any sex trade 1.18 ( ) --- Total number of sex partners 1.05 ( ) --- Injection drugs (ever) 1.78 ( ) --- Perceived HIV susceptibility 0.98 ( ) --- Service Access Jail/prison/parole past 6 months 1.49 ( ) --- Military service 2.59 ( )** 2.10 ( )* Service use (past 30 days Skid Row) Emergency/transitional shelter 0.83 ( ) --- Drop-in center 1.28 ( ) --- Alcohol and drug counseling 1.28 ( ) --- Mental health counseling 1.06 ( ) --- Medical/dental services 1.96 ( )* 1.91 ( )* z p>.10, *p<.05, **p<.01

18 Results: HIV Testing Rates High rates of HIV testing Nearly 60% were tested for HIV in the past 12 months National past year HIV rate is 19% among adults LA County: 30.3% of men were tested in the past two years % of the men in the current study reported an HIV test in the same time two-year time period County-wide HIV testing rates were the highest among African- American men, at 56.2% in the past two years % among African-American men in this study were tested in the past two years

19 Results: Risk Behavior Sexual risk behavior not associated with past year HIV testing Men reported high levels of HIV risk behavior in this study: 62% had engaged in unprotected sex 42% in sex trade in the past six months 43% of those reporting HIV risk behavior had not been tested in the past year Sizable number of men at high risk for HIV who are not utilizing HIV testing May be because they are not accessing other services that put them into contact with testing Potential for high rates of undetected HIV infection Missed opportunities for HIV prevention

20 Results: Testing Correlates Associated with HIV testing: Medical/dental services in the Skid Row area (past 30 days) 91% increased odds Being a military veteran More than 2X the odds

21 Limitations Limited generalizability Particularly to other populations at high risk for HIV, such as MSM 6.8% of the analytic sample was MSM/W; not representative of the MSM population The Skid Row area is home to a very marginalized homeless population Chronically homeless Mentally ill Substance abusing These data are cross-sectional Does risk behavior come before testing? Might testing negative increase risk behavior in this population?

22 Conclusions Positive: High rates of HIV testing Not-so-positive: Many at risk for HIV are not being tested regularly HIV testing not associated with HIV risk behavior in this population Associated with access to services and veteran status Access to care may = testing utilization, regardless of risk and/or risk indicators May reduce stigma?

23 Recommendations Encourage general medical service access Universal testing should be a priority Employ evidence-based practices to reduce sexual risk behaviors within programs that serve homeless men 60% of LA shelters for women provide NO HIV prevention services The other 40% do not employ EBIs Likely to be similar for men Should exist in a wide variety of settings that serve this population Especially settings with low barriers to access Other research has shown that HIV risk behaviors are reduced when housing status improves 22 Safe, permanent, supportive housing is important for this population

24 Future Research How housing impacts sexual risk behavior and HIV testing Pilot study is in progress Proposing larger study to follow homeless persons over 18 months as they transition into PSH Social network features

25 References 1. National Alliance to End Homelessness. (2006). Fact Sheet: Homelessness and HIV/AIDS. Washington, DC: National Alliance to End Homelessness. 2. Rhoades, H., Wenzel, S. L., Golinelli, D., Tucker, J. S., Kennedy, D. P., Green, H. D., & Zhou, A. (2011). The social context of homeless men's substance use. Drug Alcohol Depend. 3. Wenzel, S. L., Green, H. D., Jr., Tucker, J. S., Golinelli, D., Kennedy, D. P., Ryan, G., & Zhou, A. (2009). The social context of homeless women's alcohol and drug use. Drug Alcohol Depend, 105(1-2), Centers for Disease Control and Prevention. (2011). HIV Surveillance Report, 2009 (Vol. 21): CDC. 5. Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R. S. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr, 39(4), Centers for Disease Control and Prevention. (2010). HIV Surveillance Report, 2008 (Vol. 20): CDC. 7. Zetola, N. M., Kaplan, B., Dowling, T., Jensen, T., Louie, B., Shahkarami, M.,... Klausner, J. D. (2008). Prevalence and correlates of unknown HIV infection among patients seeking care in a public hospital emergency department. Public Health Rep, 123 Suppl 3, Nelson, K. M., Thiede, H., Hawes, S. E., Golden, M. R., Hutcheson, R., Carey, J. W.,... Jenkins, R. A. (2010). Why the wait? Delayed HIV diagnosis among men who have sex with men. J Urban Health, 87(4), Desai, M. M., & Rosenheck, R. A. (2004). HIV testing and receipt of test results among homeless persons with serious mental illness. Am J Psychiatry, 161(12), Stein, J. A., & Nyamathi, A. (2000). Gender differences in behavioural and psychosocial predictors of HIV testing and return for test results in a high-risk population. AIDS Care, 12(3), Brown, R. A., Kennedy, D. P., Tucker, J. S., Wenzel, S. L., Golinelli, D., Wertheimer, S. R., & Ryan, G. W. (2011). Sex and Relationships on the Street: How Homeless Men Judge Partner Risk on Skid Row. AIDS Behav. 12. Herndon, B., Asch, S. M., Kilbourne, A. M., Wang, M., Lee, M., Wenzel, S. L.,... Gelberg, L. (2003). Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles County. Public Health Rep, 118(3),

26 References cont d. 13. Jenness, S. M., Murrill, C. S., Liu, K. L., Wendel, T., Begier, E., & Hagan, H. (2009). Missed opportunities for HIV testing among high-risk heterosexuals. Sex Transm Dis, 36(11), Tucker, J. S., Wenzel, S. L., Elliott, M. N., Hambarsoomian, K., & Golinelli, D. (2003). Patterns and correlates of HIV testing among sheltered and low-income housed women in Los Angeles County. J Acquir Immune Defic Syndr, 34(4), Centers for Disease Control and Prevention. (2009). HIV Testing Implementation Guidance for Correctional Settings (pp. 1-38). Atlanta, GA: Centers for Disease Control and Prevention. 16. Desai, M. M., Rosenheck, R. A., & Desai, R. A. (2007). Prevalence and correlates of Human Immunodeficiency Virus testing and posttest counseling among outpatients with serious mental illness. The Journal of Nervous and Mental Disease, 195(9), Mares, A. S., Greenberg, G. A., & Rosenheck, R. A. (2008). Client-level measures of services integration among chronically homeless adults. Community Ment Health J, 44(5), Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep, 55(RR-14), DiFranceisco, W., Pinkerton, S., Dyatlov, R., & Swain, G. (2005). Evidence of a brief surge in safer sex practices after HIV testing among a sample of high-risk men and women. J Acquir Immune Defic Syndr, 39(5), Kaiser Family Foundation. (2009) Survey of Americans on HIV/AIDS: Summary of Findings on the Domestic Epidemic. Menlo Park, CA: Kaiser Family Foundation. 21. Los Angeles County Department of Public Health, O. o. H. A. a. E. (2007). LA Health Trends: HIV Testing Among Los Angeles County Adults: LACDPH. 22. Leaver, C. A., Bargh, G., Dunn, J. R., & Hwang, S. W. (2007). The effects of housing status on health-related outcomes in people living with HIV: a systematic review of the literature. [Research Support, Non-U.S. Gov't Review]. AIDS Behav, 11(6 Suppl),

27 Many thanks to my co-authors! Suzanne Wenzel, PhD Joan S. Tucker, PhD Daniela Golinelli, PhD David P. Kennedy, PhD Annie Zhou, MS Brett Ewing, MS Any questions? Please contact me: