Psychiatric Symptoms, Health Services, and HIV Risk Factors Among Homeless Women

Women are at the center of two converging epidemiological trends: HIV transmission and homelessness. Homeless women are vulnerable to contracting HIV because of high rates of risk behaviors including trading sex or using injection drugs. This increased HIV risk may be related to a high prevalence of psychiatric symptoms (including depression, substance abuse and psychosis) among homeless women. There has been little research concerning the role of specific health and social services contacts in reducing HIV risk behaviors among homeless women, although many homeless women may depend on what little contact they have with health or social service providers for information or resources regarding HIV risk behavior reduction.

This paper is based on data from the Access to Health Care for Homeless Women of Reproductive Age Study, a large probability cluster sample of homeless women ages 15 to 44 located throughout Los Angeles County. Women were sampled from 18 meal program sites and 60 shelters in 1996. After obtaining informed consent, participants were interviewed between mid-January 1997 and mid-October 1997 based on structured face-to-face interviews conducted by trained lay interviewers that lasted on average of one hour. Each woman was paid $2 by her interviewer for completing the screening interview and $10 for completing the full interview.

The authors hypothesized that homeless women with psychiatric symptoms were more likely to have engaged in HIV risk behaviors within the previous year than women who did not have these symptoms, after controlling for demographic attributes, socioeconomic status, general health, homeless severity (vulnerability) factors, and health or social services use. In addition, the authors hypothesized that homeless women who had little contact with health services, who did not have a case manager, who did not use substance abuse treatment, and who had no regular source of care, were more likely to engage in HIV risk behaviors than homeless women with access to these services.

A total of 2,428 women were sampled and approached for interviews. Of the 2,428 women, 1,668 were eligible to be interviewed. Among the 1,668 women, 1,464 agreed to be interviewed. A total of 974 women completed the interviews. The mean age of participants was 33.9 years; more than half were African-American. About half of the sample screened positive for depression within the past year, and a large proportion screened positive for drug abuse or drug dependence (48 percent) and alcohol abuse or alcohol dependence (40 percent). The majority of the women had a case manager or regular source of care. Although 42 percent attended self-help meetings for substance use within the past year, 8 percent reported that they had not been able to enroll in any substance abuse or drug detoxification program within the past year. For HIV risk behaviors, within the past year, 8 percent had used injection drugs, 64 percent had engaged in unprotected sex and, 22 percent had traded sex.

Despite the high prevalence of HIV risk behaviors, there have been few HIV risk reduction prevention programs tailored to homeless women with psychiatric symptoms or substance abuse problems. Findings from this study highlight policy implications for identifying homeless women who are at high risk of contracting HIV, for addressing their sexual health issues, and for directing them to programs that will assist with their social and medical needs. Homeless women with substance abuse problems are especially vulnerable to HIV transmission, and efforts should be focused on providing access to more intensive case management and drug treatment programs for this group.

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