The ache for home lives in all of us, the safe place where we can go as we are and not be questioned. —MayaAngelou

Overthepast25years,homelessnessandAIDShaveformedintersectingepidemics,sharingrootsinpovertyanddiscrimina-tion,andphysicalhealth,mentalhealth,andsubstanceusedisorders.Approximatelyone-thirdtoone-halfofpeoplelivingwithHIVintheUnitedStates arehomelessoratimminentriskofhomelessness.1HIVismorethanthreetimesasprevalentamonghomelesspeoplethanitisamongthosewhoarehoused.2

Sufferingisprominentamonghomelesspeople. Physicalhealth,mentalhealth,andsubstanceabuseproblemsarecommon,anddeathratesarehigh.3Thisarticleexplorestheexperienceofworkingwithhomelesscli-entswithHIV-relatedissuesandproposesabio-psycho-social-spiritualmodeltoaddressmultiplebarrierstopreventionandcare.

Medical ConcernsHIVisonlyoneamongmanyconditions

thataffecthomelesspeopledifferentlythanhousedpeople.Homelesspatientsoftenpres-entforcarewithadvanceddiseaseandacuteconditions,includingnutritionalanddentalproblems,dehydration,hypothermia,andthephysicalconsequencesoftraumaticassault.

Infectiousdiseasessuchaslice,scabies,andviralhepatitisarecommon.Sexuallytransmitteddiseases,skininfections,andrespiratoryinfections,especiallytuberculo-sis,arealsocommon,andarefacilitatedbytheovercrowdedconditionsmanyhomelesspeoplelivein,suchasshelters,aswellastheexposuretotheelementsexperiencedbythoselivingonthestreets.Substanceabuse,widespreadinthispopulation,canitselfleadtoahostofphysicalconsequences.Among

thesearepermanentcognitiveimpairment,andliver,lung,andheartdisease.

Psychological IssuesPsychologicaldisorders,whicharecom-

monlyundiagnosedanduntreatedinhome-lesspeople,arebothacommoncauseofhomelessnessandaregreatlyexacerbatedbyit.HomelesspeoplearefivetosixtimesmorelikelythanthegeneralU.S.popula-tiontohaveaseriousmentalillnesssuchasschizophrenia,bipolardisorder,majordepression,schizoaffectivedisorders,andseverepersonalitydisorders.4Thesepsy-chologicaldisorders,particularlypersonal-itydisorders,arealsoacauseofpoorout-comesinthecareofhomelesspeople.Theycaninterferewiththeprovider-clientrela-tionshipandcreatedifficultiesmaintaininghousing,whichcanunderminemedicationadherenceandtreatmentplanning.

Researchhasdocumentedthedispropor-tionateriskofHIVinfectionamonghome-lesspeoplewithmentalhealthdisorders5andhasimplicatedseveralfactors.Amongthesefactorsareinjectiondrugusewithneedlesharing,sexwork,survivalsex,andrape.Lackofprivacy,aswellaspsycho-logicalissues,contributetomoreunstablesexualrelationships,andinabilitytoaffordcondomsandtonegotiatetheiruseaddfurtherbarrierstoHIVprevention.

Cognitiveimpairmentisasignificantobsta-cletobothhousingandpreventionandcareformanyhomelesspeople.Evidencesuggeststhathomelesspeopleareatgreaterriskthanthegeneralpopulationfortraumaticheadinjury.Itisalsocommonfortheseclientstoexperiencecognitiveimpairmentasaresultofmentalillness,chronicsubstanceabuse,developmentaldelay,andHIVitself.6

Substanceabusefurthercomplicatesthismentalhealthpicture.WhileoneinfiveAmericanshasasubstanceuseproblem,anestimatedtwooutofthreehomelesspeopledo,7andupto50percentofpeoplewhoarehomelesshaveco-occurringmentalhealthandsubstanceusedisorders.4

FOCUSAGuideto ResearchandCounselingMarch2006 v21n3

A Bio-Psycho-Social-Spiritual Approach to HIV and HomelessnessBarry Zevin, MD

Post-traumaticstressdisorderisanothercommon,yetoftenunrecognized,problem.Inonestudyofhomelesswomen,almost90percentreportedhavingbeenviolentlyvic-timizedatsomepointintheirlives.8Home-lessmen,especiallythosewithmentalhealthdisorders,havesimilarlyhighratesofvictim-ization.Despitebeingstereotypedasdanger-ousorviolent,homelesspeopleare,infact,amongthemostfrequentvictimsofviolence.

Experiencesoftrauma,loss,fear,andshameshapethebehaviorandqualityoflifeofmanyhomelesspeople,narrowingthescopeoflivingtomeresurvival.Yetprovid-ersoftenunderestimatetherolethatshameplaysinthebehaviorofhomelessclients,especiallyshamerelatedtoHIVorHIVrisk-relatedsubstanceuseorsexualbehaviors. Further,providersmaymistakeaclient’sshame-basedavoidanceofcareaspersonalrejectionoralackofconcernforhealth.

Social InfluencesStereotypesabouthomelesspeopleare

pervasiveandmayinterferewithprovidingappropriateservices.Amongthemostcom-monofthesestereotypesarejudgmentsthathomelesspeopleareisolated,violent,unapproachable,lazy,andasexual. Supportsystemsandsocialstructuresforhome-lesspeoplemaybeunconventional,butfewhomelesspeopleareentirelyisolated,andmostprioritizepersonalrelationshipsashighlyashousedpeopledo.Interventionsforhomelesspeoplethatdiscounttheserelationshipsarefrequentlyineffective.

Thesestereotypesalsocontributetotheassumptionthathomelesspeopleareunabletoadheretoantiviralregimens.9However,researchandexperienceattheTomWaddellHealthCenterinSanFranciscohasfoundthatadherenceratesandotheroutcomesarecomparabletohousedpopulations.

Homelesspeopleareoftenunabletoworkduetodiscriminationordisability.Becausethesedisabilitiesareoftenhidden,multiple,anddifficulttoclassify,claimsforbenefitsareofteninitiallyrejected,reinforcingthe

References1. Song JY. HIV/AIDSandHomelessness:RecommendationsforClinicalPracticeandPublicPolicy.Nash-ville: National Health Care for the Home-less Council, 1999.

2. Allen DM, Lehman JS, Green TA, et al. HIV infection among homeless adults and runaway youth, United States, 1989-1992. AIDS. 1994; 8(11): 1593–1598.

3. Cheung AM, Hwang SW. Risk of death among homeless women: A cohort study and review of the literature. Cana-dianMedicalAsso-ciationJournal. 2004; 170(8): 1243–1247.

FOCUS March 2006�

AsBarryZevinpointedoutwhenwefirstdiscussedhisarticleinthisissueofFOCUS, thepublicresponsetohome-lessnesshasparalleledthepub-licresponsetoHIV.Aninitialresponseofconcern,evenasenseofemergency,hasgivenwaytoatoleranceofsuffer-ing,asenseofhopelessness,and“compassionfatigue.”

Onereasonforthisisthefeel-ingthatwearepowerlesstohelp.TheepidemicsofhomelessnessandHIVhaveattimesseemedremarkablyresistanttochange.Anotherreasonisthatforthosestandingoutsidetheepidemics,itiseasytodrawfalsedistinc-tionsbetween“us”and“them.”Weknowthatmanyindividualsandfamiliesarejustapaycheckawayfromhomelessness,butprefertobelievethatthedividinglinebetween“us”and“them”willprotectusfromasimilarfate.

Thetruthisthatmuchofthetime,itdoes.Healthandhousing

domirrorpatternsofclass,race,andotherdemographics.Whileanyonecanbecomehomeless,justasanyonecancontractHIV,somegroupsaremuchmorevulnerabletotheseconditionsthanothers.

Twenty-fiveyearsafterfightingforthepublictorecognizethatAIDSisnotjusta“gay”disease,thetruthisthatnearlyhalfofallAIDScasesinthiscountrystilloccuramongmenwhohavesexwithmen.Many,likeMichaelCooley,theauthorofthesecondarticleinthisissue,areyoungmenatthetimeoftheirinfec-tion.PeopleofcolorarealsodisproportionatelyrepresentedamongboththosewithHIVandthosewhoarehomeless,withAfricanAmericanpeoplerep-resentingalmosthalfofbothhomelessAmericansandpeoplewithAIDSintheUnitedStates.

Inthemiddleclasscommu-nitiesoftherichercountriesoftheworld,HIVincidenceisstable—notdiminishingand

stilllarge,butstable.Agenera-tionofactivismwassuccessfulin“puttingaface”onHIV.Thesuccessledtoashiftfrommoralcondemnationtosocialsupport,fromassigningoutsiderstatustogaypeopleandpeoplewithHIVtoacceptingourcommonhumanity.Itledtomoremoneyforresearch,medicaltreatment,andpsychologicalcare,and,ulti-mately,totheantiviralregimenbreakthroughsofthemid-1990s.Yet,separationsbasedoneco-nomicclassseemmoreresistantthanevertochange,andHIVandhomelessnesscontinuetothriveinourpoorestcommunities.

BothZevin’sandCooley’sarti-clesgiveusachancetoconnectwiththeconcernshomelesspeo-plewithHIVface.Zevinremindsusofthechallengeshomelesspeopleface,andthesmallwayswecanexperienceourhomelessclients’—andourown—humanity.Cooleydescribeshistransforma-tivejourneyfromhomelessnessanddesperationtocommunityandfamilyreconnection.Eachremindsusthatlackingaroofoverourheadsshouldnotmeanlosingourplaceintheworld.

Editorial: A Place in the WorldMichelle Cataldo, Clinical Editor

judgmentthathomelessnessandinabilitytoworkrepresentamoralfailure.Benefits

andresourceadvocacyoffersastrongincentiveforhomelesspeopletoseekcaredespitethesebarriers.Obtainingben-efitsnotonlystabilizesaclient’sfinancialsitu-ation,ithelpstheclientovercomeshame,buildstrustwithproviders,andpromotesbetterhealth.10

Spiritual AspectsInthecourseofassist-

inghomelesspeopleobtainbasicresourcesforsurvival,itiseasytooverlookspiritualcon-cerns—thoseaspectsoflifethatoffermeaningandpurposeandenableapersontotranscendday-to-dayexistence.Home-lesspeoplefacemanyofthesameconflictsaroundidentityandmeaningashousedpeople,but

withaddedchallengesbecausehomelesspeoplearesoseldomtreatedbyothersasvaluable.Theseconflictsincludefindingasenseofpersonalpowerversusgivingupindespair,livinginsilenceandinvisibilityversusmakingconnectionandsharingone’sstory,andseeingoneselfasdependentver-susrecognizingone’scontributiontothecommunity.ReceivinganHIVdiagnosisoftenraisesthestakesoftheseconflicts,changingaperson’sperceptionoflifeandfurtherstimulatingasearchformeaning.

Someprovidersmaybesurprisedthatsomeoftheirclientsexperiencecrisesinthespiritualrealm“justwhenthingsweregoingsowell,”forexample,clientsmovefromhomelessnesstohousingorfromaddic-tiontorecovery.Thesetransitionsinvolvelossesaswellasbenefits,andtheydemandthathomelesspeoplerenegotiateidentityandmeaningastheyrelegateoldsocialnetworksandwaysofbeingtothepast.Again,uncom-fortableemotionsmaysurfaceforclientsjustwhenprovidersassumetheyarehavingtheirgreatestsuccesses.Forexample,aclientmayexperiencelonelinessafterleavinghisorherstreetfamilyforhousing,boredomwhenwithdrawingfromthedramaof“lifeontheedge,”oranxietyinresponsetomemoriesoftraumathatreturnasclientsachievesobriety.

Whenprovidersfailtoaddresstheseissues,clientsmaymanifestincreasingisolation,drugrelapse,inabilitytoadheretomedical

treatment,exacerbationofpsychiatricsymp-toms,hopelessness,andsuicidality.Atten-tiontotheseissues,ontheotherhandcanfosterengagementinthecommunity,greaterself-care,self-expression,andself-worth.

Comprehensive CareEffectiveengagementbeginswithcli-

ent-centeredattention,inanatmosphereofdignityandrespect.Simplyaddressingaclientrespectfullyandshakinghisorherhandmaymakethedifferencebetweenengagementandalienation.Sincemanypeoplehidetheirhomelessnessduetoshameorfear,thesimplequestion,“Whatisyourlivingsituation?”maybelessstig-matizingthanthequestion,“Areyouhome-less?”Attendingtoaclient’smosturgentneeds,includingemergencyhousing,food,andmedicalcare,createsanimmediatebondandthefoundationforaworkingrelationship.Supportivelisteningandfre-quentappointmentsbuildabridgebetweenproviderandclient—evenwhenitfeelsasifnothingconcreteis“accomplished.”

Earlyinthecourseofcare,providerandclientshouldcollaborativelydefinethecli-ent’shealthandlifegoals,andlaterreviewandrevisethesegoalsasnecessary.Thesegoalswillusuallyaddressmedicalandmentalhealthcare,housing,andchoicesaboutdruguse,work,andpossiblyspiri-tualpractices.Askingaclienttodescribehisorhergoalsandreasonsforthemcannaturallyleadtodiscussionsonavarietyofissues,rangingfromwhatsupportthecli-entcanreasonablyexpectfromtheagencytoinformationaboutspiritualvalues.

Talkingwithclientsabouthowtheyspendeachday—andaskingwhotheyhangoutwith,whotheymightaskforhelp,andwhotheycannotaskforhelp—fleshesouttheprofileoftheindividualandhisorhersocialsystem.Providersfrequentlyavoidopportunitiestodevelopafullerpic-turebecauseofinaccurateassumptionsorthefearof“openingacanofworms.”Forexample,providersmayoverlooksexualhistory,becausetheyassumehomelesspeoplearenotsexuallyactiveorsexuallyattractive.Thisisparticularlyproblematicwhenprovidersmissopportunitiesforunderstandingaclient’ssexwork,sur-vivalsex,orsexualdisempowerment.

Inhomelesssheltersandotherprogramsforhomelesspeoplethereisoftensignificantdiscriminationagainstmembersofsexualandgenderidentityminorities.Homelesspeopleoftenconcealtheirsexualorienta-tion,sexualpractices,ortransgenderiden-tityforfearofbeingharassedorassaulted.Manyservicesforhomelesspeopleare

4. Get the facts: Why are so many people with serious mental illnesses homeless? NationalResourceandTrainingCenteronHomelessnessandMentalIllness. 2005; http://www.nrchmi.samhsa.gov/facts/facts_question_3.asp.

5. Cournos F, McKin-non K. HIV Serop-revalence among people with severe mental illness in the United States: A criti-cal review. ClinicalPsychologyReview. 1997; 17(3): 259–269.

6. Spence S, Stevens R, Parks R. Cogni-tive dysfunction in homeless adults: A systematic review. JournaloftheRoyalSocietyofMedicine. 2004; 97(8): 375–379.

7. Burt MR, Aron LY, Douglas T, et al. Homelessness:Pro-gramsandthePeopleTheyServe:Find-ingsoftheNationalSurveyofHomelessAssistanceProvidersandClients. Washing-ton, D.C.: The Urban Institute, 1999.

FOCUS March 2006�

Social structures for homeless

people may be unconventional,

but few homeless people are entirely

isolated. Most prioritize personal

relationships as highly as housed

people do.

organizedorsupportedbyreligiousgroupswithexplicitprejudiceagainstgays,lesbi-ans,andtransgenderpeople.Asthesemaybetheonlyservicesinaparticulararea,individualsmayneedtosuppressidentityandneedsinordertoreceiveservices.

Traumahistoriesareoftenburiedaswell,andsomeprovidersmayavoidexploringtheseareas,concernedthateventalk-ingaboutviolencemaybringoutviolentbehaviorinaclientorrevealproblemsthattheproviderdoesnotfeelqualifiedtohan-dle.Providerscanbenefitfromdiscussingwithsupervisorsorconsultantstheircon-cernsabouttheprocess,timing,andextentofsexualandtraumahistorytaking.

Inevitably,someproblemswillariseforwhichprovidershavenoreadysolutions.Whenthisoccurs,providersstrengthentheircredibilitywithclientsandreducetheirownriskofburnoutbyadmittingtheirownlimitations.Thishonestyalsogivesclientspermissiontogeneratetheirownsuggestionsandmovetowardcollab-orativeproblemsolving.

Multidisciplinary CareMultidisciplinarycare—thecoordina-

tionofmedical,psychological,andsocialserviceproviders—iscriticaltoeffectivetreatmentofhomelesspeopleandcanbeachievedbycoordinatingwithlike-mindedproviderswithinanagencyoracommu-nity. Theinclusionofpeerstaff,consistingofcurrentlyorformerlyhomelesspeople,canalsobeveryeffective.Itisimportanttonotethatpeerworkers,inparticular,needextensivesupportandtrainingtodealwithissuesofboundaries,trauma,theirownpotentialtriggers,andharmreduction.

Agencypoliciesandprocedureshelpdeterminewhetherhomelesspeopleper-ceiveservicesasaccessibleorexclusionary.Forexample,flexibilityinschedulingand

drop-inavailabilitygreatlyreducesbarri-erstocareforhomelesspeople.Limitingthenumberofpersonnelwhointeractwithanindividual—forexample,byassigningeachclienttoacasemanagerandaprimarypointpersonineachareaofcare—canhelpcreateasupportivefamilyorcommunity-likemilieuthatincreasesaclient’scomfortandtrustandreducesconfusionandser-viceduplication.Clientswithsomementalillnessesandcognitiveimpairmentmayespeciallybenefitfromanintensive,long-lastingsupportivecasemanagementrela-tionshipinwhichdiscussionsandinstruc-tionsarekeptsimpleandarerepeated.6

Itiscriticaltomatchahomelessclient’spotentialhousingsituationtohisorherneedsandcapacitiesandplanforpos-siblesetbacks.Substancerecoverypro-gramoptionsandmoneymanagementandevictionpreventionservicescanhelpclientsmaintainhousing,althoughsomeclientsperceivetheseservicesasintru-sive.Inresponse,carefulredirectionbacktocollaborativelydevelopedgoalscanbehelpful,sincetheultimategoalisnotonlyhousing,butthecreationofastablehome.Thismayrequireservicesthatsupportlearninglifeskills,andprovidestructure,creativework,andanoppor-tunityto“giveback”tothecommunity.

ConclusionAcomprehensive,integratedapproach

addressesthemultiplephysical,logistical,andpsychologicalbarrierstoHIV-relatedhealthcare,mentalhealthcare,andpreven-tionforhomelesspeople.Whilethedivisionsbetweentheseaspectsofawholehumanbeingareultimatelyartificial,examiningeachaspectseparatelycreatesaframeworkforanintegratedapproach,onethatcanhelpprovidersprioritizetheoftenoverwhelmingproblemsintheirhomelessclients’lives.

8. Bassuk EL, Buckner JC, Perloff JN, et al. Prevalence of mental health and substance use disorders among homeless and low-income housed moth-ers. AmericanJournalofPsychiatry. 1998; 155(11): 1561–1564.

9. Moss AR, Hahn JA Perry S, et al. Adher-ence to highly active antiretroviral therapy in the homeless popu-lation in San Fran-cisco: A prospective study. ClinicalInfec-tiousDiseases. 2004; 39(8): 1190–1198.

10. Riley ED, Moss AR, Clark RA, et al. Cash benefits associ-ated with lower risk behavior among the homeless and margin-ally housed in San Francisco. JournalofUrbanHealth. 2005; 82(1): 142–150.

AuthorBarry Zevin, MD is Medical Director of Tom Waddell Health Center, the largest provider of homeless healthcare in San Francisco. He is a primary care physi-cian, credentialed as an HIV special-ist, and certified in addiction medicine.

FOCUS March 2006�

ReferencesConananB,LondonK,MartinezL,etal.Adapting Your Practice: Treatment and Recommendations for Homeless Patients with HIV/AIDS. Nashville,Tenn.:HealthCarefortheHomelessClinicians’Network,NationalHealthCarefortheHomelessCouncil,Inc.,2003;http://www.nhchc.org/Pub-lications/HIVguide52703.pdf.

ConnorA.EncouragingHIVrisk-reduc-tionbehaviorsandtestingwithpeople

experiencinghomelessness.Journal of Nursing Education. 2003;42(3):138–141.

CulhaneDP,GollubE,KuhnR,etal.Theco-occurrenceofAIDSandhomelessness:Resultsfromtheinte-grationofadministrativedatabasesforAIDSsurveillanceandpublicshelterutilizationinPhiladelphia.Journal of Epidemiology and Com-munity Health.2001;55(7):515–520.

DeRosaCJ,MontgomerySB,HydeJ,etal.HIVriskbehaviorandHIVtesting:A

comparisonofratesandassociatedfac-torsamonghomelessandrunawayado-lescentsintwocities.AIDS Education and Prevention.2001;13(2):131–148.

DouaihyAB,StowellKR,BuiT,etal.HIV/AIDSandhomelessness,Part1:Backgroundandbarrierstocare.AIDS Reader. 2005;15(10):516–520.

EbnerDL,LaviageMM.TheparalleluniverseofhomelessandHIV-posi-tiveyouth.Seminars in Pediatric Infec-tious Diseases. 2003;14(1):32–37.

HahnJA,BangsbergDR,McFarlandW,etal.HIVseroconversionamongthehomelessandmarginallyhousedinSanFrancisco:Aten-yearstudy.Jour-

Clearinghouse: Homelessness and HIV

AslongasIcanremember,myrelation-shipwithmydadwasstrained.PeoplealwaysaskifitisbecauseI’mgay,butitgoesbackfurther.In1973,whenIwasconceived,myfatherwas17andinthearmy,andmyhalfbrotherswerethreeandfour.MydadleftmymomsoonafterIwasborn.WhenIwasseven,rampantalcohol-ismfinallycaughtupwithmymother.Shebecameveryillandcouldnolongertakecareofme,soshesentmetolivewithmyfatherandhisnewwife.

In1991whenIwasalmost17,Iwaskickedoutofmyfather’shomeinPrunedale,aruraltownincen-tralCalifornia.Istayedwithvari-ousfriendsforayear,butkeptthinkingaboutSanFrancisco.ItwasthegayMecca;IhadseenthePrideParadeontelevision.Ihaddroppedoutofhighschoolaftermyjunioryear,soIcametothecitywithoutahighschooleducationandwithnoplacetostay.

Ihadneverlivedinacitybefore.Iwasusedtoroosterscrowing,horses,theslowerpaceofaquietcommunity.Nooneeverspoketomeabouthowto

findwork,howtofindfood,howtolive.Iwasonmyownwithoutahome.

Waiting for a PlaceIfoundaphoneboothandcalledthe

nationalrunawayhotline.TheytoldmetogotoasocialserviceprogramforyouthintheTenderloin,butwhenIgotthere,theprogramstaffsaidIhadtobeunder18togetaplace,andIhadjustturned18.TheTenderloinisintheheartofSanFrancisco’sredlightdistrict—aneighborhoodwhereyouhadtohave“streetsmarts”inordertomakeit.IfIhadhadstreetsmartsIwould

haveliedandsaidIwas17,becauseitwouldhavemeantIwouldhavehadaplacetostayforafewdays.Instead,Itoldthetruthandwasgiventwofoodvouchersandsentonmyway.Thiswasacriticalmomentwhenanintervention—likegettingintoayouthsheltereventhoughIwas18—wouldhavekeptmeoffofthestreets.

Iwasdevastatedandhungry,soIwalkedtoataqueriaonPolkStreet.Iwasfasci-natedbythestreetlifepassingby.Iwasn’tusedtoelectric-blueMohawks,thepunks,theskaters,thecrack-

heads,thequeerhustlerboys,twoorthreeofthemoneverycorner.

Iwenttoadrop-inspaceintheheartoftheTenderloin.Anow-defunctyouthpro-gramexistedintheirbasement.Thesmellcanonlybedescribedas“homeless”:acombinationofsweat,feet,dog,cigarettes,

FOCUS March 2006�

nal of Acquired Immune Deficiency Syndrome. 2004;37(5):1616–1619.

Healthcareforthehomelessresourcecenter.Bureau of Primary Health Care. Rockville,Md.:HealthResourcesandServicesAdministration,2006;http://www.bphc.hrsa.gov/hchirc/about/default.htm.

LevounisP,GalanterM,DermatisH,etal.CorrelatesofHIVtransmissionriskfactorsandconsiderationsforinterven-tionsinhomeless,chemicallyaddictedandmentallyillpatients.Journal of Addictive Diseases. 2002;21(3):61-72.

LinnJG,NeffJA,TheriotR,etal.Reach-ingimpairedpopulationswithHIV

preventionprograms:AclinicaltrialforhomelessmentallyillAfrican-Americanmen.Cellular and Molecu-lar Biology. 2003;49(7):1167-1175.

HCHResearchUpdates.National Health Care for the Homeless Council. Nash-ville,Tenn.:NationalHealthCarefortheHomelessCouncil,2006;http://www.nhchc.org/researchupdates.html.

RobertsonMJ,ClarkRA,CharleboisED,etal.HIVseroprevalenceamonghomelessandmarginallyhousedadultsinSanFrancisco.American Journal of Public Health.2004;94(7):1207-1217.

SurrattHL,InciardiJA.HIVrisk,sero-positivityandpredictorsofinfection

amonghomelessandnon-homelesswomensexworkersinMiami,Florida,USA.AIDS Care. 2004;16(5):594-604.

ContactsBarryZevin,MD,TomWaddellHealthCenter,50IvyStreet,SanFrancisco,CA94102,415-355-7400,barry_zevin@sfdph.org(e-mail).

MichaelCooley,STOPAIDSProject,212815thStreet,SanFrancisco,CA94114,Telephone:415-575-0150,ext.225,mikecooleyjr@yahoo.com(e-mail).

See also references cited in articles in this issue.

Homeless in the Age of AIDS Michael Cooley

I went to a hospitality house in the heart of the Tenderloin.

The smell can only be described as “homeless”: a

combination of sweat, feet, dog, cigarettes,

and alcohol.

andalcohol.Anne,acasemanager,saiditwouldbeamonthorsobeforeIcouldgetabedatahalfwayhouseforyouth.SinceIhadalreadystayedthemaximumnumberofnightsattheSalvationArmy,Iwasgoingtohavetostayonthestreets.

Iimmediatelybegantointegrateintostreet-life.ThefriendsImadequickly showedmehowtomakethebestofit.Isleptin“squats,”usuallyinaburned-outbuildingorconstructionsite,butIwasalwaysonthemove.Thepolicewouldchaseusout,andwewouldwaitafewdaysandcomeback.Wehadnowhereelsetogo.OnenightIcamedownwiththefluandwastooweaktogetoutofthe“squat”togetfood.Mynewfriendsbroughtmeabaggedlunchfromamis-sionarydoingoutreachonPolkStreetthatnight.Theytookcareofme.

Aftertwomonths,Igotaplaceinthehalfwayhouse.WhileIwasthere,thestaffencouragedmetotakemyhighschoolequivalencytest.Abouttwomonthslater,Iwenttoschoolforpracticetestsanddidsowellthattheinstructoraskedmetotaketheofficialtestrightthen.Ipassedthat,too.

Really Homeless ThenImetthemanofmydreams.

Randywasanewguyatthehouse,andwebegandating.Whenthehousecasemanag-ersfoundout,theysaidwe’dhavetostopseeingeachother—itwasahouserule—orwe’dhavetoleave.IfIhadtodoitalloveragain,Iwouldhavestayedinthehouse.Butrightthen,itfeltasifthisrelationshipwasthemostimportantthingintheworld.Ididn’tknowwhattherealityofbeingwithRandywouldmeanoncewewerebackonthestreetsagain.Randywasaveteranhustlerandspeedaddict.HehadacasemanageratahomelessyouthagencythatservedHIV-positiveclients.Hemanagedtotalkthecasemanagerintolettingmepaytheextra$5.00adaytostayinarat-infested,run-downhotelonSixthStreet.

IlearnedfromRandyhowtohustle,whattosaywhennegotiatingpaymenttokeepfromincriminatingmyselfincaseIwastalkingtoacop,and,oh,alsohowtoshootupcrystalmeth.Thiswasthebeginningofmytrulyhomelessdays,scratchingtosurviveanddreadingthethoughtofgivingmybodyuptolonely,needymenwhoweresodesperateforattentionthatIcouldn’teventrytorespectthem.Ihatedthem.

Ibeganusingspeedtogetmetothecor-neranditwasspeedthatkeptmethere.Randywasgoneafterafewmonths,andIwasstilllookingforwaystopaymyrentandgethigh.Ifoundsupportinanetwork

ofotherdrugaddicts;wewerealloutcasts.EverytimeIgottestedforHIV,Iknewthatifthetestcamebackpositive,Iwouldhave aplacetolive.Ididn’twanttobeHIV-posi-tive,buteveryonearoundmealreadyhadit.Itseemedlikeitwasonlyamatteroftime.

Myvisitstothetestsiteswereunre-markable.Idon’trememberreallyworkingonawaytoreducemyrisk.Itwouldn’thavematteredanyway,sinceIletthe“Johns”dictatewhatweweregoingtodo.IfIswallowedIcouldgetmoremoney;ifIgotfucked,itwasalotmoremoney.Weneverdiscussedcondoms,andIwasinnopositiontomakedemands.

Living with HIVImetBobbysometimeafterIturned19.

Hewas36andaspeeddealer.Bobbypaidforahotelroomformefortwomonths,andIwantedfornothing.IeventuallymovedinwithhiminasmallhomeintheEastBay.Wespentthenexttwoyears“play-inghouse.”

WhenIwas21,Bobbyreplacedmewithhisnextboy-toy.Iwasbackonthestreets.Itestedagain,andthistimeIwasHIV-positive.BecauseIhadHIV,newresourceswereavail-able,andI gotintoahotelroomthatverynight,happytohavearoofovermyhead.

IspentthenextfewyearsseeingRon,acasemanager.Ronalwaystolditlikeitwas:IwouldneedtostopthedrugsifIwantedtodoanythingbuthustletricksorselldope.Lookingback,Irealizethatalthoughitwashelpfultohaveaplacetostay,Iwasstillinthedrugenvironment.Usingtheclinicformedicalcareandfoodservicessavedmylife,butitalsoallowedmetospendallmyownmoneyondrugs.

A Moment of ClarityRonwasright.Thiswasnolifeforme.Twothingshappenedthatdrovemeinto

treatment.Thefirstthinghasscarredmeforlife.IwasrobbedandseverelybeatenbyalocaldrugdealerwhoknewIwasaneasytarget.Afterthat,Icouldn’tsleepor

FOCUS March 2006�

Comments and Submissions We invite readers to send letters

respondingtoarticlespublishedinFOCUSordealingwithcurrentAIDSresearchandcounselingissues.Wealsoencourageread-erstosubmitarticleproposals.Sendcor-respondencetorob.marks@ucsf.eduortoEditor,FOCUS,UCSFAIDSHealthProject,Box0884,SanFrancisco,CA94143-0884.

eatbecauseIwasafraidofgettingbeatenagain.IhidinmyhouseuntilnighttimesothatIcouldsneaktothestoretobuyfood.Iknewmylifehadtochange.IcalledRon,whowasabletogetmeintoaninpatientalcoholanddrugtreatment facilitythenextMonday.That’sright,treatment-on-demandwasoneofthereasonsI’malivetoday.

ThesecondthingwasthatIwashav-ingtroublebreathing.Iwasinthealco-holanddrugtreatment facilityfor10daysbeforeitwasclearthatIdidnothaveacold.Iwasdriventotheemer-gencyroom,andthedoctorsaidthat,ifIhadwaitedanotherday,I“wouldnothavecomethroughthefrontdoor.”

IhadPneumocystis carinii pneumonia,sotheyhookedmeuptoanoxygenmaskandputmeonantibioticsthatmademeverysick.Iwasshaking,throwingup,andsweatingthrougheverysheetandblan-ket.IthoughtIwasgoingtodie,andIwasn’tready.“It’snotfair,”Ithought.Iwas23yearsold,andIhadwhattheycallinthe 12-stepworld,a“momentofclarity.”Icallitanepiphany.IfIwasgoingtolive,Icouldn’tdoitandgethigh.

IspentEasterandmybirthdayontheAIDSwardatthecity’sgeneralhospital.Iwrotetomydadandstep-momforthefirsttimesincetheykickedmeout.Itseemedsolongago;Iwondered:whatwouldtheythink?Ididnotcare.Iwantedthemtounderstandtheconsequencesofkick-ingmeout,andIwantedthemtohurttoo.Ihopedtheywouldbeupsetandfeelguilty.Instead,theydroveupandtoldmethattheylovedmeverymuch.

Wedidnotspeakofthepastverymuch.Iwantedarelationshipwiththem—anyrelationship—evenifitmeantthatwewereindenialaboutourexperiencestogether.IknewIcouldn’tchangethepast,butIcouldliveinthepresent,andthatincludedanewrelationshipwithmyparents.Bobbyalsocametovisitmeinthehospital,andtoldmethathe,too,hadpneumoniaandhadbeenhospitalized.He

diedshortlyafterthat.Hejustcouldn’tputthedrugsdown.IhadanotherveryrealexampleoftheconsequencesofdruguseandAIDStokeepmeonmynewpath.

ConclusionIhaven’tusedsinceMarch21,1997.I

amgratefultobealive.IwouldnothavestoppedusingifIhadn’talmostdiedofAIDS,soIwelcomeHIVintomylife.

Iwenttoatradeschoolshortlyafterdrugtreatmenttolearnaboutcomput-ersandgeneralofficeskills,thengotajobatacreditcardcompanyansweringphones.Itwasthebeginningofareallife.Ayearintomynewjob,Igotsickandhad

totakefourdaysoff.IhadnevertoldmyemployeraboutmyHIVbecauseIdidn’twanttobetreateddif-ferently,butIneededadoctor’snoteforworkandhadtocomeoutaboutwhyIhadbeensick.Iwasveryupsetabouthavingtodisclosemystatus,andwenttoseeRonattheyouthcentertotalkaboutit.Hesaidmytimingwasgreat:theyhadanadminis-trativepositionopenandifIgotsick,theywouldunderstand.

WithinayearIwasthefirstpeeradvocateatayouthcenter.Ibegandoingstreetoutreach,HIVtesting,andgroupfacilitation.Overthe

lasteightyears,IhavebeenworkingtoimprovethequalityoflifeofotherHIV-positiveguyslikeme:Ihavewatchedsomeclientsgetoutof“thelife”andotherswhohavenotbeensolucky.

ThesedaysIspendmytimethink-ingaboutwhatdriveshumanbehaviorandhowwecanchangethecourseofHIVinourcommunity.Theonlyremark-ablethingaboutthisdiseaseisthatitistransmittedsexually,sowecarrythebaggageandstigmaaroundoursexualityintomakingsafersexdecisions.Today,myjobistotrytoreducethosestigmas,whichsoundssimple,butlikeallhumanbehaviorchange,itisincrediblychal-lenging.Ihavefoundmycallinginlife,Ihaveauniqueperspective,andI’mgladtohavethischancetomakeadifference.

AuthorMichael Cooley is the Prevention with Positives Program Manager at the STOP AIDS Project and a member of the San Francisco HIV Preven-tion Planning Council.

FOCUS March 2006�

I wanted them to understand the

consequences of kicking me out, and I wanted them to hurt

too. I hoped they would be upset and

feel guilty. Instead, they drove up and told me that they

loved me very much.

Homelessness and Antiretroviral AdherenceWaldrop-Valverde D, Valverde E. Homelessness and psychological distress as contributors to antiretroviral nonadherence in HIV-positive injecting drug users. AIDS Patient Care and STDs. 2005; 19(5): 326–334. (University of Miami.)

In his overview article, Barry Zevin identi-fies obstacles to HIV antiviral drug adherence among people who are homeless. But he also notes that there is evidence that appropri-ate medical care can lead to good medical outcomes, including high levels of adher-ence, within this population. This University of Miami study, which focuses on a variety of factors that may affect injection drug users’ adherence levels, did not find a connection between homelessness and nonadherence.

Depressionmaybeamorepotentindi-catorthanhomelessnessofHIVantiviralmedicationnonadherenceamonginjectiondrugusers.

Highlevelsofadherencetoantiretrovi-ralmedicationsarerequiredtomaximizetherapeuticbenefitsandviralsuppres-sion.Injectiondruguseisassociatedwithdecreasedadherencelevels,unstablelivingconditions,andmentalhealthproblems.

Despitetheprevalenceofthesenonadher-encerisksamongHIV-positiveinjectiondrugusers,therehasbeenlittlestudyassessingtheimpactofhomelessnessandpsychologi-caldistressonadherenceinthispopulation.Thisstudyevaluatedtheeffectsofhousingstatus(homelessandmarginallyhousedver-susnonhomeless)andpsychologicaldistress,measuredviadepression,anxiety,andper-ceivedstress,onself-reportedadherencein58HIV-positiveinjectiondrugusers.

HomelessandmarginallyhousedHIV-positiveinjectiondrugusersreportedhigherlevelsofanxietyandperceivedstressthantheirnonhomelesscounter-parts.Thegroupsreportedsimilarlevelsofdepression.However,onlydepressionwassignificantlyrelatedtoadherence.Housingstatus,drugoralcoholuse,andotherdemographicvariablesincludinggender,raceandethnicity,andyearsofeducation,werenotassociatedwithadher-ence.Thestudyalsofoundarelativelyhighrateofadherenceinhomelessandmarginallyhousedinjectiondrugusers,with63percentofthesesubjectsreportingperfect(100percent)adherencelevels.

Homeless Youth and HIV RiskWagner LS, Carlin L, Cauce AM, et al. A snapshot of homeless youth in Seattle: Their characteristics,

behaviors and beliefs about HIV protective strategies. Journal of Community Health. 2001; 26(3): 219–232. (University of San Francisco; University of Washing-ton, Seattle; and National Youth Advocacy Coalition.)

Homeless youth may have an especially high risk of contracting HIV. This Seattle-based study complements Michael Cooley’s memoir by reporting on the experiences and beliefs regarding the HIV risk of homeless youth.

KnowledgeofHIVprotectivestrategiesdifferedbysexualorientation,accord-ingtothislargeSeattlestudyofyoungpeople.Heterosexualyouthhadtheweak-estknowledgeofHIVprotectionstrategies,especiallycomparedwithyoungmenwhohavesexwithmen.

Researchersinterviewed272homelessyouthinordertodeterminehowinitialHIVpreventioneffortswerereceivedandtoassesswaysthattheyouth’sbeliefsandbehaviorscontinuedtoputthematriskforHIVinfection.Themeanageforthe169maleyouthwas18;themeanageforthe103femaleyouthwas16.Mostidentifiedashet-erosexual,but20percentidentifiedasgayorlesbianand17percentidentifiedasbisexual.

Youthreportedusingcondomswithcasualpartnersduringvaginalandanalsexand,amongthoseengagedinsexwork,withclientsduringoral,anal,andvaginalsex.Condomswereoftennotusedduringvaginalsexwithmainpartnersorduringoralsexwithcasualormainpartners.

FOCUS March 2006�

Next IssueResearchhasidentifiedtrauma,the

resultofeitherorbothsexualandphysi-calabuse,asakeyfactorinfluencingthebehaviorsmostlikelytoresultinHIVtransmission.Studieshavealsoidenti-fiedhighratesoftraumaandpost-trau-maticstressdisorder—thespecificcon-stellationofpsychologicalsymptomsthatcanresultfromtraumaticexperi-ences—amongpeoplewithHIV.IntheAprilissue,Deborah J. Brief, PhD, As-sistantProfessorofPsychiatryatBostonUniversity,reviewstheliteratureontheprevalenceandmanifestationsoftraumaandPTSDamongpeoplewithHIV.

AlsointheAprilissue,Nathan B. Han-sen, PhD,AssistantClinicalProfessorofPsychiatry,andKathleen J. Sikkema, PhD,AssociateProfessorofEpidemiol-ogy,bothatYaleUniversity,describetherangeofapproachesavailabletotreat PTSDandtheapplicationofthesestrat-egiestopeoplelivingwithHIV.

FOCUSFOCUSAGuidetoAIDSResearchandCounseling

Executive Editor; Director, AIDS Health Project James W. Dilley, MD

Editor Robert Marks

Clinical Editor Michelle Cataldo, LCSW

Recent Reports Rachel Billow

Founding Editor Michael Helquist

Medical Advisor Stephen Follansbee, MD

Design Saul Rosenfield

Production Suzy Brady Carrel Crawford Jennifer J. Regan Lisa Roth

Circulation Jennifer J. Regan

FOCUS, published 10 times a year, is a publication of the AIDS Health Project, affiliated with the University of California San Francisco.

Ten issues of FOCUS cost: Individual: Paper–$48; Paper Outside U.S.–$60; Electronic–$36 (inside and outside U.S.); Both Formats

–$58; Both Formats Outside U.S.–$70; Limited Income

–$24 for either format and $30 for both formats. Institutional: Paper–$105; Paper Outside U.S.–$125; Electronic–$90 (inside and outside U.S.); Both Formats–$120; Both Formats Outside the U.S.–$140. Make checks payable to “UC Regents.” Address subscription requests and correspondence to: FOCUS, UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884. For a list of back issues and information about cost, write to the above address, call (415) 502-4930, or e-mail jennifer.regan@ucsf.edu.

To ensure uninterrupted delivery, send new address four weeks before you move.

Printed on recycled paper.

©2006 UC Regents: All rights reserved.

ISSN 1047-0719

Recent Reports

DID YOU KNOW?FREE searchable archive

You can access a FREE searchable archive of back issues of this publication online! Visit http://www.ucsf-ahp.org/HTML2/archivesearch.html.

You can also receive this and other AHP journals FREE, at the moment of publication, by becoming an e-subscriber. Visit http://ucsf-ahp.org/epubs_registration.php for more information and to register!

ABOUT UCSF AIDS HeAlTH PrOjeCT PUBlICATIOnS

The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental

health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more

information about this program, visit http://ucsf-ahp.org/HTML2/services_providers_publications.html.