HIV / AIDS Epidemic Among the Homeless

¶ … HIV / AIDS epidemic among the homeless

HIV, the epidemic that seems to have no end, rears it head year after year causing catastrophic damage. Now more than ever, all individuals regardless of race or demographics must be weary of the devastation this virus can cause. One social economic class that is particularly prone to this epidemic is that of the homeless community. According the center for disease control and prevention, the African-American community accounts for nearly 46% of people living with a HIV diagnosis (1). Of those, 23% are homeless. What is even more mindboggling is the fact that the African-American community only accounts for 13% of the current U.S. population.

Estimated Rates of New HIV Infections,

by Race/Ethnicity and Gender, 2006

(Source: CDC. Subpopulation Estimates from the HIV Incidence Surveillance System -- United States, 2006. MMWR. 2008; 57(36):985 -- 989)

Obviously, the best way to mitigate the risk of HIV is through abstinence. More individuals within the homeless community are becoming sexually active. Over the course of a lifetime, it is estimated that 1 in 16 black males and 1 in 30 black females will become infected with HIV. This is in direct contrast to their white counterparts who are significantly less likely to contract HIV with a 1 in 104 and a 1 in 588 chance respectively (2). This is of particular importance to homeless teenagers who engage in sexual behavior at early ages. For one, these activities develop habits that are inherently risky in regards to contracting general STDs. Also, many young teenagers are not properly educated on proper protection techniques. Within the homeless community more emphasis must be placed on proper education from the society itself. Often, the community relies on the government or other third party organizations to alleviate societal problems. These programs to a certain extent have created benefits for the entire society.

The nation is, however, realizing a decreasing trend in AIDs within the homeless community. For example, between the years of 1993 to 2003, sexual intercourse between the homeless overall have decreased from 53% to 47% respectively. Even more favorable, in 2003, more that 65% of all homeless teenagers were abstinent (3). This trend is even more dramatic within the African-American community with sexual intercourse rates declining from 59% in 1991 to 47.7% in 2009. Among African-American males, who are the most prone to HIV infection, the trend is also declining from 64% in 1991 to 50% in 2009 (4).

In regards to AIDs among the homeless community, low social economic status plays a role. There is a direct correlation between high school drop out rates and wealth. Only 47% of African-American males graduated from high school in 2010 (5). This is compounded by the fact that many of these drop outs becoming unproductive members of society, thus engaging in unproductive activities. These activities including drugs, sex, and other substance abuse practices can potentially lead to an increase likelihood of HIV infection. Nearly 23% of African-Americans live in poverty as mentioned above, with another 40% with only a single parent. According to the center for disease control, rates of imprisonment, death and drug use among men influence patterns of sexual behavior that spread HIV (6). The African-American community has both the highest rate of imprisonment within the United States and the highest high school drop out rates both or which contributes to high rates of HIV among the homeless.

Definition and description of epidemiology in general related to your topic / Discuss steps and methods used in epidemiology as it relates to your topic.

Epidemiology is defined by Webster's Dictionary as, "A branch of medical science that deals with the incidence, distribution, and control of disease in an entire population (7)." In regards to the homeless population, the incidence from 2006 through 2009 of HIV infections among adults and adolescents remained stable. In 2009, roughly 43,000 adults and adolescents were diagnosed with HIV infection, 5300 of which were homeless. Of these, 76% of diagnoses were among males and 24% were among females. What is interesting is the amount of homeless males diagnosed between 2006 and 2009 went up 5%, while female diagnoses decreased by 9% (8). Below is a chart depicting the above data in numerical form. These figures are from the CDC for the year 2009.

Type of Transmission

Number of HIV infections reported

Overall Percentage of the total population

Male to Male

24,132

56.4%

Injection drug use

4,172

9.7%

Both Male to Male contact with Injection Drug use

1.157

2.7%

Heterosexual Contact

13,257

31%

Other

75

.2%

How is HIV spread among the homeless populations? According to the CDC, The percentage of diagnoses of HIV infection among adults and adolescents exposed through male-to-male sexual contact has increased by 6% from 2006 to 2009. The total percentage now stands at 56% with the trend increasing with male to male intercourse (10). However, the total overall percentages of diagnosed HIV infections through the use of injections, homosexual contact, and heterosexual contact have remained relatively stable for the same period. This is somewhat reassuring as the trend overall has been stable recently. In terms of percentages, an overwhelming 74% of infections were attributed to male-to-male sexual contact and 8% were attributed to injection drug use. Meanwhile, only a mere 14% of diagnosed infections were attributed to heterosexual contact. In regards to the homeless population, a trend is starting to form. First, contrary to popular belief, homosexuals contribute a disproportionate amount to the total HIV cases in the United States. In fact, of the homeless population, male to male contact constitutes a vast majority of cases not female to male as many individuals would think. Now in regards to heterosexual contact among the homeless, an estimated 85% of all diagnosed FEMALES contracted the disease from a member of the opposite sex (9). The remaining 15% was attributed to drug use. As I have eluded to earlier in the document African-Americans constituted the largest percentage of diagnoses of HIV infection each year. From 2006 to 2009 nearly 50% of all HIV infections were from African-Americans, 28% were white, and 19% were Hispanic. The remaining portion was spread equally between Asian, Native America, and multi-racial (8).

Explain the type of epidemiology used for your topic (descriptive or analytical).

The epidemiology used for this particular paper was both descriptive and analytical. First the descriptive portion (mentioned above) described the characteristics of the homeless population who were susceptible to the given disease. I also went into detail explained how the disease was contracted and where it was most prevalent. I also went into detail describing the characteristics of those who are engaged in such activity and what activities constitute how the disease is transferred. On the analytical aspect, the research provided gives statistical accounts of how the disease is transferred and what percentages correlate to a particular transmission activity. The data also provides specifics on the exact proportion of male to male, and heterosexual accounts.

Provide an overview of population and disease and identify how characteristics of these selections influence population vulnerability.

This aspect was covered in detail above.

Identify primary, secondary, and tertiary prevention to address the disease

Currently, many forms of prevention on all levels are available to the homeless population. The first of which are shelters designed specifically to help abate the prevalence of HIV. Many of these shelters focus on intervention by providing facilities to better educate the homeless. These shelters provide access to primary care, substance abuse treatment, both of which contribute heavily to the spread of HIV. In New York City, the location with the most HIV cases, preventative measures are being used to address the female homeless population. Here condoms, gels, and other contraceptives are given to these individuals to help protect and empower them.

Personally, I believe these prevention measures are futile and do not address the bigger issue of homelessness. I believe the issue of homelessness must first be addressed. As a result HIV would diminish as a by-product of addressing the bigger issue of homelessness. I believe it to be both impractical and somewhat absurd to simply give out protective items and hope that the homeless use them. For one, even if they do use them, the effectiveness is not 100%. It is quite possible for a homeless person to use a condom and still contract HIV. Further, there is no guarantee the items will even be used. Second, it is unrealistic to believe that these shelters can provide a realistic means of defense against the transfer of HIV. It is the nature of homeless individuals to be nomadic in their movements. I concede that many congregate around the same areas, however, there is nothing hindering homeless individuals from simply moving to another area of town. The shelters however, can not move as the homeless person can. They are not as nimble and flexible in their operations. They are defendant on the prevalence of the homeless population in the surrounding area. If the homeless population suddenly moves to another area of town, the homeless shelters power and influence are significantly diminished by that distance. I believe a better solution would be to address the HIV epidemic in more unconventional way. Have stations set up in frequented areas of the HIV homeless community. Soup kitchens, shelters, hotels, and clinics should all be equipped with these HIV prevention stations. Here, the homeless individual is exposed no matter what area he or she goes to, unlike the individual shelter, thus better protecting against the spread of HIV.

Secondly, the bigger issue of homelessness must be addressed first. This document deals primarily with HIV among the homeless, however, I believe a small discussion on homelessness is warranted in this context. Speaking briefly, there is a direct correlation between homelessness, education, and income levels. Likewise the same correlation exists between HIV, education, and income levels. As such, I believe it prudent to attack the bigger issue of homeless first. Why, because by talking the bigger issue, the issue of HIV can potentially be eliminated. As the saying goes, we could, "Kill two birds with one stone." By educated individuals first on how to become productive members of society, we can help prevent HIV altogether. Homeless people will not engage in such frivolous activity as they now have a means of income, and a life that is by far superior to there homeless life.

How feasible are the above recommendations? As I will discuss briefly below, the feasibility is subject to the prevailing notions of the community at the time. If, for instance, more pressing issues abound, the feasibility of this project will be diminished. As is the case with many budgets during difficult economic times, executives must prioritize aspects they deem as the most important. In many instances, homeless HIV is not a pressing issue, when educational aspects need funding, social programs need funding, and governments are attempting to trim their overall budgets. As such, the feasibility of this project depends almost entirely on the notions and desires of the community. If the communities believes this issue to be important, and are willing to fund the initiative, the feasibility of the project is quite high. Likewise if they don't believe the issue to be important, then it will not receive the necessary funding needed to be successful.

Discuss the ethical and legal considerations of the population and the disease.

When working with the homeless population, the most immediate ethical consideration is the realization that it is nearly impossible to treat everyone effectively. This is the result of two primary assumptions. First, the current economic climate will not warrant such heavy expenditures as to justify excessive treatments of the homeless. Both federal and state budgets are being trimmed primarily due to disproportionate spending of generations past. The HIV epidemic among the homeless is simply not a top priority for many high ranking officials. As the funding to fight the HIV epidemic generally comes from these institutions, I see nothing in the immediate future that would warrant such heavily expenditure. As such, many homeless who need treatment will not receive it. Who is to say which population or individual is best suited to receive these treatments? Unfortunately, many communities will undoubtedly receive more funding and thus better treatment then others with similar needs. This is unethical because those who can use their influence and persuasive power the best eventually receive money, not those who are in need the most.

Second, in the event that funds are warranted, where will these funds ultimately come from? Eventually, as is almost always the case, the individual tax payer must foot the bill. Is it ethical to make an entire population pay for the desires of certain high ranking officials? Are there more pressing health needs in the community that can do a greater amount of good? Should we just allow the homeless to die of their diseases or should we attempt to subsidize their treatment? Why should the burden fall on the tax payer when the homeless contribute nothing to society and will die anyway? These are all ethical considerations that all stakeholders must take into account.

Now, in the event that the homeless are treated, to what extent should they be treated? Should the tax payer shoulder the burden for unproductive members of society? The answer lies primarily in the general consensus regarding HIV among the homeless community. As I alluded to earlier in the document, the homeless epidemic is increasing in absolute terms but at a decreasing rate. I society deems it necessary to continue treatment and are willing to pay for the increase expenditures, then treatment is warranted. However, in the event of an economic downturn as the one we are in currently, should the homeless be treated? Another consideration is that if the homeless have been treated in prior years, do they have a right to expect the same treatment in subsequent years after? All of these questions have a profound impact on the way HIV will spread among those in the homeless community.