The Co-Occurrence of AIDS and Homelessness : Results from the Integration of Administrative Data for AIDS Surveillance and Public Shelter Utilization in Philadelphia

Study objective—Administrative databases from the City of Philadelphia that track public shelter utilisation (n=44 337) and AIDS case reporting (n=7749) were merged to identify rates and risk factors for co-occurring homelessness and AIDS. Design—Multiple decrement life tables analyses were conducted, and logistic regression analyses used to identify risk factors associated with AIDS among the homeless, and homelessness among people with AIDS. Setting—City of Philadelphia, Pennsylvania, USA. Main results—People admitted to public shelters had a three year rate of subsequent AIDS diagnosis of 1.8 per 100 person years; nine times the rate for the general population of Philadelphia. Logistic regression results show that substance abuse history (OR = 3.14), male gender (OR = 2.05), and a history of serious mental disorder (OR = 1.62) were significantly related to the risk for AIDS diagnosis among shelter users. Among people with AIDS, results show a three year rate of subsequent shelter admission of 6.9 per 100 person years, and a three year rate of prior shelter admission of 9%, three times the three year rate of shelter admission for the general population. Logistic regression results show that intravenous drug user history (OR = 3.14); no private insurance (OR = 2.93); black race (OR = 2.82); pulmonary or extrapulmonary TB (OR = 1.43); and pneumocystis pneumonia (OR = 0.56) were all related to the risk for shelter admission. Conclusions—Homelessness prevention programmes should target people with HIV risk factors, and HIV prevention programmes should be targeted to homeless persons, as these populations have significant intersection. Reasons and implications for this intersection are discussed. (J Epidemiol Community Health 2001;55:515–520) Previous studies of the prevalence of homelessness among people with AIDS (PWAs) and the prevalence of HIV/AIDS among people who are homeless have documented that these conditions can frequently co-occur. However, estimates of co-occurrence have varied widely, because of diVerences in research methods, definitions, locales, and sample selection procedures. This study re-examines this issue by merging administrative databases that register the use of public shelters and the incidence of AIDS cases in a large US city. In so doing, this study demonstrates the feasibility of a highly reliable method for monitoring the cooccurrence of these conditions to inform health care, housing and social service resource allocations. Literature Attempts to measure the rates of co-occurrence of HIV/AIDS and homelessness have been complicated by a range of methodological challenges. Small samples, non-random samples, inconsistent definitions of homelessness, and varying measures of HIV/AIDS, have limited the comparability and generalisability of findings. Nevertheless, this research has raised concerns that homeless people are a distinct at risk group for HIV/AIDS, and that people with HIV/AIDS are at high risk for becoming homeless. The co-occurrence of these conditions is also posited as contributing to the increased rate of active tuberculosis in both the homeless and HIV/AIDS populations. Estimates of the rate of HIV/AIDS among homeless adults unaccompanied by children (single adults) have ranged from 6% to 62%. Torres et al found that 62% of a sample of 169 homeless men in New York City were HIV positive; the sample was not random, consisting of persons recommended for voluntary testing because of high risk status or presenting symptoms. Susser et al identified a 19% rate of HIV infection among homeless shelter users in New York City, based on a sample of 62 men. The sample was not random, consisting of persons in a single shelter for men receiving mental health services. In a related study, Empfield et al found a 6% rate of HIV infection among homeless persons admitted to a psychiatric inpatient unit for the “street homeless” in New York City, based on blood samples obtained over two years of admissions. Greer et al found an 11% seropositivity rate among a sample of homeless persons in Miami, but the sample was also not random, being comprised of people who requested anonymous testing at a health clinic for the homeless. Zolopa et al conducted a population-based, cross sectional study of HIV infection among 916 persons in San Francisco, producing perhaps the most reliable estimate of HIV infection among the homeless adult population, finding an overall rate of HIV J Epidemiol Community Health 2001;55:515–520 515 University of Pennsylvania, Philadelphia, USA