Risk behavior and access to HIV/AIDS prevention services in a community sample of homeless persons entering permanent supportive housing.

Homeless persons suffer disproportionately high rates of HIV infection, and moving into permanent supportive housing (PSH) can provide a stable base from which to access needed prevention services. However, little is known about HIV risk or prevention behavior during this critical time of transition. The current study investigated STI and HIV risk and prevention behavior and recent use of prevention and treatment services (i.e., education, testing, medication) among homeless persons preparing to move into PSH. Data come from interviews with 421 homeless adults before they moved into PSH. Thirty-seven percent of the respondents were sexually active; of those, 75.7% reported unprotected sex. Nearly two-thirds (64%) reported past year HIV testing and 40% reported testing for another STI. Fewer than one-third (31%) of respondents reported receiving posttest counseling at their last HIV test. HIV seropositivity was self-reported by 10%. Among those persons who were HIV-positive, 57.1% reported less than 100% antiretroviral (ARV) adherence. Among HIV-negative respondents, less than 1% had been prescribed preexposure prophylaxis (PrEP). Less than half (46.4%) of the sample reported any HIV prevention education in the past year. This population of homeless adults about to move into PSH report high rates of HIV risk behavior, but low rates of HIV prevention education and very little PrEP utilization. Further, low rates of ARV adherence among HIV-positive respondents indicate significant risk for HIV transmission and acquisition. Entering PSH is a period of transition for homeless persons when integrated care is critically important to ensure positive health outcomes, but these data suggest that PrEP and other HIV prevention services are poorly accessed among this population. As such, multipronged services that integrate PrEP and other HIV prevention services are needed to prevent transmission and acquisition of HIV in this high-risk, vulnerable population and ensure the health and wellbeing of PSH residents.

Substance use outcomes among homeless clients with serious mental illness: comparing Housing First with Treatment First programs.

The Housing First (HF) approach for homeless adults with serious mental illness has gained support as an alternative to the mainstream "Treatment First" (TF) approach. In this study, group differences were assessed using qualitative data from 27 HF and 48 TF clients. Dichotomous variables for substance use and substance abuse treatment utilization were created and examined using bivariate and logistic regression analyses. The HF group had significantly lower rates of substance use and substance abuse treatment utilization; they were also significantly less likely to leave their program. Housing First's positive impact is contrasted with the difficulties Treatment First programs have in retaining clients and helping them avoid substance use and possible relapse.

Engagement and retention in services among formerly homeless adults with co-occurring mental illness and substance abuse: voices from the margins.

This qualitative study analyzed 72 interviews with 39 formerly homeless psychiatric consumers to develop a grounded theory model of engagement and retention in mental health and substance abuse services. Person-centered themes included severity of mental illness and substance abuse (the latter also conflicting with programmatic abstinence requirements). System-related themes inhibiting service use included program rules and restrictions and a lack of one-on-one therapy. Those promoting service use were acts of kindness by staff, pleasant surroundings, and the promise (or attainment) of independent housing. Implications of these findings are discussed in terms of integrating consumers' opinions about services to enhance treatment engagement and retention.

Social relationships among persons who have experienced serious mental illness, substance abuse, and homelessness: Implications for recovery.

The new paradigm of recovery has highlighted the importance of positive social relationships, but little is known about their role in recovery among homeless individuals with serious mental illness and comorbid substance abuse. This study used within- and across-case analyses of longitudinal data from qualitative interviews with 41 dually diagnosed individuals entering residential programs to exit homelessness and receive needed services. Thematic findings include (a) "loner talk" and the need for privacy; (b) family ties as "good news, bad news"; (c) when it comes to a partner, other things come first; and (d) in search of positive people. Analyses of change in individual trajectories revealed that stronger social relationships did not coincide exactly with positive outcomes. Although positive life changes were gradual, negative changes could be precipitous. Social relationships were threatened by concentrated disadvantage, that is, a lack of social and economic currency. Findings are discussed with implications for improving services for the most vulnerable individuals who stand to benefit from the era of recovery.