Correlates and Distribution of HIV Risk Behaviors among Homeless Youths in New York City: Implications for Prevention and Policy
Clatts, Michael C., Davis, W. Rees, Sotheran, J. L., Atillasoy, Aylin, Child Welfare
Homeless youths are at high risk for poor health outcomes, including repeated exposure to STDs and high rates of unplanned pregnancies, untreated TB, HIV infection, and accelerated immune dysfunction associated with AIDS. This article examines the nature and distribution of HIV-risk behavior in a broad, streetbased sample of homeless and runaway youths in New York City (N = 929). Although street youths in general are shown at high risk, the highest risks nest within older age segments of the male street youth population. Paradoxically, these youths are least likely to be in contact with prevention services. The data demonstrate the need to reconsider the use of chronological age as a determinant for service eligibility and to reconfigure funding streams so as to more effectively and consistently target older and more vulnerable youths.
An estimated two million youths are homeless in the some 200,000 of these youths live as permanent residents of the streets [U.S. Department of Health and Human Services 1986]. In New York City, this population is estimated to be as high as 20,000 youths [Schaffer & Caton 1984]. Some of these youths are transitionally homeless, having left home for a brief period of time [Adams et al.1985; Dunford 1976]. Many others, however, have gone to the streets because they are unwelcome at home. Youths frequently cite conflict over sexual identity as a factor in their homelessness. Other youths become homeless because their families have become homeless or simply because their families are economically unable to continue to care for them [Benker et al.1990; Clatts et al.1997; Gunn 1988; Kufeldt & Nimmo 1987; Pries & Silbert 1991]. Service providers working with this population report that as many as two-thirds have "discharged" themselves from out-of-home care-often for many of the same reasons that youths not in care leave home, including physical and sexual abuse, conflict over sexual identity, and breakdown of the family as a viable socioeconomic unit.
Whatever the genesis of their move to the streets, it is clear that most of these youths enter street life at an age at which they are ill prepared to manage the social and economic tasks associated with becoming healthy, functioning adults. Many remain homeless for prolonged periods of time and face overwhelming obstacles in any effort to leave street life [Clatts et al. 1995; Clatts et al. in press]. Limited education, lack of marketable job skills, and the generalized emotional and cognitive instability associated with homelessness itself contribute to these youths' dependency on "the street economy" (e.g., sex trade, panhandling, drug dealing) as the primary source for money with which to meet their basic needs for food, clothing, and shelter [Clatts & Davis 1993; Kipke et al. 1995; Yates et al. 1988]. The constellation of sex and drug risk behaviors, together with the chronic and progressively debilitating exposure to the street environment itself, creates exceptional vulnerability to a number of poor health outcomesincluding sexually transmitted diseases, hepatitis, tuberculosis, enteric parasites, bronchial infections, asthma, pneumonia, conjunctivitis, depression, and malnutrition-and to an alarming rate of HIV infection.
Available data on the incidence of HIV infection among these youths are scarce but suggest that a substantial number have already been exposed to HIV [D'Angelo et al. 1991; Futterman et al. 1993]. For example, a double-blind 1990 study conducted in a shelter for homeless youths indicated an overall HIV seroprevalence of over 5% [Stricof et al. 1991]. Prevalence was even higher among older male youths, of whom 10% were seropositive. While alarming in their own right, these estimates probably significantly underestimate actual levels of infection since the particular institutional context in which they were collected was unlikely to have included representative proportions of gay, lesbian, or bisexual youths. …