BACKGROUND: Knowledge of human immunodeficiency virus (HIV) and its risk behaviors have not been systematically studied in homeless mothers. The identification of the factors associated with HIV-risk practices will guide interventions for low-income housed and homeless women.
METHODS: We interviewed 220 homeless and 216 low-income housed mothers living in Worcester, Massachusetts, to gather information on demographic, psychosocial , and HIV-risk practice characteristics. We used standardized instruments and questions drawn from national surveys. The primary study outcome was high HIV-risk behavior.
RESULTS: Although homeless mothers were more likely than low-income housed mothers to report first sexual contact at an early age, multiple partners during the last 6 months, and a history of intravenous drug use, homelessness was not associated with high HIV-risk practices. Both homeless and low-income housed mothers demonstrated misconceptions about HIV transmission through casual contact. Among high-risk women, approximately 75% perceived themselves as having low or no risk for contracting HIV. A history of childhood victimization, adult partner violence, or both placed women at a significantly increased likelihood of high HIV-risk practices. African American race, knowledge about HIV, and self-perception of risk were also significantly associated with high-risk practices.
CONCLUSIONS: Homeless mothers are a subgroup of poor women at high risk for HIV and should be targeted for preventive interventions. In addition, there are potentially modifiable factors associated with HIV-risk practices in both low-income housed and homeless mothers that should be directly addressed.
In recent years, the rate of human immunodeficiency virus (HIV) infection has grown rapidly among women, primarily through heterosexual contact.1 In 1993, acquired immune deficiency syndrome (AIDS) was the fourth leading cause of death among women aged 25 to 44.2 Social, economic, and cultural forces powerfully influence the susceptibility of women to HIV infection. Approximately 75% of AIDS cases in women have been documented among poor African Americans or Hispanics.1,3 Various reports have documented conditions of poverty related to HIV risk and AIDS,3,4 while others have described the relationship of sex-based inequalities involving drug usage patterns, sexuality, and violent victimization to HIV infection and risk behaviors among women.3
Among the urban poor, homeless women appear to be a subgroup who may have an added risk of HIV infection. Single women and their children make up more than one third of the overall homeless population.5 Although mothers who are homeless are at high risk for HIV infection because of poverty, minority status, and high rates of childhood and adult victimization experiences,3,6-9 it is unclear if the homeless condition confers additional risk of HIV infection.
Few reports have examined the knowledge and risk behaviors of homeless women in general10-15—homeless mothers, specifically—in relation to HIV.16-18 With the exception of a recently published report describing higher rates of adverse risk practices among a large sample of homeless mothers,18 studies have been limited by small sample sizes, a lack of comparison groups, or inclusion of nonrepresentative samples.13-17 No studies have examined the unique contribution of homelessness or factors associated with family homelessness, such as domestic violence, to HIV-risk practices.
As part of a comprehensive epidemiologic study of homeless families in Worcester, Massachusetts, we examined knowledge of HIV and the risk profile of homeless and low-income housed mothers. We also examined the contribution of potential explanatory factors, including homelessness, to high HIV-risk behaviors.
Methods
Study Population
We used a cross-sectional observational design to recruit a sample of sheltered homeless families and a comparison group of low-income housed (never homeless) families in Worcester, Massachusetts (1990 US census population estimate = 169,000).
In Massachusetts, as in many midsize and large American cities, the vast majority of homeless families are headed by single women. We enrolled only families headed by women with children younger than 17 years who were living together. We used the definition of “homeless” developed by the US Congress of having spent more than 7 consecutive nights in a car, abandoned building, public park, shelter, nonresidential building, or other non-dwelling.19 In Worcester, the overwhelming majority of families who become homeless go directly to a shelter; thus, we enrolled only families currently living in a shelter.
From August 1992 to July 1995, 220 families were enrolled from Worcester’s 9 emergency shelters, transitional housing facilities, and 2 welfare hotels. Hotels are used to house families when there is a shortage of beds in the emergency shelters. We asked all families who had been in a shelter for at least 7 days to participate in multisession interviews carried out by trained study staff. We approached 361 families; 102 refused to participate, and 39 dropped out before completing the interviews. Women who refused to participate and those who did not complete the interviews were similar to study participants in terms of race, marital status, number of children, and welfare status. Homeless women who refused to participate were younger and less likely to have graduated from high school.