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HIV Seroprevalence Among Atlanta's Homeless
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Brief communication 83 HIV SEROPREVALENCE AMONG ATLANTAS HOMELESS During the 1980s, America was hard hit by two epidemics: HIV/AIDS and homelessness. By 1990, the Centers for Disease Control and Prevention (CDC) reported more than 115,000 cumulative cases of AIDS and an estimated 1 million infected persons.1,2 The connection between poverty and poor health, including HIV infection, is a result of many interrelated factors including lack of access to health care, poor nutrition, lack of adequate housing, and increased incidence of substance dependence.3 Homelessness is one of the most dramatic indicators of poverty. Of the 185 million adults identified by the census in 1990, about 13.5 million have been literally homeless at some time during their lives with 5.7 million homeless during the past five years. The conditions of homelessness pose severe problems for the control of infectious diseases and put homeless people at risk of serious debility and disability.4 The combined effects of HTV/AIDS and homelessness make these among the most challenging and pressing of public health problems. Atlanta, Georgia has been dramatically affected by both AIDS and homelessness . The city's economic prosperity has often masked the public health challenges created by a lack of affordable housing and creation of service sector jobs with little stability and no health benefits. According to the city's Task Force for the Homeless, more than 20,000 people call Atlanta's streets "home. "5 In 1993, Atlanta ranked eighth among all U.S. cities in the cumulative number of AIDS cases.6 HIV/AIDS is not the only epidemic facing metropolitan Atlanta. In 1991 and 1992, Atlanta had the highest rate of tuberculosis of all U.S. cities7; in 1992, it also had the highest rate of syphilis infection. Both tuberculosis and syphilis are strongly associated with HTV/AIDS. Addressing the health care needs of the homeless led Mercy Mobile Health Care (MMHC) into a partnership with the Georgia Department of Human Resources (DHR). One result was a seroprevalence study designed to quantify the level of HIV infection among the homeless. The blinded study targeted the approximately 7,500 homeless persons in inner-city Atlanta who received primary care from MMHC. During seven months of 1990 (March to September), 676 clients were tested (9 percent of the estimated target population ). Clients were served in parks, shelters, soup kitchens, and labor pools by outreach workers, health advocates, nurses, and doctors. The initial result of the survey pointed to the immediate need for HIV counseling/testing and early intervention programs for the homeless, both of Journal of Health Care for the Poor and Underserved · Vol. 7, No. 2 · 1996 84 HIV Seroprevalence Among Homeless which have been initiated. Further analysis of data obtained from two and a half years of the nonblinded seroprevalence study provided information that is being used to enhance risk reduction and prevention efforts. Background MMHC was created during the mid-1980s to provide primary care, social services, and health education to Atlanta's homeless as a part of Saint Joseph Health System's outreach to the poor in the inner city. The mission of MMHC is to improve the health status of the medically underserved. This is accomplished by using an interdisciplinary multicultural staff; a fleet of vans and mobile clinics; and a network of donated community sites and numerous collaborative relationships to deliver health care, education, and social services. As information about HIV began to be collected during the late 1980s, MMHCs staff and volunteers realized that homeless clients were at significant risk of acquiring and transmitting the virus. Clients reported unprotected sex with multiple partners, exchanging sex for drugs, and substantive alcohol and drug use, and were regularly diagnosed with sexually transmitted infections. However, homeless clients did not recognize that these behaviors were associated with HIV transmission. After diagnosing with AIDS several homeless individuals who had no knowledge of the disease and were unaware of their risk for infection, the MMHC staff set out to develop a comprehensive HIV services program. The first grant was obtained in 1988 from the CDC for street outreach and risk reduction education. That same year, the DHR was selected by the CDC to...