Infectious diseases are a common cause of health problems in homeless people (Raoult, et al., 2001). The most serious of these infections include tuberculosis (TB), human immunodeficiency virus (HIV) infection, viral hepatitis, and other sexually transmitted infections. Outbreaks of TB among homeless people have been reported frequently, especially in individuals co-infected with HIV (Barnes, et al., 1999; McElroy, et al., 2003; Morrow, et al., 2003). The incidence of active TB in a cohort of homeless people in San Francisco between 1992 to 1996 was 270 per 100,000, or 40 times higher than that seen in the U.S. general population in 1998 (Moss, et al., 2000). Homeless people with TB require more hospital-based care than non-homeless people with TB, resulting in average hospital costs that are higher by $2,000 per patient.(Marks, et al., 2000) Contact tracing in the homeless population is difficult, and in one study only 44% of identified contacts completed treatment for latent TB infection (Yun, et al., 2003). Among street youth, latent tuberculosis is more common than in the general population, but probably less prevalent than among homeless adults. In a study conducted in Sydney, Australia, 9% of homeless young people aged 12-25 years had latent TB infection (Kang, et al., 2000).
Homeless people are at increased risk of HIV infection. Data from an older U.S. survey conducted from 1989 to 1992 in 14 cities found median HIV seropreva-lence rates of 4.0% in adult men, 1.8% in adult women, and 2.3% in youths (Allen, et al., 1994). In more recent studies, HIV seroprevalence was 10.5% among homeless and marginally housed adults in San Francisco in 1996, a rate five times higher than in San Francisco generally (Robertson, et al., 2004). HIV infection was present in 1.8% of homeless veterans admitted to residential programs from 1995-2000 (Cheung, et al., 2002). Female street youth and young homeless women who are involved in prostitution are at increased risk of HIV infection, due to both injection drug use and risky sexual behaviors (Weber, et al., 2002). In one study of homeless adolescents, the HIV infection rate was alarmingly high at 16% (Beech, et al., 2003). Among substance users, homelessness is associated with higher rates of HIV seroprevalence (Surratt and Inciardi, 2004; Smereck and Hockman, 1998). Among HIV-infected persons, those who are unstably housed (homeless or temporarily staying with friends or family) are less likely to receive adequate health care than those who are stably housed (Smith, et al., 2000).
Homeless people are at increased risk of viral hepatitis, primarily due to high rates of injection drug use. Infection with hepatitis C was found in 22% of homeless men in Los Angeles (Nyamathi, et al., 2002), 32% of individuals using a mobile medical van in New York City (Rosenblum, et al., 2001), and 27% of homeless persons in Oxford, England (Sherriff and Mayon-White, 2003). In a Veterans Affairs population, the prevalence of anti-hepatitis C virus antibody was 41.7% and the prevalence of hepatitis B surface antigen was 1.2% (Cheung, et al., 2002). Among street youth, the prevalence of these markers of infection was also high: 12.6% and 1.6%, respectively, in Montreal (Roy, et al., 1999; 2001) and 5.0% and 3.6%, respectively, in a northwestern U.S. city (Noell, et al., 2001b).
Sexually transmitted diseases (STDs) are a particularly serious problem among street youth. In a longitudinal study of homeless adolescents, the annual incidence of Chlamydia trachomatis infection was 12.1% in females and 7.4% in males; the annual incidence of herpes simplex virus type 2 was 25.4% in females and 11.7% in males. (Noell, et al., 2001) A study of street youth and sex workers in Quebec City, Canada found that 13% of women less than 20 years old were infected with Chlamydia trachomatis and 1.7% had Neisseria gonorrhoeae (Poulin, et al., 2001). Newer urine-based screening tests make it easier to screen homeless youth for STDs in outreach settings (Van Leeuwen, et al., 2002).
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