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PROBLEM: Major barriers to care included a lack of culturally competent, accessible care despite the proximity of numerous health service agencies serving homeless youth. METHODS: A qualitative approach using semistructured focus groups was used to assess the perspectives of 54 homeless and drug-using youth, aged 18-24 years, recruited from street- and shelter-based settings. FINDINGS: Substance use was perceived as an adaptive response to psychological pain and survival on the streets as well as a health risk and barrier to care. CONCLUSIONS: Facilitators to care and suggestions for improved health delivery and quality of care included utilization of health "mentors" to assist in navigating the medical system, cultural competency enhancements, improved amenities in clinic wait areas, and expanded pharmaceutical services.

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BACKGROUND: The efficacy of a nurse case-managed intervention was evaluated in subsamples of participants with one of the following characteristics: female gender, African American ethnicity, recruited from a homeless shelter, a history of military service, lifetime injection drug use, daily alcohol and drug use, poor physical health, and a history of poor mental health. OBJECTIVE: To determine whether a validated nurse case-managed intervention with incentives and tracking would improve adherence to latent tuberculosis infection treatment in subsamples of homeless persons with characteristics previously identified in the literature as predictive of nonadherence. METHODS: A prospective 2-group site-randomized design was conducted with 520 homeless adults residing in 12 homeless shelters and residential recovery sites in the Skid Row region of Los Angeles from 1998 to 2003. RESULTS: Daily drug users, participants with a history of injection drug use, daily alcohol users, and persons who were not of African American race or ethnicity had particularly poor completion rates, even in the nurse case-managed intervention program (48%, 55%, 54%, and 50%, respectively). However, the intervention achieved a 91% completion rate for homeless shelter residents and significantly improved latent tuberculosis infection treatment adherence in 9 of 12 subgroups tested (odds ratios = 2.51-10.41), including daily alcohol and drug users, when potential confounders were controlled using logistic regression analysis. DISCUSSION: Nurse case management with incentives appears to be a good foundation for increasing adherence to 6-month isoniazid treatment in a variety of homeless subgroups and, in particular, for sheltered homeless populations. However, additional social-structural and environmental strategies are needed to address those at greatest risk of nonadherence.

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In the United States, homeless youth are becoming increasingly entrenched in problem substance use, including high prevalence of alcohol abuse and injection use. A total of 54 substance-using homeless youth (18-25 years) participated in focus groups in order to provide their perspectives on barriers to and facilitators of seeking treatment. Participants were recruited from shelters in Hollywood, CA, and from a street-based, drop-in site in Santa Monica, CA. Participants identified personal barriers to treatment, but reported that facilitators of treatment tended to be more systematic. Homeless youth used and abused substances to dim the psychological effects of living on the streets. They appreciated programs that facilitated treatment and rehabilitation such as mentoring, support groups, and alternative choices to substance use. Implications point to the need for further development and research on culturally-appropriate, age-sensitive programs for homeless youth. The experiences of these youth underscore the need for strategic interventions.

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In this study of factors related to Hepatitis C virus (HCV) infection in 104 homeless HCV-infected men and 94 uninfected homeless men, findings reveal that homeless men with HCV infection are older and more likely to be cocaine injectors than those not infected. Moreover, the sharing of needles, use of injected cocaine during the past 6 months, previous incarceration, veteran status, fair or poor health, and having multiple tattoos are also associated with HCV infection. Reports of having completed the HBV vaccination series, weekly marijuana use, and snorting cocaine or methamphetamine are negatively associated with HCV infection. Among men not reporting lifetime injection drug use, factors such as sharing toothbrushes, having multiple tattoos, being in fair or poor health, and past incarceration are associated with HCV infection. These findings may need to be considered when making screening decisions and counseling homeless male patients about HCV.

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OBJECTIVES: Homeless youth are at a high risk of substance abuse, mental illness and blood-borne infections, such as hepatitis C. In this paper, we review the implications of these conditions, discuss the unique challenges faced by homeless youth, and explore potential strategies for harm reduction and intervention in this vulnerable population. RESULTS: Interventions that combine youth-centered, service-based care, street outreach, case management, and motivational interviewing with integrated health services such as hepatitis A/B vaccination, and mental health and substance abuse programmes, are presented as innovative approaches to address the healthcare needs of homeless youth. CONCLUSION: Recommendations for age-appropriate interventions and further research are made.

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The purpose of this study was to examine predictors of screening results for depressive symptoms in a Los Angeles homeless population with latent tuberculosis (TB). Four hundred and fifteen homeless adults participating in a nurse case managed intervention were included in this analysis. Logistic regression results indicated that those who reported a physical health limitation, multiple sex partners, daily drug use, alcohol dependence, or not having completed high school, were more likely to screen positive. Social support from non-drug users was protective. Given the importance of adherence to TB treatment regimens, the high prevalence of a positive screening for depressive symptoms in the homeless and the potential for depression to reduce adherence rates, routine screening and treatment for depression in high risk homeless adults being treated for TB may be warranted.

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