Understanding Homeless Men's Condom Use with Women: An Event-Based Approach
The purpose of this study is to investigate homeless men’s condom use with their female sex partners. Heterosexual contact accounts for approximately 80% of new HIV infections among women and one-third of annual new HIV diagnoses. Homeless individuals have higher rates of HIV/AIDS than stably housed persons. We used an event-based approach to understand condom use: Context surrounding sexual events is especially important for homeless men, since they cope with circumstances not typically conducive to healthy intimate relationships. Existing literature and our formative research guided this study. A key research question is to understand the importance of contextual variables relative to attitudes that are targeted in prevailing social cognitive theories of HIV risk and prevention.
Participants were 305 homeless men (72% African American; mean age of 46) selected through stratified random sampling and interviewed in the 50 square block area of Los Angeles known as Skid Row, home to the highest concentration of homeless persons in L.A. Men were eligible if they were at least 18, had vaginal or anal intercourse with a woman in the past 6 months, and met the study definition of homelessness. We assessed attitudes (e.g. condom use self-efficacy, attitudes toward condoms), relationship characteristics (e.g. partner type, length of relationship), and context surrounding the last sexual event (e.g. setting/location, alcohol or drug involvement, discussion of condom use). We used logistic regression to determine whether a condom was properly used at the last sexual event involving vaginal or anal intercourse with a woman.
Half of the men reported condom use at the last sexual event. In terms of context, 47% of events occurred in a residence, 34% in a motel, and 18% in a public setting. Half involved alcohol use and 26% involved hard drug use. Half of the events occurred with primary (“steady”) partners. Discussion about condoms preceded sex in 31% of events. In logistic regression analysis adjusting for demographic characteristics, men holding more negative attitudes about condoms (OR=0.53, 95% CI =0.35, 0.81) and whose last sexual event was with a primary partner (OR=0.42, 95% CI=0.22, 0.82) had significantly lower odds of condom use. Men with higher condom use self-efficacy (OR=3.24, 95% CI=1.82, 5.76) and who discussed condoms with their partners prior to sex (OR=3.37, 95% CI=1.67, 6.80) had significantly higher odds of condom use.
Conclusion and Implications:
Negative condom attitudes and poor self-efficacy in using condoms have been highlighted as among the most important barriers in the larger literature on heterosexual condom use and risk prevention among more advantaged samples. Their relevance to homeless men, despite the complexity and challenges surrounding this population, is an important finding and suggests that it may be promising to adapt an existing, evidence-based prevention program based in social cognitive theory for delivery in non-traditional settings frequented by men who are homeless. Tailored interventions for HIV sexual risk reduction may reduce a significant point of disparity for the largely African American population of homeless men.