Condom Use during Survival Sex Among LGBTQ+ Young Adults Experiencing Homelessness: A Seven-City Study

Background and Purpose: Over 40% of young adults experiencing homelessness (YAEH) identify as LGBTQ+. Compared to their heterosexual and cisgender peers, LGBTQ+ YAEH face multilayered discrimination and limited access to resources and support. These adverse experiences place LGBTQ+ YAEH at greater risk of survival sex involvement to meet their subsistence needs. Involvement in survival sex may partly explain why the HIV prevalence rate among LGBTQ+ YAEH is twice as high as that of their non-LGBTQ+ homeless peers. Condom use during survival sex may be critical for reducing HIV risks among LGBTQ+ YAEH. However, the literature on this topic is scarce. Therefore, this study aims to explore correlates of consistent condom use during survival sex among LGBTQ+ YAEH with the goal of informing future HIV risk reduction interventions targeting this vulnerable population.

Methods: This study utilized a subset of a cross-sectional dataset involving a purposive sample of YAEH from seven major cities in the US. Respondent completed a self-administered computer-assisted anonymous survey that covered individual characteristics (e.g., survival sex involvement) and egocentric social network properties. Only YAEH who identified as LGBTQ+ and had engaged in survival sex (N=142) were included in the current study. The dichotomous outcome was condom use during the last survival sex engagement. Independent variables included mental health history, substance use behaviors, HIV testing, and social support ties (e.g., number of supportive homeless peers within a respondent’s network). To address the purpose of this study, logistic regression analyses were conducted.

Results: Approximately 62% of respondents used a condom in their last survival sex. The mean age of respondents was 21.3 years old (SD=2.0). Racial minorities (74%) were well represented in the study. Compared to White LGBTQ+ YAEH, both Black (OR = 5.25, 95% CI [1.40, 19.75]) and Latinx YAEH (OR = 12.40, 95% CI [2.01, 76.65]) had significantly higher odds of condom use during survival sex, with all other variables taken into consideration. Positive diagnosis of any mental health conditions was adversely associated with odds of condom use during survival sex (OR = 0.17, 95% CI [0.04, 0.72]), as was having a greater number of supportive street peers in one's social network (OR = 0.61, 95% CI [0.42, 0.87]).

Conclusion and Implications: Among LGBTQ+ YAEH engaged in survival sex, condom use was uncommon. Such a finding highlights the imperative needs of safe sex or PrEP adherence promotion intervention targeting this population. The significantly lower odds of condom use during survival sex among White LGBTQ+ YAEH and those with a mental health diagnosis suggest that HIV prevention efforts should prioritize these subgroups through culturally responsive and mental health responsive interventions. Additionally, the negative association between number of street peer who provided social support within the networks and condom use emphasizes the complex role that social networks may play in shaping sexual risk behaviors among LGBTQ+ YAEH engaged in survival sex. Future network interventions targeting LGBTQ+ YAEH involving in survival sex should be aware that supportive social ties may not always be protective, as sources of social support matter.