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Interventions that provide personal motivational messages in response to real-time thoughts, feelings, sexual urges, and substance use may be more effective than interventions that are homogeneous and primarily informational in nature. One method to reach and engage YEH in interventions is to utilize mobile technology. In a group-based study with YEH, there were positive intervention effects on alcohol use, motivation, and condom self-efficacy even though 52% of participants did not attend all intervention sessions. Importantly, when programs are tailored and relevant, YEH are interested in health promotion programs, can be recruited and retained in interventions and research studies, and demonstrate improved outcomes despite challenges with sustaining intervention engagement. Using real-time, personalized HIV prevention messages may provide more timely information and produce more motivation for behavioral change than those seen in prior interventions. To date, HIV prevention interventions for YEH have not specifically addressed modifiable real-time factors such as stress, sexual urge, or substance use, or been delivered at the time of heightened risk. Finally, in one study using ecological momentary assessments (EMAs), the odds of having sex on a given day were found to be highest on days when YEH experienced sexual urge and used drugs, and the odds of substance use were highest on the days when youth experienced high stress and drug urge.
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Substance use is also associated with condomless sex and sexual victimization among homeless and urban youth. For example, experiencing sexual urges has been found to influence YEH’s decision to engage in condomless sex.
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In a systematic review of sexual behaviors among YEH, most studies did not examine how situational variables affect sexual risk despite the mounting evidence of the significant correlations between elevated stress, sexual urge, and substance use with HIV risk behaviors in female youth and YEH. Engagement in risk behaviors may be heightened by low motivation for HIV prevention related to time spent on the streets and exacerbated by high levels of trauma experienced prior to and while homeless. Young adults engage in HIV risk behaviors. Finally, a history of traumatic stress and current substance use are associated with more frequent sexual urges among MSM. Stress has also been correlated with inconsistent condom use number of sexual partners and substance use in young females, African American adolescent females, urban Black heterosexual men, and young men who have sex with men (MSM). HIV risk behaviors such as condomless sex and substance use are also correlated with factors such as stress and depression. Stress, sexual urge, and substance use negatively impact sexual decision-making and increase HIV risk. Further, modifiable factors have been found to predict HIV risk in nonhomeless youth populations. HIV risk among all youth is correlated with sexual orientation, childhood abuse, and histories of foster/juvenile justice involvement. While HIV prevalence data for YEH are sparse, one study found a self-reported HIV diagnoses rate of 4%. This is particularly salient as people experiencing homelessness have higher rates of HIV than those who are stably housed. The implications of mental health needs, substance use problems, and issues unique to YEH such as the lack of stable sheltering options need to be considered with regard to HIV prevention. Unstable housing is a significant barrier to accessing and engaging in HIV care, maintaining viral suppression, and reducing HIV transmission. The mortality rate for youth experiencing homelessness (YEH) is 5 to 10 times higher than peers in the general population, and many YEH have chronic mental and physical conditions, engage in substance use, and have unmet health and mental health care needs. Securing food and shelter while experiencing the hardships and dangers of living on the streets creates enormous challenges to maintaining one’s health and well-being. Young adult homelessness continues to be a major public health problem with 1 in 10 young adults aged 18 to 25 years experiencing homelessness over the course of a year and an estimated 1.7 to 2.5 million youth under 25 years experiencing homelessness each year in the United States.