Dr. Elise Riley: The Health of Homeless Women

reprinted from Issue 21, Fall 2015 of Frontiers of Medicine (PDF)

Elise Riley, PhD, and her colleagues investigate the health of homeless, HIV+ women in the Tenderloin, one of the poorest neighborhoods in San Francisco.

"If someone doesn’t have a place to sleep, they’re also at risk for other consequences of poverty like malnutrition, violence and infections," said UCSF epidemiologist Elise D. Riley, PhD, MPH. "Sometimes risks play off each other, creating what researchers call 'syndemics’ – it’s when different epidemics overlap and make each other worse."

Much of Riley’s research focuses on homeless women with HIV, a population she got to know in graduate school when interviewing incarcerated women. "Their stories gave me insight into the many ways our social fabric can fall apart or spiral out of control, and how challenging it can be to get out of those situations," she said. "I wanted to find ways that health care and social service systems could not only help vulnerable people pick up the pieces, but preemptively intervene and more effectively deliver care to avert future health emergencies."

She points out that health does not start in hospitals or clinics. "Health starts at home and in communities, so that’s where my colleagues and I go to do our studies," said Riley, who leads investigations in the Tenderloin, one of the poorest neighborhoods in San Francisco. "We conduct 'community- based research’ to include people both in and outside of the health care system. It allows us a better understanding of how multiple risks converge to influence the health of people with limited resources and options."

Riley and her colleagues focus on how social and structural factors, unmet needs, other health problems and changing life situations influence health and the use of health services. "Hospitals, particularly emergency departments, are sometimes the last stop on a path that includes a multitude of risks and ends in poor health," she said. "What if we could keep people healthy so they would not end up needing urgent care so often? As a nation we’re having more dialogue than ever before around consistent access to quality health care for all Americans. This is an exciting time for transformation! My colleagues and I are contributing to this positive change by including the perspective of vulnerable people who have extra challenges and who have not often been included in traditional clinical research."

Key findings of recent studies include:

First things first:

Riley found that a lack of food and shelter had stronger negative influences on physical and mental health among HIV+ homeless adults than other social stressors, and even clinical factors like problems with medication adherence. "Having these basic needs met is really important before people are able to engage with the health care system and medication adherence," said Riley. "Working in the San Francisco General Hospital HIV/ AIDS Division, I have a huge appreciation for 'team care’ that includes providers, case managers and social workers as integral members of our health care teams, who take things like housing into consideration as they evaluate each patient’s overall situation."


In another study, 60 percent of homeless women reported physical, sexual or emotional abuse within the last six months. "We expected to see violence, but the degree to which it was reported was off the charts," said Riley. Unlike the general population, homeless women were much more likely to be abused by someone who was not a primary partner. Another unexpected finding was how social isolation appeared to reduce the risk of experiencing violence, which is the opposite of the findings in many studies conducted in the general population. "If you have social networks that are violent or unhealthy and you can’t afford to get out of the community, social isolation is a form of self-protection," said Riley. "Housing is important, but safe housing is critical for homeless and unstably housed women."

Heart health:

In a 2013 JAMA Internal Medicine report, Riley’s team described mortality rates among homeless women that were ten times higher than in the general population. Although half of their study participants were HIV+, most deaths were caused by drug overdoses rather than conditions related to HIV. "Traditionally, a lot of drug research has not included many women, but to create effective services we need to understand their situations conditions, risks, behaviors, and how they all come together to influence homeless women’s health," said Riley.

Her unexpected findings about this population’s high mortality rate and causes of death led to a new National Institutes of Health-funded study investigating how medications and substances (both legal and illegal) impact cardiac health in homeless women. Along with her research team, which includes cardiologists, toxicologists, HIV physicians, statisticians and behavioral researchers, Riley looks forward to advancing this line of health research. "UCSF is a special place because it values researchers and clinicians who are focused on health disparities and caring for at-risk populations," said Riley. "I get to work with great colleagues in a strong environment, and I’m lucky to be here."

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