Adherence Strategies

Homeless HIV program uses creativity, myriad of approaches to improve adherence

Program even has staff at race track

HIV clinicians and researchers routinely note that one of the most difficult populations with which to achieve HIV antiretroviral adherence is the homeless.

Often, HIV-infected people who are homeless are coping with extreme psycho-social problems, including substance abuse, exposure to violence, joblessness, poverty, and mental illness.

Despite these issues and the inherent transient nature of a homeless population, the Boston Health Care for the Homeless Program in Boston, MA, has an HIV program that has succeeded in helping many patients stay on their medications and maintain undetectable viral loads.

In a recent outcomes analysis, the program found that 54 percent of the HIV-infected homeless people who worked with the program staff had undetectable viral loads six months after they were admitted into the program, says Carole Hohl, PA-C, MHS, director of HIV services.

"Fifty-four percent actually is not bad," Hohl notes. "It's in the same ballpark as other populations that have been studied, so we're pleased with that and will look at what's happened with those who didn't succeed."

The program provides a multidisciplinary team approach to care, including case management, dental, and ophthalmological services at locations that are convenient to the area's homeless population, including medical care clinics at Boston homeless shelters, says Peggi Marini, ACRN, HIV chair manager.

"Our team is accessible to our patients all day, every day," Marini says. "It has made a huge difference for our population."

There also are clinics at Massachusetts General Hospital in Boston and at a local horse racing track, Hohl says.

"People are really surprised at this, but most of the workers at the race track are homeless and live in track rooms," Hohl says. "Most don't have insurance, including Medicaid, so we run the clinic out there two days a week."

The track has hundreds of workers, and when the HIV team is there they typically see 10-15 patients per day, Hohl adds.

In addition, when homeless patients become too sick or unstable to reliably seek care and take their medications, the program has a respite facility with 90 beds and a 24/7 nursing care staff, Hohl says.

Funded by Medicaid, the facility provides homeless patients with a much-needed break from the shelters and streets, and the patients can be seen by a physician and physician's assistant, as well as the nurses, Hohl explains.

"If someone is very ill, and we're not sure they can handle taking meds on their own in the shelter system or in the streets or if we're concerned about the side effects, then we put them in the respite facility and follow them there after they've started on their meds," Marini says.

From years of working with HIV-infected homeless people, the program's staff have learned to slowly develop relationships and trust with their clients, Marini says.

"We invite them to come to our clinic, and we have an open door policy and very few barriers to their coming into the clinic," Marini says. "A nurse case manager is available every day from Monday to Friday, 8:30 a.m. to 5 p.m.."

Also, the program's staff visit homeless shelters and meet with clients wherever they are located, she says.

A client's drug or alcohol problem does not mean he or she will be prevented from receiving medications, but it does result in the case manager incorporating those challenges into a treatment plan, Marini explains.

"We prefer clients to be clean and sober in treatment, but that's not always the case," Marini notes. "We frequently use harm reduction, which has been very successful with a lot of our clients."

To build up antiretroviral adherence, the staff assist homeless patients with taking prophylactic drugs, as well as using pill boxes, having nurses hand out their pills daily, and some directly observed therapy (DOT), Marini says.

The medical staff at the homeless shelter is taught the importance of antiretroviral drug adherence and are directed to notify the program when clients don't come in for their medication, she adds.

Most of the adherence strategies boil down to developing trust, Hohl says.

"We've done alarms and reminders and we call people—a lot of homeless people have cell phones, but going out to where they are probably is the key to getting them into care," Hohl says.

"We also help people have access to a phone service where they can receive messages," Marini says. "We can call and remind them of clinic visits."

A street team visits homeless people who may not frequent shelters and convinces them to be tested or to receive treatment if they have already been tested positive for the virus, Hohl says.

"Most of the time the people living on the street aren't ready for intense treatment, but we see them regularly to let them know the option is available for them," Hohl adds.

Since homeless people often are lost in health care systems, the program staff also visit local hospitals to meet new homeless clients and to assist them with access to primary care and HIV care, Hohl says.

The program's approach to initiating antiretroviral therapy is to take it on a case-by-case basis, looking at each person's issues with substance use, mental health status, and commitment, Marini says.

"Their commitment could be their understanding of the importance of medications and what their lab values mean," Marini says. "They could be committed to showing up for their appointments."

A client may not be able to remain clean and sober, but if he or she is able to cut the drug or alcohol abuse in half then that's seen as a commitment, she says.

"It's really individualized, and we don't demand that our patient always be clean and sober," Marini notes. "We look at a lot of different things."

Other examples of commitment might include these, she says:

  • Does the client come in for appointments?
  • What is their understanding of the disease?
  • Are they willing to reduce the amount of alcohol they're drinking?
  • Do they show a willingness to take prophylactic medications?
  • Do they see the nurse on a consistent basis?

When patients are put on antiretroviral therapy, they receive support, including psychotherapy and access to support groups, Marini says.

The staff often go to creative lengths to assist their clients.

For example, one nurse will meet with a client every morning for breakfast, which is when the client takes antiretroviral medications, Marini says.

In another instance, there was a homeless client who was drinking and had a very low CD4 cell count and a very high viral load, Marini recalls.

"We started him on prophylactic medication and had him come into the clinic on a weekly basis, and the nurse met with him at shelters at night," Marini says. "Eventually she gained his trust, and now he drinks about half of what he was drinking."

All of this means accepting the clients where they are at and not making the program structured in such a strict way that clients cannot qualify when they show small improvements, Marini says.

"The man now has been on medications successfully for about 10 months and he has an undetectable viral load," Marini adds. "His CD4 cell count is still very low, but his percentage has gone up, and his health is good."

The man even has received extensive dental work, and he is interested in finding permanent housing, so it works to meet him at his level, accepting that he is a drinker, Marini says.

"We hear from many clients that in previous experiences they were not offered medications because they weren't clean or sober," Marini says.