It’s not a secret that unstable housing, hard drug use, and mental health challenges can make it difficult for a person with HIV to manage their condition, even if they’ve been linked to care. A study published in the Aug. 1 edition of Journal of Acquired Immune Deficiency Syndromes (JAIDS) found that not only linkage to care, but holistic care for any or all of these three life issues, can significantly reduce the viral load for people living with HIV.
The study, led by Michael Li, Ph.D., M.P.H., a researcher at the UCLA Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, evaluated the effectiveness of Los Angeles County’s Medical Care Coordination (MCC) program in managing viral load for its participants. MCC was launched in 2013 to provide holistic care to more than 6,400 people living with HIV who also face challenges staying in care and achieving viral suppression. Specific challenges Li and colleagues studied were housing insecurity (or homelessness), stimulant use (meth or cocaine), and depression.
Analyzing data from 35 clinics participating in the program from Jan. 1, 2013, to Sept. 31, 2017, Li and his team assessed factors associated with viral suppression (defined as <200 copies/mL) from one year before enrollment through three years after enrollment. They found that linking people with help for these struggles paid off: the percentage of people virally suppressed increased from 35% to 77% within the first six months after enrollment, and that level was maintained for up to 36 months. The benchmarks for evaluation were the proportion of individuals who experience viral load suppression and how rapidly newly enrolled individuals become virally suppressed.
The MCC program is tailored to individual participants, Li said. Some require housing assistance, some need substance abuse treatment, and there are of course overlaps in these needs. The study, which was funded by the National Institutes of Health, showed that slightly lower percentages of people with housing instability or stimulant use were able to achieve viral suppression by 36 months, but a significant proportion of them did improve, a result that came as a pleasant surprise to Li.
“The magnitude of improvement was bigger than I thought, and I was pleased that at six months, all groups improved,” Li said. He added that the program has a “soft graduation” out of the program when people stabilize, but contact doesn’t completely end.
Studies have shown that people living with HIV/AIDS are at a higher risk of homelessness than the general population, and it’s been speculated that up to half of people with HIV/AIDS nationwide are at risk of homelessness due to unaffordable housing costs and the high cost of medical care. Managing HIV/AIDS is difficult for people who are homeless or housing insecure: Accessing health care and adhering to regimens—just protecting meds and other belongings—is a challenge while living on the streets or in shelters.
Homelessness in Los Angeles has been a growing problem for years. The city’s annual homeless count, released last month, showed more than 66,000 people living on the streets, in shelters, and in vehicles within the county, an increase of more than 12% from 2019. Within the city of LA, the homeless count was more than 41,000, a 14% increase over last year. The region also has a significant and growing meth crisis fueled partly by a rise in “chemsex” among gay men, according to public officials. It’s too soon to show how the COVID-19 pandemic will affect drug use, homelessness, and depression over the long term, but it’s hard to imagine how it could be helpful.
Li said his study suggests that Los Angeles and other cities need to build capacity for housing and meth addiction, and that Los Angeles County’s MCC, which was funded by Ryan White HIV/AIDS Program (RWHAP) dollars and managed by the county, could be a model for other cities.
One major city already has a similar program: New York. The HIV Care Coordination program managed by New York City’s health department and also supported by RWHAP contracts with 25 hospitals, community clinics, and community-based organizations citywide to provide intensive medical case management services to those most in need of assistance with initiating HIV care and treatment, remaining engaged in care and treatment, and achieving and sustaining viral load suppression.
Several internal studies have demonstrated that New York City’s program achieved strong positive effects on key HIV care continuum outcomes, including retention in HIV care, re-engagement in HIV care, and viral load suppression. An independent study also showed benefits, though more modest rates of suppression, for those in the program.
Mary Irvine, Dr.P.H., at the New York City health department’s Bureau of HIV/AIDS Prevention and Control, author of the internal study, said the program has been improved recently and is now able, through telehealth and other methods, to reach to more people most likely to benefit.
In an email, Irvine said the HIV Care Coordination program “relies on care coordinators and patient navigators who operate as full members of the medical care team, and requires the active participation of patient enrollees, primary care providers, care coordinators, and patient navigators, among others. Given the resources required, those considering replicating the program should prioritize enrolling patients who are not virally suppressed and who require the most support.
“Rigorous comparison-group analyses have shown particular benefits of the program among individuals who have been previously out of HIV care or virally unsuppressed during the prior year,” Irvine said. “Our combined findings from early analyses comparing the same clients before and after enrollment and surveillance-based comparison-group analyses highlight the value of this program, particularly for individuals with recognized, substantial barriers to establishing and maintaining engagement in HIV care and treatment.”
Irvine added that, based on pilot findings, key components of New York City’s HIV Care Coordination program could be successfully used in other cities. The Centers for Disease Control and Prevention (CDC)–funded STEPS to Care project piloted in New York City and three other U.S. cities, and then finalized a toolkit of supports for HIV Care Coordination program planning, training, and implementation, including a patient-facing self-management website and a website for jurisdictions or agencies contemplating adoption of such a program.
Li said he plans to conduct follow-up research on LA’s MCC, looking at how telehealth and the COVID health crisis are affecting the program’s ability to stabilize participants’ viral loads, as well as a deeper dive on how processes and referrals “move the needle” on housing insecurity, stimulant abuse, and depression.