"HIV is actually not the problem. It's a symptom," said Michelle Kohler, RN, of St. Luke's Hospital in Bethlehem, Pennsylvania, who attended the recent Association of Nurses in AIDS Care conference in Portland, Oregon. One of these underlying problems is lack of stable housing, as various studies have shown. In San Francisco, for example, new HIV diagnoses have declined, but 20% of last year's diagnoses were among people who do not live in regular accommodations, Adam Leonard, M.P.H., NP, AAHIVS, of the San Francisco Department of Public Health, reported at the conference. Viral suppression rates in the city are 81% overall and 51% among homeless people. Between 2005 and 2019, the number of homeless people there rose 30%.
But not everyone without housing needs intensive support services, Elizabeth "Lizzy" Lynch, M.S.N., RN, of the University of California, San Francisco, explained. She developed an HIV Acuity Scale to help assess individuals' required level of support. The scale runs from 0 -- someone who can manage their HIV medications and appointments on their own -- to 3, where someone needs intensive support, possibly also for comorbidities including mental health or substance use issues.
Most of San Francisco's programs to address HIV among homeless or unstably housed people are run out of Ward 86, the largest HIV clinic in the city. It provides services for those at levels 0 to 2, Lynch said, with much of the outreach and care coordination performed by nurses. The oldest program, PHAST (Positive Health Access to Services and Treatment), began in 2002. It focuses on various barriers to care engagement and provides same-day treatment start, care coordination, expedited clinic intake, appointment reminders, and follow-up.
Project OPT-IN (outreach, prevention, treatment integration) is a U.S. Centers for Disease Control and Prevention–funded four-year demonstration project geared toward homeless people. Beyond additional outreach and partnerships with local HIV organizations, it will also serve as a data-gathering tool, the Bay Area Reporter explained at the start of the project in 2018.
Positive Health Onsite Program for Unstably Housed Populations (POP-UP) is the newest program. It is currently accepting new patients, according to Elizabeth Imbert, M.D., M.P.H., the program’s medical director. The program provides level 2 services, which include daily drop-in hours, snacks and other incentives, as well as referral to HIV-related housing programs. Clients come from urgent care or drop-in clinics, as well as jail health.
The city's street medicine program includes clinics embedded in homeless shelters and a mobile unit that visits homeless encampments, explained Hazel Demonteverde, RN, a nurse with the program. It is focused on harm reduction and includes mobile assessments to start people with substance use disorders on buprenorphine.
Of the 9,784 homeless people counted in San Francisco in January 2019, 393 were youth. By contrast, the only shelter for young people in Houston, Texas, serves more than 7,000 people a year, Diane Santa Maria, Dr.P.H., of the University of Texas, explained. Some of them come from the juvenile justice system, others are dropped off by their foster parents when they age out of care. Her program's study of 1,400 18-to-25-year-old homeless people in "non-coastal areas" found that 27% had been raped within the past year and 84% met eligibility criteria for pre-exposure prophylaxis (PrEP).
Study participants and a youth advisory group helped design a sexual health pilot program for homeless youth. It includes a smartphone app that allows users to track goals, such as more consistent condom use. Progress toward these goals is reviewed in biweekly meetings with a nurse. The phones themselves were loaned to study participants and could be used as regular smartphones. Contrary to expectations, all phones have been returned, noted Santa Maria.
Such "expectations" and other stigma faced by people without stable housing lead many to distrust medical and government systems. Thus, multiple touchpoints are needed to build trust in the programs described above, presenters noted. Another crucial component is cooperation with other organizations that interact with unhoused people. "It takes decades of relationship-building" to establish such ties, Lynch said. The Houston program partners with religious organizations, such as Covenant House and the Salvation Army, because these are the largest shelter providers, Santa Maria explained.
Local conditions matter, too, Paul Kawata of NMAC said in the closing plenary at the conference. San Francisco has more billionaires per capita than any other city in the world, he noted. Some of this money is donated to charitable endeavors. Models developed under such conditions may not be applicable elsewhere, particularly in states like Texas that did not expand Medicaid.
Nonetheless, programs can learn from each other's experiences. Including those affected in program design also helps to mitigate differences and adjust services to local conditions.
[CORRECTION 1/14: In an earlier version of this article, a source incorrectly stated that the POP-UP program is at capacity. The POP-UP clinic is not at capacity and is actively enrolling new patients at this time, according to Elizabeth Imbert, M.D., M.P.H., the clinic's medical director. We have corrected the error.]