• July 24, 2008, Ziagen (abacavir sulfate): The U.S. Food and Drug Administration (FDA) has notified the maker of abacavir and abacavir-containing medications of the need to add information to the current BOXED WARNING about the recommendation to test all patients for the HLA-B*5701 allele before starting or restarting therapy with abacavir or abacavir-containing medications.

• Basic education about HIV Learning about HIV and how to control it can help homeless patients regain a sense of control over their lives and provide an impetus for change and incentive to work on other issues (e.g., begin drug treatment, reunite with family). Begin at the first visit and provide ongoing education, support and reinforcement at each subsequent visit. Provide answers to basic questions about HIV: What is the virus? What is it doing to your body? Why do you need medication? Educate patients about the natural course of the disease. Provide printed information in language they can understand.

  Teach homeless patients how to know if they are sick, how to tell if the illness is more serious than a cold, how to care for themselves when sick, and when to seek urgent or emergent care. Educate them about warning signs of HIV complications (fevers, coughs that won’t go away, exhaustion) and what you can do to help alleviate these symptoms. Tell patients where they can go to get medicine and where they can go to recuperate when ill. Explain that the more advanced their disease is, the more preventive medications will be required to keep them from getting sicker.

• HIV transmission Explain that the HIV virus can be passed through intravenous drug use (IVDU), sexually, perinatally, and via breast milk from an HIV-positive mother to her baby. Stress the need for protection, even after beginning HIV treatment, in sexual relationships (condoms and other contraception, abstinence) and with self-administered injections (cessation of any sharing of drug paraphernalia, participation in a needle exchange program).

  Counsel HIV-infected pregnant women about how to reduce the risk of transmitting HIV infection to their babies. Stress the importance of antiretroviral prophylaxis to reduce perinatal transmission of infection. Breastfeeding is not recommended for HIV-positive mothers if there is a safe alternative (i.e., if infant formula is available, if there is access to clean water to prepare formula milk and cleanse bottles and nipples, if refrigeration is available to store prepared formula, and if the mother can manage formula feeding with appropriate hygiene) (Heymann & Vo, 1999; CDC & National Center for HIV, STD and TB Prevention, 2001) (refer to footnote #7 in the original guideline).

• Prevention Discuss ways to reduce HIV risks for the patient and others. To effect behavioral change, use individual, small group, and community interventions based on careful investigation of actual patient behaviors and an intimate understanding of their daily life—how they spend their time, what activities interest them, and potential structural barriers to desired change. Use motivational interviewing (refer to footnote #8 in the original guideline document), risk reduction techniques, and social skills training. Know what is really happening in the patient’s life; then try to figure out how you can help behavioral change occur within that context (Health Care for the Homeless [HCH] Clinicians’ Network, 2000).

  Teach safer practices to injection drug users unwilling or unable to stop using drugs (e.g., abscess reduction, use of tourniquets). Provide general sexual/reproductive health education and counsel the patient about safer sex practices (contraceptive use for pregnancy prevention and STI protection, fewer sex partners or abstinence). Reinforce this information with interactive activities that involve repetition, positive feedback, and acting out new skills, such as proper condom use (Susser, 1998) and role playing (how to talk to a partner). All members of the clinical team should participate in patient education. At every visit, provide male/female condoms or information about where the patient can obtain them.

• Addiction management Try to find out how patients with chemical dependencies use psychoactive substances—whether they engage in erratic substance use ("binging") or are regular users. People who binge have more problems with treatment adherence than do regular users; they forget to take their medications while binging and often forego food and sleep, which also interferes with disease prevention and health promotion. Some people with chemical dependencies are already experienced at organizing their time to accommodate regular drug use and avoid withdrawal symptoms.

  Work with these patients to identify strategies already employed to manage illicit drug or alcohol use and apply them to HIV treatment adherence, substituting HIV medications for other drugs. For patients with demonstrated regularity in their daily routine who are unable or unwilling to stop drug/alcohol use, consider advising that HIV medications be taken prior to other drugs, if no adverse drug interactions are likely. Recognize that many homeless people use alcohol or drugs to cope with underlying emotional problems. Facilitate access to appropriate behavioral health care to promote recovery and readiness for HIV treatment.

• HIV therapy Inquire about the patient’s understanding of HIV therapy. Some patients refuse treatment because they don’t understand it, have lost hope, and don’t think treatment will matter. Emphasize the positive; assure HIV-infected homeless patients that they are candidates for treatment and can manage it successfully. Highly-active antiretroviral therapy (HAART) can be as effective for highly motivated persons who are homeless as for those who are housed, as confirmed by comparative measurement of viral loads following treatment (refer to footnote #9 in the original guideline document). Explain what CD4 counts and viral loads are, and how these measurements are used to help determine how advanced the patient’s disease is, predict risk of complications, and monitor treatment adherence.
• Written instructions/reminders Write down instructions about when to take medications each day. Use graphic illustrations and color coding to clarify and reinforce verbal instructions. Then make sure that instructions are understood. Ask the patient, "What medications are you going to take this morning and how?" Instruct the patient to "keep written instructions with you." If a patient discloses that s/he has trouble reading, designate someone on the clinical team who can spend extra time to help him/her understand instructions, and offer referral to a literacy program or instruction in English as a second language. Specify any dietary restrictions associated with antiretroviral therapy or other treatment (i.e., whether medications must be taken with food or on an empty stomach). It is sometimes possible to enlist the help of shelter staff in reminding patients to take medications.
• Drug resistance Explain the risk of developing resistance to HIV medications if they are not taken consistently or appropriately. Acknowledge that for all persons taking antiretrovirals, as for persons receiving treatment for TB, development and spread of drug-resistant infection is a serious concern; but stress that lack of treatment is no more acceptable an alternative for HIV than it is for TB.
• Treatment advocates Use social workers, nurses, or case managers as treatment advocates, serving as liaisons between the patient and providers to promote successful adherence to HIV therapy. The patient may feel more comfortable discussing side effects of treatment with social workers or other advocates who have more time to explain than medical providers. Treatment advocates should be part of an integrated clinical team and treated as peers by medical providers. Consider using consumer advocates (formerly homeless persons) to accompany homeless HIV patients to appointments with specialists and attend clinic sessions with the patient and primary caregivers. This can help homeless patients overcome communication barriers sometimes experienced in encounters with mainstream health care providers.

  Use of consumer advocates to explain information conveyed by the medical provider to other consumers is often helpful, but must be done with sensitivity to patient privacy and confidentiality and in compliance with requirements of the Health Insurance Portability and Accountability Act (HIPAA). (For information about HIPAA privacy requirements, see www.hhs.gov/ocr/hipaa/whatsnew.html.)

• Directly observed therapy Good results have been reported with directly observed therapy (DOT) when homeless patients come to the clinic once daily to take medications (Mitty et al., 2003). DOT is recommended for patients with co-occurring tuberculosis, substance use disorders, and/or mental illness, but can present staffing and transportation challenges when patients must take psychiatric medications 2 to 3 times per day. Provide transportation or carfare to assure feasibility of this treatment option. Some communities are exploring the possibility of directly observed HIV therapy at methadone clinics. Although some patients may benefit from an adherence program that provides medication storage and directly observed therapy, others are quite capable of managing medications on their own. Homelessness has enabled them to develop a fairly rigid routine. (Some schizophrenic clients can adhere well to treatment regimens and other routines.)
• Side effects management Recognize that medication side effects are a primary reason for lack of adherence to HAART. Be candid about possible side effects of antiretroviral treatment, such as diarrhea, and how long they will last, so the patient knows what to expect and can identify and better describe side effects that do occur. Explain that nausea may result if medications are taken without food. Provide snacks (e.g., peanut butter crackers, individual boxes of cereal with Parmalat milk, individual containers of juice, granola bars, high energy bars) to help the patient avoid this side effect and promote adherence to treatment. Ask what side effects the patient has noticed; if there is no medical alternative with fewer/less severe side effects, explore strategies to minimize and/or accommodate them within the patient’s lifestyle.
• Urgent medical problems Help patients understand the difference between common medication side effects (e.g., diarrhea from nelfinavir) and symptoms of life-threatening toxicities (such as nevirapine or abacavir hypersensitivity, pancreatitis, hepatitis, or lactic acidosis). Patients need to know what side effects to expect with HAART that may be mild and go away over time, so they don’t stop their medications; but they also need to know how to recognize a potentially fatal drug reaction, so they will seek medical care early. Other medical emergencies include late stage opportunistic infections such as Pneumocystis carinii pneumonia (PCP), toxoplasmosis, and cryptococcal meningitis — major complications of HIV that are usually lethal if not treated. Stress the need for prompt evaluation if the following symptoms occur: fever, new rash, difficulty breathing, abdominal or back pain, vomiting, headache, or vision changes.
• Supportive relationships Reluctance to inform others about their illness results in lack of supportive feedback for individuals with HIV. Encourage a supportive relationship with a social worker, provider, or friend — someone in whom the patient can confide fears, questions and concerns, including problems with medication side effects. Advise the patient, "If your doctor doesn’t have time to listen and discuss your concerns, find someone who does." Link the patient with a support person or "sponsor" through HIV/substance abuse treatment programs or other community-based programs. Network with law schools to provide pro bono legal assistance with child custody, drug arrest, or immigration issues as part of substance use treatment programs.
• Support groups For patients who experience extreme stigmatization or isolation, create a support group where they can share concerns and learn how others are coping with their disease. Members of ethnic/sexual minorities and migrant workers may experience more marginalization and isolation than other homeless individuals with HIV. Help such patients find each other for mutual support. Offer social support groups, not just groups for therapy or counseling. Help patients moving into transitional housing learn how to live successfully in a community setting (e.g., respect personal boundaries).
• Nutrition counseling Educate patients about nutritional health, diet, and dietary supplements. If possible, include a nutritionist familiar with the issues of homelessness on the interdisciplinary health team to do screening and frequent consultation. Some practitioners recommend the use of bioelectrical impedance analysis (BIA), which measures body composition (fat and lean body mass), to educate patients about their nutritional status and promote early detection and management of HIV-associated nutritional changes (Swanson & Keithley, 1998). Prescribe multivitamins with minerals. Assure that pregnant patients receive appropriate vitamin supplements (with folate). Consider prescribing nutritional supplements with less familiar brand names and lower resale value to reduce risk of theft.
• Medical home Many homeless people have never had a regular medical provider and only receive medical care episodically from hospital emergency room staff. Discuss benefits of forming relationships with care providers who can help the patient avoid becoming acutely ill. Explain what primary care is and how to use a regular source of care ("medical home"). Present regular primary care as an opportunity to be in charge of one’s own health. Many medical problems, including those related to HIV, are preventable.
• Education of service providers Educate medical providers about the special needs of homeless patients. Explain how treatment adherence and successful outcomes are possible even for homeless individuals with mental health/substance use problems. Stress the importance of developing a nonjudgmental, therapeutic relationship based on unconditional acceptance of the patient and harm reduction. Understand your own feelings about substance use, sex work, and mental illness. Take time in a safe setting to explore your feelings about people who are homeless. Talk about your experience, biases, and stereotypes with other providers who are more experienced in caring for homeless patients.

  Help specialists understand that homeless people may not be able to follow the treatment plan they prescribe, and how to modify the plan of care so homeless patients can better adhere. Educate primary care providers about chronic pain management and addiction medicine. Educate all homeless service providers about HIV, including prevention measures and the need for nonjudgmental, compassionate care. Provide basic education about the natural history of the disease, what to expect if the patient is or is not treated, transmissibility of infection, and universal precautions. Help pastors learn how to talk about HIV with members of their faith community. Work with food services at shelters and soup kitchens to provide appropriate meals.

Medications

• Medical priorities If acute retroviral syndrome is not suspected or if early HIV treatment is not warranted for other reasons, deal with other medical priorities first (e.g., psychotropics for severe mental illness, methadone for heroin addiction, prophylaxis for opportunistic infections and tuberculosis [if +PPD], treatment and management of uncontrolled hypertension, diabetes, and seizures), any of which can undermine a patient’s ability to adhere to HIV treatment. With all HIV-infected patients, weigh benefits against potential risks of early antiretroviral treatment.
• Prophylaxis Start prophylaxis for opportunistic infections as soon as indicated by standard clinical guidelines ("2001 USPHS/IDSA guidelines for the prevention of opportunistic infections," 2001). Explain the importance of OI prophylaxis at each visit, if the patient is not initially interested or willing to accept preventive treatment. Minimally, antiretroviral prophylaxis to reduce perinatal transmission of infection should include antenatal azidothymidine [AZT] therapy and intrapartum intravenous AZT therapy for the mother, and 6 weeks of AZT for the infant. Use of antenatal HAART is recommended if the maternal antenatal HIV RNA level is >1,000 copies/ml and treatment adherence is likely.
• Immunizations Given their high risk for exposure to respiratory infections in congregate living situations, all homeless patients should receive influenzae vaccine annually and be immunized against pneumococcus according to standard clinical guidelines. Also provide hepatitis B and A vaccines and update tetanus (Td) if the last immunization was more than 10 years ago. (See Quick Reference Vaccines Chart at: http://www.cdc.gov/vaccines/vpd-vac/vaccines-list.htm.) Lacking reliable food and shelter, most homeless people welcome immunizations as a way to prevent illness.
• HIV treatment readiness Never rush to antiretroviral treatment; build a therapeutic relationship first. Encourage more frequent visits to prepare homeless/formerly homeless patients for treatment. Evaluate patient readiness for treatment and ability to adhere to a plan of care by first attempting to understand the patient’s current behavior in light of his/her life story. Elicit this information in a nonjudgmental way; understand the patient’s lifestyle and how basic needs are met. If the patient desires treatment, look for evidence of a daily routine to discover how to prescribe medications that can fit into that routine. (A patient who must leave the shelter at 5:00 a.m. may not be able to take medications at that time.)

  Ask what the patient does after leaving the shelter (e.g., go to a drop-in center or the library? Have breakfast?) Ask if there is a "private time" when the patient can take medications. Privacy is frequently an issue for homeless individuals, who worry about taking medications that have street value or that reveal their diagnosis. (If others discover they have HIV, some may refuse to sit near them or talk to them, and they may be at increased risk for abuse.) Ask the patient, "Who can help you take your medicines and keep track of them?" Outreach provides a unique opportunity to observe patients in their own environment and assess stability, evidence of regularity, and capacity to follow a schedule (sleep pattern, access to food/water/clock, daily activities, regular appointments with parole officer/methadone program, etc.), in order to assess their potential for treatment adherence. For best outcomes, engage patients and assure that they have a comfortable medical home before beginning treatment. Address issues that may complicate treatment adherence. The patient should be part of the team that helps to decide when to begin treatment.

• "Practice" medications For a patient desiring HIV therapy whose ability to adhere to treatment is questionable, consider using placebos or vitamins as "practice medications" for a week or two. Put medications of the same size and number to be prescribed for HIV in a pillbox; follow up in a week. Ask the patient how many pills were taken, how many missed. This may convince the patient that s/he is not yet ready for HIV therapy (e.g., needs to work on substance abuse issues first). Realize that some patients may not take practice medications seriously, possibly confirming their lack of readiness for HAART.
• Antiretroviral medications Be knowledgeable about HIV treatment alternatives and when to use them (refer to footnote #10 in the original guideline). Although treatment may be provided at the initial visit if medically warranted or if refilling a prescription, most providers recommend waiting 3–6 months before beginning HAART. Working on prophylaxis, immunizations, and obtaining housing and access to other health and social services before initiating HIV therapy can strengthen the therapeutic relationship, help the provider decide on the best medical regimen, and result in more successful treatment. Individualize initiation of HIV therapy and continually re-assess treatment adherence and effectiveness. Ensure access to medications that can be taken once or twice daily.
• HIV specialist HIV is a primary care disease that requires special knowledge to treat. Partner with an HIV specialist (a certified clinician who follows at least 26 to 50 HIV patients every six months and pursues continuing education) in prescribing treatment through consultation or referral. The team approach to care for homeless individuals is optimal; an HIV specialist, primary care provider, case manager, nutritionist, mental health professional, and outreach worker should all be part of the team. A primary care provider serving a community with a fairly high incidence/prevalence of HIV should develop HIV treatment skills. The critical mass of patients with HIV is key: if fewer than 5, refer; if 5 to 10 or more, develop expertise in primary HIV care. Consult with an infectious disease specialist and other specialists in planning medications for patients with comorbidities. Consultation is a two-way street; specialists may consult primary care providers with expertise in serving homeless patients.
• Simple regimen The simplest treatment, tailored to individual needs, is best for all HIV patients. Pill count, frequency, and dosing are extremely important for homeless patients; once-a-day dosing will increase adherence. For some patients, it will help to dispense medications a day or a week at a time, recognizing that this is feasible only if transportation to and from the clinic is available and affordable for the patient. (If possible, provide transportation or carfare for homeless patients.) If giving trimethoprim/sulfamethoxazole (TMP/SMX) for PCP prophylaxis, one dose per day is best and probably easiest for most homeless patients, but 2 to 3 times per week is acceptable; it’s better to take some of the medication than none. The opposite is true for antiretrovirals: it’s better not to take medications at all than to take them only some of the time. Overcome the common perception that HAART medications are too complicated. Don’t undertreat HIV or opportunistic infections just because a patient is homeless.

  Once-a-day therapy is preferable for homeless patients if clinically indicated, especially for those who may be unable to adhere to a more complex regimen. Antiretrovirals that can be taken once a day include: nucleosides – lamivudine (Epivir® or 3TC), didanosine (ddI or Videx®), tenofivir (Viread®), stavudine (D4T or Zerit®); non-nucleosides – nevirapine (Viramune®) and efavirenz (Sustiva®). A protease inhibitor that can be taken once daily is expected to be available soon. Trizivir (combination of AZT, 3TC, and abacavir in one pill, taken twice daily) offers a low pill burden that is easy to tolerate. However, recent data suggest that Trizivir alone does not completely suppress the virus, so it must be taken either with a non-nucleoside reverse transcriptase inhibitor (NNRTI) such as efavirenz or with a protease inhibitor (refer to footnote #11 in the original guideline).

• Dietary restrictions Awareness of the patient’s access to regular meals is important because some HIV medications must be taken with food. Other medications must be taken on an empty stomach. If possible, prescribe medications without dietary restrictions.
• Side effects Prescribe medications with fewer/less severe gastrointestinal (GI) and other side effects. (Some NNRTIs and protease inhibitors have fewer gastrointestinal side effects.) The severity of side effects experienced by the patient may not be apparent to the provider. Diarrhea creates an added burden for a homeless person with limited access to toilets and bathing facilities. Address the likelihood of diarrhea with certain protease inhibitors (e.g., nelfinavir) and provide anti-diarrhea medication for patients with symptoms. Nausea, which often results from taking medications on an empty stomach, may also be incapacitating; providing nutritious snacks can prevent this side effect. Be more aggressive with homeless patients in treating side effects or changing medication, if an equally effective alternative is available.
• Drug toxicities Be aware of serious toxicities that can occur with HAART (refer to footnote #12 in the original guideline). Abacavir hypersensitivity reaction (rash, fever) occurs in a small number of patients taking this medication (Ziagen® or as part of Trizivir [3TC, AZT, and abvacavir]). In a few cases, Nevirapine (NVP) has been associated with hepatic necrosis or a severe skin reaction called Stevens Johnson Syndrome. Pancreatitis, lactic acidosis, and severe anemia are other medical emergencies that can be caused by antiretroviral medications.
• Drug interactions/contraindications Chronic illness may complicate HIV treatment because of the potential for drug-drug interactions. Awareness of drug interactions is important when prescribing HIV medications. Some medications may be contraindicated if the patient has history of pancreatitis or alcoholism, or should be used with caution and more frequent monitoring with co-occurring mental illness, hepatitis C, high cholesterol, or diabetes. Some HIV medications and HIV itself may cause metabolic changes, which can include diabetes, hyperlipidemia, changes in body fat distribution, osteoporosis, and lactic acidosis. HAART can also exacerbate pre-existing diabetes. All persons on antiretrovirals for HIV should be carefully monitored for the development of glucose intolerance and diabetes, as well as for lipid abnormalities and lipodystrophy, and treated according to accepted guidelines and standards of care.
  • Efavirenz (Sustiva®) can be a good choice for homeless patients because it is one pill once a day. However, it does have neuropsychiatric effects. Efavirenz causes sedation, which can be dangerous for street dwellers, and can exacerbate underlying mental illness. If already treating a patient with a severe psychiatric disorder, monitor him/her closely or avoid using this drug, which in some areas has a high "street value" because of these effects (induces a "dream-like state"). Because of the potential for birth defects, pregnancy should be avoided in women receiving efavirenz; counseling women about this is important. For women of childbearing age for whom this drug is clinically preferable, prescribe double contraceptives (a barrier method in addition to an oral or injected contraceptive) to prevent pregnancy. It is recommended that efavirenz not be given to pregnant women except when there are no therapeutic alternatives (AIDSinfo Drugs Database, National Institutes of Health: http://aidsinfo.nih.gov). Before initiating therapy with efavirenz, women of childbearing potential should undergo pregnancy testing. If a woman receiving efavirenz should become pregnant and the pregnancy is recognized during the first trimester, efavirenz should be discontinued (nevirapine could be substituted), at least for the first 12 to 14 weeks of pregnancy.
  • Methadone Recognize that alcohol and drug use is common among homeless people, and prescribe medications that are compatible with substances used. Evaluate use of methadone by patients on HAART. Be aware that NNRTIs (e.g., nevirapine and efavirenz) and certain protease inhibitors (particularly ritonavir) can reduce the efficacy of methadone by as much as 50%. Avoid these medications, if possible, in any patient with opioid dependence; consider using a ritonavir-boosted protease inhibitor instead (Mitty et al., 2003). If this is not feasible for a patient on methadone, it is essential to work directly with the patient’s methadone maintenance treatment program to adjust the dosage upward. (Many practitioners begin with a 20% increase in methadone dosage when HAART is initiated). Recognize that successful adherence to methadone therapy for persons addicted to heroin can increase adherence to HAART (Clarke et al., 2003). Some patients won’t begin HIV treatment or may stop taking medications because of the misconception that all prescription drugs are incompatible with alcohol or other drug use. Most antiretrovirals are chemically compatible with commonly used street drugs, although use of psychoactive substances, including prescribed psychotropics, can interfere with remembering to take medications. Address these issues candidly with the patient to promote adherence.
• Drug resistance Be cautious about prescribing HAART for homeless adolescents and youth because of their higher risk for drug resistance if unable to adhere to treatment. Many are in denial and fail at the first treatment attempt. Recognize that drug resistance can be conveyed to others via blood, semen, or sexual contact; the higher the viral load, the more likely infection will spread in any given contact. Although antiretrovirals decrease infectivity (an argument for treatment despite the risk of instability), they are never 100% effective, even if the patient is adherent. Resistance is not always indicative of nonadherence; mutation of the organism can occur even if the patient adheres to treatment.

  Homeless individuals should have the same access to HIV medications as others. If the patient requests HIV therapy, is willing to begin treatment, and is medically appropriate for treatment, select an initial regimen to which the patient can adhere, preferring medications with a low pill burden where possible. Consider avoiding NNRTIs and 3TC in patients suspected to have trouble with adherence. (Resistance to NNRTI drugs can be induced by a single mutation, and there is crossresistance. Therefore, poor adherence to a NNRTI regimen may easily induce resistance to the whole NNRTI drug class. 3TC resistance can also result from a single mutation.)

• HIV treatment and substance use An automatic assumption that people with substance use disorders cannot adhere to HIV treatment is inappropriate. The primary challenge is determining when to initiate therapy. Patients can learn how to organize their lives so they can keep appointments and take medications while actively using psychoactive substances. Indicators of readiness include keeping regularly scheduled appointments with medical and ancillary staff. If patients desire HIV therapy and there is evidence that patients can adhere to a regular schedule despite substance use, consider advising them to take HIV medications before using other drugs.

  If appointments are missed, seek patients out and explore in a nonjudgmental manner what has changed in their lives to motivate a change in behavior (common triggers of relapse: contact with/rejection by a family member, anniversary of a painful event). Look for indications of new stresses and difficulty coping; help patients find ways to cope. Most important, maintain communication with them. Many actively using, chronically homeless people have successful treatment outcomes. Knowing that medications can prolong life can give patients hope and motivate lifestyle changes to promote health. Successful HIV treatment is not only possible but extremely desirable for homeless people with chemical dependencies.

• Pain relief Recognize that HIV and hepatitis C can be painful diseases, and that other common comorbidities in homeless patients, including traumatic injuries, can result in chronic pain. It is important to remember that some HIV medications can decrease or increase the efficacy of pain medications, including methadone and other narcotics. Work with the patient to understand the underlying cause of pain, prescribe appropriate pain medication, and document why you prescribe it. Understand chronic pain management; if you don’t, the patient may seek relief from practitioners known to provide pain medications indiscriminately, without understanding HIV care or monitoring for possible misuse. If necessary, refer to a pain management specialist and maintain open communications with the patient and other providers. To avoid overmedicating or contributing to drug-seeking behavior, inform and encourage cooperation from the patient with a contract that specifies the plan of care and designates a single provider for pain prescription refills.
• Adherence monitoring To facilitate adherence, use a harm reduction approach, outreach, intensive case management, directly observed therapy, and medication monitoring. Provide incentives (e.g., carfare, meal vouchers), and don’t require clients to be drug and alcohol free to receive them. Outreach and assertive case management will contribute to successful outcomes for active substance users. Address obstacles to taking medications appropriately. Ask the patient, "Who can help you take your medicine and keep track of it?" Some patients will benefit from treatment and a reduced risk of transmission even if viral loads are not entirely suppressed. Monitor adherence by measuring CD4 counts and viral load every 3 months; if the patient’s viral load increases and the CD4 count decreases, find out why and address the reasons. (Reduced treatment adherence is often triggered by depression or a relapse in recovery). Explore barriers to adherence and problem solve with the patient.
  • Pill packs Consider providing "blister packs" for all medications, labeled for each day of the week, each meal per day. Some pharmacies provide pre-packaged pill boxes with handles or "easy packs" — a cellophane roll with perforated sections that enable patients to tear off morning and evening doses and carry them in a pocket or bag. This helps patients with memory loss keep track of their medications and makes resale more difficult. Some people prefer using their own system to remember what pills to take when.
  • Pagers Some pharmacies provide patients with pagers that vibrate when it’s time to take medications and allow caregivers to page them with a toll-free number. This can be a helpful aid to promote treatment adherence and clinical follow-up.
• Medication storage Allow homeless patients to store HAART medications at the clinic and come there daily for treatment. This protects against having medications stolen or confiscated by police if arrested for public nuisance offenses and assures that they are taken as prescribed. If medications are not stored in the clinic and the patient does not have access to refrigeration, avoid prescribing medications that require it. Shelter residents may be required to turn in all medications to shelter staff, who sometimes lose/misplace them or fail to return medications to the patient when needed. Lack of privacy/confidentiality is a major problem for shelter residents, who may be reluctant to complain to shelter staff for fear of disclosing their diagnosis and too embarrassed to tell the provider if medications are lost repeatedly. Educate shelter staff about the importance of making stored medications easily available to patients; explain that medications are costly and necessary for the patients’ health.
• Financial barriers The availability of free or low-cost HIV medications may be limited, particularly in smaller communities and rural areas. For homeless patients, even a small co-payment can be excessive, and for those without health insurance or access to programs that provide free medications, the cost of antiretroviral therapy may be prohibitive. Before initiating treatment, assure continuous access to medications.
• Pharmacy access In some cities, homeless patients are restricted to use of one clinic or pharmacy, to prevent misuse of medications. Lack of transportation to this or other pharmacies can present barriers to getting prescriptions filled. Since homeless people do not have regular access to telephones, coordinating delivery of medications to these patients can be difficult. Provide transportation to pick up medications or arrange for delivery of medications to a location where the patient can obtain them reliably and wants to receive them (e.g., a friend’s home, social work center, or clinic). Delivery of medications to a clinic for pick up and distribution can provide another opportunity for hands-on education about treatment adherence.

Associated Problems, Complications

• Medication side effects Side effects are a primary reason for nonadherence to antiretroviral treatment. Medications that interfere with survival on the streets, making people feel sicker or more fatigued, will not be acceptable. Common side effects of HAART include diarrhea (particularly from some protease inhibitors), nausea (if taken on an empty stomach), peripheral neuropathy (numbness/tingling in extremities, exacerbated by poor nutrition and constant walking), and nightmares. Living in a shelter or on the streets is especially difficult for patients with these symptoms, which are exacerbated by chronic sleep deprivation and depression. If alternative medications with fewer negative side effects are not medically indicated, treat side effects symptomatically. Some clinicians recommend the medical use of marijuana to help control pain and nausea and reduce alcohol or other drug use. Some medications (e.g., TMP/SMX [Bactrim], commonly prescribed for PCP prophylaxis) increase sensitivity to sun exposure; homeless patients who spend most of their time outdoors should be advised to wear long sleeves and sunscreen to avoid sunburn. Be more aggressive with homeless patients in treating side effects or changing medication, if an equally effective alternative is available.
• Severe drug toxicities Some HIV-infected patients receiving antiretroviral therapy experience symptoms of life-threatening toxicity, which would be fatal if the drugs associated with the reactions were continued. Abacavir hypersensitivity reaction, hepatic necrosis, Stevens Johnson Syndrome, pancreatitis, and lactic acidosis are among the drug reactions that should be considered medical emergencies. (For a comprehensive summary of severe drug toxicities associated with particular antiretroviral drugs, see: www.who.int/docstore/hiv/scaling/anex11b.htm.)
• Masked symptoms Lactic acidosis may be harder to diagnose in a homeless patient because symptoms (abdominal pain, shortness of breath) may be present for other reasons (e.g., diabetes, chronic obstructive pulmonary disease [COPD]).
• More acute illness Because homeless people with HIV may not seek care until their disease is advanced and symptomatic, they often present with more acute illness. Even in areas with free access to exceptional HIV care, new patients with advanced AIDS are not unusual, and many of them are homeless. Patients with advanced disease require complicated treatment regimens. Opportunistic infections and diseases unrelated to HIV may increase the severity of illness. Major complications of HIV include late-stage opportunistic infections such as Pneumocystis carinii pneumonia (PCP), invasive candidal infection, toxoplasmosis, and cryptococcal meningitis, and CMV retinitis (which can lead to blindness if untreated). Provide respite care facilities where homeless patients can convalesce when ill or following hospitalization. A medical respite facility may be the only place a homeless patient can get end-of-life care. Develop close linkages with inpatient service providers and facilities.
• Mental illness/substance use Mental illness, substance use, and HIV are frequently linked. A large proportion of mentally ill homeless people use psychoactive substances that result in loss of inhibition, which can result in unsafe behaviors that increase their risk of exposure to HIV, tuberculosis, and hepatitis. Mental illness (both Axis I and Axis II disorders) and drug-induced psychosis can interfere with treatment adherence. Optimally, co-occurring mental illness and substance abuse should be treated simultaneously within the same program. Underlying mental illness is often the issue that keeps homeless patients out of care; or if in care, may be their most pronounced disorder. Involve a psychiatrist who is interested in the co-occurrence of these disorders with HIV in the assessment and management of homeless patients. A key issue is pharmacodynamics (the cumulative side effects of polypharmacy). In practice, overlapping side effects are more problematic than drug interactions. Some mental health problems can be treated by a primary care provider. Refer more complicated cases to a dedicated mental health program while maintaining good coordination of mental health and primary care.
• Cognitive impairment If patients have difficulty remembering appointments, don’t automatically assume nonadherence; question their cognition. Cognitive impairment may be associated with mental illness, chronic substance abuse, AIDS-related dementia, and/or opportunistic infections. Accurate diagnosis may require specialty evaluation.
• Tuberculosis The association between TB, HIV infection, and homelessness is well document (McElroy et al., 2003; Moss et al., 2000; Zolopa et al., 1994; "Prevention and control of tuberculosis," 1992). Homeless shelters are among the most likely sites of TB transmission, and growing numbers of HIV-infected persons have contributed to the resurgence of tuberculosis in the United States. HIV coinfection increases the risk of progression from latent TB infection to active tuberculosis. Recommended control measures include more frequently screening of HIV-infected homeless persons for TB infection, initiation of isoniazid prophylaxis in any HIV-infected person with a positive tuberculin skin test, and directly observed TB/HIV therapy to promote treatment adherence and reduce the risk of drug resistant organisms (Moss et al., 2000).
• Hepatitis Some homeless persons (especially injection drug users) are at increased risk for hepatitis. Hepatitis C (HCV), hepatitis B (HBV), and HIV are chronic, potentially fatal diseases that can be symbiotic. In patients with co-occurring HIV, treatment of HCV/HBV is important. "Although all antiretroviral drugs are associated with hepatotoxicity,...antiretroviral therapy should generally not be avoided, and specific agents should not be avoided in patients with HBV/HCV co-infection. Nevertheless, these patients should have careful monitoring of liver enzymes during therapy" (Bartlett & Gallant, 2001-2002). Always consult a specialist experienced in the treatment of hepatitis when planning HIV care for patients with HCV or HBV coinfection. A psychiatric consult is recommended prior to initiating HCV treatment, which may have depression as a side effect. For patients with co-occurring alcoholism, behavioral contracts and/or other treatment/rehabilitation strategies should be used concurrently with HCV treatment to promote sobriety and reduce the risk of liver damage.

  Two antiretroviral agents, lamivudine (3TC) and tenofovir, are active against HBV. When initiating HAART in an HBV-infected person, one of these drugs should be considered as part of the regimen. However, lamivudine or tenofovir should only be used as part of a fully suppressive antiretroviral regimen in an HIV-infected person. In general, treatment of these patients requires careful follow-up and consultation with a specialist, as they may be more likely to develop drug related liver complications. Ensure that all patients are immunized against HBV (especially injection drug users) and hepatitis A (HAV), if seronegative. Recognize that the cost of HBV/HAV vaccines and HCV/HBV treatment may be prohibitive for uninsured patients.

• Abuse Homeless individuals with HIV may be at risk for various kinds of abuse from other homeless people and shelter staff who find out they are infected. A significant number of these patients also have a history of physical or sexual abuse that may have precipitated homelessness. Work with all service providers in clinics and shelters to protect homeless patients from physical assault and verbal abuse.
• Pregnancy HIV-positive pregnant women should receive HAART for themselves and to prevent transmission of infection to the fetus. Many are highly motivated to protect their baby, but women with other children may not agree to treatment that includes residential care. (Family-based treatment centers that permit substance-using mothers to bring one or more children to live with them in a therapeutic residential drug treatment community are disappearing for lack of funding.) Develop good consulting relationships with obstetricians (including academic departments of obstetrics) to help pregnant homeless patients with HIV. Be knowledgeable about national guidelines for the treatment of HIV-infected pregnant women (perinatal guidelines: http://aidsinfo.nih.gov/).
• Lack of transportation Many poor and homeless people cannot access health services because they lack transportation for trips to and from appointments. This can present serious barriers to HIV testing and care. Become familiar with transportation resources in your community. All state Medicaid programs are required to provide non-emergency medical transportation (NEMT) to approved health services. Each state is responsible for designing and operating its own NEMT, and programs differ from state to state. (For a list of Medicaid transportation contacts in each state, see: http://www.ctaa.org/ntrc/medical/contacts.asp.)
• Lack of stable housing HIV treatment is extremely difficult for individuals without stable housing. Meeting needs for food and shelter leaves little time for medical appointments. Lack of privacy, risk of abuse, theft of medications with street value, and no place to lie down during the day compound discomforts associated with HIV and HAART. Homeless persons need a stable residence and routine in order to begin the process of recovery. In many communities, housing is simply not available for homeless persons with HIV. Conversely, in some places, the only way for homeless adults unaccompanied by children to get housing is if they are HIV positive. Sometimes the partner of an HIV-positive person who is HIV-negative or untested desperately tries to get infected in order to qualify for housing and other benefits. Individuals with HIV may sleep outside to be with a partner, at risk to their own health.

  Despite some availability of transitional housing for HIV-infected individuals in larger metropolitan areas, insufficient housing stock, long waiting lists, and policies that exclude active substance users or ex-inmates limit access for homeless people in many communities. Most housing, rehabilitation, or transitional programs available to homeless persons with HIV infection require sobriety for admission or continued residence. Unfortunately, such supports become attainable only when homeless individuals with co-occurring addiction disorders become too ill to support a habit, often at a time far advanced in the course of HIV infection (O’Connell & Lebow, 1992).

  The federal Fair Housing Act prevents discrimination based on health history, including mental illness and addiction. Nevertheless, some local communities and permanent housing programs continue to use "housing readiness" as a subjective measure of appropriateness for housing. Strongly advocate for "low demand" housing models in your community that serve people coming directly from the streets or shelters, without clean and sober requirements or other standards for housing readiness.

• Barriers to health insurance/disability assistance Efforts to deliver quality health care are hampered by barriers to obtaining public benefits, including health insurance and disability assistance.
  • Insufficient documentation Entitlement programs in many states and localities require extensive documentation, including photo identification, birth certificates, Social Security cards, pay stubs, etc., to verify eligibility. Proof of identity, residence, and income is difficult to come by for someone without a home, a car, or continuous employment. Obtaining required documentation is often costly, time-consuming, and intimidating. Homeless people may have trouble obtaining transportation to various agencies where required documents are available, cannot get there during working hours without losing their jobs, or are unable to pay fees required for copies. Even if they are able to get required documentation, homeless individuals may have no safe place to keep it. Personal papers are often stolen or lost in moving from place to place on foot. Lack of required documentation to verify eligibility is the most frequently cited obstacle to Medicaid enrollment for eligible homeless people (Post, 2001).
  • Denied disability claims It is important to realize that most homeless people (particularly adults unaccompanied by children) do not qualify for Medicaid under current policy. Few state Medicaid programs cover nondisabled adults, and those that do may not cover needed services. For many homeless people, Supplemental Security Income (SSI) (Federal disability assistance) is the only door to Medicaid. SSI regulations still exclude persons with asymptomatic HIV or those with disabling addictions without evidence of underlying mental illness. Only Centers for Disease Control and Prevention’s (CDC’s) AIDS-defining diagnoses are considered sufficient evidence of permanent disability (O’Connell, 1997), despite the fact that many persons with chronic fatigue and other constitutional symptoms are too incapacitated to engage in gainful employment. There is evidence that homeless disability claimants have higher denial rates than other claimants. Insufficient medical evidence of functional disability (inadequate documentation by medical providers) and failure of homeless patients to show up at consultative evaluations partially explain this discrepancy (Post, 2001).

    Realize that in most states, except for pregnant women and children, Medicaid eligibility is linked to SSI for persons with disabling conditions including HIV/AIDS. Facilitate applications for disability assistance and SSI-related Medicaid. Keep detailed records of all functional impairments (refer to footnote #14 in the original guideline). Develop a working relationship with your local Social Security Administration Disability Services office. Secure a representative for homeless disability claimants. Ensure that consultative examinations are conducted by physicians with significant experience in treating homeless patients. Advocate for all patients to obtain needed health care, regardless of their insurance status.

• Stigmatization Strong stigmas against HIV and homelessness, particularly in smaller communities and rural areas, result in extreme marginalization of HIV-positive homeless individuals and reduced self-esteem, often exacerbating self-destructive behaviors (e.g., substance abuse, sex work). Sexual minorities and immigrants with limited English proficiency are especially vulnerable to stigmatization and low self-esteem. Fear of abuse and eviction from shelter motivates many HIV-infected homeless patients to conceal their diagnosis.
• Incarceration Many homeless people are frequently arrested or incarcerated for loitering, sleeping, urinating, or drinking in public places—activities that are permissible in the privacy of a home. A number of them contract HIV and hepatitis while in prison. Periods of detention or incarceration can also interrupt continuity of care for pre-existing conditions.
• Special populations:
  • Homeless women The overwhelming majority of homeless patients in most clinic settings are male, which can be intimidating for homeless women, many of whom have a history of physical/sexual abuse. Increasing heterosexual transmission of HIV associated with sexual abuse, sex work, and intravenous drug use warrants programs specifically targeted to homeless women, who can be harder to reach than men and may require more intensive services. Offer social support and counseling through a weekly women’s group. If high-risk sexual behavior is perceived as necessary to meet basic survival needs, try to engage the patient for services and find another way of meeting underlying needs. If high-risk behavior is used to obtain a drug on which the patient is dependent, continually offer detoxification/substance abuse treatment as an alternative.
  • Homeless youth Most homeless adolescents and youth (ages 14 to 24) have been abused or neglected. HIV infection, usually identified in 18 to 20 year olds (ages when most willing to be tested), is often seen as an asset by homeless youth because it may increase their access to services (substance abuse treatment and shelter). Adolescents and youth tend to be more recently infected than older adults, who are likely to be more acutely ill when identified. Younger patients have more time to address psychosocial problems; treatment is not as urgent. Homeless adolescents and youth are often developmentally less advanced than peers of the same chronological age; concrete thinking predominates over abstract reasoning skills, according to providers who are experienced with this population. When discussing behavioral change with these patients, focus on immediate concerns rather than possible future consequences.
  • Sexual minorities Homeless sexual minorities (gay, lesbian, bisexual, transgender [GLBT] persons) need special support to counteract extreme marginalization, victimization, and frequent exclusion from mainstream health care systems. A significant number of homeless adolescents and youth are sexual minorities who have been rejected by their families and communities. Victimization, psychopathology, use of addictive substances, and multiple sexual partners increase their risk for HIV infection (refer to footnote #15 in the original guideline document). Create a safe and nondiscriminatory clinical environment for all GLBT patients; build trust and rapport with these patients, and assure their access to comprehensive health care.

    Transgender adults and adolescents (male-to-females and female-to-males) comprise a significant proportion of the homeless population in some areas. Injection of hormones or other drugs with nonsterile needles and unprotected sex with infected partners place some of these individuals at especially high risk for HIV (refer to footnote #16 in the original guideline document). Among sexual minorities, persons with gender variance are least likely to receive appropriate medical care; many have been denied screening and treatment for life-threatening diseases such as cervical cancer and HIV infection. Give these patients the information they need to make informed choices. Educate patients using injected hormones about clean needle exchange, and explain gender-related health risks (e.g., a male taking estrogen may have increased risk for thromboembolic disease and cervical cancer; a female taking testosterone still requires screening for breast and cervical cancer, and runs the risk of hair loss and early cardiac disease). This information should be conveyed to promote informed choices, not to frighten or dissuade.

  • Immigrants Although homeless immigrants from certain areas may be at high risk for HIV (e.g., Africa) and tuberculosis (Mexico, the Philippines, and Southeast Asia), their access to prophylaxis and treatment may be limited. Undocumented immigrants may be reluctant to seek care for fear of being deported. Language and cultural barriers often compound financial barriers to health care. (For guidance in providing linguistically appropriate and culturally competent health services to homeless individuals, see Holzwarth, 2002). Recognize that some of these patients may qualify for Medicaid as refugees, and that many immigrants, undocumented or not, are explicitly barred from the Medicaid program by Federal law (Post, 2001).

Follow-Up

• Contact information At every visit, seek contact information (telephone/cell phone numbers and/or mailing/email addresses) for the patient, a family member or friend with a stable address, the shelter where the patient is currently staying or other location where s/he might be found, and the patient’s case manager and health care providers. A clinician should be available to the patient via beeper or other means 24 hours a day.
• More frequent follow-up Try to see homeless patients more frequently, especially early in the course of treatment. (Most HIV patients are told to return monthly; homeless patients should return within 1 to 2 weeks.) Follow-up intervals also depend on comorbidities. Contact the patient a few days after starting medications and schedule a return visit within a week. Review adherence; give the patient a pillbox, if desired. At the beginning of a therapeutic relationship, reinforce the patient’s understanding of the plan of care repeatedly. Ask if medications were missed and if so, why they were missed and what happened (e.g., stolen, forgot to take them while binging). Frequent contact encourages patient bonding and willingness to return to the clinic on a drop-in basis. Let homeless clients come back as frequently as is comfortable for them.
• Drop-in system Create a routine drop-in time at primary care clinics (e.g., every Tuesday afternoon) with no appointment required for new patients. Encourage routine follow-up for established patients, supplemented by an open-door policy for drop-ins. A drop-in system is far more effective than appointments for people who are disorganized or whose lives are chaotic.
• Help with appointments Help patients make and keep clinical appointments and routinely remind them of their appointments. Find out what their regular commitments are (e.g., when and where they receive wages or disability checks) and at what time(s) of day they can come to the clinic. Recognize that a homeless patient may be forced to miss a meal at a soup kitchen if the clinic appointment runs past serving hours.
• Incentives Give the patient "carefare" (carfare plus a meal voucher) for every kept appointment or group meeting attended. Escort each patient to the first clinic appointment; explain how to obtain carfare for the next visit, and take them to the cafeteria to demonstrate how to use the meal voucher. Provide a client advocate to accompany the patient to appointments for magnetic resonance imaging (MRI), colposcopy, or ambulatory surgery. Be the family member or friend most people call on if they have to do something frightening or unpleasant.
• Transportation Provide transportation to and from specialty referrals; arrange to pick up new patients and those unable to come to the primary care clinic on their own.
• Intensive case management Use a clinical team to support the patient and promote continuity of care, which is essential for good HIV care. Visit inpatients daily to reinforce engagement, facilitate discharge planning, and promote better follow-up (e.g., call the library, help patients get methadone/nicotine patches, talk with patients about where to go after they leave the hospital). Encourage discharge to a nursing/recuperative care facility, if available. Establish and maintain contact with other service providers who know your patient (make phone calls and have lunch from time to time). Ask the patient to sign a release, in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements, so that you can share health information with other clinicians and service providers when s/he leaves your care. Information sharing is important, particularly during transition from homelessness to transitional housing, to identify any variations in the patient’s behavior that may indicate a change in health status or problems with adherence. Be compassionate and caring.
• Peer support Start a "breakfast club" for patients having difficulty with HAART medications, to create positive peer support. Provide food and encourage members to take medications together. Include staff to work with clients on medical and social issues in a social setting. This helps patients to establish a regular wake-up time, begin the day with food and medications, share resources and coping strategies, and receive both medical and social support.

References open in a new window

U.S. Public Health Services (US PHS) guidance documents for the medical management of HIV infection and other issues surrounding HIV infection (http://aidsinfo.nih.gov/guidelines):

Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, February 2002.

Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, 2002.

The guideline has been distributed to 161 Health Care for the Homeless grantees across the United States. In addition, links to the document are posted on Web sites maintained by the National Health Care for the Homeless Council (www.nhchc.org) and the HIV/AIDS Bureau (HAB)/HRSA/HHS. HAB also sent a publication announcement to all grantees. Adapted clinical guidelines including this one are also being used in workshops at national and regional conferences (e.g., Housing and Homeless Institutes sponsored by the HIV/AIDS Bureau, and National Health Care for the Homeless Conferences sponsored by the Bureau of Primary Health Care/HRSA/HHS).

The recommendations in this guideline presuppose the following model of health care delivery to unstably housed individuals.

Model of Care

Service Delivery Design

• Flexible service system Access to care for initial evaluation or ongoing treatment depends on the existence of a flexible service system that homeless individuals can use on a walk-in basis or through outreach workers. "One-size-fits-all" systems of care are inadequate to meet the complex needs of homeless people. Help to identify and resolve system barriers that impede access to care, recognizing that some barriers are not within the patient’s capacity to control. Don’t focus on what the patient is not doing (e.g., on "noncompliance" with a plan of care); instead focus on what service providers can offer to enable homeless patients to obtain effective treatment, such as assuring service flexibility and providing appropriate medical assistance to anyone who walks into the clinic. Be creative; enlist the patient’s assistance, and with his/her permission, utilize everyone in the community with whom s/he has contact to facilitate delivery of care.
• Integrated, interdisciplinary model of care Successful initiation and maintenance of human immunodeficiency virus (HIV) therapy requires a holistic approach to care provided by an interdisciplinary clinical team, including case managers, social workers, medical providers, mental health professionals, and substance abuse counselors who share care planning and coordination. The patient is an essential member of this team. Optimally, medical and psychosocial services should be easily accessible at the same location; fragmented service systems do not work for homeless people. Those with multiple and complex health problems need integrated services that are accessible from multiple points of service, outreach and engagement, and stabilization in short- and long-term housing. Coordinate medical and psychosocial services across multiple disciplines and delivery systems, including the provision of food, housing, and transportation to service sites.
• Access to mainstream health system Ensure that all people with HIV infection have access to the mainstream health care system. HIV care involves multiple medical specialties, including infectious diseases, cardiology, hematology, nephrology, obstetrics/gynecology, psychiatry, neurology, dermatology, and pulmonary medicine. Full collaboration between primary care providers and specialists is the only effective treatment and management strategy. Network with community service providers who are sensitive to the needs of homeless patients to facilitate specialty referrals; assist with transportation and accompany patients to appointments. Problems that distinguish homeless HIV patients from others are primarily system and provider access problems, rather than client problems or differences in intent or desire to adhere to a plan of care. Treatment readiness is a function of the degree to which the mainstream health care system is accessible and welcoming to these patients.

Engagement

• Outreach Use outreach workers to locate hard-to-reach individuals and their contacts and encourage them to obtain medical care. View each patient contact as an opportunity for medical and psychosocial evaluation. Offer diagnostic testing and treatment at outreach sites whenever possible. Remember that unmet basic needs may prevent a person from seeking health care. Promote engagement by including nutritious snacks as part of outreach. Offer to bring patients to the grocery store or food bank, and use this as an opportunity to learn about their needs and do a psychosocial history. Homeless HIV-positive youth are often reluctant to seek care on their own. Use a "roving case manager" to help them connect with available health and social services. Work with religious leaders and faith communities ("health ministries") to encourage their participation in outreach activities. Maintain a consistent presence in places where homeless people congregate.
• Clinical team The team should include professionals and paraprofessionals with strong engagement skills who make themselves available to listen to patients and help them address obstacles to care. This is especially important for homeless people who experience extreme social isolation and may have no one else to listen to their concerns. A team member with strong engagement skills should see the patient first. Specifically address psychosocial barriers to health as well as medical issues, employing an intensive case management model.
• Therapeutic relationship Engagement involves building mutual trust with people who are alienated from traditional health care systems. Successful HIV care requires effective engagement skills to meet medical as well as psychosocial needs. Nonjudgmental and supportive patient interactions with all members of the clinical team are essential to successful engagement. Recognize that caring for homeless patients is as much about building relationships as about clinical expertise. Spend time getting to know your patients. Listen to their concerns and engage with their interests. Both the quality and frequency of encounters are important in building a therapeutic relationship with homeless people. Realize that seeing the same provider over time facilitates engagement. Take good care of professional staff to promote provider retention and continuity of patient care. Recognize that engagement of homeless patients often takes a long time. Small, brief conversations may be all a person can tolerate at first, but the length of an encounter will grow as the patient’s comfort level increases. Often clinicians presume that a person isn’t interested after they fail to get very far in one or two contacts. Be patient and persistent; listen well. Measure success in small increments.

U.S. Public Health Services (US PHS) guidance documents for the medical management of HIV infection and other issues surrounding HIV infection (http://aidsinfo.nih.gov/guidelines):

Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, February 2002.

Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, 2002.

Electronic copies: Available in Portable Document Format (PDF) from the National Health Care for the Homeless Council, Inc. Web site.

Print copies: Available from the National Health Care for the Homeless Council, Inc., P.O. Box 60427, Nashville, TN 37206-0427; Phone: (615) 226-2292

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