Homeless and unstably housed urban
poor, who have preconceived fears towards health care services, may
not seek care (55). However, homeless persons can receive effective
healthcare if it is delivered in context of their usual life
activities at a community-based level (56). By increasing
availability of free HIV testing at a “non-clinical” site in high
seroprevalence area will help clients on their own terms (57). A
facility in San Francisco implemented a successful program that
supported adherence among those who face the greatest barriers to
utilizing medical clinics and complying with a complicated HAART
medication regimen (58). Within five months of opening in 1999,
Action Point showed promising results: compared to a strikingly low
27% adherence rate (59), 62% of the initial 68 clients continued to
come in at least once a week. Among the 44 receiving therapy, 25 had
a viral load at least 2 months after enrollment. Only 2 of the 44
clients showed an increase in HIV relative to their levels prior to
enrollment (60).
This
program has had considerable success, perhaps because the facility
is housed on a block in the heart of high prevalence of drug-related
arrests and deaths among homeless people (61). Not only choosing
their location wisely, this community-based organization encourages
homeless to “hang out” during open hours as well, recognizing and
respecting the autonomy of the individual patient and in turn
fostering trust. Their philosophy maintains, “each client, rather
than the staff member, ultimately determines whether he or she will
begin and be able to maintain combination therapy” (62). The
emphasis on developing a collaborative doctor-patient relationship,
one that provides youth with feeling of mutual understanding and
acceptance, might encourage youth to discuss adherence with their
providers (63).
I plan to emulate a similar adherence centered
development program for youths in the preexisting Englewood STD
Specialty Clinic, implementing several significant changes within
the center that will hopefully encourage disclosure of HIV status
among homeless youth who and a system of trust within the clinic
community. Because this Chicago clinic already has established
financiers and foundations to support free testing as well as low
cost medical treatment (78), implementing adherence interventions
among trained professionals within the clinic is much more cost
effective than building an entire new shelter or clinic in the same
neighborhood. This clinic is near where many potential homeless
youth live, eliminating transportation as a potential barrier to
adherence (64) and making it easier for staff members to reach out
and establish initial contact with those in the neighborhood.
1.
To evade homeless youth’s tendency to avoid persons
of higher authority at first glance, I hope to implement youth-run
services within a drop-in clinic that offers free testing and
counseling (payment comes from third-party payers), provides client
medications, which are filled and delivered by a neighborhood
pharmacy (65/78), and grants access to social service referrals,
such as nearby homeless shelters or job locators, and adherence
education. Consistent with findings at the San Francisco Action
Point Clinic (66), I feel that the casual atmosphere diminishes an
intimidating, authoritative setting. Rather, it is a youth friendly
environment allowing youth to access a range of referral and
information services available.
2.
Include incentives to come and continue treatment at
drop-in center: Provide meals at center, which may attract youth
who do not have food available to them on a consistent schedule.
Additionally, like Action Point, an adherence support service, such
as a $10 cash incentive should be dispensed weekly to clients who
use services at least once a week (68). Additionally, alarm clocks
should be provided for each patient, which will have an alarm for
each designated time to take medication.
3.
A Youth Pride Center on the North Side of Chicago has
implemented fraternity and sorority like groups that hold weekly
meetings- promoting brother and sisterhood, discipline, respect, and
service (69). I feel similar youth run services should be
implemented on the south side communities of color and at high risk
of homelessness as well. These groups may initiate and encourage a
level of trust in which persons living with HIV may feel comfortable
enough disclosing their status with other peers, ultimately
eliminating the sense of loneliness and depression.
4.
One-on-one intervention with a primary care physician
must be implemented in order to ensure a bond and sense of trust- a
reason to adhere to medication regimen. These providers can fill a
familial figure if the patient has been rejected from family,
playing a key role in helping youth develop social skills that might
be lost without authoritative nurture or discipline (70). Physician
should explore both benefits and consequences of self-disclosure of
HIV status as well as initiate harm reduction, which positively
supports adherence despite active drug or alcohol addiction (71).
According to related studies, role-plays surrounding disclosure with
peers and family members, could be beneficial to adolescents rather
than just simply information intervention programs (72).
5.
Develop an effective stigma reduction program. This
will reduce overall non-adherence tendencies, and by extension, can
protect public health by limiting the emergence of treatment
resistant HIV strains (73). Programs need to address a fragment of a
population that not only believes sex between two men, in itself,
carry a risk for AIDS (74) but also believes casual contact can
spread AIDS (75). AIDS can only be contracted from MSM when certain
conditions are met: one of the men are infected with HIV, sexual
conduct is capable of introducing HIV-infected semen into
bloodstream (i.e. anal intercourse), and this can only occur if men
do not take appropriate protective measures (i.e. no condom use).
6.
Provide anonymous HIV testing and free or low cost
services of antiretroviral treatments. Medical treatment is
estimated at 4,250 per client (76), while management and general
supporting services (i.e. employee’s salaries) - a relatively
reasonable cost if working with externally funded sources (77/78).
CONCLUSION