Plan and Management

Plan of Care  TOP

• Next Steps – Develop an agreed-upon plan of care with the patient’s active involvement.
• Interdisciplinary team – Interdisciplinary clinical team managed by the patient, including addiction mental health counselors, a medical care manager, and a treatment advocate.
• Basic needs – Food, clothing, housing and mental health issues may be perceived as more important. Develop an individualized plan of care with patient to incorporate strategies to meet needs.
• Patient priorities & goals – Address immediate medical needs first (the patient’s reason for the visit) rather than underlying causes. Encourage the patient to specify his/her own goals and prioritize issues to be addressed.
• Governmental assistance – Patient applies for Ryan White Comprehensive AIDS Resources Emergency (CARE) Act services, Housing Opportunities for Persons with AIDS (HOPWA), disability assistance (SSI/SSDI), Medicaid, Food Stamps, and any other programs that facilitate access to health and social services.
• Communication – Explanation in simple language. Use an interpreter and/or lay educator to facilitate communication.

Education, Self-management  TOP

• Basic education about HIV – Provide answers to basic questions about HIV: What is the virus? What is it doing in your body? Why do you need medications? Educate patients about the natural course of the disease. Teach homes 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. 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 how the virus can be passed. 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).
• Prevention – Discuss ways to reduce HIV risks for the patient and others. Know what is really happening to the patient’s life; then try to figure out how you can help behavioral change occur within the context. Teach safer practices to injection drug users unwilling or unable to stop using drugs. Provide general sexual reproductive health education and counsel the patient about safer sex practices.
• Addiction management – Find out how patients with chemical dependencies use psychoactive substances. Identify strategies already employed to manage illicit drug or alcohol use and apply them to HIV treatment adherence, substituting HIV medications for other drugs.
• HIV therapy – Inquire about the patients’ understanding of HIV therapy. Highly active antiretroviral therapy (HAART) can be as effective for highly motivated persons who are homeless as for those who are housed. Explain what CD4 counts and viral loads are, and how these measurements are used to help determine how advanced the patients’ disease is, predict risks of complications and monitor treatment adherence.
• Drug resistance – Explain the risk of developing resistance to HIV medications if they are not taken consistently or appropriately.
• Patient treatment advocates – Use social workers, nurses, or case managers as treatment advocates. 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.
• Directly observed therapy – 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 2-3 times per day.
• 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. Provide snacks to help the patient avoid this side effect and promote adherence to treatment.
•  • Urgent medical problems– Help patients understand the difference between common medication side effects and symptoms of life threatening toxicities.
• Supportive relationships – Encourage a supportive relationship with a social worker, provider, or friend. Link the patients with a support person or “sponsor” through HIV/Substance abuse treatment programs or other community-based programs.
• Nutrition counseling – Educate patient 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. Prescribe multivitamins with minerals. Ensure that pregnant patients receive appropriate vitamin supplements. Consider prescribing nutritional supplements with less familiar brand names and lower resale values to reduce risk of theft.
• Medical home – Discuss benefits of forming relationships with care providers who can help the patient avoid becoming acutely ill. Present regular primary care as an opportunity to be in charge of one’s own health.
• Support groups – 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.

Medications  TOP

• 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
• Prophylaxis – Start prophylaxis for opportunistic infections as soon as indicated by standard clinical guidelines. Explain the importance of opportunistic infections prophylaxis at each visit, if the patient is not initially interested or willing to accept preventive treatment.
• Immunizations – All homeless patients should receive influenza vaccine annually and be immunized against pneumococcus according to standard clinical guidelines. Also provide hepatitis A and B vaccines and update tetanus (Td) if the last immunization is more than 10 years old.
• 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. Address issues that may complicate treatment adherence. Be knowledgeable about HIV treatment alternatives and when to use them. Homeless individuals should have the same access to HIV medications as others.

1. Nucleosides

1. Lamivudine (Epivir^® or 3TC)
2. Didanosine (ddI or Videx^®)
3. Tenofivir (Viread^®)
4. Stavudine (D4T or Zerit^®)

2. Non-nucleosides

1. Nevirapine (Viramune^®)
2. Efavirenz (Sustiva^®)

3. A Protease Inhibitor – taken once a day is expected to be available soon.
4. An Antiretroviral that can be taken twice daily 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 Trizivir alone does not completely suppress the virus so it must be taken with a NNRTI such as Efavirenz or with a Protease Inhibitor.
5. Pill packs-Consider providing “blister packs” for all medications, labeled for each day of the week, each meal per day.

• Side effects – Awareness of the patient’s access to regular meals is important because some HIV medications must be taken with food. Prescribe medications with fewer/less severe GI and other side effects. Nausea, which often results from taking medications on an empty stomach, may also be incapacitating; providing nutritious snacks can prevent this side effect. Address the likelihood of diarrhea with certain protease inhibitors (e.g., Nelfinavir) and provide anti-diarrhea medication for patients with symptoms.
• Drug toxicities – Be aware of serious toxicities that can occur with Highly Active Anti-Retroviral Therapy (HAART)

1. diarrhea (particularly from some protease inhibitors)
2. nausea (if taken on an empty stomach)
3. peripheral neuropathy (numbness/tingling in extremities, exacerbated by poor nutrition and constant walking)
4. nightmares
5. 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.
• Some medications may be contraindicated if the patient has history of pancreatitis or alcoholism.
• Some medication should be used with caution and more frequent monitoring with co-occurring mental illness, Hepatitis C, high cholesterol, or diabetes.

• 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.

• Be cautious about prescribing HAART for homeless adolescents and youth because of their higher risk for drug resistance if unable to adhere to treatment.
• Resistance is not always indicative of non-adherence; mutation of the organism can occur even if the patient adheres to treatment.

• Recognize that alcohol and drug use are common among homeless people, and prescribe medications that are compatible with substances used.
• Knowing that medications can prolong life can give patients hope and motivate lifestyle changes to promote health.
• Most important, maintain communication with them.
• Successful HIV treatment is not only possible, but extremely desirable for homeless people with chemical dependencies.

Associated Problems, Complications  TOP

• Medication side effects – Medication side effects are a primary reason for non-adherence to antiretroviral treatment. Common side effects of HAART include diarrhea, nausea and peripheral neuropathy. Be more aggressive with homeless patients in treating side effects or changing medications, if an equally effective alternative is available.
• Severe drug toxicities – Some HIV infected patients receiving antiretroviral therapy experience symptoms of life threatening toxicity, which can be fatal if drugs are continued (for a comprehensive summary see www.who int/docstore/hiv/scaling/anex11b.html.)
• More acute illness – Homeless people with HIV may not seek care until their disease is advanced and symptomatic. New patients with advanced AIDS are not unusual, and require complicated treatment regimen. Major complications include late stage opportunistic infections such as Pneumocystis carinii pneumonia (PCP), invasive candidal infection, toxoplasmosis, and cryptococcal meningitis.
• Mental illness/substance abuse – Mental illness, substance use and HIV are frequently linked. Underlying mental illness (both Axis I and Axis II disorders) and drug induced psychosis can interfere with treatment. Overlapping side effects are more problematic than drug interactions.
• Cognitive impairment– Patients may have difficulty remembering appointments; cognition should be evaluated. Cognitive impairment may be associated with mental illness, chronic substance abuse, AIDS related dementia and/or opportunistic infections.
• Tuberculosis/Hepatitis – 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. Some homeless persons (especially injection drug users) are at increased risk for hepatitis. Hepatitis C (HCV), hepatitis B, and HIV are chronic, potentially fatal diseases that can be symbiotic.
• Pregnancy – HIV-positive pregnant women should receive HAART for themselves and to prevent transmission of infection to the fetus. It is important to develop good consulting relationships with obstetricians to help pregnant homeless women with HIV.
• Lack of stable housing – HIV treatment is extremely difficult for individuals without stable housing. Meeting needs for food and shelter leave little time for medical appointments. Homeless persons need a stable residence and a routine in order to begin recovering.
• Barriers to health insurance/disability assistance – There are many barriers to obtaining public benefits, including health insurance and disability assistance. Entitlement programs in many States and localities require extensive documentation, including photo identification, birth certificates, and social security cards, to verify eligibility. Proof of identity, residence and income is difficult to obtain for homeless persons. Most homeless people (particularly adults not having children) do not qualify for Medicaid under current policy. In most States, except for pregnant women and children, Medicaid eligibility is linked to SSI for persons with disabling conditions including HIV/AIDS.

Follow-up  TOP

• Contact Information: At every visit, seek the following contact information for the patient.
  1. a. A family member
  2. b. Friend with a stable address
  3. c. The shelter where the patient is currently staying
  4. d. Location where he/she might be found
  5. e. Case manager and health care providers
• Clinical Visits:

A clinician should be available 24 hours a day.

1. Drop-in system – Create a routine drop-in time at primary care clinics with no appointment required for new patients.
2. Help with appointments – Recognize that a homeless patient may be forced to miss a meal at a soup kitchen if the clinic appointment runs past serving hours.
3. More frequent follow-up – Try to see homeless patients more frequently.
   1. Follow-up intervals also depend on comorbidities.
   2. Develop a therapeutic relationship.
   3. Reinforce the patient’s understanding of the plan of care repeatedly.
   4. Review adherence; give the patient a pillbox, if desired.
   5. Ask if medications were missed and if so, why they were missed and what happened (e.g., stolen, forgot to take them while binging).
   6. Frequent contact encourages patient bonding and willingness to return to the clinic on a drop-in basis.

• Intensive case management – Use 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 with follow-up. Encourage discharge to nursing recuperative care facility, if available. Establish and maintain contact with other service providers who know your patient. Ask the patient to sign a release, in compliance with HIPAA requirements, so that you share health information with other clinicians and service providers. Information sharing is important, particularly during transition from homelessness to transitional housing to identify any variations in the patients’ behavior.
• 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.