This is the second part of a two-part series on rising HIV among the homeless. The first part examines how public and private health systems must adapt after being caught unprepared to deal with the challenges of this outbreak.
James Macht was sitting in the emergency rooms five or six times during the summer, languishing. Slim on his best day, the 5-foot-1 man continued to lose weight until he reached 115 pounds, suffering from poor nutrition and uncontrollable diarrhea caused by HIV.
Then, on August 14, OHSU Hospital finally admitted him with a fungal arm infection, bronchitis, and norovirus, which he suspects had caught sleeping in Portland's crowded shelters.
Macht's T-cell count, an indicator of how strong the immune system is, was in one digit. A healthy score is 400 or higher.
Macht is among the thousands of homeless people across the country who make up a recent rise in HIV cases. The Portland area is one of the hardest hit by this new HIV transmission front, emerging among intravenous drug users and their sexual partners.. In Multnomah County, 71 people were diagnosed with HIV this year, almost double the number reported in this population in 2016 and 2017 together.
The outbreak is increasingly difficult to contain because of people like Macht, who languish while trying to find the stable housing they need to help them effectively treat HIV.
In the Portland area, social workers and health care providers are scrambling to adapt to the challenges of finding homeless people and helping them take medication. It's a race against time to keep the virus from spreading – and to keep the infected alive.
But they find that for homeless patients like Macht, it may be impossible to take a pill daily when each day is an attempt to survive.
That's what haunted Macht during his three months at OHSU, when he slowly gained weight to 150 pounds. He knew that decades of untreated HIV had ravaged his immune system to such an extent that poor Pacific Northwest food shortages, proper hygiene, and exposure to rainy winter were likely to lead back to the ER or worse.
But his options seemed bleak: he could enter a nursing home at 41, hope that a permanent home would pass or be discharged back to the street.
"I know I can't stay here forever," he said, trying to balance his fifth cup of coffee of the day with shaking hands. "I don't know what to do when I get out of the hospital, man. I'm not going to spend another winter out there."
HIV took to the street
Macht contracted HIV from an ex-girlfriend who used intravenous drugs.
At the time, he didn't know she had HIV – nor was he sure she had. When he located her after the diagnosis, she was already dead.
Macht, who says he never used intravenous drugs, got confused when he started to feel tired all the time. He slept 10 hours straight just to wake up exhausted again. He constantly suffered from respiratory and other infections. Thinking it was minor, he kept his job as a hawker and was in Texas at the time of his fourth visit to the hospital for mysterious symptoms, which he later discovered was a rare type of pneumonia.
Its virus has penetrated your body for so long that the white blood cells that the virus targets – T cells – have dropped hundreds of points below the healthy average. Macht asked the doctor what this pneumonia meant to him, but he said the doctor tapped his shoulder and said, "Don't worry. You have AIDS. So you left.
At first he lay in bed for hours paralyzed with despair. He was told that seven years remained. Maximum. Still, he resumed his work, hoping he could at least keep himself busy. He was knocking on the doors of Portland selling cleaning solutions when he got too sick to work.
Macht entered the hospital and when he was released a month later, he had lost his job because he could not keep up with the schedule. He went back to a motel until the money ran out and then ended up on the streets of Portland.
There, Macht became one of a growing number of homeless people on the West Coast, who then discovered that HIV becomes yet another barrier to accessing stable housing – and in turn whose lack of stable housing. tends to make them sicker.
Portland, like most places, does not offer a special path to street services for people with HIV. Federal studies found that the number of homeless people with HIV rose from more than 7 percent to 9 percent between 2015 and 2017, the first three years of a five-year plan for health care agencies across the country seeking to reduce it. to 5%. The percentage continues to grow. This is alarming because the data also show that people who are homeless are less likely to see a doctor regularly and even less likely to get good health if they are on treatment.
But no matter how sick and immobile Macht and the people in his position become, they need to do the same paperwork, show up in the same offices, and stay in line with everyone who needs a place to live.
Hard to stay healthy
AIDS used to be a death sentence. But over the decades, the medication has become so effective that the line between HIV and AIDS is largely a measure of temporary severity. Someone with a T cell count below 200 is considered to have AIDS.
People who take regular medication, however, do not stay so low for long. And if they do, they may still be healthier with a low T-cell count than someone with a higher untreated T-cell count.
Today, HIV medication is also simpler than ever. The pattern is similar to birth control – one pill a day at a similar time. And it can offer such a high rate of effectiveness that someone can make your virus undetectable because there is so little virus in the bloodstream.
This is a huge improvement in the quality of life of people who feel that their HIV status isolates them from friendships or romantic relationships.
Like many people living on the street, however, Macht will never be able to manage their HIV this way.
Lack of hope or challenge led him to sometimes resist treatment, which gave the virus a chance to settle. Even when he consistently tried to take the medicine, it was stolen while he was in shelter by people who thought the vials contained opiates or other pills that could produce a high.
Before landing in the hospital most recently, Macht said his drug had been stolen four times in a few months. This can make it impossible to stay on track, as most insurance plans will only pay to replace stolen drugs about three times.
Difficult treatment without accommodation
Macht is treated at the Multnomah County HIV public clinic in northwest Portland. The clinic is one of several that receives federal dollars to be innovative and to address more than just the medical needs of patients.
About 20 percent of the clinic's 1,400 patients are homeless or, like Macht, in and out of housing, said social worker and grant manager Emily Borke.
When an insurance company threatens to discontinue Macht from losing his medication too often, the county pharmacy still replenishes the prescription – perhaps in one to two week doses rather than a full month so that if stolen again, there is less loss. . They can also pack medicines in blister packs, which helps some people better control their pills instead of rummaging through a backpack with their life's belongings looking for the amber pill bottle.
But these solutions did not work for Macht.
These interruptions in your prescription routine are dangerous, giving the virus an opening to bolster its defenses against the drug. When one pill a day stops working, treatment becomes more complicated. Multiple tablets should be taken simultaneously, which means that more pill bottles should be lost or stolen. Or, in the hectic cycle of packing and unpacking your stuff to carry between lines to the clinic, shelter and meals, two of the same pill can be taken at the same time instead of the two different pills needed.
The more complicated the medication regimen, the more side effects. One of the most terrible for people living on the street or in shelters is nausea and diarrhea. Without access to clean, enclosed toilets and showers, side effects can be embarrassing and inconvenient.
That's where Macht met. Persistent gastrointestinal problems make it nearly impossible to gain enough weight to deal with other impediments that make navigating a social service system even harder than paperwork: neuropathy-damaged legs, five teeth left to eat, vision so bad it's hard to he read.
The county HIV clinic offers some relief. He has a case manager who picks him up in a cab and goes with him to buy new pants or other things. The clinic also hired a full-time housing specialist two years ago to help patients find shelter and then permanent accommodation as soon as possible. She also tries to lighten the burden of a housing system that requires Macht to leave the hospital once a week to visit an office so he won't lose his place on housing waiting lists.
The clinic's medical staff also spend a lot of time talking about patients' priorities, which are sometimes not medical. They face mental health problems which can also disrupt the medication.
Still, for Macht, the lifestyle is so brutal in his immune system that when his health inevitably worsens, the clinic forwards him to the emergency room.
Macht said he often feels stereotyped by emergency responders who find he doesn't have an address or know that a Bud Clark Commons address means he's homeless. He said he was removed after brief examinations several times in recent months, even when he lost weight and infections occurred.
Your doctor, Mary Tegger of the HIV Clinic, said you are probably right. It's infinitely frustrating for her to send her clients to hospitals to be admitted just to return to her office next week.
Some of Tegger's patients are able to keep HIV under control. But for those who are too scattered or ill, or suffering too much from addiction or depression to take medicine, she said, they end up in a private health system that stigmatizes the homeless and drug use or lacks the resources to afford it. admit patients with HIV.
Tegger said Macht is an example of why the HIV Clinic prioritizes housing and other social services for its clients. His T-cell count was in the double digits when he entered OHSU Hospital and would likely fall again once discharged if he turned to a treadmill on a shelter floor.
"His nutritional status is so bad, his immune system is so bad, so something like that could be the end for him because his body has so little to fight with," Tegger said.
"Staying or dying"
Macht left the hospital in mid-October. He spent four nights at the men's shelter and then moved to The Biltmore Hotel, a building run by the nonprofit Central City Concern.
Usually a little annoyed, Macht was excited the day he moved. A permanent home made him optimistic about the future. First, he would get glasses. So new dentures. And then, perhaps, he said, enroll in college classes. He was looking forward to the future for the first time.
But just a week later, he began to lose weight again. He left the hospital at 150 pounds, but the constant confusion over finding three healthy meals a day had worn him out. He returned to 127 and fell.
He told the doctor that he was taking his various medications every day, but she knows he has not always done this in the past.
Mostly, Macht is alone. He tells people he knows that his HIV status makes him feel like red jujube in a blue bag. And while he is still able to infect others, he feels too much guilt and shame to form new romantic relationships.
This stress did not disappear just because he found housing. He turned 42 last week and knows that getting back on the streets would make it impossible to stay healthy.
"I don't care how good your diet is, how much you exercise," Macht said, sitting on his bed in an empty apartment after the first night he slept there. "This will get you. You have to take your medicine. It's like turning the hourglass on the sand. How big do you want yours to be? Small, you run out of time quickly."
"You stay in and take your medicine or die."
– Molly Harbarger
firstname.lastname@example.org | 503-294-5923 @MollyHarbarger
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