This is the second part of a two part series on the rise of HIV among homeless people. The first part examines how public and private health systems need to adapt after being caught unprepared to deal with the challenges of this outbreak.
James Mach sat in the emergency ward five or six times in the summer, losing himself far away. At his best, the 6-foot-2 man continued to lose weight until he lost 115 pounds, suffering from poor nutrition and uncontrolled diarrhea caused by his HIV.
Then on Aug. 1
The number of Makht T cells, an indicator of how strong the immune system is, is in single digits. The health count is 400 or greater.
Maht is one of the thousands of homeless people across the country who make up the recent spike in HIV cases. The Portland area is one of the hardest hit by this new frontier of HIV transmission, growing among intravenous drug users and their sexual partners . 71 people were diagnosed with HIV this year in Multnomah County, which nearly doubles the number of people reported in this population in 2016 and 2017 combined.
Outbreaks are increasingly difficult to cope with due to people like Maht, who are struggling while trying to find the stable homes they need to help them effectively treat their HIV.
In the Portland area, social workers and healthcare providers are in a hurry to adapt to the challenges of finding homeless people and helping them get medication. This is a race against time to prevent the spread of the virus – and to keep those infected alive.
But they find, for homeless patients like Mach, that it is impossible to take a daily pill when tried every day to survive.
This is what haunted Mach during his three months at OHSU, as he slowly gains weight until he reaches 150 pounds. He knew that decades of untreated HIV had devastated his immune system to the extent that lack of good food and proper hygiene and exposure to the humid winter in the Pacific Northwest would probably lead to a return to the EP or worse.
But his capabilities seemed bleak. : he or she may enter a nursing home at the age of 41, hope for a permanent home to pass or be discharged back to the street.
"I know I can't stay here forever," he said as he tried to balance his fifth cup of coffee for the day with shaking hands. "I don't know what to do when I'm out of the hospital, man.
HIV leads on the street
Mach infected HIV by a former girlfriend using an intravenous drug.
At that time, he didn't know she had HIV – he wasn't even sure she did. By the time he was followed after her diagnosis, she was already dead.
Maht, who says he has never taken intravenous medications, went astray when he began to feel tired all the time. He will sleep for 10 hours straight just to wake up exhausted again. She was constantly coming down with respiratory and other infections. Considering it to be a minor matter, he kept his job as a traveling salesman and was in Texas until his fourth hospital visit because of mysterious symptoms, which he later learned was a rare type of pneumonia.
His virus has been torn into the body for so long that the white blood cells that the virus targets – the T cells – have dropped hundreds of points below the healthy average. Mach asked his doctor what this pneumonia meant to him, but he said the doctor slapped him on the shoulder and said, "Don't worry about it. You have AIDS. "Then it came out.
At the beginning, he just lay in bed for hours, paralyzed by despair. He was told he was seven years old. The most. Still, he resumed his work, hoping he could at least stay busy. He knocks on a door in Portland selling cleaning solutions when he becomes ill again for work.
Maht arrived at the hospital and by the time he was released a month later he had lost his job because he could not keep up with the schedule. He returned to the motel while his money ran out and then found himself on the streets of Portland.
There, Maht became one of a growing number of homeless people on the West Coast who then found that HIV was becoming another barrier to access to stable housing – and in turn, whose lack of stable housing usually made them sick.
Portland, like most places, does not provide a special path to homeless services for HIV. Federal studies have found that the number of homeless people with HIV increased from over 7% to 9% between 2015 and 2017, the first three years of a five-year plan for health agencies across the country aim to reduce it to 5%. The percentage continues to rise. This is worrying because the data also show that people without homes are less likely to see a doctor on a regular basis and even less likely to achieve good health if treated.
But no matter how sick and motionless Makht is and the people in his position are getting up, they must produce the same documentation, appear in the same offices and stand in the same rows as everyone else who needs a place to live.
Hard to keep healthy
AIDS was a death sentence. But over the decades, medicines have become so effective that the line between HIV and AIDS is largely a measure of temporary burden. Someone with a T-cell count below 200 is considered AIDS.
However, people who regularly take medication do not stay so low for long. And if they do, they may still be healthier with a lower T-cell count than someone with a higher untreated T-cell count.
Treating HIV today is also simpler than ever. The standard is similar to birth control – one pill a day at a similar time. And it can provide such high efficiency that one can make its virus undetectable because there is so little virus in its 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, Maht will never be able to manage his HIV this way.
Hopelessness or the challenge causes him to resist at times, enabling the virus to possess. Even when he tried to take his medication consistently, he was abducted while staying in shelters by people who thought the bottles had opiates or other pills that can cause high levels.
Before landing at the hospital soon, Match said his medications had been stolen four times in a few months. This may make it impossible to hold on, as most insurance plans will only pay to replace your stolen medicines about three times.
Hard Housing Treatment
Mast is being treated at a publicly funded HIV clinic in Multnomah County in Northwest Portland. The clinic is one of several that receive federal dollars to be innovative and to meet patients' more medical needs.
About 20% of the 1,400 patients in the clinic are homeless or, like Mach, are in and out of the home, said clinic director Emily Borket.
When an insurance company threatens to deny Maht that he lost his medication too many times, the county pharmacy would still supplement the prescription – maybe in one or two weeks instead of a whole month, so if they steal it again, there are less to lose. They can also put medicines in bubble wrap packages that help some people better monitor their pills instead of digging through their bags in their lives for a bottle of amber pill.
But these decisions did not work for Mach.
These disorders in his routine prescription are dangerous, giving his virus an opening to increase his defenses to drugs. Once one pill a day stops working, treatment becomes more complicated. Multiple pills must be taken at the same time, which means losing or stealing more pill bottles. Or in a frantic cycle of packing and unpacking your belongings to move between clinic, shelter and food lines, two of the same pills can be taken at the same time instead of the required two different pills.
The more complex the medication regimen, the more side effects. One of the worst for people living on the streets or in shelters is nausea and diarrhea. Without access to closed and clean toilets and showers, the side effects can be confusing and uncomfortable.
It was there that Makht appeared. The ongoing gastrointestinal problems make it almost impossible to put on enough weight to deal with its other obstacles, which make navigating the social services system even more difficult than the documents: Legs damaged by neuropathy, five teeth left behind nourishment, vision is so poor that it is difficult
The HIV Regional Clinic provides some relief. He has a case that takes him in a taxi and rides with him to buy new pants or other orders. The clinic also hired a full-time residential specialist to help patients find shelter and then permanent residency as soon as possible. She also tries to ease the burden of the housing system, which requires Mach to leave the hospital once a week to visit an office so as not to lose space on housing lists.
Clinical staff also spend a lot of time talking about patients' priorities, which are sometimes not medical. They are confronted with mental health problems that can also interfere with medication.
Still, for Maht, his lifestyle is so brutal for his immune system that when his health inevitably turns to worst, he points to the clinic
Maht stated that he often feels stereotyped by ER employees who find that he has no address or know that Bud Clark Commons' address means he is homeless. He said he had been rejected after brief examinations several times in the last few months, even when he lost weight and became infected.
His primary care, Mary Teger of the HIV Clinic, said he was probably right. It is extremely frustrating to send your clients to hospitals for admission only so that they can return to her office next week, no better.
Some of Teger's patients are able to keep their HIV under control. But for those who are too scattered or sick, or too deep in addiction or depression to take medication, she said, they find themselves in a private health system that stigmatizes homelessness and drug use or lacks resources to accept patients with HIV.
Teguer said that Maht was a textbook case of why the HIV clinic prioritized housing and other social services for its clients. His T-cell count was in double digits when he entered the OHSU hospital and would likely fall back after being released if he returned to bed on the shelter floor.
"His nutritional status is so bad, his immunity system is so bad, that something like that might be the end for him because his body has so little to contend with," said Teger.
"Put or Die"
Mach left the hospital in mid-October. He spent four nights at a men's asylum and then moved to the Biltmore Hotel, a building run by the non-governmental center of the city's homeless services concern
Usually a little grunt, Mach was alive the day he moved. A permanent home made him optimistic about the future. First, he'll take his glasses. Then new dentures. And then maybe, he said, he'll enroll in colleges. He was looking forward to the future.
But only a week later he began to lose weight again. He left the hospital by nearly 150 pounds, but the constant agitation of finding three healthy meals a day had exhausted him. He returned to 127 and dropped out.
He told his doctor that he repeatedly took his medication every day, but she knew that he had not always done so in the past.
Mostly Mach is lonely. He tells people that his HIV status makes him feel like a red grain in a bag of blue. And while he is still able to infect other people, he has too much guilt and shame to create new romantic relationships.
This stress did not disappear simply because he found a home. He turned 42 last week and knows that returning to the street would make it impossible for you to stay healthy.
"I don't care how good your diet is, how much you exercise," Mach said, sitting on his bed in an otherwise empty apartment after the first night he slept there. "We will take you. You should take your medicine. It's like turning this clock on the sand. How big do you want yours to be? Little, you're running out of time.
"Either you settle in and take your medicine, or you die."
– Molly Harbarger
email@example.com | 503-294-5923 | @MollyHarbarger
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