A number of programs across the country are designed to reach and provide healthcare to people experiencing homelessness, including those who are living with HIV. However, these initiatives also face challenges in finding adequate funding. To help meet their needs, the HIV Medicine Association (HIVMA) and Center for Health Care Strategies have issued guidance to help providers develop and sustainably fund low-barrier clinics and street medicine (bit.ly/4lon89p-IDSE).
“Ultimately, our goal as HIV care providers is to serve all individuals, and the people who need us the most and have the most difficult time accessing care are often those who experience homelessness. This guidance we hope helps clinics think about how to do that effectively,” said Wendy Armstrong, MD, a past chair of HIVMA and the chief of the Division of Infectious Diseases at the University of Colorado School of Medicine, in Aurora.
Roughly 1 in 500 people experience homelessness, and it is disproportionately higher in minorities. For example, the guidance reported that Blacks comprise 37% of those experiencing homelessness in the United States, even though they represent only 13% of the overall population.
People experiencing homelessness also have less access to health and social services. This becomes even more critical for people living with HIV who need regular treatment to achieve viral suppression, which allows them to lead long, healthy lives and prevents transmission of HIV to others.
“If you’re homeless, finding food may be the most important endeavor in a single day rather than getting to a doctor’s appointment, and then you are also dealing with challenges that can include communication with clinics, transportation and storing medications,” Dr. Armstrong said.
Both Dr. Armstrong and Judith Feinberg, MD, also a past chair of HIVMA and professor of infectious diseases at West Virginia University School of Medicine, in Morgantown, stressed that HIV and homelessness are not just an urban challenge. In fact, five of the 10 states with the highest HIV rates are in the Southeast, with cases often occurring in rural counties. They are often tied to using illicit drugs, according to Dr. Feinberg.
This guidance lays out the ways provider organizations can establish street medicine programs and low-barrier models for care and keep them funded through Medicaid and other sources listed in Exhibit 1 in the document. It also offers a road map on setting up collaborations between health-system leaders and state Medicaid leadership in operating these programs. (This guidance was written before the federal government was cutting Medicare and funding for many HIV programs.)
“The challenge is consistently how do we continue to pay for providing any of these services. We wanted to really dig in deep to understand how we could try and make these systems sustainable because so many of us are doing this as pilot projects or research projects but can’t scale them because of funding,” Dr. Armstrong said.
Drs. Armstrong and Feinberg acknowledged that obtaining funding in this area is going to be even more challenging given the current political environment. Dr. Feinberg said providers need to be vigilant in convincing their state Medicaid officials to maximize the use of existing Medicaid authorities, using State Plan Amendments to expand services and obtaining Section 1115 waivers to pilot innovative initiatives.
“I think we really just have to double down on trying to address this at a local level across all 50 states and territories. There’s a lot of work that has to be done at a grassroots level,” Dr. Feinberg said.
In trying to sway policymakers, Dr. Feinberg encouraged education about the fact that once HIV is in their community, you cannot “just close your eyes to and pretend it is not there.
“There is no such thing as containing an infectious disease. Sooner or later, somebody who injects drugs will have sex with someone who does not inject drugs, so the concept that you can wall this off is very misguided,” she said.
Drs. Armstrong and Feinberg reported no relevant financial disclosures.
This article is from the April 2025 print issue.