Every month, Tim Menza receives reports about new HIV diagnoses and compares them to previous years. As a doctor and data analyst for the Oregon Health Authority’s sexually transmitted disease and HIV program, he’s familiar with how the HIV epidemic has waxed and waned.
Oregon is four years into a five-year, federally sponsored program to end HIV transmission by testing vulnerable Oregonians, alerting them of their HIV status and providing them with treatment and preventative medication. Menza had been optimistic Oregon was on track to eliminate future HIV transmissions.
But a year ago, he noticed a troubling trend that Oregon was ill-prepared to tackle – an HIV outbreak exacerbated to a deadly pitch by the harsh living conditions of the street.
While the uptick in new cases is driven by drug use, it is difficult to contain because of homelessness.
Few places nationwide have seen such a wave of new HIV cases as Multnomah County, where the number has more than tripled to 71 over the past two years. In this year alone, 37 people have been diagnosed – close to equaling the total for 2016 and 2017 combined.
The virus has historically targeted marginalized communities, devastating an entire generation of gay men in the U.S. in the 1980s and ‘90s, and later taking hold in communities of color. But in the past few years, the outbreak has surged among intravenous drug users who are – or who soon become — homeless, and their sexual partners.
Public health officials have had to start envisioning their work as tied to the homeless services system, actively canvassing camps to seek out those who are sick. While health care providers have become homeless service providers, troubleshooting patients’ needs beyond medication.
People who have homes can fairly easily survive HIV, a pill taken once daily allowing them to live nearly symptomless. Yet it remains a potential death sentence for homeless people, who have their medication stolen, lack clean shelter facilities and suffer poor nutrition and sleep — leaving their immune systems unguarded against the deadly virus.
A compounding factor
When Menza looked at the data a year ago, he found that across the state — in both rural and urban areas — new HIV cases were popping up among people who inject drugs and didn’t have access to stable housing.
It wasn’t necessarily a surprise. He had seen reports of syphilis and Hepatitis C rising in those populations — often precursors to an HIV infection.
He knew the state needed to take immediate action, but the traditional path wouldn’t work this time.
HIV cases among people who use heroin and methamphetamines jumped to 30% in the last two years, more than double the percentage of years before, according to state data.
Drug users typically separate themselves into social and sexual networks based on their drug of choice. But recently, those circles seemed to overlap more than ever. Officials say cheap, high-quality meth has flooded into the state over the past few years, a popular drug for people who live outside and want to stay up through the night to avoid being assaulted or robbed. The spike in meth use coincides with an existing opiate crisis, and many people have turned to using both the depressant and stimulant.
On top of that, Menza said that there is growing evidence that homelessness is a compounding factor.
Every time a campsite or group of people who use drugs together is dispersed through sweeps or clean-ups, the people there move and form new networks. Single-sex shelters split heterosexual couples up, making it hard to stay with one partner long-term.
That slowly extends the number of people who are capable of spreading the disease geographically and demographically.
A public health worker trying to contain an outbreak in a small group of people now must navigate ever-expanding networks.
“If you’re trying to do an intervention in a camp,” Menza said, “you have to work fast.”
Taking healthcare to camps
In Multnomah County, many people who are homeless or on the brink of it receive HIV care from the publicly funded HIV Clinic, housed in the gleaming new health department headquarters near Union Station.
From that outpost, public health workers are adjusting how they mobilize around the HIV outbreak nearly on the fly.
Jaxon Mitchell leads the county’s disease investigation team and field outreach. He’s used to tracking people down. Usually he can look up someone’s cell number or send them a message on social media. But that doesn’t work with this outbreak.
To locate people, Mitchell and his team must search camps, scour social media profiles for clues and trace leads from hospitals and friends. That’s made even harder by strict health privacy laws that mean Mitchell often can’t tell neighboring campers why he is looking for a specific person.
The rise in HIV — and its accompanying diseases of syphilis, shigella, hepatitis A and C — mean that Mitchell often receives test results for homeless people who went to an ER for short-term treatment but were discharged to the street before the results came back.
When he does find the person he is looking for, he often has to work quickly to identify anyone else who might be infected — sexual partners or people that have shared needles — and get them tested or into treatment.
Out of a van designed for such field work, the county offers on-the-spot medical help, testing and provides other necessities like clean socks, snacks and tampons.
The public health department has faced smaller scale outbreaks before. For instance, Mitchell’s team is dispatched when a homeless person is diagnosed with tuberculosis and they must make sure the patient takes several months worth of pills to contain it.
But this is a much larger undertaking than ever before.
“It’s all based on being able to find people,” said Jennifer Vines, the county’s deputy health director. “Now suddenly we’re in a new situation of having to figure out how to use our tools when people are hard to find — or not wanting to be found.”
Training the front lines
In his role at the county, Chris Hamel must train service providers on how to talk to their clients and patients about getting tested for HIV.
He seeks out homeless service agencies, primary care doctors, detox centers, parole and probation officers — anyone who might interact with people at risk of HIV — to try to make that step easier.
County officials have found that if they can get someone who is newly diagnosed into HIV care within 30 days, they are more likely to stay in care long-term. So field workers try to keep in contact through the first few appointments.
“We’re trying our hardest now to go to people,” Hamel said. “But I would like to see us continue to build a public health system that people feel comfortable enough that they will come to us.”
Public health workers face the challenge of being as focused on those who haven’t yet contracted HIV as they are on people with positive test results.
Pre-exposure prophylaxis, or PrEP, is a daily medication that is highly effective at preventing transmission of the disease. Mitchell and his team also track down everyone they can who might be in the orbit of a someone with HIV to make sure they have access to the medication.
That’s a new sell to many. The pill has largely been targeted at gay men because it works even without use of a condom. But state data shows a 600% increase in women getting syphilis — a sure sign that HIV will parallel that rise.
In this outbreak, the people most at risk are women, sex workers and intravenous drug users who tend to be straight men — all people who likely never considered needing the preventative medicine.
“It’s the art of public health,” Vines said. “We’re thinking about the individual, but we also have to think about the person’s social circle.”
Hard to help
In 2014, Indiana had more than 200 cases among intravenous drug users in one county. Last year, West Virginia experienced 80 new HIV cases tied to intravenous drug use.
Officials are seeing the HIV resurgence across the country, but the West Coast is unique in its profound lack of housing affordable to sick or addicted people.
In 2018, a cluster of HIV cases in Seattle caught the federal government’s attention. The outbreak was within a distinct group of people who hadn’t before been a driving force among new cases: Heterosexual people who were homelessness and using intravenous drugs.
Twenty-one homeless people in Seattle were found to have passed around HIV sharing needles and sex. The cluster bumped King County’s rate of HIV among homeless heterosexuals who inject drugs by 286%. Months after the cluster was identified, seven of the 21 people were still not receiving HIV care.
“The King County outbreak demonstrates how difficult it is to engage the most socially marginalized persons with medical care,” said a U.S. Centers for Disease Control and Prevention report.
San Francisco has seen a steady increase in deaths among this growing population. Someone with HIV who is homeless is 27 times more likely to die than a person with HIV who is housed, said Elizabeth Imbert, the doctor who oversees a new private clinic at Zuckerberg San Francisco General Hospital.
The city’s homeless people account for 14% of all new HIV diagnoses, despite making up only 1% of the city’s population, according to the local public health department.
The hospital’s Ward 86 served at the forefront of a burgeoning AIDS crisis in the 1970s. Now it’s launched the POP-UP Clinic, a program designed to get homeless people in the door and in treatment.
Imbert knew from local data that only one-third of San Francisco’s infected homeless population has been able to lower the amount of HIV in their blood stream to the point where they can’t transmit it anymore – what health officials call “viral suppression.” That is well below the average rate of 74% for all people with HIV in San Francisco.
The hospital launched its own survey to find that of 1,200 patients, the amount of the virus in their body increased as their housing situation became more unstable. And, as the amount of virus in their body went up, the more they missed primary care appointments and ended up in the emergency room and urgent care.
So leaders of Ward 86 created a new way to treat those patients. They had to find a way to get sick people in the door who don’t trust institutions like hospitals.
Ward 86 employs people who focus on non-medical needs in hopes that it will help patients stabilize enough to stay on their medication. They also work with housing specialists from the state health department and community organizations to connect patients to services — and ask that those workers come into the health clinic to do so.
The clinic is open four hours daily on Monday through Friday, and patients don’t need appointments to see a doctor. Currently, about 180 patients are eligible for the program, which targets people who have missed an appointment in the last year.
Once they do come in the door, they are offered financial incentives to keep coming. The hospital offers a $10 gift card for every week they’re in the program, a $10 gift card to have blood work done and $25 if the patient achieves viral suppression.
Nearly a year in, 60 people are enrolled. Most have started on medication and Imbert said that she’s already seen some in the program who’ve had their virus become undetectable. About half of the patients come regularly, while a quarter visit a few times a week.
“We are using essentially every resource in the city,” Imbert said, “to get them indoors, housed, on a waiting list.”
— Molly Harbarger
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