This is the second in a two-part series on the rise of homeless HIV. The first section discusses how public and private health systems need to be adapted after being caught unprepared to cope with the challenges of this phenomenon.
James Maht sat in the emergency room five or six times during the summer, losing himself. In his best day, the 6-foot-2 man continued to lose weight until he hit 115 pounds, suffering from malnutrition and uncontrolled diarrhea caused by his HIV.
Then, on August 14, the OHSU hospital finally treated him with a fungal infection of the arm, bronchitis and norovirus, which he suspected collected as he slept in overcrowded Portland shelters.
The Maht T-cell count, an indicator of how strong the immune system is, was in the single digits. A healthy number is 400 or greater.
Makt is among the thousands of homeless people across the country that are making up the recent spread of HIV cases. Portland is one of the hardest hit by this new HIV transmission front, growing among intravenous drug users and their sex partners. In Multomach County, this year, 71 people were diagnosed with HIV, almost double the number reported in that population in 2016 and 2017.
The outbreak is increasingly difficult to contain because of people like Maht, who are upset as they try to find the stable housing they need to help them effectively treat their HIV.
In the Portland area, social workers and healthcare providers are rushing to adapt to the challenges of finding a homeless person and helping them access medication. It's a race against time to stop the spread of the virus – and keep those infected alive.
But they find, for homeless patients like Maht, it may be impossible to take a daily pill when every day is a test to survive.
This is what haunted Maht during his three months at UCSU, as he slowly gained weight until he had reached 150 kg. He knew that decades of untreated HIV had destroyed his immune system to the point that a lack of good food and proper hygiene and exposure to the drier Pacific winter in the northwest would likely lead to PR or worse.
But his options seemed bleak: he could enter a nursing home at the age of 41, hoping to get a permanent home or be emptied back into 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 shaky hands. "I don't know what to do when I'm out of the hospital, man. I won't do it any other winter there. "
HIV was taking to the streets
Macht contracted HIV from a former girlfriend who used intravenous drugs.
At the time, he didn't know he had HIV – he wasn't even sure he did. By the time she broke down after the diagnosis, she was already dead.
Macht, who says he never made intravenous medications, was confused when he started feeling tired all the time. He slept for 10 hours straight just to wake up exhausted again. Constantly went down with respiratory and other infections. Thinking he was a minor, he retained his job as a travel salesman and was in Texas until his fourth visit to the mysterious symptoms hospital, which he later learned was a rare type of pneumonia.
His virus was torn in his body for so long that the white blood cells of the virus – the T-cells – fell hundreds of points below the healthy average. Macht asked the 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 he came out.
At first, he just lay in bed for hours paralyzed by despair. He was told he was seven years old. Mostly. However, he continued his work, hoping he could at least be busy. He knocked on Portland doors selling cleaning solutions when he became too ill to work again.
Macht was examined at the hospital and when he was released a month later, he lost his job because he could not comply with the schedule. He returned to motel until his money ran out and then ended up in Portland's streets.
There, Maht has become one of a growing number of homeless people on the West Coast who are discovering that HIV is becoming another obstacle to access to stable housing – and whose lack of stable housing tends to make them more painful.
Portland, like most places, does not provide a separate pathway for homeless people with HIV. Federal studies found that the number of homeless people with HIV rose from more than 7% to 9% between 2015 and 2017, the first three years of a five-year plan for health agencies across the country to try to reduce it to 5%. The percentage continues to grow. This is alarming because the data also shows that people who do not have homes are less likely to see a doctor regularly and even less likely to achieve good health if they are in treatment.
But no matter how sick and motionless Macht and the people in his position are, they need to produce the same documentation, appear in the same offices and stand in the same rows as anyone else who needs a place to live.
It's hard to stay healthy
AIDS was formerly the death penalty. But as decades have passed, the drugs have 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 are regularly treated do not stay so low for long. And if they do, they can still be healthier with a lower T-cell count than someone with a higher T-cell count who is untreated.
HIV remedies today are also simpler than ever. The standard is similar to birth control – one pill a day at a time. And it can deliver such a high rate of efficacy that someone can make their virus invisible because there is so little virus in their bloodstream.
This is a huge improvement in the quality of life for people who feel that their HIV status isolates them from friendships or romantic relationships.
Like many people on the street, however, Maht will never be able to manage this HIV.
Hopelessness or defiance made him resist treatment at times, allowing the virus to survive. Even as he repeatedly tried to take the drugs, he was stolen while staying in shelters by people who thought the bottles contained opiates or other high-yielding tablets.
Prior to landing at the hospital recently, Macht said his drugs had been stolen four times in several months. This can make it difficult to stay on track, as most insurance plans pay only to replace stolen drugs about three times.
Hard treatment without housing
Yacht is being treated at a publicly funded clinic for Multomach HIV in Northwest Portland. The clinic is one of the few receiving federal dollars to be innovative and meet more than patients' medical needs.
About 20% of the clinic's 1,400 patients are homeless or, like Mahtt, in and out of the home, said social worker and grant manager Emily Bork.
When an insurance company threatens to discontinue Macht for too many drug losses, the county pharmacy will still supplement the prescription – perhaps in one or two week doses instead of a whole month, so if stolen again, you have less to lose. They can also put drugs in bubble wraps, which help some people to better monitor their tablets, rather than striking a backpack with amber-looking animal objects.
But those solutions didn't work for Maht.
Those breaks in his prescription routine are dangerous, giving his virus an opening to bolster his defense of drugs. Once a single pill regimen is stopped, treatment becomes more complicated. More pills must be taken at the same time, which means more pills should be lost or stolen. Or, in the frenetic cycle of packing and unpacking your stuff to switch between clinic, shelter and meals lines, two of the same pill could be taken at once instead of the two different tablets needed.
The more complicated the drug regimen, the more side effects. One of the worst for people who live on the street or in shelters is nausea and diarrhea. Without access to close and clean toilets and showers, side effects can be embarrassing and unfavorable.
This is where Maht found himself. Other gastrointestinal problems make it nearly impossible to put on enough weight to cope with his other hurdles that make navigating the social service system even more difficult than documentation: Legs damaged by neuropathy, five teeth left to eat with, his eyes so poor. difficult to read.
The district's HIV clinic provides some relief. He has a case manager who collects him in a taxi and drives with him to buy new pants or other bugs. The clinic also hired a housing specialist two years ago to help patients find shelter and then permanent housing as soon as possible. She is also trying to relieve the burden of the housing system that requires Maht to leave the hospital once a week to visit an office so as not to lose her place on the housing waiting lists.
The clinic's medical staff also spends a lot of time talking about the priorities of patients, who are sometimes not medical. Problems with mental health bursts, which can also be a way of taking medication.
However, for Maht, his lifestyle is so brutal on his immune system that when his health inevitably turns to the worst, the clinic directs him to the emergency room.
Maht said he often feels stereotyped by ER staff who find that he has no address or knows that the Bud Clark Commons address means he is homeless. He said he had been away from short exams several times in the last few months, even when he had dropped weight and infections were holding up.
His primary care provider, Mary Teger at the HIV Clinic, said she was probably right. It is endlessly frustrating for her to send her clients to hospitals to be admitted only to return to the office next week, no better.
Some of Tiger's patients are able to keep HIV control under control. But for those who are too scattered or sick, or too deeply addicted or depressed to take medication, she said, they end up in a private health care system that stigmatizes homelessness and drug use or lacks resources to accommodate HIV patients.
Teger said Maht is a case study of why the HIV Clinic prioritizes its clients for housing and other social services. His T-cell count was double-digit when he entered the OHSSU hospital and is likely to go down after being released if returned to a mattress on the floor of the shelter.
"His nutritional status is so weak, his immune system is so weak that something like that could be the end for him because his body has so little it can fight," Teger said.
"Settles or dies"
Maht left the hospital in mid-October. He spent four nights in a men's shelter and then moved to the Biltmore Hotel, a building run by non-profit Central City Services.
Normally inconvenient, Maht rejoiced on the day he moved in. The Permanent Home made him optimistic about the future. First, he will get glasses. Then new dentures. And then maybe, he said, he applied for college classes. He was looking forward to the future.
But just a week later, he started losing weight again. He left the hospital with nearly 150kg, but the constant mix of finding three healthy meals a day broke him down. He returned at 127 and was falling.
He told his doctor that he was taking multiple medications every day, but she knew he had not always done so in the past.
Mainly, Maht is lonely. He tells people he encounters that his HIV status makes him feel like a red bean in a blue bag. And as long as he is still able to infect other people, he feels too much guilt and shame to form new romantic relationships.
That stress didn't just go away because he found a home. He turned 42 last week, and knows that returning to the street will make it impossible to stay healthy.
"I don't care how good your diet is, how much you work," Maht said, sitting on his bed in an otherwise empty apartment after the first night, he was sleeping there. “They arrested you. You should take the medicine. It's like turning that sand clock with sand. How much do you want yours to be? Small, fast running out of time.
"You will either be housed and take medication, or you will die."
– Molly Harberger
firstname.lastname@example.org | 503-294-5923 | @MollyHarbarger
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