Purpose: Twenty years into the epidemic, HIV now disproportionately affects persons of color, lower income individuals, and marginalized populations. In light of treatment advances there is now a need for interventions to promote HIV medication adherence as well as ongoing HIV prevention. In response to this need, researchers at the Jane Addams College of Social Work at the University of Illinois at Chicago in partnership with Heartland Health Outreach, a primary healthcare clinic for homeless persons, received funding from the National Institute of Mental Health and the National Center on Minority Health and Health Disparities to develop, pilot, and evaluate an innovative case management-based intervention (DAART+) that integrates directly observed therapy for HIV and HIV risk reduction counseling for a sample of marginally housed and homeless persons. This paper provides an overview of the project's conceptual framework, the research objectives, methods, and findings and concludes with a discussion of implications and next steps.

Methods: This research employs a modified interrupted time-series/removal design extending over a period of up to 12 months for each participant. The DAART+ case management intervention is an adaptation of directly observed therapy, an intervention already proven effective in tuberculosis treatment, combined with HIV risk reduction counseling. The intervention consists of a readiness for treatment assessment followed by several tapering stages (Intensive, Tapered, and Follow-up) during which the intervention is administered and gradually removed. The sample is comprised of 30 homeless or marginally housed HIV+ individuals many of whom have a history of mental illness and/or substance use. Adherence outcomes are measured through self-report (Patient Medication Adherence Questionnaire-PMAQ), the use of computerized pill bottles (MEMSCaps), chart reviews to assess reduced morbidity and hospitalization, and blood samples to determine HIV viral load and CD4 counts. Risk reduction outcomes are measured through self-report (Timeline Follow Back Interview) and STD testing. Data are collected weekly or monthly depending on the stage of the intervention. Each outcome is analyzed separately using a mixed effects regression model with both fixed effects and a random effect to properly account for correlation of repeated measurements within individuals.

Results: Preliminary analysis of the data indicates that the participants have benefited significantly from the intervention. Self-report corroborated by MEMSCap data reveal very high levels of adherence. Analysis of medical charts and blood test results indicate that nearly all the participants have improved their health status and have enhanced immunologic capacity as measured by statistically significant increases in CD4 levels as well as decreases in HIV viral load. Risk behaviors likewise show significant decreases.

Implications: As a pilot study, the findings suggest that the DAART+ intervention is effective in helping highly vulnerable HIV infected persons to adhere to their medication regimens, improve their health, and to reduce their ongoing risk behaviors. As an effective intervention, DAART+ may help to engage and retain homeless persons in care and to redress ongoing health disparities. Further research that would include controls is necessary and is being pursued by the research team.