Mechanisms Contributing to Medication Adherence for Residents of a Harm Reduction Housing Program
Chronically homeless individuals living with HIV/AIDS experience significantly higher rates of health disparities and mortality compared to the stably housed. Housing as a structural intervention has been shown to be feasible and to improve access to care for this population. The Open Door is a harm reduction housing program that has been shown to be effective in reducing viral loads for chronically homeless people living with HIV. This study examines residents’ reports of variables that contribute to improved medical adherence and the ability to achieve undetectable viral loads within a very high risk HIV infected population.
Since 2006, The Open Door (TOD) has housed 34 chronically homeless HIV positive individuals with the co-occurring issues of active substance abuse and untreated serious mental illness. Services are provided by two part-time staff members, each of whom is a consumer living with HIV and/or in recovery from addiction. The annual program budget is less than $40,000. Previous research documents that 69% of residents were able to achieve undetectable viral loads during a three year study period. The current study utilized qualitative interviews with twenty current and former residents of the program to explore facilitators to medication adherence. Interviews were analyzed using ATLAS.ti 6.2. Open, axial, and selective coding were utilized to develop grounded theory.
Factors contributing to adherence success included acceptance regardless of drug use; peer role modeling for problem solving; practical support, which included having a representative payee; an increased sense of community and belonging; and reduction of chaos in the lives of residents. Peer staff members were identified as being effective in role modeling problem solving and access-to-care skills for residents. Feeling as if they were a part of a community was a new experience for many residents, who indicated that this phenomenon helped them to prioritize their own health status. Further, seeing that their peers shared multiple barriers yet were able to achieve medication adherence and positive relationships was highly motivating.
Harm reduction, peer modeling and community engagement may be important underutilized mechanisms in helping chronically homeless people living with HIV to improve medication adherence. Our findings are consistent with research in therapeutic communities, which has demonstrated that joining a supportive community may help relieve neurotic distress and improve social functioning. Given that this housing intervention operates on a program budget of less than $40,000 per year, this approach may be a cost-effective and replicable method of improving medication adherence among homeless people living with HIV, thus reducing HIV health disparities and reducing secondary transmission rates.