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Disparities in HIV health care continue to exist among New York City's marginalized populations. We describe the evolution and development of a unique collaborative program that blends harm reduction and medical care. This program addresses disparities and needs of a particularly marginalized population: unstably housed substance users with HIV infection.
In the U.S. and New York City, HIV/AIDS continues to affect some marginalized populations disproportionately, particularly substance users, the unstably housed, and communities of color.1-5 These marginalized populations have poor access to and utilization of health care services, and poor health outcomes.4,6-10 To address these disparities, we developed a partnership between a harm reduction community-based organization and an academic medical center to improve health care access to marginalized HIV-infected individuals. In this report, we describe the development and evolution of a unique collaborative program that combines harm reduction and medical care.
The harm reduction model recognizes the importance of reducing thresholds to access care and adapting service delivery to accommodate evolving needs of individuals. This fluid perspective on care differs from the rigid one used in traditional medical settings, where individuals must adapt to medical systems to obtain services. For example, in some medical settings, substance users are denied access to care until achieving abstinence, which creates a vicious cycle and prevents the receipt of services. Harm reduction programs accept that individuals may not become abstinent. In doing so, harm reduction programs may improve access to services by providing non-judgmental environments to facilitate behavior change and providing alternative measures of success.
The harm reduction model tends to oppose the traditional medical model.11 For example, harm reduction is grounded in a philosophy that embraces individuals as experts. This contradicts the medical model that relies on the authority, expertise, and specialized knowledge of medical providers. Additionally, harm reduction providers view their roles as information resources, educators, advocates, and guides for services. In contrast, medical providers' roles are to prescribe treatment and care. With these differences in philosophical frameworks, our collaborative program specifically incorporated the harm reduction model into medical care.
The Health Services Program is a collaborative program that blends harm reduction and medical care between a harm reduction community-based organization (CitiWide Harm Reduction) and an academic medical center (Montefiore Medical Center). The Health Services Program is an umbrella program that consists of several grant-funded harm reduction and medical programs. Rather than there being one lead organization, the Program is a true collaboration, with medical staff employed by Montefiore and supportive staff employed by CitiWide. Additionally, funding that supports components of the Health Services Program is awarded to both Montefiore and CitiWide.
The Health Services Program provides comprehensive care to unstably housed substance users with or at-risk for HIV infection. Evolving from several years of service modification to expand and enhance participants' access to medical care, the Health Services Program now provides a variety of medical and supportive services (see Table 1). Medical services include medical outreach; comprehensive HIV care; acute care; gynecological care; vaccinations; Hepatitis C Virus testing, assessment, and treatment; HIV counseling and testing; and referrals to specialty care. Supportive services include health education, supportive counseling, escorts, care coordination, and referrals for social services. Services are now provided in three locations: single room occupancy (SRO) hotels, Montefiore's Community Health Center (CHC), and CitiWide's drop-in center.
The majority of Health Services Program participants reside in single room occupancy (SRO) hotels. In New York State, individuals with symptomatic HIV or AIDS are eligible for housing placement through the Human Resources Administration (HRA).12 Individuals in need of emergency housing are placed in commercial SRO hotels. These hotels are typically dormitory-like buildings in which individuals are assigned a small room with a bed and dresser, shared bathrooms, and (occasionally) shared cooking facilities. Single room occuppancy hotels are generally poorly maintained; many are infested with cockroaches, and are common sites of drug use, sex work, and violence. Individuals are often housed in one SRO hotel for 28-90 days, and then must return to HRA to be re-housed again in the same or different SRO hotel for another 28-90 days, a cycle that may repeat many times.
the university teaching hospital of the Albert Einstein College of Medicine, has over 20 community-based health centers throughout the Bronx. The largest community health center (CHC) is located in a neighborhood with very poor health indicators, including high HIV and drug-related mortality rates.13 The CHC, which provides a wide array of primary and specialty care services, is the medical home of the Health Services Program. The CHC also provides comprehensive HIV-specific services to over 400 HIV-infected individuals. The HIV team at the CHC includes a nutritionist, adherence counselor, pharmacist, psychiatrist, social worker, and three HIV-experienced general internists.
a harm reduction community-based organization in the Bronx, has provided outreach and social services since 1995. CitiWide's participants are substance users with or at-risk for HIV infection, who reside in SRO hotels in New York City. Services provided at CitiWide's drop-in center include medical care (via the Health Services Program), syringe exchange, case management, holistic therapies, group support, mental health care, permanent housing placement, peer education and training, and respite care (safe space, meals, showers, self-care supplies). CitiWide employees are similar to the population they serve, with many having personal histories of homelessness, substance use, and HIV infection.
In 1995, CitiWide staff noted that SRO hotel residents received little medical care despite their heavy burden of HIV-related illnesses. Seeking to improve access to medical care among SRO hotel residents, CitiWide explored partnerships with several different medical institutions. In 1996, medical providers from Montefiore volunteered with CitiWide's evening outreach team delivering door-to-door care in SRO hotels. In 1999, CitiWide formalized the collaboration with Montefiore through a grant sub-contract, which led to regular integration of medical providers into the evening outreach team. Since that time, medical services have significantly expanded, leading to the establishment of the Health Services Program.
Since evening outreach in SRO hotels began in 1996, it has continued and expanded from one to four evenings per week. Led by CitiWide staff, the outreach team goes door-to-door offering harm reduction education, syringe exchange, personal care supplies, and referrals to medical and support services. As members of the outreach team, medical providers engage residents around medical care, perform triage and evaluation, and encourage residents to seek more comprehensive care through enrollment in the Health Services Program.
In 2001, we secured additional funding to establish the SRO hotel room-based program in which comprehensive HIV care is delivered in SRO hotel rooms. Montefiore's medical providers perform history and physical exams, and provide prescriptions, vaccinations, and limited blood tests. CitiWide's supportive providers visit SRO hotels to engage individuals around health care, and address barriers to accessing care. Visits in SRO hotel rooms are either scheduled ahead of time, or are same-day appointments. Key elements of delivering medical care in SRO hotels have been consistency and accessible services. When the same medical provider arrives on the same day of the week, at the same hour to deliver services, SRO hotel residents anticipate the provider's presence. This consistency facilitates a trusting relationship, which is crucial when providing medical care for marginalized populations.
Montefiore's CHC is the medical home of the Health Services Program, yet several barriers to receiving care at the CHC have been identified. Examples of barriers included lack of transportation, inability to access the CHC via telephones, long waits for appointments, long lines and waiting times, and insensitive CHC staff. We developed strategies to reduce barriers, which included providing transportation, next-day appointments, CHC registration prior to visits, designated appointment slots for Health Services Program participants, and incentives (food coupons) for keeping appointments. In addition, all appointments at the CHC were with medical providers familiar to Health Services Program participants. These providers also conducted outreach in SRO hotels, provided care in SRO hotels, and provided care at CitiWide's drop-in center. Additionally, Health Services Program providers (medical and supportive providers) frequently joined the CHC's staff meetings to address problems as they arose.
With the growth of Citi-Wide from 1998 to the present, participants requested health care services at CitiWide's drop-in center. To address this request, in 2002, we piloted medical care provision at CitiWide's drop-in center, and subsequently established this component of the Health Services Program after securing additional funding in 2003. The provision of medical care within CitiWide's drop-in center is modeled on the empirically demonstrated success of services for marginalized populations integrated into a single location.14-16 Important elements of this component of the Health Services Program include (a) same-day appointments to provide immediate access to medical care; (b) care delivered by familiar providers (those who conduct evening outreach, provide care at SRO hotels, and provide care at Montefiore's CHC) to build trusting patient-provider relationships; (c) transportation to appointments for those who lack transportation; and (d) supportive services providing assistance navigating health care systems and facilitating retention in medical care.
Because the harm reduction model emphasizes inclusion and reflection of the community served,11 we developed the Health Services Program in line with this principle. The majority of Health Services Program staff members are Black and Hispanic, and four are bilingual Spanish/English-speaking. CitiWide supportive staff is based at CitiWide's drop-in center with daily outreach responsibilities to the SRO hotels. Montefiore medical staff split their time among SRO hotels, Montefiore's CHC, and CitiWide's drop-in center. To coordinate participants' care and address the Health Services Program's evolving needs, conferences occur weekly. The supportive staff members also routinely interact with other CitiWide program staff (e.g., case managers) to ensure participants' needs are met.
The success of the Health Services Program has largely been due to on-going re-examination of the harm reduction/medical collaboration through regular communication among Health Services Program staff, and between Montefiore and CitiWide administrations. Given the two opposing models of care, the common goal of engaging and retaining participants in medical care has been essential to successful collaboration. The harm reduction model is uncommon in traditional medical settings, yet it creates an environment in which participants feel comfortable setting agendas for their medical care. This participant-driven environment has been a driving force in program evolution. Other factors contributing to the successful growth of the Health Services Program include ongoing evaluation led by the Health Services Program directors, and applying evaluation findings to program modification.14,17-19 The integration of medical and supportive services, and the co-location of medical services in a broader social service organization also contribute to the Health Services Program success.
With limited financial resources and increasing and changing demands for services, retention among the Health Services Program supportive staff has been difficult. Other factors contributing to poor retention include personal challenges such as substance abuse or mental health issues. Despite these staffing challenges, the medical and administrative directors and medical providers have been stable for several years. Integrating a medical program into a harm reduction organization has been challenging from the beginning, yet it has served as the cornerstone of the Health Services Program evolution. In addition to the collaboration's practical and economic struggles, the difficulty of merging philosophies has fostered mutual respect and growth.11
The next step of program evolution will focus on understanding participants' services utilization, particularly that of infrequent users. Analysis of medical services utilization such as emergency room visits, hospitalizations, and antiretroviral medication utilization is also warranted. Ultimately, we hope to demonstrate improved health outcomes among Health Services Program participants. Currently, all of the medical and supportive services are grant-supported. To maintain a sustainable program we must consider establishing a clinic that will allow for revenue generation to support medical service provision.
Uniquely tailored medical programs providing culturally appropriate, sensitive and respectful care can address HIV health care disparities among some marginalized populations, including substance users, the unstably housed, and communities of color. The Health Services Program, a unique medical program providing comprehensive HIV care to these marginalized individuals, is one example of successful collaboration between a harm reduction community-based organization and an academic medical center aimed at reducing HIV health care disparities.
This report was supported by the Centers for Disease Control and Prevention, Minority HIV/AIDS Research Initiative, (#U65/CCU223363-03), the Health Resources and Services Administration, HIV/AIDS Bureau, Special Projects of National Significance (#H97 HA 00247-03), and the Center for AIDS Research at the Albert Einstein College of Medicine and Montefiore Medical Center funded by the National Institutes of Health (NIH AI-51519). In addition, the program received support from Ryan White Title I funding via the Medical and Health Research Association of New York City, HIV Care Services (#00-OMS-165, #03-HRC-748) and the Housing Opportunities for People with AIDS. Dr. Cunningham is also supported by the Robert Wood Johnson Foundation's Harold Amos Faculty Development Scholar Program.