ADAPTING 

YOUR PRACTICE 

Treatment and Recommendations 

for Homeless Patients 

with HIV/AIDS 

Pocket Guidebook 
CREDITS: 

This condensed pocket guidebook was adapted by the 

HRSA/HAB Homelessness and Housing Workgroup using 

the original document authored by the NHCHC Advisory 

Committee on Adapting Clinical Guidelines for Homeless 

Patients with HIV/AIDS 

Conanan B, London K, Martinez L, Modersbach D, O’Connell J, O’Sullivan M, 

Raffanti S, Ridolfo A, Post P, Santillan Rabe M, Song J,Treherne L. Adapting Your 

Practice:Treatment and Recommendations for Homeless Patients with HIV/ 

AIDS, 62 pages. Nashville: Health Care for the Homeless Clinicians’ Network, 

National Health Care for the Homeless Council, Inc., 2003. 

DISCLAMER 

The information and opinions expressed in this pocket guidebook are 

those of the Advisory Committee for the Adaptation of Clinical Guidelines 

for Homeless Patients with Asthma, not necessarily the views of the U.S.

Department of Health and Human Services, the Health Resources and 

Services Administration, or the National Health Care for the Homeless 

Council, Inc.

ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with HIV/AIDS

(NHCHC) National Healthcare for the Homeless Council, Inc. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

INTRODUCTION 

Adherence to complex HIV treatment regimens presents 

special challenges for homeless patients and their caregivers. 

Many homeless people lack regular access to food, water, 

and other resources needed to facilitate adherence. Mental 

illness and chemical dependence present special challenges to 

developing and adhering to a plan of care. Nevertheless, there 

are no absolute contraindications to antiretroviral therapy. 

While it is important to prescribe HIV therapy for homeless 

patients desiring treatment who have demonstrated regularity 

in their daily routines, it is just as important to ensure the 

most effective non-antiretroviral HIV care (i.e., prophylaxis 

and treatment of comorbidities) for all HIV-infected 

patients, including those with more chaotic lives, for whom 

antiretroviral treatment is not yet appropriate. Social support 

is an essential component of HIV care for all patients who are 

homeless, many of whom lack family or friends to help them 

cope with the added stress of serious illness. 

Clinical practice guidelines for people with HIV/AIDS who are 

homeless are fundamentally the same as for those who are 

housed. Nevertheless, primary care providers who routinely 

serve homeless patients recognize an increased need to 

take their living situations and co-occurring disorders into 

consideration when working with their patients to develop a 

plan of care. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

MODEL OF CARE 

Service Delivery Design 

• Flexible service system – “One size-fits all” 

system of care is inadequate to meet the complex needs 

of homeless people. Identify and resolve system barriers 

that impede access to care, recognize that some barriers 

are not within the patient’s capacity to control. Don’t 

focus on what the patient is not doing; instead focus on 

what service providers can offer to enable homeless 

patients to obtain effective treatment such as assuring 

service flexibility and providing appropriate medical 

assistance to anyone who walks into the clinic. Be 

creative! 

• Integrated, interdisciplinary model of care – 

Successful initiation and maintenance of HIV therapy 

requires a holistic approach to care provided by an 

interdisciplinary clinical team. The patient is an essential 

member of this team. Optimally, medical and 

psychosocial services should be easily accessible at the 

same location; fragmented service systems do not work 

for homeless people. Coordinate medical and 

psychosocial services across multiple disciplines. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

MODEL OF CARE 

Service Delivery Design continued 

• Access to mainstream health system – Full 

collaboration between primary care providers and 

specialists is the only effective treatment and 

management strategy. Problems that distinguish 

homeless HIV patients from others are primarily system 

and provider access problems, rather than client 

problems or differences in intent or desire to adhere to 

plan of care. 

ENGAGEMENT 

• Outreach – Use outreach workers. Offer diagnostic 

testing and treatment at outreach sites whenever 

possible. Remember that unmet basic needs may prevent 

a person from seeking health care. Promote engagement 

by including nutritious snacks as part of outreach. Use a 

“revolving care manager” to help them connect with 

available health and social services. Work with religious 

leaders and faith communities (“health ministries”). 

Maintain a consistent presence in places where 

homelessness people congregate. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

MODEL OF CARE 

Engagement continued 

• Clinical team – The clinical team should include 

professionals and paraprofessionals with strong 

engagement skills who make themselves available to 

listen to patients and help them address obstacles to 

care.This team member should see the patient first. 

Address psychosocial barriers to health as well as 

medical issues, employing an intensive case management 

model. 

• Therapeutic relationship – Nonjudgmental and 

supportive patient interactions with all members of the 

clinical team are essential to successful engagement. 

Listen to their concerns and engage with their interests. 

Realize that seeing the same provider over time 

facilitates engagement. Take good care of professional 

staff to promote provider retention and continuity of 

patient care. Recognize that engagement of homeless 

patients often takes a long time. Be patient and spend 

time getting to know your patients. Success should be 

measured in small increments. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

DIAGNOSIS & EVALUATION 

History 

• Living conditions – Ask where patient is staying. 

Explore access to food, water, restrooms, place to store 

medications, exposure to toxins, allergens, infection; 

threats to health/safety. Be alert to possible 

homelessness. 

• History of homelessness – What precipitated it: 

whether first time, episodic, chronic. History of foster 

care (“Has your child ever had to live away from you?”) 

• Psychosocial History – Obtain a detailed social 

history. Ask about the patient’s family, extended family 

and current social supports to determine the 

patient’s degree of isolation. Ask if they have thought 

about who might make decisions for them if they get 

very sick and have to go to the hospital. 

• Regular activities – Ask if the patient has any sort 

of schedule or daily routine. How many meals did you eat 

yesterday? Do you get up at a certain time? Explore 

evidence of consistency in the patient’s life to assess 

whether a medical regimen can be integrated into his/her 

regular schedule of activities. 

• Previous providers – What worked well? Does patient 

have regular source of primary care? 

• Mental health history – Ask whether the patient has 

ever been treated or hospitalized for a mental health or 

substance use problem and if s/he is currently taking 

psychotropic medications. Explore the patient’s strengths 

and weaknesses, stressing positive assets. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

DIAGNOSIS & EVALUATION 

History continued 

• History of abuse/current risk – Assess for a history 

of emotional, physical or sexual abuse and exploitation. 

Ask all patients if they have ever been physically hurt, 

afraid of being hurt, or made to do things sexually they 

didn’t want to do. Assess for violence, abusive 

relationships, and patient safety. 

• Alcohol/nicotine/other drug use – Ask about current 

and previous use of alcohol and drugs, including nicotine. 

(amount, frequency, duration) Look for signs of substance 

abuse/dependence. Obtain a history of intravenous 

drug use and alcohol consumption to assess the patient’s 

risk for HIV, hepatitis, and liver damage. Asking questions 

in a nonjudgmental manner establishes rapport and 

makes it easier for patient to talk about substance use. 

• Legal/history of violence – Legal problems, violence 

against persons or property, domestic/interpersonal 

violence, history of arrest/incarceration, treatment while 

incarcerated. 

• Work history – Longest time held a job, occupational 

injuries, vocational skills and interests. 

• Literacy – If “trouble reading,” offer help with intake 

form; assess ability to read English. 

• Nutrition/ hydration – Diet, food resources, 

preparation skills, liquid intake. 

• Community – Ask questions to elicit information about 

the patient’s cultural heritage and religious or spiritual 

history and affiliation. Some patients can be contacted 

through faith communities. Ask about attitudes of the 

patient’s family, friend, community and cultural group 

toward HIV risk behaviors and person. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

DIAGNOSIS & EVALUATION 

Physical Examination 

• Comprehensive exam – At 1st encounter if possible, 

following standard clinical guidelines. 

• Serial, focused exams – For patients uncomfortable 

with full-body, unclothed exam at 1st visit. 

• Dental assessment – Age appropriate teeth, obvious 

caries, dental/referred pain, diabetes patients.

• Special populations – Victims of abuse, sexual 

minorities. 

• Homeless women – Female patients should have 

the option of being examined by a health care provider 

of the same sex. High percentages of poor and homeless 

women have been victims of physical or sexual abuse. 

Close evaluation to detect carcinoma insitu, pregnancy 

detection and other gynecological evaluations should be 

performed. 

• Signs & Symptoms of HIV – These may include oral 

thrush, shingles, dermatitis, Kaposi’s sarcoma, tuberculosis, 

diarrhea, and recurrent fevers. Symptoms of dehydration 

and weight loss can be exacerbated by homelessness. 

• Neurological/psychiatric evaluation – A thorough 

neurological examination and mental health evaluation 

are critical. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

DIAGNOSIS & EVALUATION 

Diagnostic Tests 

• HIV test – Offer testing to client, and to partners and 

children of the HIV-positive client; encourage use of 

oral and rapid testing technologies. Offer pre- and posttest counseling in accordance with CDC guidelines. 

• Confirmatory HIV test – If HIV test is positive, 

confirm result using Western blot or 

immunofluroescence assay. 

• Baseline labs – Perform baseline laboratory tests 

as specified in standard clinical guidelines, including a 

CBC, electrolytes, glucose, BUN, creatine, liver function 

tests (LFTs), lipid studies and urinalysis. Pay attention 

to LFTs, as this population is at high risk for liver damage 

secondary to hepatitis and/or alcoholic cirrhosis. 

• Viral load – Perform a virologic test (e.g., HIV RNA) to 

determine viral load only on clients with confirmatory 

HIV positive test. 

• Resistance assay – Consider drug resistance testing 

(genotyping or phenotyping) for clients with acute HIV 

infection, treatment naïve clients, and those who have 

failed or not responded optimally to antiretroviral 

treatment regimens. 

• Tuberculosis testing (PPD) – For those who test 

positive, follow up with a baseline chest X-ray and 

symptom screen every 6 months, re-check clients who 

test negative every 6 months. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

DIAGNOSIS & EVALUATION 

Diagnostic Tests continued 

• Hepatitis C test – Due to the high prevalence of 

hepatitis C in this population, a hepatitis C test 

should be done on initial screening for every HIV 

infected person, and is especially recommended for 

injection drug users and their partners. 

• Pap smear – To be done twice in the first year 

after HIV diagnosis, and yearly after that. Women 

who have frequent STI’s, multiple partners, or who 

exchange sex for goods should have a Pap smear 

every 6 months. HIV-infected women with abnormal 

Pap smears or inflammation that does not respond to 

treatment should be referred for colposcopy. 

• Pregnancy test – Offer pregnancy testing (UCG 

urine test) to heterosexually active female clients of 

childbearing age. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Plan of Care 

• Next Steps – Develop an agreed-upon plan of care 

with the patient’s active involvement. 

• Interdisciplinary team – Interdisciplinary clinical 

team managed by the patient, including addiction mental 

health counselors, a medical care manager, and a 

treatment advocate. 

• Basic needs – Food, clothing, housing and mental health 

issues may be perceived as more important. Develop an 

individualized plan of care with patient to incorporate 

strategies to meet needs. 

• Patient priorities & goals – Address immediate 

medical needs first (the patient’s reason for the visit) 

rather than underlying causes. Encourage the patient to 

specify his/her own goals and prioritize issues to be 

addressed. 

• Governmental assistance – Patient applies for Ryan 

White Comprehensive AIDS Resources Emergency 

(CARE) Act services, Housing Opportunities for Persons 

with AIDS (HOPWA), disability assistance (SSI/SSDI), 

Medicaid, Food Stamps, and any other programs that 

facilitate access to health and social services. 

• Communication – Explanation in simple language. Use 

an interpreter and/or lay educator to facilitate 

communication. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Education, Self-management 

• Basic education about HIV – Provide answers to 

basic questions about HIV: What is the virus? What is it 

doing in your body? Why do you need medications? 

Educate patients about the natural course of the disease. 

Teach homes patients how to know if they are sick, 

how to tell if the illness is more serious than a cold, how 

to care for themselves when sick, and when to seek 

urgent or emergent care. Educate them about warning 

signs of HIV complications. Tell patients where they can 

go to get medicine and where they can go to recuperate 

when ill. Explain that the more advanced their disease is, 

the more preventive medications will be required to keep 

them from getting sicker. 

• HIV transmission – Explain how the virus can be 

passed. Stress the need for protection, even after 

beginning HIV treatment, in sexual relationships 

(condoms and other contraception, abstinence) and with 

self-administered injections (cessation of any sharing 

of drug paraphernalia, participation in a needle exchange 

program). 

• Prevention – Discuss ways to reduce HIV risks for the 

patient and others. Know what is really happening to the 

patient’s life; then try to figure out how you can help 

behavioral change occur within the context. Teach safer 

practices to injection drug users unwilling or unable to 

stop using drugs. Provide general sexual reproductive 

health education and counsel the patient about safer sex 

practices. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Education, Self-management continued 

• Addiction management – Find out how patients with 

chemical dependencies use psychoactive substances. 

Identify strategies already employed to manage illicit drug 

or alcohol use and apply them to HIV treatment 

adherence, substituting HIV medications for other drugs. 

• HIV therapy – Inquire about the patients’ 

understanding of HIV therapy. Highly active antiretroviral 

therapy (HAART) can be as effective for highly motivated 

persons who are homeless as for those who are housed. 

Explain what CD4 counts and viral loads are, and how 

these measurements are used to help determine how 

advanced the patients’ disease is, predict risks of 

complications and monitor treatment adherence. 

• Drug resistance – Explain the risk of developing 

resistance to HIV medications if they are not taken 

consistently or appropriately. 

• Patient treatment advocates – Use social workers, 

nurses, or case managers as treatment advocates. 

Treatment advocates should be part of an integrated 

clinical team and treated as peers by medical providers. 

Consider using consumer advocates (formerly homeless 

persons) to accompany homeless HIV patients to 

appointments. 

• Directly observed therapy – DOT is recommended 

for patients with co-occurring tuberculosis, substance use 

disorders, and/or mental illness, but can present staffing 

and transportation challenges when patients must take 

psychiatric medications 2-3 times per day. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Education, Self-management continued 

• Side effects management – Recognize that 

medication side effects are a primary reason for lack 

of adherence to HAART. Be candid about possible 

side effects of antiretroviral treatment. Provide snacks to 

help the patient avoid this side effect and promote 

adherence to treatment. 

• Urgent medical problems – Help patients 

understand the difference between common medication 

side effects and symptoms of life threatening toxicities. 

• Supportive relationships – Encourage a supportive 

relationship with a social worker, provider, or friend. Link 

the patients with a support person or “sponsor” 

through HIV/Substance abuse treatment programs or 

other community-based programs. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Education, Self-management continued 

• Nutrition counseling – Educate patient about 

nutritional health, diet and dietary supplements. If 

possible, include a nutritionist familiar with the issues of 

homelessness on the interdisciplinary health team to do 

screening and frequent consultation. Prescribe 

multivitamins with minerals. Ensure that pregnant 

patients receive appropriate vitamin supplements. 

Consider prescribing nutritional supplements with less 

familiar brand names and lower resale values to reduce 

risk of theft. 

• Medical home – Discuss benefits of forming 

relationships with care providers who can help the 

patient avoid becoming acutely ill. Present regular 

primary care as an opportunity to be in charge of one’s 

own health. 

• Support groups – Members of ethnic/sexual minorities 

and migrant workers may experience more 

marginalization and isolation than other homeless 

individuals with HIV. Help such patients find each other 

for mutual support. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Medications 

• Priorities – If acute retroviral syndrome is not 

suspected or if early HIV treatment is not warranted for 

other reasons, deal with other medical priorities first. 

• Prophylaxis – Start prophylaxis for opportunistic 

infections as soon as indicated by standard clinical 

guidelines. Explain the importance of opportunistic 

infections prophylaxis at each visit, if the patient is not 

initially interested or willing to accept preventive 

treatment. 

• Immunizations – All homeless patients should 

receive influenza vaccine annually and be immunized 

against pneumococcus according to standard clinical 

guidelines. Also provide hepatitis A and B vaccines and 

update tetanus (Td) if the last immunization is more 

than 10 years old. 

• HIV treatment readiness – Never rush to 

antiretroviral treatment; build a therapeutic relationship 

first. Encourage more frequent visits to prepare 

homeless/formerly homeless patients for treatment. 

Address issues that may complicate treatment adherence. 

Be knowledgeable about HIV treatment alternatives and 

when to use them. Homeless individuals should have the 

same access to HIV medications as others. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Medications continued 

1. Nucleosides 

a. Lamivudine (Epivir® or 3TC) 

b. Didanosine (ddI or Videx®) 

c. Tenofivir (Viread®) 

d. Stavudine (D4T or Zerit®) 

2. Non-nucleosides 

a. Nevirapine (Viramune®) 

b. Efavirenz (Sustiva®) 

3. A Protease Inhibitor – taken once a day is expected to 

be available soon. 

4. An Antiretroviral that can be taken twice daily Trizivir 

(combination of AZT, 3TC and Abacavir in one pill) 

taken twice daily offers a low pill burden that is easy to 

tolerate. However, recent data suggest Trizivir alone 

does not completely suppress the virus so it must be 

taken with a NNRTI such as Efavirenz or with a Protease 

Inhibitor. 

5. Pill packs-Consider providing “blister packs” for all 

medications, labeled for each day of the week, each meal 

per day. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Medications continued 

• Side effects – Awareness of the patient’s access to 

regular meals is important because some HIV 

medications must be taken with food. Prescribe 

medications with fewer/less severe GI and other side 

effects. Nausea, which often results from taking 

medications on an empty stomach, may also be 

incapacitating; providing nutritious snacks can prevent 

this side effect. Address the likelihood of diarrhea with 

certain protease inhibitors (e.g., Nelfinavir) and provide 

anti-diarrhea medication for patients with symptoms. 

• Drug toxicities – Be aware of serious toxicities that 

can occur with Highly Active Anti-Retroviral Therapy 

(HAART) 

Common side effects of HAART include: 

1. diarrhea (particularly from some protease inhibitors) 

2. nausea (if taken on an empty stomach) 

3. peripheral neuropathy (numbness/tingling in 

extremities, exacerbated by poor nutrition and 

constant walking) 

4. nightmares 

5. Pancreatitis, lactic acidosis, and severe anemia 

are other medical emergencies that can be caused by 

antiretroviral medications. 

• Drug interactions/contraindications – Chronic 

illness may complicate HIV treatment because of the 

potential for drug-drug interactions. 

• Some medications may be contraindicated if the 

patient has history of pancreatitis or alcoholism. 

• Some medication should be used with caution and 

more frequent monitoring with co-occurring mental 

illness, Hepatitis C, high cholesterol, or diabetes. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Medications continued 

• HAART can also exacerbate pre-existing diabetes. 

All persons on antiretrovirals for HIV should be carefully 

monitored for the development of glucose intolerance 

and diabetes, as well as for lipid abnormalities and 

lipodystrophy. 

Drug resistance 

• Be cautious about prescribing HAART for homeless 

adolescents and youth because of their higher risk for 

drug resistance if unable to adhere to treatment. 

• Resistance is not always indicative of non-adherence; 

mutation of the organism can occur even if the patient 

adheres to treatment. 

HIV treatment and substance use 

• Recognize that alcohol and drug use are common 

among homeless people, and prescribe medications that 

are compatible with substances used. 

• Knowing that medications can prolong life can give 

patients hope and motivate lifestyle changes to promote 

health. 

• Most important, maintain communication with them. 

• Successful HIV treatment is not only possible, but 

extremely desirable for homeless people with chemical 

dependencies. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Associated Problems, Complications 

• Medication side effects – Medication side effects are a 

primary reason for non-adherence to antiretroviral 

treatment. Common side effects of HAART include 

diarrhea, nausea and peripheral neuropathy. Be more 

aggressive with homeless patients in treating side effects 

or changing medications, if an equally effective alternative 

is available. 

• Severe drug toxicities – Some HIV infected patients 

receiving antiretroviral therapy experience symptoms 

of life threatening toxicity, which can be fatal if drugs are 

continued (for a comprehensive summary see www.who 

int/docstore/hiv/scaling/anex11b.html.) 

• More acute illness – Homeless people with HIV 

may not seek care until their disease is advanced and 

symptomatic. New patients with advanced AIDS are not 

unusual, and require complicated treatment regimen. 

Major complications include late stage opportunistic 

infections such as Pneumocystis carinii pneumonia (PCP), 

invasive candidal infection, toxoplasmosis, and 

cryptococcal meningitis. 

• Mental illness/substance abuse – Mental illness, 

substance use and HIV are frequently linked. Underlying 

mental illness (both Axis I and Axis II disorders) and drug 

induced psychosis can interfere with treatment. 

Overlapping side effects are more problematic than drug 

interactions. 

• Cognitive impairment – Patients may have difficulty 

remembering appointments; cognition should be 

evaluated. Cognitive impairment may be associated with 

mental illness, chronic substance abuse, AIDS related 

dementia and/or opportunistic infections. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Associated Problems, Complications continued 

• Tuberculosis/Hepatitis – Homeless shelters are 

among the most likely sites of TB transmission, and 

growing numbers of HIV-infected persons have 

contributed to the resurgence of tuberculosis in the 

United States. Some homeless persons (especially 

injection drug users) are at increased risk for hepatitis. 

Hepatitis C (HCV), hepatitis B, and HIV are chronic, 

potentially fatal diseases that can be symbiotic. 

• Pregnancy – HIV-positive pregnant women should 

receive HAART for themselves and to prevent 

transmission of infection to the fetus. It is important to 

develop good consulting relationships with obstetricians 

to help pregnant homeless women with HIV. 

• Lack of stable housing – HIV treatment is extremely 

difficult for individuals without stable housing. Meeting 

needs for food and shelter leave little time for medical 

appointments. Homeless persons need a stable 

residence and a routine in order to begin recovering. 

• Barriers to health insurance/disability assistance – 

There are many barriers to obtaining public benefits, 

including health insurance and disability assistance. 

Entitlement programs in many States and localities 

require extensive documentation, including photo 

identification, birth certificates, and social security cards, 

to verify eligibility. Proof of identity, residence and 

income is difficult to obtain for homeless persons. Most 

homeless people (particularly adults not having children) 

do not qualify for Medicaid under current policy. In most 

States, except for pregnant women and children, Medicaid 

eligibility is linked to SSI for persons with disabling 

conditions including HIV/AIDS. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Follow-up 

• Contact Information: At every visit, seek the 

following contact information for the patient. 

a. A family member 

b. Friend with a stable address 

c. The shelter where the patient is currently staying 

d. Location where he/she might be found 

e. Case manager and health care providers 

• Clinical Visits: 

A clinician should be available 24 hours a day. 

1. Drop-in system – Create a routine drop-in time at 

primary care clinics with no appointment required 

for new patients. 

2. Help with appointments – Recognize that a 

homeless patient may be forced to miss a meal at a 

soup kitchen if the clinic appointment runs past 

serving hours. 

3. More frequent follow-up – Try to see homeless 

patients more frequently. 

a. Follow-up intervals also depend on comorbidities. 

b. Develop a therapeutic relationship. 

c. Reinforce the patient’s understanding of the plan 

of care repeatedly. 

d. Review adherence; give the patient a pillbox, if 

desired. 

e. Ask if medications were missed and if so, why 

they were missed and what happened (e.g., stolen, 

forgot to take them while binging). 

f. Frequent contact encourages patient bonding and 

willingness to return to the clinic on a drop-in 

basis. 
ADAPTING YOUR PRACTICE:

Treatment and Recommendations for Homeless Patients with 

HIV/AIDS

PLAN & MANAGEMENT 

Follow-up continued 

• Intensive case management – Use clinical team to 

support the patient and promote continuity of care, 

which is essential for good HIV care. Visit inpatients daily 

to reinforce engagement, facilitate discharge planning 

with follow-up. Encourage discharge to nursing 

recuperative care facility, if available. Establish and 

maintain contact with other service providers who know 

your patient. Ask the patient to sign a release, in 

compliance with HIPAA requirements, so that you share 

health information with other clinicians and service 

providers. Information sharing is important, particularly 

during transition from homelessness to transitional 

housing to identify any variations in the patients’ behavior. 

• Transportation – Provide transportation to and from 

specialty referrals. Arrange to pick up new patients and 

those unable to come to the primary care clinic on their 

own.