For people living with HIV, the goal is to become “undetectable,” to suppress the virus so much that it’s untransmittable and that a blood test would not even distinguish it.
Modern drugs make this possible — when a person takes them every day.
But many of the patients who find their way to an HIV “medical home” in a nondescript, beige-brick building in east Denver don’t manage to fill their prescriptions or take their antiretroviral therapy pills regularly. That’s because they have more pressing problems — like where to sleep and how to get food.
About 170 of the 750 patients who are receiving case management services through Vivent Health’s clinic, which also provides medical, dental and behavioral health care, are homeless. An additional 300 are at risk of losing their housing.
For years, the medical nonprofit tried to help its homeless patients by linking them to local housing agencies. But the volume was so large that, two years ago, Vivent created its own housing department and voucher program, with a team of case managers who help move people off the streets and into apartments, or provide monthly rent assistance to protect them from eviction and foreclosure.
“We can all imagine that if we don’t know where you’re going to lay your head at night, it’s almost impossible to follow through on any other medical well-being, or really any other goals in life,” said Brooke Murray, Vivent’s housing programs manager. “You are in constant survival mode. You’re not thinking ahead about how to make a doctor’s appointment next week or taking medicines.”
It’s hardest for those living outside in encampments, where belongings are often stolen, or lost in the chaos of constant moving.
“Or there’s a sweep, and everything’s gone — the syringes are gone, the medicines are gone. So then they start all over again,” said Lyssa Towl, who directs Colorado operations for Vivent, a health care nonprofit that began as an HIV and AIDS prevention and treatment clinic in Wisconsin and now operates in five states.
The Denver office’s outreach work includes sending a team of workers into encampments, where they offer syringes so people injecting drugs can use clean needles, the opioid-antidote naloxone and HIV tests.
“They’re in white mom vans, and they do harm reduction, trying to stop the spread of disease,” Towl said. “They literally pull up to the encampments and walk the encampments and help people. We pick up syringes. We retrieve 80% of the syringes we give out. In Denver, if you’re down on the river at REI, and you’re not walking over syringes, it’s because my folks are out there picking them up.”
HIV rates have been rising in Colorado
While an HIV diagnosis was considered a “death sentence” decades ago, the virus is now preventable, through a drug called PReP, and treatable, through a combination of daily medications that suppress the virus.
After years of declining HIV rates, Colorado over the past five years has seen a rise in the number of people diagnosed with the virus and the rate of new cases per 100,000 people. The state has 14,903 people with HIV, including 428 who were diagnosed with the virus last year, according to data collected by the Colorado Department of Public Health and Environment.
All of Vivent’s patients have HIV or are at risk of contracting the virus, which is transmitted through unsafe sexual practices and injecting drugs. Some are part of the LGBTQ community, and a smaller portion are women who immigrated from African countries and contracted the virus from their husbands.
Among those who are chronically homeless, many had given up on treatment — and given up on housing.
“Not everybody is ready to be housed the moment you come in and offer them housing,” Murray said. “They have built that community, and that trust, and of a lifestyle of living in places that are not typically meant for human habitation.
“When a lot of our clientele was first diagnosed, it was something of a death sentence, so their life became very much just surviving until they died. And we really get to step in and say, ‘No, you can thrive, and we’re here to help you get to that point.’”
Unstable housing reduces the likelihood of viral suppression by 51 percentage points, according to a 2018 study. Vivent has a 93%-96% viral suppression rate for people in its housing programs who have been in housing for at least three months, according to the nonprofit’s data. That’s close to Vivent’s overall 96%-98% undetectable rate for patients, housed or unhoused, who have been coming to the health clinic for at least six months. About 2,000 people visit the Denver office for medical appointments.
Since Murray built up Vivent’s housing department, the team has housed 65 people in two years. The team not only goes along during inspections to make sure the apartments are clean and safe, they check in on clients every few months to make sure they are keeping up with the lease agreements.
For one client who had lived outside for years, Murray’s team created a chart to designate what the person needed to clean daily, weekly and monthly.
Unlike other voucher programs, Vivent will house people who are not living in the country legally and if they are struggling with addiction, Murray said. “All people deserve to be housed, regardless of their use or their past,” they said. “It should be a human right to be housed and that’s what we actively try to do.”
From September 2022 through August, Vivent has paid $818,338 in housing payments and vouchers to keep 390 people in Denver from homelessness.
“You don’t got time to be taking some medicine”
A patient named Sherry, who goes by the nickname “Touch,” said she didn’t take her HIV medication when she lived on the streets. “You don’t got time to be taking medicine,” she said. “You ain’t got nowhere to take it. What are you going to do? Take it with some soda pop at the corner store?”
Touch, who wears fuzzy pink slippers and a long, thick braid over one shoulder, lives in an apartment near the Vivent office with her black cat, Snowball. She cruises over to the clinic every day or two on her electric wheelchair — for appointments, the pharmacy or the on-site food bank.
At the food bank, people can fill their bags and backpacks with apples and pears, fresh vegetables delivered by Colorado farmers, and bread donated by King Soopers. There’s a freezer with meat and shelves filled with pancake mix and soup, toilet paper and laundry detergent. Next to the toothpaste, there’s a stack of business cards for Vivent’s dental clinic, which is a suite of exam rooms and labs in one corner of the building.
This food bank has far fewer rules than most. People can come as many times each week as they want. They can shop for whatever they want, and it’s up to them to define what they consider their family. There is no requirement that someone provide proof of how many people are in their household.
“Family is family,” Murray said. “Especially within the LGBT community, typically with our older folks who felt a lot of stigma about having a same-sex partner, so we don’t ask for proof of that.”
Between the waiting room check-in desk and the doors to the food bank, sits a shelf of free snacks — bags of Goldfish and fruit bars that entice people to come closer to the food bank. Everyone is welcome to shop there, but it often takes people several visits to the snack stand to get comfortable enough to enter.
Since Touch uses a wheelchair and can carry home only what she puts in a bag strapped to the back of the chair, she shops at the food pantry about every other day. Her home now is better than any she’s had in decades, not like the apartment with rats she once lived in on Detroit Street or the years of living with whatever man was providing a place to sleep.
“I’ve been homeless so many times it’s pathetic,” she said before visiting the Vivent pharmacy last week. “It used to be drugs until I stopped fighting that. There are all kinds of ways. It’s the men you choose to be with, that lay around and watch the women do everything. They’ve got no job, no hustle. That stuff rubs off on you.”
For Touch, housing was the key to getting off drugs and taking care of her health.
“When you are hopping from couch to couch and floor to floor like that, you are never gonna get off drugs. I hate to fight to get off crack, it was hard for me,” Touch said. “You have to pacify yourself to make yourself feel better.”
Federal, state HIV programs support the clinic
Vivent has multiple housing programs, including one for people who have homes but are at risk of losing them because they struggle to pay the rent or mortgage. The housing situation has worsened in the past few years as rent in Denver climbs — now the average price for a one-bedroom apartment is about $2,000 per month. Through Vivent, people can enroll in a program in which they pay about 30% of their income for rent and the rest is subsidized.
The nonprofit also created its own housing voucher program, funded through the Housing Opportunities for Persons with AIDS, which is part of the U.S. Department of Housing and Urban Development, or HUD. The housing team at Vivent will help people find apartments and landlords who accept the voucher.
Vivent also offers “crisis housing,” which is temporary motel rooms for people who are living on the streets with HIV.
Vivent’s medical home operates at a loss, and is funded by a patchwork of federal, state and local dollars, including from the Colorado Department of Public Health and Environment and the county health department. During last year’s outbreak of monkeypox, which spread primarily among gay men but also in homeless encampments where people shared bedding, Vivent’s Denver clinic treated 30% of the city’s monkeypox cases and administered more monkeypox vaccines than any other Vivent clinic.
The federal money supporting Vivent comes not only from HUD, but from the U.S. Health Services and Resources Administration Ryan White program. The instability of those funding sources, however, has pushed Vivent’s housing team to link patients with other government housing vouchers, just in case.
“In the federal budget, there is a constant back and forth of how much funding goes to these things, especially as we get more into a world where HIV isn’t seen as such a health crisis,” Murray said. “We always want to make sure that our clients stay housed for the long term.”