Since 2019, Boston’s Department of Public Health has sounded an alarm: HIV cases among people experiencing homelessness were on the rise, particularly for those who use intravenous drugs. By early 2022, nearly 170 cases were identified.
But one nonprofit, Boston Health Care for the Homeless Program, is largely responsible for helping turn the corner on the outbreak. From their tireless work, cases plummeted. In 2021, positive HIV cases in the homeless population peaked at 62. In 2022, it was 20 cases. And in 2023, cases were reduced to single digits—just five individuals tested positive for HIV.
BHCHP continues to be the primary HIV care provider for Boston’s homeless population, and their experimental model of bringing care directly to their patients on the streets has proven to be a success. Other cities seeing similar outbreaks may just follow their lead.
Dr. Jennifer Brody, director of HIV services at Boston Health Care for the Homeless Program, joined GBH’s All Things Considered host Arun Rath to discuss the organization’s efforts that led to the sharp decline. What follows is a lightly edited transcript.
Arun Rath: These numbers are astounding: 170 down to five cases. We need to break those numbers down because it kind of makes your head spin. How did you get there?
Dr. Jennifer Brody: I think it’s important to note that the numbers you cited are the number of individuals who were diagnosed with HIV, as you said, who are experiencing homelessness and using substances who passed through the doors of our program.
So, it doesn’t necessarily include every person who was diagnosed with HIV in Boston. But I can say that most of the lion’s share of those cases did cross our threshold, so I do think the numbers you cited are a reflection of the outbreak in Boston.
I think there are multiple reasons for the drop in cases — starting a street outreach program that was multidisciplinary and included not just medical providers and nurses, but also behavioral health workers and other harm reduction workers to provide people who were newly diagnosed with HIV or living with HIV with medicines, without even having to come into a clinic.
We were able to provide people with their HIV treatment on the street seven days a week. A nurse would hand people those medicines to make sure that we were getting those HIV virus levels down, which, when an HIV virus level is undetectable, people are at a much-reduced risk of passing that virus forward.
But not only did we do that for people who were still testing negative for HIV, but who were at risk; we were providing them with medications to prevent HIV, also known as pre-exposure prophylaxis, or PrEP. Those medications dramatically reduce someone’s risk of getting HIV.
We were giving people those medications in addition to counseling and lots of harm reduction work to help people who are actively using substances reduce their risk. I think it was our program’s efforts, as I said, and also, really, an “all hands on deck” approach from our city and state partners who were not only funding this work but also helping to support other programs in the area to reduce the rates of HIV.
Rath: This approach of taking the care directly to the people who need it seems like it makes so much sense. But I have to imagine, on the ground, it must be difficult to do that—to establish trust and provide care in this unique way. Can you talk about what it’s like?
Dr. Brody: You are exactly right. So many of the folks who are unsheltered and using substances who are living with HIV or at risk for HIV have had many challenges accessing health care.
Oftentimes, they’ve had very negative experiences in other settings and have experienced tremendous amounts of stigma and feel quite shunned. Our work was really to begin to build trust that had been broken, so a lot of our initial work was really just trying to ask people how they were doing, address any of their basic survival needs, even just have some small talk so that they would begin to get to know us and trust us.
I think one of the most powerful interventions that we made—especially early on, particularly during the pandemic in 2020, when a lot of people had their access to services even further disrupted—was doing overdose response.
Our teams were out. If someone had an overdose while they were outside, our teams would go out and provide Narcan, which is an overdose reversal drug, and also even help people breathe by using all the strategies that we have: supplying oxygen and providing CPR many, many times a day.
When the community saw our team members out there doing that lifesaving work, I think that went a long way to more quickly help us establish trust. We could then leverage that trust to talk about HIV testing, prevention, treatment and get people connected to primary care. All of those things combined help us get there, get HIV under control and also to prevent further HIV cases.
Rath: Late last year, homeless encampments at Mass. and Cass. were cleared. I imagine that was an area where a lot of your work was done.
Dr. Brody: That’s correct. Over the summer, our capacity to provide intensive services was interrupted. Then, a few months later, the encampment was cleared, so our team really had to readjust. We worked very quickly to put into place teams that could do more extended outreach across the city.
We set up medication carts with our nurses down in our lobby, as well as at our nearby syringe services program so that we could help to continue to provide those HIV treatment medications and prevention medicines every single day.
We were able to continue to have connections with many people, though we did lose touch with some. We still continue to struggle to connect with them, so we are quite concerned about what will happen to the people that we can’t reach. Will they continue on their HIV treatment or HIV prevention treatment? Will they be able to use safely? So, we are concerned that all the gains that we made are tenuous; they require continued efforts to sustain.
Rath: Keep us posted on that. We’d like to follow up on how that goes this coming year.
Finally, outbreaks like this, as I mentioned at the top, have happened in other cities. Do you think that this approach would work in other places, or are there things about the causes of the outbreak here that are unique?
Dr. Brody: I think this effort could absolutely work in other cities with HIV outbreaks, such as we experienced in Boston. This multidisciplinary team effort, this approach of providing street-based services, non-judgmental care and harm reduction-based care, I think, has the potential to be effective in other localities.