An intensive, low-barrier HIV care program helped vulnerable people experiencing homelessness or unstable housing stay on antiretroviral treatment and achieve viral suppression, according to a study published in AIDS. A related study found that offering testing and treatment in temporary hotels during COVID-19 improved outcomes for homeless people with hepatitis C.
Homelessness and unstable housing are known risk factors for inadequate access to care and poor health outcomes. People without a stable place to live may lack privacy, can lose their medications to theft or raids on their encampments and may be experiencing other challenges such as mental health issues and substance use. The COVID-19 pandemic has thrown a wrench into HIV and hepatitis treatment and prevention services, but it has also offered new opportunities and led to innovative approaches for this population.
POP-UP HIV Clinic
Elizabeth Imbert, MD, MPH, and colleagues from the University of California at San Francisco evaluated outcomes among people served by POP-UP (Positive-health Onsite Program for Unstably-housed Populations), a program operated out of the Ward 86 HIV clinic at Zuckerberg San Francisco General Hospital, the first dedicated HIV clinic in the United States.
“The POP-UP program at the Ward 86 clinic in San Francisco is a novel low-barrier, incentivized comprehensive primary care program for people living with HIV who experience homelessness or unstable housing with viremia and for whom usual care is not working,” Imbert told POZ. “This program demonstrated success in improving care engagement and viral suppression for this highly vulnerable population.”
Ward 86 serves around 2,500 people with HIV, most of whom do not have health insurance or rely on Medicaid or Medicare. Launched in January 2019, POP-UP is a low-barrier program for homeless or unstably housed people, who account for more than one third of patients seen at Ward 86.
People living with HIV in San Francisco have good treatment outcomes overall: 95% of newly diagnosed individuals are linked to care within one month and 81% achieve an undetectable viral load within 12 months. But disparities are stark, and the rate of viral suppression falls to just 39% for people experiencing homelessness.
POP-UP includes a low-threshold clinic that doesn’t require appointments; it is open for drop-in visits on weekday afternoons. The clinic offers primary care—including mental health care, substance use treatment and onsite medication pick-up—provided by a care team that includes physicians, nurses, a social worker a pharmacist and a psychiatrist on call. A patient navigator assists with linking patients to medical care and other services, such as case management, housing assistance and help obtaining insurance coverage. Participants receive $10 grocery store gift cards as an incentive for coming to the clinic and getting lab tests as well as $25 cards every three months if they achieve and maintain viral suppression.
The program was shaped by interviews with homeless or unstably housed Ward 86 clients, who revealed that they valued drop-in visits without appointments and patient-centered care with providers who “get to know me as a person.”
This prospective cohort study included 75 people who enrolled in POP-UP before the COVID-19 pandemic, out of the 192 people referred to the program and 152 deemed eligible.
Eligible participants are HIV-positive individuals experiencing homelessness or unstable housing who either are not on antiretroviral therapy or are on treatment but have a viral load of 200 or higher. They must have missed at least one primary care appointment and made at least two drop-in visits to Ward 86 during the prior year.
Most participants (85%) were cisgender men, 9% were cisgender women and four identified as transgender, nonbinary or gender-nonconforming; one third were older than 50. Looking at race and ethnicity, 45% were white, 35% were Black and 9% were Latino. In comparison, 35% of all people newly diagnosed with HIV in San Francisco are white, 17% are Black, 33% are Latino and 11% are Asian or Pacific Islander; the respective proportions in the city population as a whole are 53%, 6%, 37% and 15%.
At the time of enrollment, all participants were off antiretroviral treatment and had a detectable viral load; 40% had a CD4 count below 200, indicating advanced immune suppression. All had a substance use disorder, with most using methamphetamine. More than three quarters had a mental health diagnosis. Just over half lived on the street, while the rest were staying in shelters, single-room-occupancy residences, transitional housing or residential treatment facilities or were temporarily “couch surfing.”
As reported in the journal and at the 2020 International AIDS Conference last summer, more than three quarters of participants (79%) restarted HIV treatment within one week after enrollment in POP-UP. A majority returned for a repeat visit within a month, and 91% did so within three months. At six months, 55% had achieved viral suppression (viral load below 200).
“A novel care model for [homeless or unstably housed people with HIV] demonstrates early success in engaging viremic patients in care and improving viral suppression,” the study authors concluded. “Low-barrier, high-contact primary care programs offering comprehensive services and incentives may improve outcomes for this vulnerable population.”
One challenge the program faces is that the high cost and low availability of housing in San Francisco means it’s not always possible to help people promptly access stable housing.
The most important thing that can be done for POP-UP participants is to get them housed, study coauthor Diane Havlir, MD, told the San Francisco Chronicle soon after the program opened. “But short of us doing bake sales and building a hotel on our own, we had to ask, ’Was there anything else we could do?’”
POP-UP kept its doors open during San Francisco’s COVID-19 shelter-in-place order, issued in March 2020, even as many other health services in the city shut down.
The Ward 86 team previously reported that its patients were 31% more likely to have an unsuppressed viral load after the clinic pivoted to telemedicine, and this was especially true for people experiencing homelessness.
But an analysis of 85 unhoused individuals in the POP-UP program during the first five months after the shelter-in-place order—including 14 new patients who enrolled during the pandemic—found that care engagement and viral suppression did not decrease. The number of monthly visits stayed the same, and the proportion of people who made monthly visits was similar before and after the order. However, more people dropped out of the program: five pre-COVID and eight during COVID.
“Low-barrier, in-person HIV care for homeless individuals may be important for maintaining HIV outcomes during COVID-19,” the study authors concluded.
Providing Care in Temporary Hotels
During the COVID-19 crisis, several cities have temporarily housed people experiencing homelessness in unused hotels.
As described in the journal Sexually Transmitted Diseases, Katherine Cironi, a medical student at Tulane University School of Medicine, and colleagues evaluated a linkage-to-care model for HIV and hepatitis C treatment for temporarily housed people in New Orleans between May and July 2020.
In conjunction with CrescentCare, a community clinic, residents were offered HIV and hepatitis C virus (HCV) testing, telehealth services for linkage to care and free transportation to the clinic. An in-house case manager at each hotel coordinated care with the clinic and helped people with insurance enrollment if needed.
During this period, 102 temporary hotel residents were tested for HIV and/or hepatitis C. A majority (62%) were men, 69% identified as heterosexual and 57% were Black. A quarter reported a history of injection drug use, and a third of those said they had shared injecting equipment.
Twenty-five people (25%) tested positive for hepatitis C; among those with a history of sharing injection equipment, the positivity rate was 75%. More than half were previously unaware of their HCV status. Of these, 21 people (84%) were connected to the clinic for follow-up care, 15 (60%) participated in a telehealth appointment, 10 (40%) picked up their prescribed hepatitis C medication and two (8%) were cured. One person stopped treatment after it was determined that they did not have active infection, and others were lost to follow-up as the temporary housing ended, and the program had difficulty confirming treatment completion.
Of note, only seven of the 25 people who tested positive for HCV had ever heard of HIV pre-exposure prophylaxis (PrEP), and none were currently using it.
Three of the 98 individuals tested for HIV (3%) were found to be positive, including one with HIV and HCV coinfection. One person started antiretroviral therapy for the first time and the other two restarted HIV treatment.
“The temporary housing shelters created a unique opportunity to screen for HIV and HCV among a notoriously difficult-to-reach population that does not seek regular health care screenings,” the researchers concluded. “Targeting homeless persons living in temporary residences for HCV and HIV screening can be effective at promoting access to care,” but “continued outreach strategies are needed to assist patients in retention of care.”
Click here to read the POP-UP study abstract.
Click here to read the New Orleans study abstract.
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