People living with HIV (PLWH) who are also experiencing homelessness are much more likely to die than those with stable housing. A lack of stable housing is like an anvil, weighing down a person who must focus on day-to-day survival, and making appointments with HIV specialists a lower priority. Substance use and inability to adhere to treatment add to the vulnerability.
One prospective cohort study, recently published in the medical journal AIDS), evaluated a safety net program in San Francisco that included wraparound services and strategies to reduce barriers to care among people living with HIV and get this population on treatment.
San Francisco General Hospital’s Ward 86 HIV Clinic was the setting for the study, which looked at how the new program—called POP-UP (which is short for Positive-health On-site Program for Unstably-housed Populations)—improved outcomes for homeless and housing-unstable patients between January 2019 and February 2020.
Out of 152 people who met the study criteria (PLWH who were viremic or not on antiretrovirals, and who had missed at least one primary care appointment and two drop-in visits to Ward 86 within the past year), 75 enrolled. Of that 75, more than three quarters had a mental health diagnosis, and all had a substance use disorder, primarily involving methamphetamines. Half were experiencing street, rather than shelter-based, homelessness.
“These folks are a very high-risk population,” said the study’s lead author, Elizabeth Imbert, M.D., M.P.H., an associate professor of medicine at Zuckerberg San Francisco General Hospital and the clinical lead of POP-UP. Imbert said goal of the program was to reduce barriers to care and to build trust. They did so by prioritizing the availability of:
- Drop in, rather than scheduled services. A patient could come in any afternoon for any reason.
- A small multi-disciplinary team, including a navigator, HIV specialist, and nurses who discuss their patients in a weekly case conference.
- Meds available right at the clinic.
- A psychiatrist available for phone consultation during the visit.
- Substance use treatment, if requested.
- Incentives, including $10 gift cards per week, and a $25 card for achieving the milestone of viral suppression.
- Housing assistance.
To decide how to design services, the team relied on a discrete choice experiment which showed that this population valued personal relationships with team members and drop-in convenience more highly than financial incentives. Offering drop-in services, where a patient could see anyone they wanted to during operating hours, lowered the clinical structural barriers that kept many out of care. Two-way texting (for those with cell phones) helped build trust and improve adherence.
The results: 79% of enrolled participants restarted their antiretroviral therapy within a week of enrolling, 55% were virally suppressed after six months, and 90% came for follow-ups within three months.
Imbert told TheBodyPro that with a small team, it’s possible to develop relationships with patients and learn how their health goals and priorities fit into their lives. “A lot of the interventions, such as frequent contact and incentives, had been standard [at Ward 86],” she said. “The POP-UP clinic tries to rethink the care you’re already providing, making it easier to meet all of their needs.” Even soup and snacks are offered in the clinic, she added.
POP-UP continues to operate; it stayed open even during COVID-19 lockdowns, with additional safety protocols. Imbert said that, while viral suppression overall dipped for Ward 86 during lockdown, overall suppression remained stable for POP-UP users. “We found that for this population, telehealth doesn’t necessarily work,” she noted. “Not everyone has a cell phone.”
Although substance use treatment is an option at POP-UP, it is not pushed on patients. “We use a harm reduction model, including safe injections and overdose prevention methods,” Imbert said. The team did not track whether study participants started treatment for substance use.
Although Ward 86’s POP-UP program is novel, it is part of what could be a growing number of urban safety net clinics designed to engage the hardest-to-reach people in HIV care and other services. Another such program, Seattle, Washington’s walk-in Max Clinic, has been a leader in collaborating with a comprehensive HIV clinic, with evidence of strong improvement in viral suppression for its patients.
Imbert said that because the cost of incentives at POP-UP clinic is low—the mean total was $16 per patient per month—the model could be replicated in other cities. She added that no new staff was needed; their team worked with the San Francisco Department of Health to find navigators and with Alliance Health for case managers and psychiatrists.
Imbert acknowledges that while 55% viral suppression in six months is good for this group, but it could be higher. “Our next steps include looking at additional models to reach others who have fallen out of care,” she said. She added that Ward 86 and the POP-UP team would also continue to advocate for stable housing; “That, more than anything, will help people [experiencing homelessness] stabilize.”