Multiple support strategies help improve HIV suppression rates in the era of COVID-19

• After the imposition of COVID-19 control measures, some clinics found decreased rates of HIV suppression in patients
• In response, a San Francisco clinic conducted outreach and facilitated access to housing and other services
• After implementing these measures, viral suppression rates increased significantly

The onset of the first wave of infections associated with the COVID-19 pandemic caused many countries, regions and cities to impose restrictions on gatherings and the concentration of people indoors. These restrictions were designed to help reduce the spread of SARS-CoV-2, the virus that causes COVID-19.

However, as a result of these restrictions, some people became less likely to seek new or ongoing care for HIV (and possibly other conditions). Some people may have felt more isolated or depressed because of the social and economic effects of the pandemic control measures. Some people with HIV may even have disengaged from care, as has been reported from one clinic in San Francisco. At that clinic, researchers found that after the onset of the pandemic, rates of viral suppression fell, particularly among homeless people.

As a result, clinic staff and volunteers engaged in multiple interventions to try to improve the health of their patients by engaging in what they called “proactive outreach” to achieve the following:

• facilitate access to food
• deliver medicines
• provide referrals for mental health support and harm reduction services
• facilitate access to housing
• provide in-person (vs. telemedicine) appointments when requested

Additionally, the clinic maintained what it called “a low-barrier, high-intensity drop-in primary care program for people with HIV who were experiencing homelessness” (they referred to it as a “pop-up”).

Researchers at the clinic compared trends in HIV viral suppression before and after the implementation of these services. They found that, overall, providing these services resulted in a 34% increased likelihood of patients achieving viral suppression. When researchers focused on homeless patients, the provision of these services, particularly housing, had a more dramatic effect with the likelihood of achieving viral suppression rising to 94%.

Study details

Doctors, nurses and pharmacists at the “Ward 86” HIV clinic located at San Francisco General Hospital provide care for many vulnerable people, particularly those with a low income.

As part of the implementation of the previously mentioned measures to engage with patients, clinic staff and volunteers made at least three attempts each quarter to locate patients and interact with them in order to help provide for their needs.

City-wide measures to limit the spread of SARS-CoV-2 were first put in place on March 16, 2020. To assess the impact of the clinic’s interventions (which were implemented shortly thereafter), researchers compared electronic health records before and after that date, through April 2021.

The average profile of the 1,816 people in the clinic who were part of this study was as follows:

• 88% men, 12% women
• age – 51 years
• major ethno-racial groups: White – 43%; Hispanic – 26%; Black – 18%; Asian – 8%
• CD4+ count – 505 cells/mm³
• 83% of participants had a suppressed viral load

At the beginning of March 2020, researchers found that the following proportions of participants had the following issues:

• 5% were homeless
• 9% had unstable housing
• 16% had severe mental illness

Results

Once the pandemic began, clinic staff and volunteers were able to contact 91% of participants to offer services. The researchers found that “79% of people who were experiencing homelessness received permanent housing or [temporary shelter via placement in a hotel room allocated by the city].”

In assessing changes to the overall clinic population’s viral load after the implementation of the clinic’s outreach and services, researchers found that the proportion of people with a suppressed viral load rose by 34%.

Specific subgroups

• In the subpopulation of people who were homeless who made use of the pop-up program, their chances of having a suppressed viral load rose by 51%.
• In the subpopulation of people who were homeless or had unstable housing and who received permanent or temporary housing (in a hotel room), their chances of having a suppressed viral load rose by 94%.

Bear in mind

Although this was not a randomized, controlled clinical trial, the present study underscores the importance and stabilizing impact of housing and other services for people with HIV. The researchers stated: “Anecdotally, some patients initiated ART for the first time in their lives as a result of receiving supportive housing.” They added that “increases in supportive housing and targeted programs which seek to meet the unique needs of housing-insecure people with HIV, including outreach, in-person drop-in availability and incentives, will likely be needed to make further gains among homeless people with HIV.”

—Sean R. Hosein

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