A return to in-person care and intensified social services helped reverse a decline in the rate of HIV viral suppression seen at a safety-net clinic in San Francisco after the city imposed its COVID-19 shelter-in-place order, according to a presentation at the Conference on Retroviruses and Opportunistic Infections 2022 (CROI 2022).
People living with HIV in San Francisco have good care and treatment outcomes overall, with 77% of newly diagnosed people achieving an undetectable viral load within 12 months (down from 81% pre-COVID). But disparities are stark, and the rate of viral suppression falls to just 20% (down from 39% pre-COVID) for people experiencing homelessness.
As previously reported, Matthew Spinelli, MD, Monica Gandhi, MD, MPH, and colleagues from the University of California at San Francisco initially evaluated retention in care and viral suppression at Zuckerberg San Francisco General Hospital’s Ward 86 HIV clinic after COVID-19 mitigation measures were implemented and services largely transitioned to telemedicine. They compared outcomes before the shelter-in-place order (December 2019 through February 2020) and after it was imposed in March 2020.
Ward 86 serves a largely disadvantaged and vulnerable population, including many people experiencing homelessness, substance use and mental illness. Such individuals may lack the technology or know-how to participate in telehealth and may need extra social services and support that are best provided in person. The clinic’s POP-UP program, launched prior to COVID in 2019, is a low-barrier program for homeless or unstably housed people with HIV who have difficulty maintaining viral suppression.
Although the overall rate of “no-shows” at Ward 86 remained similar after the transition, younger people were less likely to miss telehealth appointments (perhaps reflecting greater comfort with technology) while homeless people were more likely to do so. The likelihood of having a detectable HIV viral load (defined as above 200) was 31% higher during shelter-in-place compared with before COVID-19. Homeless people, especially, were more likely to have unsuppressed HIV after the transition.
“Telemedicine may facilitate retention in care in the context of shelter-in-place for those without a digital divide, but is unlikely to compensate for the loss in clinic-based social services and support for people with HIV with vulnerabilities,” the researchers concluded at the time.
After seeing the drop in viral suppression, Gandhi’s team reinstated in-person care with precautions in place to ensure the safety of clients and staff. The clinic scaled up face-to-face appointments and drop-ins, did proactive outreach to offer social services and expanded housing assistance.
“Although telemedicine worked for many patients during the COVID-19 pandemic, those who were particularly vulnerable on public insurance seemed to benefit from in-person care and Ward 86 adjusted accordingly,” Gandhi told POZ.
At CROI, Spinelli provided an update on outcomes at the clinic, assessing viral suppression rates a year after the shelter-in-place order was imposed.
The study cohort included 1,816 Ward 86 clients. Nearly 90% were men, the median age was 51 years and 14% lacked stable housing. Some 15% had advanced immune suppression with a CD4 count below 200.
All clients resumed in-person visits, and 91% were successfully reached by proactive phone outreach. The proportion of telephone visits declined from a maximum of 65% to a minimum of 10% at the end of the analysis period. Loss to follow-up was similar to or lower than pre-COVID rates. Among 240 POP-UP clients, 15% were linked to permanent housing and 28% were placed in a shelter-in-place hotel room provided by the city.
What’s more, the likelihood of viral suppression increased by 1.34-fold—from 81% to 90%—after services were intensified, rising by 1.05-fold per month during the intervention period. Homeless clients, in particular, saw the greatest improvement. Those in the POP-UP program had a 1.51-fold higher likelihood of viral suppression. For those who received permanent housing after being homeless or unstably housed, the odds of viral suppression increased by 1.94-fold.
“Maintaining in-person care with flexible telemedicine options, increased provision of social services and permanent expansion of housing assistance will be needed to support viral suppression among underserved populations during the COVID-19 pandemic,” the researchers concluded.
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