Homeless people living with HIV prefer flexibility, in-person care and incentives

According to a study presented this week at the 11th International Conference of the International AIDS Society on HIV, people who are homeless or in precarious housing differ in the types of HIV care they prefer, with a majority favoring flexibility while ‘about a third still wanted to see the same provider. Sciences (IAS 2021). Telemedicine, which many HIV clinics have adopted due to COVID-19, was not a popular option.

Homelessness and unstable housing are risk factors for low engagement in HIV care, difficulty maintaining viral suppression, and a higher risk of death. Public health officials fear the COVID-19 pandemic could lead to even worse outcomes for this population.

“During the COVID-19 pandemic, people living with HIV who are homeless or in unstable housing in the United States have faced aggravating medical and socio-economic challenges,” the senior researcher told aidsmap, Dr. Elizabeth Imbert of the University of California at San Francisco. “At the same time, public health orders have reduced the capacity of in-person services while accelerating the adoption of telehealth. “


virological suppression

Stopping the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction in viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

detectable viral load

When the viral load is detectable, it indicates that HIV is replicating in the body. If the person is on treatment for HIV but their viral load is detectable, the treatment is not working properly. There can always be a risk of transmitting HIV to sexual partners.

cisgender (cis)

A person whose gender identity and expression matches their biological sex assigned at birth. A cisgender person is not transgender.


In discussions of consent to medical treatment, a person’s ability to make a decision for themselves and understand its implications. Young children, the unconscious, and some people with mental health issues may lack capacity. In the context of health services, the personnel and resources available for patient care.


In the United States, a health insurance program for low-income people of all ages. The benefit varies from state to state, although certain types of care are covered in all states.

People living with HIV in San Francisco have overall good treatment results, with 75% of all people living with HIV having an undetectable viral load, but this figure drops to just 39% among homeless people. In 2019, 18% of new HIV diagnoses were among people who were homeless or in unstable housing.

Imbert’s team conducted a discreet choice experiment to assess preferred strategies for improving care engagement among homeless and unstably housed people living with HIV, asking them to choose from exclusive options.

The analysis focused on 59 people who participated in the POP-UP (Positive On-Site Health Program for Unstably Hosted Populations) at the Ward 86 HIV clinic at San Francisco General Hospital, as well as 56 people who had access to traditional primary care and whose viral load had not been suppressed recently. Ward 86 serves a vulnerable population. Most patients do not have commercial health insurance or rely on Medicaid (coverage for low-income people) or Medicare (coverage for people over 65 and people with disabilities). More than a third are homeless or have poor housing.

Launched in January 2019, POP-UP includes a low-threshold clinic that does not require an appointment and is open for walk-in visits on weekday afternoons. It offers comprehensive primary care, including mental health care, addiction treatment and on-site medication pickup. A patient navigator helps connect patients with services such as case management, housing assistance, and obtaining insurance coverage. Participants receive grocery gift cards to encourage them to come to the clinic, have lab tests, and maintain an undetectable viral load. Eligible participants are not on antiretroviral therapy or treatment with a viral load of 200 copies / ml or more and have a history of missed primary care appointments.

At last year’s International AIDS Conference, Imbert and colleagues reported that the POP-UP program helps people stay engaged in care, get on antiretroviral therapy, and achieve viral suppression. But that was before COVID-19. Researchers reported at the end of last year that patients in Ward 86 were 31% more likely to have a detectable viral load after the city imposed its stay-at-home order and the clinic switched to telemedicine in March 2020. But POP-UP has kept its open doors even like many other health services in the closed city, and commitment to care and viral suppression did not decrease.

This analysis enrolled participants between July and November 2020. Of the 840 people screened, 146 were deemed eligible and 115 responded to the survey. Half were white, 34% were Latino, and 20% were black (the corresponding proportions in the city’s population are 53%, 37% and 6%). More than three-quarters were cisgender men, 6% were cisgender women, and 11% were transgender women. More than half reported using methamphetamine daily. Four in ten say they have recently lived outdoors. Although a majority (76%) owned a phone, 56% said they had recently lost or stolen a phone.

Researchers identified different care preferences among survey participants. While 68% were in favor of flexible care, 32% said they preferred to see the same provider. Respondents strongly preferred walk-in visits to scheduled appointments, and they wanted in-person care rather than video or telephone consultations. Many said they would like an additional clinic site in addition to Ward 86 (located in the largely Latino Mission District). And all respondents were in favor of incentives to receive care.

“Service models for public HIV clinics that include options for in-person prompted care, provider continuity and flexibility of services can improve care engagement and reduce disparities in viral suppression for people living with with HIV who are homeless or in unstable housing, ”the researchers concluded.

The references

Imbert E et al. Preferences for engaging in care for people living with HIV who are homeless or in unstable housing: an experience of discreet choice. 11th IAS Conference on HIV Science, abstract no OAD0603, 2021.

About Bradley J. Bridges

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