Clínica Bienestar

In September 2013, Prevention Point Philadelphia and Philadelphia FIGHT Community Health Centers (Philadelphia FIGHT) developed and implemented Clínica Bienestar (Spanish for “Wellness Clinic”), to provide comprehensive, integrated HIV primary care services to Spanish-speaking and bilingual people of Puerto Rican ancestry, with HIV who inject drugs in Philadelphia. Clínica Bienestar is a multilevel, multipronged intervention combining evidence-based practices in behavioral health and HIV medical care with a transnational approach to care. Clínica Bienestar positively impacted retention in HIV medical care and viral suppression.

Philadelphia, PA

Implementation Guide
False
Evidence-Informed Intervention
Icon for Intervention Type
Clinical service delivery model; Support service delivery model
Icon for HIV Care Continuum
Retention in HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Strategy
Treat
Icon for Focus Population
Hispanic/Latina(o/x) people
Icon for Priority Funding
RWHAP Part F SPNS
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RWHAP-funded clinic or organization; Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

Hispanic/Latina(o/x) people with HIV consistently have lower rates of retention in care and viral suppression than their white counterparts.1 A range of social, structural, and cultural factors act as barriers to timely and consistent HIV care for this population, including HIV stigma and discrimination, language barriers, difficulty navigating the health care system, and fear of deportation.2 Concurrent drug use is an additional barrier: people who inject drugs have the lowest levels of retention in HIV care and the lowest HIV viral suppression rates in the United States. To address these issues, in 2013, Prevention Point Philadelphia – a nonprofit public health organization providing harm reduction services – and Philadelphia FIGHT – a community health center providing comprehensive and culturally responsive HIV primary care, consumer education, advocacy, and social services – developed and implemented Clínica Bienestar. This multilevel, multipronged intervention combines evidenced-based practices in behavioral health and medical care with a transnational approach to the provision of comprehensive HIV primary care for people of Puerto Rican descent. This group represents 65% of Hispanic/Latina(o/x) people in Philadelphia.

Core Elements
Transnational approach to providing services

Taking a transnational approach requires providing services that pay close attention to geographical, cultural, and epidemiological contexts. Several ways this is addressed in Clínica Bienestar are that: the clinic is geographically located at the epicenter of the intersecting opioid and HIV epidemics in North Philadelphia; many medical and case management staff members are of Puerto Rican descent and a few grew up in the neighborhood surrounding the clinic; and staff help coordinate medical and case management services for patients who travel between Philadelphia and Puerto Rico.

Integration of HIV primary care and case management

Clínica Bienestar includes comprehensive, integrated HIV primary care services along with case management and medical case management.

'Critical time approach’ to HIV care

Clínica Bienestar takes a ‘critical time approach’ that focuses on peoples’ readiness for treatment and engagement in their own HIV care; it offers same-day medical appointments and aims to provide the first HIV-related medical appointment within five days of enrollment in the intervention.

Harm reduction approach

The clinic added on-site medication-assisted treatment (MAT), MAT education, and comprehensive management of medications for substance use disorders. Clínica Bienestar does not require participants to abstain from substance use to receive HIV primary care.

Outcomes

From September 2013 to December 2017, 70 people enrolled in Clínica Bienestar (average age = 43.2 years; 81.4% male). At baseline, most had experienced major challenges to engagement in HIV care, including being unstably housed (40% in the previous month), chronic hunger (44.3% in the past week), and severe depressive symptoms (51.4% in the past seven days). An evaluation comparing outcomes between Clínica Bienestar participants in 2018 and overall HIV surveillance data from the City of Philadelphia in 2016 showed that Clínica Bienestar participants had higher rates of retention in HIV medical care and viral suppression.

CategoryInformation
Evaluation data
  • Electronic medical record data and City of Philadelphia HIV surveillance data
Measures
  • Linkage to care (defined as the number of people linked to care over the total number of eligible people)
  • Retention in care (defined as completing two HIV primary care visits in one year, at least six months apart)
  • Viral suppression (defined as < 200 copies/mL of blood)
Results

Comparing HIV care continuum outcomes between Clínica Bienestar participants and overall City of Philadelphia data, Clínica Bienestar participants had higher rates of:

  • Linkage to care: 88.6% versus 87.3% 
  • Retention in care: 85.4% versus 44.7%* 
  • Viral suppression:  82.9% versus 40.9%*

*statistically significant

Source: Bamford L, Benitez J, Muñoz-Laboy M. Providing HIV comprehensive care to Latino/as who inject drugs: Philadelphia, 2013-2018. Am J Public Health. 2019;109(2):273-275.

Planning & Implementation

Staffing to support the population. The team includes the following staff members:

  • Peer health educators in long-term recovery from substance use disorders for the outreach to clients
  • Bilingual staff who received training on Puerto Rican migration to Philadelphia, the HIV needs of transnational populations, street drug culture, and HIV/AIDS-related stigma
  • Medical providers with expertise and experience in dealing with populations who use drugs
  • Bicultural senior case managers with more than 20 years of substance use disorder experience

Transnational approach to HIV linkage and retention in care. Clínica Bienestar embraces addressing the needs of a transnational “air bridge” population. The air bridge migration from Puerto Rico to the mainland U.S. of populations who use drugs may be motivated by their attempt to avoid drug-related violence, and HIV and substance use stigmas in Puerto Rico, as well as their search for substance use treatment.3

Sustainability

While originally funded through the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Latino Access Initiative, from 2013 to 2018, in April 2018, the organizational boards leading Prevention Point Philadelphia and Philadelphia FIGHT integrated Clínica Bienestar into the standard health service programs provided by their interorganizational collaboration. The sustainability of this intervention stems from: 1) the co-location of medical services, social services, and substance use disorder services within one building, which prevents this historically marginalized population from needing to prioritize any of these life-sustaining services over others; and 2) the delivery of services in a culturally and linguistically responsive and nonjudgmental manner, which encourages the development of participants’ rapport with staff and their return to access the available services.

Lessons Learned
  • The deepening opioid crisis required the team to reallocate resources to scale up naloxone trainings, safer injection practices education, referrals to housing and substance use disorder treatment programs, and medication-assisted treatment prescription.
  • High prevalence of incarceration within the population of focus prompted a partnership with the Institute for Community Justice, a comprehensive prison services and reentry program providing health linkages and supportive services for people impacted by incarceration.
Contact
Philadelphia FIGHT
Laura Bamford, MD

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