East Bay Advanced Care (EBAC), the largest HIV care provider in California’s East Bay, developed and implemented Eradicating Racism and Striving for Excellence in HIV Care (ERASE) to address the unique needs of Black men who have sex with men (MSM). Through an intensive case management intervention, peer case managers provide health education and wellness support, and connect clients to medical and behavioral healthcare. ERASE also offers a physical “safe space” for Black MSM to meet with a case manager, access medical services, or connect with peers. Enrollment in ERASE improved retention in HIV care for clients.
California’s East Bay, one of the most racially and ethnically diverse regions in the nation, faces large inequities in HIV care and health outcomes. Black individuals face higher rates of HIV incidence and lower levels of linkage to care and viral suppression than their white counterparts.1 Approximately half of youth (ages 13–24) with HIV in the region are Black. Outcomes are worse for Black residents who identify as MSM. Stigma, racism in healthcare, higher levels of unemployment and neighborhood poverty, and lack of access to behavioral healthcare all play a part in these disparities.2 EBAC found that short-term intensive case management programs were not as effective for clients with long-standing challenges engaging in HIV care. Therefore, they developed ERASE to provide a longer-term solution, lasting for 18 months for some clients.
Peer case managers serve as a bridge between clients and the complex medical system. Their in-depth knowledge of the client population allows them to provide culturally responsive care and address barriers not apparent or revealed to other staff, such as confusion around medication dosing. Peer case managers develop individualized treatment plans with clients based on comprehensive assessments and help clients work through the treatment plans through bi-weekly meetings during the first two months of the program and monthly meetings during the subsequent months. They schedule medical appointments, meet with clients at EBAC and in the community, and introduce them personally to other care providers to increase client comfort.
Decorated with Black MSM-affirming artwork and messages, the ERASE physical space helps to reduce social isolation by offering clients a location to connect with peers and access case management services. It is located across the hall from medical services, including the lab, to facilitate access to healthcare. Ample drop-in hours, music, and a mini-fridge with snacks make it inviting for clients.
Structural barriers to care are addressed through the following policies:
- Same-day appointments
- No penalties for no-shows
- Cell phone access to peer case managers
- Home visits
- Transportation through ride-share services and staff pick-ups
ERASE leverages the existing suite of services at EBAC and Sutter Bay Hospitals, the system with which it is affiliated, to provide clients with comprehensive services. Clients have seamless access to HIV care, emergency housing vouchers, an onsite pharmacy, benefits enrollment support, and specialty care. Available behavioral health supports include inpatient and outpatient psychiatry services, outpatient psychotherapy, group counseling, support groups, and substance use treatment. Behavioral health specialists on the ERASE team coordinate these services. EBAC clinicians also visit clients when they are admitted to the hospital. EBAC’s external partners provide additional support, such as legal help and home-delivered meals.
ERASE was implemented as part of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black MSM, a Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects and National Significance (SPNS) initiative. Clients were eligible for ERASE if they were over the age of 13, self-identified as Black MSM, and had a new HIV diagnosis, were out of care, or were at risk of falling out of care (e.g., experienced behavioral health issues or housing or employment instability). From 2019–2021, ERASE enrolled 160 clients, 144 of whom completed the intervention. These clients experienced an increase in retention in HIV care from baseline to one year into the intervention; viral suppression rates also improved slightly.
Source: East Bay Advanced Care. Implementation Manual. Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men who have Sex with Men Initiative. 2022.
- Client recruitment. ERASE identifies eligible clients from multiple sources, including the EBAC client roster (existing and previous clients), referrals from partner organizations (e.g., other HIV service providers, local health departments, and planning collaboratives), and marketing via EBAC’s client-facing website.
- Staffing. ERASE relies on existing EBAC and Sutter Bay Hospitals staff, including two dedicated peer case managers, two behavioral health specialists, and a team of administrators that support grants management. The RWHAP Part F SPNS project was led by two project co-directors and a project coordinator.
- Staff training. Staff participate in trainings on cultural responsiveness, trauma-informed care, racial equity, and local community resources, in addition to the workforce compliance trainings required by EBAC for all staff.
- Team meetings. The ERASE team holds regular meetings to coordinate client care and improve processes. Peer case managers and leadership meet weekly to discuss client cases and streamline referrals. The clinical team meets monthly to ensure that all care needs are being met.
RWHAP Part F SPNS initiative funding covered the cost of program staff, client incentives, travel, improvements to the physical space, training, marketing, and outreach. EBAC receives ongoing funding through health insurance programs, RWHAP Parts A, B, and D, and various other local grants. While the SPNS initiative has ended, EBAC continues to implement ERASE and has expanded participation to Black MSM who do not have HIV and could benefit from the program.
- Initially, one behavioral health specialist was part of the ERASE team. Staff quickly realized that service needs exceeded capacity and added a second. A psychiatrist also joined the ERASE team to improve access. Services were provided in person or via telehealth, depending on client preference.
- While community meetups were always part of the ERASE program design, staff did not anticipate the demand would be so high. Travel became an added cost to ERASE given peer case managers traveled up to 70 miles to meet clients in their homes, often to deliver food and meals to address food insecurity. Virtual visits were also offered, and many clients preferred a combination of visit types.
- On average, clients received 17 case management visits, which lasted approximately 20 minutes each; they missed 2.4 visits on average. Clients who were chronically homeless or who suffered housing insecurity were less likely to meet regularly with their peer case managers. Peer case managers let clients know that they could meet them in the community and that they were welcome back to the program at any time.
- ERASE was implemented during a difficult time in many people’s lives, which exacerbated mental health issues. COVID-19, the racial justice movement, and high turnover in the mental health and medical fields meant peer case managers had to work extra hard to support clients. Weekly mental health sessions were offered to peer case managers, and ERASE developed onboarding documents to address staff turnover.