Multicomponent Support Strategies

A week after the shelter-in-place order for the COVID-19 pandemic was implemented, San Francisco General Hospital’s Ward 86 HIV Clinic launched Multicomponent Support Strategies, composed of proactive outreach and social services support for people with HIV. Ward 86 Clinic staff and trained volunteers provided outreach to 1,816 clients about the availability of various supports, including in-person medical care, mental health and substance use services, medication delivery, food assistance, housing support services, and Positive Health Onsite Program for Unstably Housed People (POP-UP), a low-barrier high-intensity drop-in program. Results showed that viral suppression increased at a faster rate after Multicomponent Support Strategies was implemented.

San Francisco, CA

Implementation Guide
False
Evidence-informed intervention
Evidence-informed intervention
Icon for Intervention Type
Outreach and reengagement activities; Support service delivery model
Icon for HIV Care Continuum
Viral suppression
Icon for Focus Population
All clients; People who are unstably housed; People experiencing food insecurity
Icon for Priority Funding
Non-RWHAP
Icon for Setting
Hospital or hospital-based clinic
Need Addressed

The provision of ambulatory care in San Francisco decreased due to the shelter-in-place order and fear of contracting COVID-19. Many services deemed nonessential were either paused or conducted only via telehealth. Ward 86 HIV Clinic is a safety net clinic with many clients experiencing unstable housing, food insecurity, and mental health concerns. Ward 86 HIV Clinic staff were concerned that people would not reach or maintain viral suppression due to interruptions in services resulting from the shelter-in-place order. These challenges, combined with the logistical and travel difficulties posed by the COVID-19 pandemic, meant people served by Ward 86 HIV Clinic were at risk of not maintaining viral suppression.

Core Elements
Proactive outreach

A week after the shelter-in-place order was instituted, Ward 86 HIV Clinic staff (medical assistants, nurses, clinicians, and trained volunteers) began offering outreach to 1,816 clients via phone or when they attended a clinic visit. Clients were selected if they had at least two visits in the 24 months prior to the shelter-in-place order, at least one clinic visit in the six months prior to the order, and at least one HIV viral load measured in the six months prior to the order. Individuals were offered several support service referrals that included mental health services, food assistance, and housing services. Initial outreach was completed by the end of June 2020 and repeated quarterly through March 2021. Of the 1,186 people contacted, 1,661 (91%) were successfully reached.

Drop-in program (POP-UP)

The Ward 86 Clinic runs POP-UP, a low-barrier, high-intensity drop-in program. POP-UP provides primary care without an appointment, financial incentives, enhanced outreach and patient navigation, and case management.1 The program remained open during the shelter-in-place order and was one of the services offered to clients as part of Multicomponent Support Strategies. The drop-in primary care services provided on weekday afternoons included pharmacy access, same-day restart of antiretroviral therapy (ART), onsite laboratory testing, and substance use treatment.1 Housing referrals were also provided as part of this program. 

Referrals to shelter-in-place hotels and other housing placements

Stable housing is known to be highly correlated with viral suppression rates.2 Ward 86 HIV Clinic was able to provide temporary and permanent housing referrals through its POP-UP program. In addition, the City of San Francisco’s shelter-in-place hotel program provided hotel rooms to those experiencing unstable housing or homelessness from March of 2020 through December 2022.3 Additional permanent housing purchased by the City of San Francisco was also made available during this timeframe.4

Outcomes

Multicomponent Support Strategies was evaluated for 1,816 clients who had at least two visits in the two years before to the shelter-in-place order (issued on March 16, 2020) and who also had at least one clinic visit and at least one HIV viral load measured in the six months prior to the order. People who received POP-UP or housing services through Multicomponent Support Strategies in particular were more likely to be virally suppressed than before the shelter-in-place order.

CategoryInformation
Evaluation dataWard 86 HIV Clinic electronic health record (EHR) data for client demographics and viral suppression, and the San Francisco Department of Public Health HIV surveillance database for additional viral suppression data
Measures

Percent of clients identified who were successfully contacted and offered support services

Viral suppression rates before and after the intervention

Results

1661/1816 (91%) of clients were offered support services

Viral suppression was more likely at post-intervention than pre-intervention (AOR = 1.34, 95% CI 1.21–1.46)*

Viral suppression was more likely for those who participated in the POP-UP program at any time than those who did not (AOR = 1.51, 95% CI 1.07–2.11)*

Individuals who were homeless or unstably housed and received permanent housing or a shelter-in-place room were more likely to be virally suppressed than those who did not receive housing supports. (AOR = 1.94, 95% CI 1.05–3.59)*

* statistically significant

Notes: AOR = adjusted odds ratio, CI = confidence interval

Source: Spinelli MA, Le Tourneau N, Glidden DV, et al. Impact of Multicomponent Support Strategies on Human Immunodeficiency Virus Virologic Suppression Rates During Coronavirus Disease 2019: An Interrupted Time Series Analysis. Clinical Infectious Diseases. 2022;75(1):e947–e954.

Planning & Implementation

Collaboration with the City of San Francisco. The Ward 86 Clinic partnered with the City of San Francisco to identify additional housing opportunities to offer clients through Multicomponent Support Strategies, including through San Francisco’s shelter-in-place hotel program and other permanent supportive housing projects. More than 100 clients received either a shelter-in-place hotel room or permanent housing through this referral process.

Community partnerships. Multicomponent Support Strategies’ preexisting POP-UP program provides referrals to various community partners to address client needs. By leveraging these existing partnerships, Ward 86 Clinic staff could launch outreach immediately after the shelter-in-place order was issued, instead of needing to establish referral partnerships first.

Sustainability

Multicomponent Support Strategies received funding from the National Institutes of Health, National Institute of Allergy and Infectious Diseases. While the bundled intervention was in response to the shelter-in-place order instituted at the beginning of the COVID-19 pandemic, the POP-UP program predated the shelter-in-place order and remains in place today for people with HIV.

Lessons Learned
  • The use of telehealth can increase access to care. However, populations experiencing homelessness or unstable housing have less access to technology, making in-person care during the shelter-in-place crucial. Availability of drop-in care, including The POP-UP program, at the Ward 86 HIV Clinic ensured that those without access to technology would still be able to receive services. Proactive outreach helped to ensure that clients remained connected to the clinic and facilitated referral to additional services.
  • While this bundled intervention was implemented in response to the shelter-in-place order at the onset of the COVID-19 pandemic, all of the intervention components, including proactive outreach, drop-in programs, and housing support have been shown to be effective strategies to support people with HIV.
Contact
San Francisco General Hospital Ward 86 HIV Clinic
Matthew A. Spinelli, MD, MAS

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