Optimizing novel strategies to increase virologic suppression rates among unstably housed patients living with HIV

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Homelessness and unstable housing are major barriers to achieving the goals of the Ending the HIV Epidemic in the United States. In San Francisco, unstable housing is the strongest risk factor for poor HIV outcomes, including viremia. Single-component interventions (text messaging, patient navigation) have had limited efficacy in improving virologic suppression rates in this population, largely due to significant structural and individual-level barriers that are not addressed comprehensively by single interventions. Therefore, in January 2019, we started the POP-UP program (the Positive-health On-site Program for Unstably-housed Populations) comprised of a set of interventions to serve patients living with HIV (PLHIV) and unstable housing who are not virologically suppressed, including 1) drop-in primary care and social work services without the need for scheduled appointments; 2) financial incentives including food/meal cards and transportation aid to encourage patient visits; and 3) patient navigation for those who fail to achieve retention and virologic suppression from the previous efforts. The COVID-19 pandemic and the resulting public health responses of social distancing and encouraging telehealth and video visits instead of in-person care, along with the closure of social services and economic effects, will hinder outcomes for PLHIV with homelessness and unstable housing in San Francisco and across the U.S. even further.

This grant propose an implementation evaluation of the POP-UP intervention to date using the Reach, Effectiveness, Adoption, and Implementation (RE-AIM) framework to understand the effectiveness of POP-UP to date, including evaluating the impact on care utilization patterns and virologic suppression. Given the disruptive effects of the COVID-19 pandemic for all patients living with chronic illness, especially those with HIV who are unstably housed, we will assess changes in care engagement and virologic suppression from before, during and in the aftermath of social distancing mandates. We will also describe patterns of patient referral and enrollment to POP-UP during these time periods. Finally, we propose a discrete choice experiment to assess patient preferences in POP-UP for alternative care models, including tele-health, community-based navigation, financial incentives, and methods of clinic communication between visits. This study will contribute to a broader understanding of ways to increase care access and engagement among PLHIV with homelessness and unstable housing to help achieve Ending the HIV Epidemic goals.