75% People homeless at Viral suppression among HIV diagnosis - PDF document

2/13/2020 Background 75% People homeless at Viral suppression among HIV diagnosis PLWH who are housed had 27-fold higher odds of 33% POP-UP Clinic, Ward 86 death Viral suppression among compared with PLWH who experience those with homelessness Elizabeth Imbert, MD MPH housing in SF. Spinelli M. AIDS 2019 Housing Instability in Our Clinic Housing needed…in the meantime? What is your current living situation? • Pictorial survey at clinic Which picture applies best? check-in at Ward 86, Feb-July 2017 • More nuanced look at housing categories • 1222 pts • 51 yrs median • 13% female; 40% White, 25% Black, 26% Latino, 9% other 1

2/13/2020 Percen ent t of P of Patients tients with Viral with Viral Suppre Suppression on and Mean Viral Load and Mean Viral Load Patie tients ts with mo with more unst re unstable le ho housin using ha have hi higher er num numbers of dr of drop op-in visits by Liv Living Arrangemen ng Arrangement at at Ward 8 rd 86 ( (N=1222) 222) (and ER ER visits sits and hosp spitalizations) a italizations) at Ward 8 rd 86 (N=11 =1198 98) Viral load drawn +/- 90 days before survey Clemenzi A. OFID 2018 Clemenzi A. OFID 2019 What are our patient’s What are some of the barriers for our patients? preferences for care? • Forgetting Date and Time of Appointment • Discrete choice experiment • Drug Use • Sequential sampling of patients • Negative provider-patient interactions reporting homelessness and • Lack of Knowledge of Routine Primary Care Needs unstable housing; ≥ 1 missed primary • Transportation care visit; recent viremia • Financial • 65 pts • Food • 61% > 40 yrs • 45% white; 77% male; 46% • Loss of property heterosexual • Housing • 56% living outdoors or in • Stigma emergency housing; 44% • Motivation temporary housing Conte et al (unpublished data) Clemenzi-Allen et al (unpublished data) 2

2/13/2020 Positive-health On-site Program for Unstably-housed Populations Patients willing to trade $32.79 in gift cards per visit to see providers and staff who know them as a person. Conte et al (unpublished data) Who is eligible? 1. Homeless or Unstably housed 2. Viral load non-suppressed or off ART 3. Poor primary care visit adherence Referred from Ward 86 4. 2+ drop-in visits at Ward 86 in the last year providers & staff, LINCS program, PHAST team, reach-out to patients who qualify 3

2/13/2020 Identified at front desk Patient visit Components of POP-UP Clinic as POP-UP patient Provider Provider Medi Medical ser services Lif Life ser services -ART: Onsite start DOT 5 days -Food resources RN RN Pharmacist Pharmacist a week & counseling -Financial incentives -Health maintenance care -$10 gift card once a week- -$10 gift card for lab draws (vaccines, STI screening, -$25 gift card for undetectable VL cancer screening) -Social services -On-site mental health -Emergency housing Medical Medical services & medication- Patient Patient SW SW assessments and referrals assisted treatment assistant assistant Januar nuary 20 y 2019-December 20 -December 2019 64 patients Janu January 20 y 2019-Dec ecember 20 2019 83% cis-men, 11% cis-women, 6% transgender/non-binary 59 (92%) restarted ART, most at enrollment (median 0, IQR 0-12 days) 59 (92%) 47% white, 36% black, 8% Latinx 59 (92%) returned for follow-up within 90 days 59 (92%) 55% street homeless Cumulative incidence of viral suppression at 6 months post-enrollment 100% with a substance use disorder (>90% using was 60% 60% (95%C (95%CI 4 47-7 -74%) ) methamphetamines) Nine patients were unenrolled from the program (3 died, 1 moved, 2 76% with a mental health disorder transferred back to PCP, 3 for threatening behavior) 39% with CD4<200 4

2/13/2020 The POP-UP team Ultimate goals Elizabeth Imbert MD Monica Gandhi, MD Diane Havlir, MD Reduction Reduction duction i duction i in in Reduction Reduction duction i duction i in in R edu R edu eduction in eduction in in in dispar dispar arities i arities i ities in ities in dispar dispar arities i arities i ities in ER/ ities in ER/ / / dispar dispar arities i arities i ities in ities in Helen Lin SW Jon Oskarsson RN Mary Lawrence Hicks NP Jack Kelly SW vir virologic vir virologic urgen urgent car urgen urgent car care/ care/ / / mortal mortal ality ality ity ity supp suppres suppres supp ression ra ression ra rates rates hospitalizat hospitalizat italizations italizations ions ions Bill Blum Dean Goodwin Erin Collins SW 50% 50% 50% 50% 50% 50% Darpun Sachdev, MD Sandra Torres SW Asa Clemenzi-Allen MD Matt Hickey, MD 75% housed vs. 33% 3x as many ER Mortality much Seamus McCoy, NP George Harrison, M homeless so reduce that Funders: City of San Francisco; visits: reduce to 1.5 higher - reduce Gilead Sciences; AIDS Walk 42% disparity to 21% John Friend NP Elia Arias Lizzy Lynch RN Midori Hiyagon Erin Antunez Miguel Ibarra, SW 5