It’s been decades since San Francisco was ground zero for the AIDS epidemic, but for one population, it still is.
Viral suppression drugs have made HIV a survivable disease for many, but there is a major discrepancy when it comes to people who are marginally housed or homeless.
Seventy percent of housed persons in San Francisco are virally suppressed, compared to 33 percent of homeless persons, according to the 2017 San Francisco HIV Epidemiology annual report. Further, homeless patients accounted for 14 percent of newly diagnosed HIV cases, despite representing 1 percent of the population.
“We know that we’ve had the lowest number of new HIV infections ever reported in the city last year, which is remarkable,” Grant Colfax, MD, director of the San Francisco Department of Public Health, said during an event to launch the clinic. “And we also know that, going to the issue of health equity, we have a lot more to do in addressing inequities in the HIV epidemic, including among the people living with homelessness, where there is tremendous disparities in HIV infection.”
Shifting Needs Based on Housing Situations
An issue that arises when working to treat people who are homeless is that their exact living situation can shift their ability to receive the medical care and medications that they need. In data generated by Ward 86, patients with progressively unstable housing in the city have a lower chance of virologic suppression. So, for example, patients who are staying on the street are more likely to have a high viral load than those even in a shelter or in transitional housing.
POP-UP was designed on the principle that patients who are unstably housed are failing to link to current models of care, so we have to change our model of care to conform to what the patient needs.
With the knowledge that HIV treatment in the homeless population isn’t simply about putting patients on a medication schedule, the new POP-UP clinic – which stands for Positive Health Onsite Program for Unstably Housed People – has assembled a multidisciplinary team of physicians, nurses, and social workers to treat not just HIV but also primary care, psychiatric and housing needs.
POP-UP was designed as a walk-in model: primary care on demand, with a constant group of health care workers who know the patient’s case.
Monica Gandhi, MD, MPH, professor of Medicine at UCSF and the Medical Director of the Ward 86 HIV Clinic, states “POP-UP was designed on the principle that patients who are unstably housed are failing to link to current models of care, so we have to change our model of care to conform to what the patient needs.”
Elizabeth Imbert, MD, MPH, an assistant professor of Medicine at UCSF and the medical lead for POP-UP, adds about patients who are unstably housed with HIV: “We were failing them in terms of what we were addressing,” she says. “This program attempts to completely change the way we approach this population.”
Combining Care for the Patients
Among the patients that Ward 86 sees, many have substance use or mental health issues, food insecurity and the other challenges of street homelessness – moving from place to place, losing medicine or having it stolen, and exposure to violence.
Therefore, homeless patients often miss the primary care appointments where HIV medication is prescribed and continued. When they do come in, it’s for urgent care issues, such as an injury or an ear infection. By addressing only what was emergent, fundamentals were often missed.
“Their care was fragmented,” says Jon Oskarsson, nurse manager of the clinic. “There was no specific doctor following them. There was no care plan in place. Things worked on in one urgent care visit wasn’t necessarily dealt with in the next.”
POP-UP puts a system into place to treat the patient for all of their needs no matter when they show up.
“A person is not just a diagnosis,” says Erin Collins, the clinical social worker for POP-UP. “You can’t just treat someone who’s homeless. You’ve got to come back to the fundamental problems.”
To date, POP-UP has enrolled 23 patients. Imbert says the clinic is actively looking for more funding to expand further. POP-UP itself continues to evolve.
“We’re trying to figure out what works and what doesn’t,” says Imbert. “Right now we’re actively iterating the clinic’s model, asking questions about how to encourage patients to come in more regularly. Do incentives like food cards matter? Is it better to have a provider who knows them? To be close to where they live?”
Building on the Historic Work at Ward 86, in SF
The POP-UP clinic builds on the work that UCSF has accomplished over the last few decades at ZSFG. Ward 86, which opened more than 35 years ago, was the first dedicated HIV/AIDS clinic in the country.
Since then, the clinic has continued to evolve as the health care needs of HIV and AIDS patients has changed. In 2017, UCSF opened the Golden Compass program, which helps older HIV patients navigate the health care system.
The new clinic is also a piece of the citywide effort among the San Francisco Department of Public Health and other partners to achieve zero new HIV infections, zero HIV-associated deaths and zero HIV stigma in San Francisco. San Francisco has made strides toward the goals of Getting to Zero – co-founded by UCSF’s Diane Havlir, MD, Susan Buchbinder, MD – but better serving the homeless population remains.
“We can’t get to zero without working with this population,” said Gandhi.
Havlir noted that it will take work across all of the Getting to Zero partners to achieve the goal, but the POP-UP clinic is one more place where change can happen.
“Not one person, not one initiative is going to be the solution to this problem,” Havlir said. “But if we can do a little bit more in our part, where we are, we can be part of the solution.”