Adapting HIV Care and Prevention Strategies for People Experiencing Homelessness


San Francisco has seen HIV prevention and control success, however how people experiencing homelessness present unmet needs which require transforming traditional models of care.

Since 2012, new cases of HIV infection in San Francisco have decreased by more than 50%. Moreover, almost three-fourths of people living with HIV in San Francisco are virally suppressed. Despite these gains, sizable disparities exist for people experiencing homelessness, who make up 1% of the city’s population, yet accounted for 14% of new HIV diagnoses in 2017.

People experiencing homelessness in San Francisco also have a lower rate of viral suppression compared to the city average at 32%. In 2016-2017, enhanced mortality surveillance of 50 people without stable housing revealed that 68% of HIV-associated deaths occurred among people who experienced homelessness, used substances, and/or had mental health diagnoses.

Previous studies have focused on the broad success of HIV prevention and control in San Francisco, but in an oral abstract presented at the Association of Nurses in AIDS Care Conference (ANAC 2019) a team of investigators provided examples of clinic-based, community-delivered, and public health-level HIV care models recently implemented in San Francisco, focusing on their impact for people experiencing homelessness.

The clinic-based program discussed was initiated by San Francisco General Hospital Ward 86. The Positive-health Onsite Program for Unstably housed Populations, or POP-UP, was launched in March 2019. POP-UP provides drop-in services for people living with HIV who are homeless, are not virally suppressed, and are reliant on urgent care.

The abstract authors also focused on a program initiated by the San Francisco Department of Public Health. These health officials provide community-delivered street and shelter pre-exposure prophylaxis, post-exposure prophylaxis, and treatment as prevention services for people experiencing homeless. Abstract authors highlighted that these services provide care for the most vulnerable “beyond the traditional 4-wall clinic.”

Additionally, the San Francisco Department of Health is also implementing a US Centers for Disease Control and Prevention-funded public health-level demonstration project known as Outreach, Prevention, Treatment — Integration (OPT-IN). OPT-IN seeks to increase viral suppression rates and decrease new HIV cases for people experiencing homelessness through cross-sector collaboration.

The abstract authors emphasized that San Francisco’s homelessness crisis presents a social need for which rigid models of care are insufficient to meet, and that nurses will be a vital component in addressing. The mix of integrated, low-barrier services discussed in the presentation provide guidance for nursing leaders to reimagine traditional systems of care by integrating services into the community and transforming clinic practices.

The abstract, Charting the Constellation: Reimagining HIV Care and Prevention Services Amidst the Homelessness Crisis in San Francisco, was presented in an oral abstract session at ANAC 2019 in Portland, Oregon.

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