Preparedness
A general theme among interviewed HIV service organizations about addressing issues raised by the COVID-19 pandemic was utilizing ingrained disaster and epidemic response techniques learned from dealing with the HIV crisis in the past because “you think about back in the late 70s early 80s when AIDS hit, this country was woefully unprepared. That's why everybody ended up, a lot of people ended up decompensating physically and dying.” Yet, explicit preparation plans for an airborne, respiratory-based pathogen were nonexistent, “it was pretty much doing everything on the fly. We have like a safety manual, but we didn't have anything about a pandemic in there. And so definitely on the fly,” so organizations had to and did act swiftly to properly address urgent, upcoming needs for both their clients and the PLWH population as a whole.
One organization reported preparing extensively for the pandemic while it was in its infancy, “So we did an assessment. I want to say like the last week of February, first week of March, maybe, where our care coordinators contacted every client in every one of our programs to find out if they had what they needed to be able to shelter in place for 14 days. So that was a huge undertaking, and then we bought stuff.” After the initial items and supplies had been purchased, they were compiled, organized, and distributed via no-contact “home visits.” Moreover, because of longitudinal relationships and familiarity with existing clients, staff members were able to identify clients that were particularly at risk for prescription non-compliance, “we could identify like these are the people that I do a lot of medication management with. So we know if we're not doing that we know they're not taking them…whether we can document it or not, I know they're not taking them.” Consequently, staff ensured these individuals were able to receive and adhere to taking their medications by having their medications shipped to the office and communicating to clients “alright your meds are here, I'm going to hand out the pillbox, they go back to their car, they fill the pillbox, they go in and hand it back, so you just, you know, you make it work.” Multiple organizations also educated their clients on likely scenarios going forward, “we had been able to let most of our clients know like, this is what's happening with COVID and it is highly likely that Indiana will be on a stay at home order.”
Additionally, because of the reciprocal nature of housing instability and infection, many organizations attempted to preemptively protect PLWH by assisting with their housing. For a period of time, preventing potential new instances of homelessness supplanted the shifting of existing clients around the housing case management network, with one organization stating “we did very little of our normal like more comprehensive housing case management. It was very much crisis response for that entire time period like doing the application getting the documentation. Getting bills paid was pretty much what they were doing.” Much of this effort was made in an attempt to mitigate the effects of lifting finite eviction moratoria, working with clients during the moratoria to avoid the need for a large amount of urgent aid, “we went ahead and tried to help people along the way, because we knew the second that it was lifted, people were going to be facing eviction. So we tried to work with clients to prepare as if there wasn't a hold on evictions.”
Although long-term or permanent supportive housing programs may not have been the focus at the time, service providers did offer housing assistance and solutions to the newly homeless as well, “we made sure to put them directly into some type of housing whether we put them in a hotel, or we found an apartment to put them in,” although “there [was] a lack of housing, rental housing. And if you [could] find rental housing, it [cost] was extremely high.”
Outreach and Testing
The COVID-19 pandemic severely affected the medium from which community-based organizations (CBO) interfaced with potential and existing clients. Many organizations stressed that they follow a harm reduction model and meet the client “where they’re at, no judgement,” indeed at times “meet[ing] the people directly on the street.” Organizations emphasized that they prefer face-to-face meetings, especially with initial intakes to pacify the nerves of new clients, “I would like to think that this should be done in person at first, if at all possible… the person that’s coming in as a consumer is meeting you. They're scared to death. They don't know what to expect. They need to know who you are.”
Prior to COVID-19, organizations made significant efforts building rapport with the communities with which they engage in an effort to better attract and retain clients: “they trust us in a way that they won't trust other places…rapport is an important part of retention and maintenance.” In the past, having this level of rapport enabled CBOs to engage potentially at-risk clients, stating “when we're out on our mobile unit for our syringe exchange, we'll go find somebody if we hadn't seen him in a while just to check on and make sure they're doing okay, why haven't we seen you.”
With the onset of COVID-19 restrictions, however, new intakes and face-to-face interactions were severely limited, with providers reporting “we did not have new intakes for like a good month period…there was a solid several months there where people didn't do health care in person at all” and “there were things that we did do in person, but I could probably count them on one hand.”
Most organizations reported HIV testing significantly decreased during periods where in-person access to existing and potential clients was suspended or severely limited. Prior to COVID-19, HIV providers would typically test “out in the community” or “every three months we were testing certain people especially at our drug treatment facilities…or the jail” which comprised “a significant portion of our HIV testing right there.” Testing at these external sites, however, was no longer possible with public health restrictions in place. Moreover, the space limitations of testing facilities – “physically our testing rooms were tiny” – and the physical requirements of common testing modalities– “we were doing fingerpick pricks at the time so you had to be pretty close to people” – prevented adherence to safe public health practices.
Additionally, it was suggested that a decrease in HIV testing was also linked to COVID-induced changes in procedure. Once limited in-house testing resumed, one organization noted that their STD testing increased significantly from baseline while their HIV testing decreased significantly from baseline. It was hypothesized that these trends were observed because the STD testing underwent no location or procedural changes while location of HIV testing – previously out in the community – was forced to move in-house: “our STD testing has always been done in house, so everybody knew that if you wanted STD testing you had to come to us we weren't going to be in the community doing that…now for HIV they were not, they just knew that we were going to be in the community somewhere and if you found us you can get an HIV test. They were never trained to come to our office, or to sign up online like they were for STD.”
To attempt to remedy the gap in testing due to social distancing, one service provider specified that they obtained more self-swab tests to limit client-provider contact, “people could swab themselves. So you could sit farther or they could do it themselves and then you just look at it together in 20 minutes.” Another provider further obtained a customized physical barrier between the tester and client: “protection shields, so the client could stick because the test is doing a finger prick. So they could slide the hand through the shield. And so both people were protected.” Other providers decided to eschew indoor testing altogether and maintained that outdoor testing would be most feasible and beneficial, “so we do testing in the park, instead of testing an office or education at sites so people can just show up at a park and get tested for two hours at a time.” To gain access to hard-to-reach populations in jails or vulnerable populations in treatment centers during in-person restrictions, one organization arranged special accommodations with such places, setting up zoom calls to undergo virtual testing and education: “we’ll be zooming and then they’ll be referring people to us for testing, or we'll be dropping off test kits at the facilities, and we'll be zooming with them to do the testing after we do the education.”
Although the pace of intakes initially slowed because of in-person outreach and testing restrictions, providers were eventually able to acquire the appropriate technology to perform virtual intakes and utilized basic phone calls and texting to obtain patient information: “intakes [were] mostly done over the phone…we just asked people hey you know if you want we could get some basic information from you right now…and they can text us pictures of those things, they can email it, they can drop it off the office, we can go pick it up, we can do, like, what I call, like a door dash.” Because of the newfound importance of connection via the telephone – for both interactions with the service organization and outside entities in a now predominantly virtual world – some organizations provided clients with funds to pay their telephone bill: “that was their form of communication… So that was about 20 people we assisted who had lost their jobs to keep their cell phone on for a month, we thought it would just be a month. But it turned out, we had to do that a couple of times because people were not able to go back to work.”
To assist both new and existing clients in accessing necessary case management services, many HIV service organizations provided select clients with tablets: “for those who don't have phones, or some people whose phones only work on Wi Fi, we're able to distribute [tablets]. So people can do telehealth appointments, mental health appointments, anything with our programming, they'll be able to do it from their tablet.”
In regard to distributing goods to clients intermittently throughout the pandemic, organizations offered at-will pick up pursuant to social distancing guidelines, “so right now, anybody who needs the supplies that we offer we have to just have them come and stand outside our door and give it to them or we can drop them off like there's a table, and we just usually drop goods off there. And then, anybody can get it when they want.” The distribution of supplies was not only as needed but proactive as well, placing provisions in highly trafficked areas, “we've also resorted to just setting up pockets of supplies inside gas stations, hotels, things where we know that people use intravenous drugs are. And our pamphlets we've put in local community centers so that they can just hand them out to patients that they know may need them.”