key: cord-0979397-ujgunesb
authors: Sherbuk, Jacqueline E; Williams, Brooke; McManus, Kathleen A; Dillingham, Rebecca
title: Financial, food, and housing insecurity due to COVID-19 among at risk people living with HIV in a non-urban Ryan White HIV/AIDS program clinic
date: 2020-09-18
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofaa423
sha: ac2be6077b56f4aef1e6096834b2af9ad9c4609a
doc_id: 979397
cord_uid: ujgunesb

COVID-19 negatively impacts social determinants of health that contribute to disparities for people living with HIV. Insecurity of food, housing, and employment increased significantly in April 2020 among patients with lower incomes at a Ryan White HIV/AIDS program clinic in the Southern United States.

social determinants of health known to influence health disparities in PLWH. [4, 12, 13] PLWH with unmet needs are less likely to remain engaged with care, especially when the unmet needs are subsistence needs such as housing, food, and financial needs. [14] During a crisis with such widespread and far-reaching impact as COVID-19, the level of need is expected to rise substantially, with a concurrent decline in ability to access services. HIV clinics, especially Ryan White HIV/AIDS Program (RWHAP) clinics, must respond to meet these needs quickly through existing mechanisms.

The University of Virginia RWHAP clinic, located in the non-urban Southeastern United States, serves a population of over 850 PLWH. The clinic population is 48% white and 43% black. (Supplemental Table) Forty-one percent have incomes below the federal poverty level (FPL), and 53% are age 50 years or older, placing them at risk for complications from COVID-19 infection based on age. [15] Our clinic responded to the COVID-19 pandemic in the third week of March 2020 by replacing most inoffice visits for routine care with telehealth or phone visits. Clinic visits were prioritized for those out of care, those new to or newly engaged in care, and those not virally suppressed, similar to the approach of other clinics.

[7] Due to institutional guidance related to social distancing in the workplace, our case management staff largely shifted to telework.

A c c e p t e d M a n u s c r i p t 4 While our local region has avoided being overwhelmed by COVID-19 hospitalizations and mortality, many clinic patients worked in industries quickly impacted by layoffs related to state-mandated shutdowns to slow spread of COVID-19. We conducted a proactive rapid needs assessment for the most vulnerable PLWH in our clinic and to respond to escalating needs for support services during the initial weeks of the pandemic in April 2020.

Developing an intervention to identify and respond to patient needs required a coordinated clinic response. As clinic visits shifted primarily to telehealth, both medical and non-medical case managers, supported by RWHAP, shifted from in-person visits to remote contact as well. Virtual contact, both medical care and case management, was facilitated by a tailored mobile platform to support engagement with care that is used by approximately two thirds of patients in our clinic. The platform, smartphone and mobile service are supported by the clinic for eligible patients. [16, 17] The clinic medical director, clinic grants manager, and lead case manager identified available resources for patient support, including RWHAP resources, and they also appealed to the community for donations to the clinic to support the small number of clients without up-to-date RWHAP eligibility.

We used existing processes to meet identified needs, such as responding to emergency housing needs. However, we modified some processes such as food delivery. Support to reduce food insecurity continued to include grocery store gift cards, but we also initiated provision of food boxes to support clients' sheltering in place. The food boxes, built by RWHAP nutritionists to provide 2 weeks of balanced meals for the household, were delivered directly to patients' residences by clinic staff.

A c c e p t e d M a n u s c r i p t 5

We aimed to identify and respond to patient needs rapidly in the setting of the pandemic. Based on available personnel resources, we recognized that screening all patients immediately was impractical, and we needed to prioritize patients at increased risk for financial impacts due to COVID-19. Patients targeted for rapid needs assessment screening had (1) income under 100% FPL or (2) were currently or previously assigned case management services, both measures that could be rapidly identified for all clinic patients. Patients are screened for enrollment in medical case management, using Virginia Ryan White program standards, at the first clinic visit and every six months. A provider or staff member can also refer a patient for medical case management at any time. A rapid screening tool was developed for inclusion in the electronic medical record to evaluate COVID-19 related needs. Case managers attempted to contact all "increased risk" patients during the 6-week period from mid-March through the end of April.

We tracked changes in emergency financial assistance for housing costs and food bank/home delivered meals services provided by the clinic during April 2020. We compared services provided in April 2020 to the monthly average over the preceding 12 months (March 2019 to February 2020), excluding March 2020 as the pandemic's effects began partway through the month. The clinic uses CAREWare (https://hab.hrsa.gov/program-grants-management/careware) as its information system for data on clients and client-level services. Emergency financial assistance for housing costs and food bank/home delivered meals included food cards, food boxes, emergency housing, and emergency utilities support. We did not differentiate services received in response to completing the COVID-19 screening tool from services received as part of standard clinic care. The variables used to assess financial, housing, and food insecurity included: change in employment among patients at risk based on self-report; financial assistance provided for housing costs including rent and utilities; and food support provided through gift cards or delivery of food boxes.

This study was deemed quality improvement/non-human subject research by the University of Virginia Institutional Review Board and written patient consent was not required.

500 patients (58% of the clinic population) met the criteria for increased risk of financial impacts due to COVID-19 and were targeted for screening. Case management encounters were documented for 170 patients, representing 34% of prioritized patients and 20% of the clinic's total population.

(Supplemental Table) A c c e p t e d M a n u s c r i p t 7 those affected, 74% lost their jobs and 26% reported decreased hours. The most common industries among those affected were restaurant/food services (35%) and retail (14%). Employed patients who did not experience changes in employment most commonly worked in healthcare-associated settings (32%) or grocery stores (12%).

Food bank/home delivered meals support was the most commonly provided form of support.

( Figure 1 ) Support for food services increased 66% during April 2020, from 131 average monthly services to 218 services. Emergency financial assistance for housing costs increased from an average of 23 services per month to 39 services in April 2020, a 69% increase in services provided.

This snapshot from a non-urban clinic shows a substantial and immediate impact of COVID-19 on key social determinants of health among the PLWH served. Among a group of patients suspected to be at high risk for financial insecurity, the vast majority of those employed lost wages or became unemployed due to COVID-19. These employment impacts were pronounced and happened quickly, despite our region experiencing a relatively low rate of COVID-19 illness and mortality. The availability of funds for services such as emergency financial assistance for housing costs and food bank/home delivered meals through RWHAP was essential for quick response. Targeted Part D funds (for women, infants, children and youth) and associated staff may have facilitated contact to and support of a relatively high proportion of women. The subsequent release of additional funds through the CARES Act [18] in mid-April provided additional needed support.

Adhering to the requirements of funding through RWHAP, including client maintenance of RWHAP eligibility as well as documentation that RWHAP is a payor of last resort, is more challenging in the midst of the COVID-19 epidemic due to limitation of in-person contact to allow for signatures and A c c e p t e d M a n u s c r i p t 8 exchange of documents. These pandemic-related barriers to continued care coincide with substantial increases in need for services. In our context, the ability to accept self-attestation to complete eligibility was important. Clinic provision of phones and cell service facilitated uninterrupted contact to some degree. However, alternative methods to meet eligibility requirements, such as electronic signature, providing home delivery with signature, and selfattestation must be further developed. Continued advocacy efforts aimed at policy and practice changes to reduce documentation required to receive services during the COVID-19 pandemic and post-pandemic are needed.

Food insecurity is already prevalent among our patients, and there was a dramatic rise in need for support services during April 2020. Among PLWH, food insecurity is associated with worse health outcomes. [12, 13, 19] Providing support services for PLWH improves access to care and engagement in care. [20] [21] [22] We note that, through modification of our food support services, we augmented home delivery of tailored food boxes to ensure that our most vulnerable patients could shelter in place. RWHAP support for nutritionists affiliated with our clinic was essential for provision of expertise about recommended content of food boxes, tailored for co-morbid conditions like diabetes, which are increasingly prevalent in our aging population.

Our findings have clear limitations, including the use of a single site, as the impacts of COVID-19 may differ by location. For the purposes of this brief report, we have focused on the impact of COVID-19 on specific, measurable parameters, and acknowledge that COVID-19 has impacted many facets of patients' lives such as mental health, substance use, access to health care for chronic and acute concerns, and ability to reach pharmacies to pick up medications. Due to practical constraints, we aimed to contact the most vulnerable patients, who we suspected would be more likely to experience impacts on employment, therefore our findings on employment cannot be generalized to the entire population of PLWH. However, the results confirm we targeted an appropriate population at risk of financial insecurity. Nonetheless, we were unable to reach many of the most vulnerable

COVID-19 and African Americans

County-Level Association of Social Vulnerability with COVID-19 Cases and Deaths in the USA

A County-Level Examination of the Relationship Between HIV and Social Determinants of Health: 40 States

Part A: Census Tract-level Social Determinants of Health Among Adults with Diagnosed HIV Infection 13 States, the District of Columbia, and Puerto Rico Part B: County-Level Soci

Labor Markets During the COVID-19 Crisis: A Preliminary View

2020: COVID-19 Impact. watch/managing-hiv-during-covid-19-working-to-end-one-epidemic-while-confrontinganother

The Burden of COVID-19 in People Living with HIV: A Syndemic Perspective

COVID-19 Pandemic Disrupts HIV Continuum of Care and Prevention: Implications for Research and Practice Concerning Community-Based Organizations and Frontline Providers

Maintaining HIV care during the COVID-19 pandemic

Association Between Food Insecurity and HIV Viral Suppression: A Systematic Review and Meta-Analysis

Food insecurity and low CD4 count among HIV-infected people: a systematic review and meta-analysis

The Association of Unmet Needs with Subsequent

Retention in Care and HIV Suppression among Hospitalized Patients with HIV Who Are out of Care

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the

Long term impact of PositiveLinks: Clinicdeployed mobile technology to improve engagement with HIV care

PositiveLinks: A Mobile Health Intervention for Retention in HIV Care and Clinical Outcomes with 12-Month Follow-Up

Does Food Insecurity Undermine Adherence to Antiretroviral Therapy? A Systematic Review

HIV multidisciplinary teams work: Support services improve access to and retention in HIV primary care

The impact of ancillary HIV services on 17

Figure 1. Provision of emergency financial assistance for housing costs and food bank/home delivered meals services by month in a Ryan White HIV/AIDS Program clinic in the Southeastern United States

Solid lines demonstrate the number of services provided in each category, by month

Dotted lines demonstrate the monthly average over the 12-month period preceding widescale impact of the COVID-19 pandemic

We thank the patients of the UVA Ryan White HIV/AIDS Clinic, all clinic staff who were involved in assessing patient needs and providing support including case managers, community health workers, and nurse practitioners. We acknowledge the RWHAP and HIV Care Services at the Virginia Department of Health for their funding of our services through RWHAP Part B.

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t