Improving HIV, HCV, STD, and Harm Reduction Services in the Era of COVID-19 and Beyond

The COVID-19 pandemic has led to significant disruptions in California’s efforts to expand and improve services for HIV, hepatitis C (HCV), sexually transmitted diseases (STDs), and harm reduction. On November 18, 2020, the California HIV/AIDS Policy Research Centers and the End the Epidemics coalition convened a community meeting to discuss these challenges and to identify priorities for improving HIV, HCV, STD, and harm reduction services both during and after the COVID-19 pandemic. The event brought together over 120 advocates, researchers, public health officials, and service providers from across California to discuss the many ways COVID-19 has affected their efforts to reach vulnerable communities and maintain progress in addressing these intersecting epidemics. The overall objectives of the meeting were to:

The meeting began with presentations from Senator Scott Wiener (D-San Francisco) and community leaders about the current political landscape and the impact of COVID-19 on the state budget and legislative process. They highlighted that while state revenues are higher than previously anticipated, the state is expected to face an ongoing budget deficit. Securing significant new funding for HIV, HCV, STD, and harm reduction services will be extremely challenging in the current economic climate. Senator Wiener urged attendees to pursue a more limited approach and maintain a focus on health equity given the disproportionate impact of COVID-19 and other communicable diseases on Black, Latinx, and other communities of color. Attendees then participated in facilitated breakout groups to discuss key challenges and priorities in the areas of HIV, HCV, STDs, and harm reduction. This summary outlines primary findings and recommendations that emerged during the discussions and is intended to help inform policy and research priorities over the coming year.

Participants were asked to respond to the following question, “What are the biggest challenges you or your organization are currently facing to maintain and improve HIV, HCV, STD, and harm reduction services during the COVID-19 pandemic?”

Reduced Access to Services

Participants discussed how efforts to address HIV, HCV, STDs, and harm reduction needs have been thwarted in the face of the COVID-19 pandemic. Participants discussed the varying degrees to which shelter-in-place and physical distancing measures have decreased in-person contact, changed the tenor of in-person services, and eliminated low barrier services such as drop-in services. They reported how some jurisdictions ceased offering harm reduction services in the face of the pandemic. Participants identified barriers to communication and outreach, making it harder to stay in contact with clients/patients. One individual explained how newly diagnosed individuals have been unable to link to care—a short-term problem of long-term consequence. Participants reported limited lab capacity and slower turnaround with routine administrative hurdles such as prior authorization. Remote K-12 public school education has interrupted school-based services that once served as an effective intervention point to educate and serve young people. Participants talked of lay-offs and high rates of unemployment and its effect on service delivery and the daily lives of both staff and client/patient populations.

Redeployment of Public Health Department Staff

Participants reported that public health department staff have been re-deployed and activated to address COVID-19, happening in some jurisdictions at rates as high as 70-100 percent of personnel. Public health efforts are being prioritized to meet needs related to the pandemic. A significant number of participants described how the diversion of public health resources has placed a burden on already strained health and social services providers, especially with regard to contact tracing services that continue to be underpowered to address multiple public health crises.

Exacerbation of Health Inequities

Participants described how the pandemic has exacerbated existing problems, with the harshest impact falling on low-income, racial/ethnic, sexual and gender minorities, and those with co-morbid conditions. Testing rates for HIV, HCV, STDs have been low due to a decline in routine office visits and shifts in service delivery. Screening and routine testing appear to be replaced by an increase in positive diagnoses among those presenting with symptoms in the Emergency Department or in alternate testing sites (e.g. mobile). According to participants, clients/patients are engaging in more high-risk behaviors (e.g. increased use of methamphetamine by men who have sex with men). Participants expressed additional concerns with behavioral health implications of COVID-19-related loss, increased rates of sexual assault, domestic violence, trauma and other psychosocial stressors related to the pandemic.

Increased Housing Need

Finally, the continued rise in homelessness was a consistent theme. While increased funding has resulted in temporary housing opportunities, the challenge of planning, organizing and implementing such programs has been difficult. Innovative policy solutions to house formerly homeless populations (e.g. Project Roomkey) have given rise to other unintended consequences. Participants stressed that isolation while using substances is dangerous and can increase the risk for overdose. Participants report that housing providers unaccustomed to housing large numbers of formerly homeless populations or people who use drugs have not been sufficiently trained in harm reduction strategies.

Participants were asked to respond to the following question, “From your perspective, what are the most urgent needs that must be addressed to maintain the state’s progress in addressing HIV, HCV, STDs, and harm reduction?”

Self-Testing Programs

Self-testing programs have increased considerably since the onset of COVID-19, particularly through the Building Healthy Online Communities initiative. Participants said it would be important to continue building the infrastructure for self-testing and ensure self-testing programs are inclusive of HIV, HCV, and STDs. Cost remains a barrier to implementing self-testing programs and participants said self-testing should be a covered benefit through the state’s Medi-Cal program. Participants stressed that increased resources are still needed for testing in community-based settings as self-testing may not be feasible or acceptable in all communities.

Testing and Treatment in Non-Traditional Settings

Participants underscored the importance of expanding HIV, HCV, and STD testing and/or treatment in non-traditional settings, including hospital Emergency Departments (EDs), mobile units, homeless encampments, and pharmacies. This will require sustained resources as well as training to address implementation challenges, particularly in EDs. A 2019 report from the California State Office of AIDS offers key recommendations for expanding routine opt-out testing for HIV in EDs.

Testing and Treatment in Carceral Settings

Participants highlighted the need to improve access to testing and treatment in city and county jails, including requiring opt-out testing for HIV, HCV, and STDs. Additional resources may be needed to support care and treatment for inmates, as high medication costs remain a significant barrier to implementing routine testing in jails. Participants also said that many justice-involved individuals are falling through the cracks, particularly during reentry, and policy changes are needed to better coordinate medical, behavioral health, and social services prior to and upon release from confinement.

Telehealth

Participants emphasized the importance of making permanent flexibilities for telehealth and telephonic care that have been put in place during the COVID-19 pandemic. A recent report from the California Health Care Foundation found that low-income Californians report high satisfaction with telehealth visits and, if implemented correctly, telehealth can help increase access to health care and reduce health disparities among low-income Californians. Assemblymember Cecilia Aguiar-Curry (D-Winters) has introduced legislation that would indefinitely extend the current flexibilities for telehealth and telephonic care. Participants also highlighted the need to address the digital divide and expand access to broadband services.

Prior Authorization Requirements

Participants noted that prior authorization (PA) requirements remain a significant barrier to medication access, particularly for HCV treatment and pre-exposure prophylaxis (PrEP). Eliminating PA for HCV medications in Medi-Cal would help improve access to care and decrease administrative burden for health care providers. Medi-Cal eliminated PA for PrEP in 2014, but many commercial insurers continue to require PA for PrEP. State regulators should ensure health plans comply with SB 159, which generally prohibits insurers from requiring PA or step therapy for PrEP and post-exposure prophylaxis (PEP). It is important to note that some group health plans, known as self-insured employee health benefit plans, are exempt from state insurance laws and may continue to require PA for PrEP.

PrEP Education and Access

The PrEP landscape is becoming increasingly more complex. There are now three medications approved by the U.S. Food and Drug Administration (FDA) for PrEP and the first long-acting injectable medication will likely be approved next year. The U.S. Preventive Services Task Force (USPSTF) grade A recommendation and SB 159 also have significant implications for PrEP coverage and access. Participants articulated provider training and public awareness campaigns as necessary to accelerate PrEP uptake and increase understanding of these changes.

Syringe Service Programs

Several participants conveyed the need to increase funding for the Syringe Exchange Supply Clearinghouse, which provides a baseline level of supplies to California’s syringe service programs (SSPs). The Clearinghouse, flat funded at $3 million since it was established in 2015, now supports an additional 19 new SSPs. Participants also bemoaned the lack of support for SSPs in some parts of the state and called for legislation to protect programs from politically motivated civil lawsuits.

Drug Decriminalization

Participants voiced strong support for efforts to decriminalize drug possession and identify alternatives to incarceration for substance use. Oregon recently became the first state in the nation to decriminalize use of all drugs, including cocaine and heroin. Senator Scott Wiener (D-San Francisco) has announced plans to introduce legislation “to decriminalize psychedelic drugs” when the legislature reconvenes in early 2021.

Stimulant Use

Participants highlighted increases in methamphetamine use, particularly among gay and bisexual men, and stressed the importance of expanding the use of proven intervention and treatment approaches for stimulant use disorder. Earlier this year, Senator Wiener introduced legislation to include contingency management – a behavioral intervention for methamphetamine use – as a covered benefit under Medi-Cal.

Overdose Prevention

Participants said that COVID-19 has increased the urgency to establish overdose prevention programs, as both overdoses and substance use have increased significantly since the onset of the pandemic. Senator Wiener recently introduced legislation to allow the City and County of San Francisco, the County of Los Angeles, and the City of Oakland the discretion to establish and run overdose prevention programs. Participants stressed that community education will be critical to securing support for these programs.

Medication-Assisted Treatment

Participants expressed a desire to address challenges with California’s “Hub and Spoke System” – also known as the Medication Assisted Treatment (MAT) Expansion Project – including the need for improved linkage to care and increased buy-in from providers. Participants also called for elimination of the so-called X waiver, which limits the number of providers who can offer MAT for opioid use disorder.

Data Collection

Participants expressed their support for the collection of more comprehensive HIV, HCV, and STD data at the local and state level (e.g. HCV RNA negative data). These data must include race/ethnicity, sexual and gender status, and co-morbidities. Uniform data collection by local jurisdictions that is supported, organized and maintained by the state can help inform local planning efforts. Participants stressed the importance of analyzing these data from a syndemic perspective, across disease conditions, as necessary to understanding continued health disparities among the most vulnerable Californians.

Provider Training

Throughout the convening, participants identified multiple forms of stigma (e.g. related to HIV, substance use, race/ethnicity, sexuality and gender) as barriers to testing and treatment. Participants highlighted the promise of addressing stigma through provider training and education, including additional support to integrate harm reduction strategies to address all disease conditions. A clear target for training and education is health care providers. Participants prioritized the need to bring more clinicians onboard and up to speed on providing universal testing and treatment for HIV, increased testing and treatment for HCV, STD screening, as well as substance use treatment (e.g. medication-assisted treatment).

Structural Factors

Participants emphasized that social and structural inequities have become even more pronounced during the COVID-19 pandemic and policy responses targeting structural interventions should remain a top priority. These include efforts to ameliorate the homelessness crisis, address systemic racism in health care and social service programs, expand access to mental health and substance use treatment, and improve economic opportunity for low-income Californians.

Syndemic Approach

Multiple participants stressed that an effective response to HIV, HCV, STDs, and substance use requires a syndemic approach, which responds to health conditions concurrently and addresses the structural factors that drive health inequities. Increased efforts are needed to integrate funding streams and break down silos across state and local agencies that administer HIV, HCV, STD and harm reduction services. Participants suggested advocating for more clearly defined and accountable partnerships across state and local agencies and improving service integration to better reach vulnerable communities.

During this convening, participants helped identify challenges they face as well as their priorities for addressing HIV, HCV, STD, and harm reduction services moving forward. There is some clarity with regard to next steps, especially where a priority is in significant alignment with current policy proposals at the federal and state level. Hidden among these identified priorities are potential opportunities for targeted research and invitations to engage in continued conversation and coordinated action to help meet the needs of our most vulnerable communities. We thank all participants that helped shine a light on challenges and disparities across California and for their input on urgent priorities.