Examining the Impact of COVID-19 on Organizations Providing HIV-Related Services in California

Continuity of care engagement in HIV-related services is essential to the well-being of people living with and at risk for HIV. In March 2020, the COVID-19 pandemic rapidly shifted how routine medical care was delivered and disrupted all aspects of everyday life, including HIV social and medical services. Our Policy Centers conducted a qualitative study to understand how organizations serving people living with or at risk for HIV and their clients were affected by the pandemic as well as examining the changes put in place to continue providing access to HIV-related services.

• Semi-structured interviews were conducted with representatives from 14 medical and nonmedical agencies across California (a total of 15 key informants) between October 2020 – February 2021.
• Participants were recruited from a prior survey assessing the initial organizational impact of COVID-19 [1].
• Representatives from a variety of medical (n=5) and community-based organizations (CBOs) (n=11) across 11 counties participated in interviews
• Interview guide topics included: COVID-19 Impacts on Service Delivery, HIV Prevention, and Treatment Services, & Lessons Learned. Transcripts were analyzed using template analysis [2].

“. . .when we reopened, we reopened with a team that reflects the community, right. . .We had people who quit, didn’t want to come back. . . . Many of us gay men that work here -not all , but many – we are HIV-positive. So, all you needed to hear was “compromised immune system.” We felt like we were just walking sponges of COVID, you know? And so it was tough to deliver a service to an anxious community when the providers were anxious themselves. That was just hard to do.”

-CBO-based interviewee

• Organizations adapted to COVID in distinct ways; all but one re-opened for service provision.
• Clinics were better positioned than CBOs to accommodate COVID restrictions and to quickly re-open.
• Technology inequities created significant challenges for organizations to be able to reach clients.
• Increased demands on staff led to burnout.
• Drop-in services, typically accessed by vulnerable patients, were the most impacted due to COVID restrictions. This led to distress for clients and their providers.
• New partnerships between organizations were forged in order to coordinate services.

• Given temporary regulatory changes, agencies could bill healthcare coverage for telehealth visits, phones for clients, and over-the-counter cold and flu medications.
• Many livelihoods were disrupted, causing issues with mental health, housing, food, and increased isolation.
  • While patients newly diagnosed with HIV preferred to be seen in-person, other patients preferred telehealth encounters and hoped to continue to have the option in the future.
• Mental health services delivered remotely were described as at capacity or “very busy.”

The impact on HIV prevention was mixed, with some successes — e.g., loosening of PrEP followup requirements — and challenges, e.g., reduction in HIV testing. In settings able to maintain syringe access, programs adjusted protocols to secure more syringes and relied more heavily on street outreach. Social distancing requirements and PPE shortages limited walk-in appointments and necessitated the use of at-home HIV tests. The relaxed follow-up requirements for PrEP allowed for less frequent lab monitoring.

Participants shared a number of reflections on lessons learned and recommendations moving forward. Major themes were:

• Flexibility over strict regulations mattered more than ever. The changes to reimbursement policies and procedures facilitated the use of telehealth.
• Continuation of HIV treatment and prevention services was possible when rules and regulations allowed for client and organization-centered adaptations.
• There were compounding stressors experienced by individuals from BIPOC/COVID impacted populations. This impacted not only patients but also providers and clinic/CBO staff.