PROGRAM DIRECTOR REPORTS OF COVID-19 LOCKDOWN-DRIVEN SERVICE CHANGES IN COMMUNITY-BASED STI CLINICS AND SYRINGE SERVICES PROGRAMS IN THE SOUTHEASTERN U.S.

Abstract

The COVID-19 pandemic strained the U.S. health care system, posing logistical challenges for community-based programs. This study surveyed 11 program directors in sexually transmitted infection (STI) clinics and syringe services programs (SSPs) that served people who use substances and are at risk for HIV in five southeastern U.S. states. Brief survey questions asked about programs’ use of in-person and telehealth services. Results indicated widespread reduction of in-person services and concomitant adoption of telehealth services. In STI clinics, telehealth replaced in-person visits for all but urgent treatment of active symptoms. In SSPs, in-person contact continued or increased from pre-pandemic volumes. In both programs, the most salient telehealth use barrier was limited device or internet access and limited technological ease. Services were sustained through innovative adaptations. This snapshot of response to the early COVID-19 lockdown phase offers actionable guidance about service preparedness for future public health catastrophes in community-based programs serving vulnerable populations.

Community-based programs are often the primary venues for health and basic services for lower income, multiply stressed people at higher risk for HIV and involved in substance use. Converging stressors of unstable housing, unemployment, lack of entitlements, mental health symptoms, and medical problems pose formidable challenges to engagement in health care systems (Greene et al., 2022; Kreuter et al., 2016; Sharpe et al., 2012). Greater likelihood of encountering stigma and discrimination associated with race and ethnicity, sexual identity, and/or substance use may generate medical mistrust (Fields et al., 2021). In response, community programs provide services with the lowest possible barriers using immediate, face-to-face methods such as walk-in services, street outreach, case management, and navigation to off-site services (Nagendra et al., 2020).

In the era of the HIV and opioid epidemics, community programs have been the mainstay of HIV prevention services, focusing on sexual, drug, and injection use–related transmission risks and interventions. Common features of these programs include HIV/pre-exposure prophylaxis (PrEP) education, information, testing, counseling, and linkage to off-site wrap-around treatment and care (e.g., substance use and mental health). Community programs such as sexually transmitted infection (STI) clinics and syringe service programs (SSPs) can also have unique HIV prevention approaches. STI clinics typically offer on-site medical screening, STI treatment, and sometimes PrEP and HIV treatment. SSPs offer syringe exchange, Narcan training and distribution, testing, harm reduction education, and sometimes a range of additional supportive services, such as food pantry, clothing exchange, and mobile health care (Behrends et al., 2022).

Starting in March 2020, the COVID-19 pandemic triggered restrictive, widespread disease mitigation policies (Morawska & Cao, 2020). To minimize COVID-19 transmission, marked reduction in in-person services occurred (Mistler et al., 2021) along with widespread transition to combined services (National Coalition of STD Directors, 2020). Telehealth—the use of telephone or computer-based technologies to deliver health care—emerged as a key innovative, contactless solution (Mellis et al., 2021; Molfenter et al., 2021; Oesterle et al., 2020).

The transition to combined services differentially impacted STI clinics and SSPs. STI clinics markedly pivoted from primarily in-person to primarily telehealth services (Nagendra et al., 2020; National Coalition of STD Directors, 2020). Telehealth was found to be an effective means of PrEP initiation. PrEP telehealth visits during the pandemic significantly increased compared to pre-pandemic in-person rates (Hill et al., 2021). Most participants expressed positive opinions about PrEP telehealth visits, citing increased discretion and lack of need for transportation (Rogers et al., 2020). However, telehealth was not a one-size-fits-all panacea and quickly revealed a digital divide of socio-economic inequity in access to privacy, devices, and Wi-Fi infrastructure (Ramsetty & Adams, 2020; Rosen et al., 2022).

In contrast to the effect on STI clinics, pandemic-necessitated restrictions had a profoundly chilling effect on SSPs, including temporary or permanent closures (S. N. Glick et al., 2020; Wenger et al., 2021). By April 2020 alone, approximately 43% of SSPs decreased their services, and 25% closed completely nationwide (S. N. Glick et al., 2020). Wenger and colleagues (2021) conducted in-depth interviews with 18 SSP representatives (e.g., leadership, staff, volunteers) across the U.S. to describe the impact of the pandemic on operations. Lack of staff and loss of funding were significant barriers; innovative responses included drive-by syringe delivery by volunteer drivers, mail-order syringe delivery, and contactless pickup of pre-packaged client supplies (S. N. Glick et al., 2020; Wenger et al., 2021). Some SSPs developed combined approaches to integrate telehealth, such as online enrollment to receive medications for opioid use disorder (MOUD) and online overdose prevention training (Wenger et al., 2021).

The current study contributes to the existing body of literature by adding program director reports of service changes in both STI clinics and SSPs in five southeastern U.S. states during COVID-19. For instance, Nagendra et al.’s (2020) brief survey was based on 73 providers in STI clinics in New York City. S. N. Glick et al. (2020) reported on findings from 173 SSP staff across the U.S. Wenger et al. (2021) interviewed 18 SSP representatives across seven of the nine U.S. Census regions and divisions. Notably, five states in our study are not included in the Wenger study. Moreover, program directors offer a unique perspective on COVID-19-related service changes given their role in leadership and decision-making at the organization level, compared to frontline staff without managerial positions.

We leveraged the NIDA Clinical Trials Network (CTN) multisite Protocol 0082 platform of 11 community-based sites: six STI clinics and five SSPs in eight southeastern cities. The southeastern U.S. was an especially important region of focus at the time due to high HIV incidence, high COVID-19 prevalence, and low rates of COVID-19 vaccination (Centers for Disease Control and Prevention [CDC], 2016, 2021). Using quantitative and qualitative approaches, this ancillary study surveyed program directors’ views of the uses, benefits, and limitations of combined in-person and telehealth services at their sites in response to early COVID-19 pandemic disease mitigation policy and prior to vaccine approval and rollout. From directors’ perspectives, we sought to identify implications for how such community-based programs might continue to adapt, innovate, and thrive under circumstances of severe pandemic stress.

METHODS

PARENT STUDY

This survey of program directors was a supplement to the parent NIDA CTN0082 implementation survey study of PrEP and opioid use services in the southeastern U.S. For the parent study, agencies were identified through outreach to participating CTN Nodes and their local partners. Clients, direct care providers, and agency directors in eight Southern U.S cities across five states (Florida, Georgia, Louisiana, Mississippi, and Tennessee) with high HIV incidence at the time of the study (CDC, 2016) were enrolled. Three types of community-based programs (n = 6 STI clinics, n = 5 SSPs, n = 2 substance use treatment programs) participated in the parent study. In accordance with the purpose of the current study, only STI clinics and SSPs are included in the analyses.

STUDY SURVEY

The University of Washington Human Subjects Division determined the parent and current studies met criteria for exemption from federal human subjects regulations. The current study focuses on the eleven STI and SSP sites during the pre-vaccine phase of the pandemic. Directors completed the e-mailed supplemental surveys between October 2020 and January 2021. Directors were asked to respond to quantitative questions and write free-text responses to open-ended qualitative questions. Sixteen broad questions and multiple sub-questions addressed three areas: (1) in-person services (two forced-choice and two open-ended questions), (2) telehealth services (12 forced-choice and 10 open-ended questions), and (3) diverse methods for delivering services during the COVID-19 pandemic (one forced-choice and four open-ended questions). The survey took approximately 20 minutes to complete. Directors did not receive remuneration for completing this survey.

DATA ANALYSIS

Descriptive statistics were used to quantify directors’ accounts of changes to in-person and telehealth service delivery in their programs during the COVID-19 pandemic (see Table 1). Results for the two program types are presented separately. Small cell sizes precluded statistical significance testing across the two agency types. Instead, we drew from directors’ open-ended responses for a richer understanding of first-person accounts. Four co-authors (ST, MH, LW, and MPW) reviewed these responses and discussed common themes until consensus was reached. More in-depth qualitative analysis was beyond the scope of the current brief survey study.

TABLE 1.

Descriptive Statistics: Director Reports of In-Person Services, Telehealth Services, and Program Logistics During the COVID-19 Pandemic in STI Clinics and Syringe Service Programs

	STI	SSP
	(n = 6)	(n = 5)
	n (%)	n (%)
In-Person Services
Able to see clients in-person during pandemic	6 (100)	5 (100)
% Visits delivered in-person
20–30%	2 (33)	2 (40)
50–75%	2 (33)	0 (0)
85–100%	2 (33)	3 (60)
In-person clients now differ from clients pre-pandemic	3 (50)	2 (40)
Telehealth Services
Telehealth offered during pandemic by
Phone, Yes	6 (100)	2 (40)
Video, Yes	6 (100)	2 (40)
% Telehealth visits delivered during pandemic by
Phone
0%	0 (0)	3 (60)
1–25%	5 (83)	1 (20)
26–50%	1 (17)	0 (0)
51–75%	0 (0)	0 (0)
76–100%	0 (0)	1 (20)
Video
0%	0 (0)	3 (60)
1–25%	3 (50)	1 (20)
26–50%	2 (33)	0 (0)
51–75%	1 (17)	1 (20)
76–100%	0 (0)	0 (0)
Services offered by telehealth
Intake/evaluation	6 (100)	3 (60)
Individual therapy	5 (83)	3 (60)
Group therapy	2 (33)	1 (20)
Case management	6 (100)	3 (60)
Medication management	6 (100)	2 (40)
Medical visits	5 (83)	3 (60)
% Clients have computers to use for telehealth
0%	1 (17)	0 (0)
1–25%	0 (0)	3 (60)
26–50%	1 (17)	0 (0)
51–75%	2 (33)	0 (0)
76–100%	0 (0)	0 (0)
Don’t know/missing/not applicable	2 (33)	2 (40)
% Clients have tablets to use for telehealth
0%	0 (0)	0 (0)
1–25%	1 (17)	3 (60)
26–50%	1 (17)	0 (0)
51–75%	1 (17)	0 (0)
76–100%	0 (0)	0 (0)
Don’t know/missing/not applicable	3 (50)	2 (40)
% Clients have smart phones to use for telehealth
0%	0 (0)	0 (0)
1–25%	0 (0)	0 (0)
26–50%	0 (0)	1 (20)
51–75%	1 (17)	1 (20)
76–100%	3 (50)	1 (20)
Don’t know/missing/not applicable	2 (33)	2 (40)
% Clients have phones for audio calls to use for telehealth
0%	0 (0)	0 (0)
1–25%	0 (0)	1 (20)
26–50%	0 (0)	1 (20)
51–75%	0 (0)	1 (20)
76–100%	3 (50)	0 (0)
Don’t know/missing/not applicable	3 (50)	2 (40)
Clients struggle with telehealth technology access by
Phone	2 (33)	4 (80)
Video	6 (100)	4 (80)
Program Logistics During COVID-19
Offered combined option for ongoing care	5 (83)	2 (40)
Offered mobile treatment services	6 (100)	4 (80)

RESULTS

IN-PERSON SERVICES

Results for in-person services by program type are presented in Table 1. Regardless of type, when asked whether their agency was currently seeing clients in-person, all directors reported that during this period their agency was still offering some in-person appointments. Most also noted that more than half of visits were delivered in-person during the pandemic. When asked whether their clients receiving services in-person now differed in from those who were seen in person in the year prior to COVID-19, (i.e., being sicker, poorer, without reliable access to Wi-Fi/internet/devices or physical space, or too cognitively disorganized to do telehealth visits), roughly half of the directors across agencies agreed with this statement.

Directors expanded on these characteristics of in-person clients in their free-text responses. STI clinic directors noted that due to COVID-19, in-person services had generally been restricted to three types: acute medical services, testing for symptomatic STIs, and COVID-19 testing. They also described their struggle to provide in-person services to people who “don’t have technology devices” such as smartphones, computers, tablets, or the “[technological] proficiency” that would support use of telehealth. One director reported that “people with no technology can walk in for services.” Another STI clinic director reported that in-person services had “deteriorated” during the pandemic; a third director noted that such services had been “restricted to reduced designated service hours.” In contrast, SSPs largely reported that their services continued for all “interested clients,” or “all who use injection drugs,” despite public health-related restrictions. Only one director noted that in-person service delivery was at the discretion of the provider.

TELEHEALTH SERVICES

Results for telehealth services by program type are presented in Table 1. Telehealth services were adopted early on. All STI clinic directors and two of the five SSP directors reported that their agency offered services by phone and video.

The types and extent of services offered by telehealth across programs were diverse. The most frequently mentioned services were intake and evaluation, case management, individual therapy, medical visits, and medication management. Group therapy was mentioned to a lesser extent.

When asked about the proportion of telehealth visits delivered by video versus telephone, all STI clinic directors reported that less than half of visits were delivered by phone; three of five SSP directors stated that no visits were delivered by phone. Delivery was slightly higher for video-based telehealth.

Barriers to telehealth, such as client lack of access to telehealth technology, were of major concern across program types. When asked about clients’ access to devices that could be used for telehealth, directors’ responses varied widely by program type, but a common theme was uncertainty about access. Most directors reported that at least half of their clients had access to smartphones, but a substantial proportion were uncertain. Similarly, a sizeable number of directors indicated that at least half of their clients had access to phones for telehealth audio calls, but a substantial proportion were uncertain. Directors noted that fewer clients had access to computers and tablets.

Free-text responses provided insight into policies driving the use of telehealth services. STI clinics reported that telehealth services had been widely adopted, wherever applicable, to replace in-person services that were restricted or shut down during COVID-19–related lockdowns. At the same time, telehealth decisions were made on a case-by-case basis, usually according to client need. In these clinics, telehealth was used in three ways: (1) to provide any health service that could be delivered by audio telephone or video, did not involve acute care of symptomatic problems, did not require in-person medical examination or procedures, and was not for the purpose of medical diagnosis; (2) to screen for COVID-19, including routine phone screening for all clients and more detailed screening of clients reporting risk of or exposure to COVID-19, and determination of need for additional services such as quarantine, transportation, or linkage to in-person COVID-19 medical services; and (3) to accommodate individual clients’ varying levels of risk tolerance by offering a telehealth alternative to in-person services.

Within SSPs, telehealth services were used far less frequently, as they were not a feasible means for carrying out core syringe distribution services. Nevertheless, three SSP directors indicated that telehealth services were implemented ad-hoc when clients reported COVID-19 symptoms, such as providing a separate physical space and a device to permit medical screening questions prior to check-in for onsite medical appointments.

PROGRAM LOGISTICS AND INNOVATIONS

Directors were also asked about program logistics, or the modalities by which services were offered, including combined and mobile modes during the pandemic (see Table 1). All directors offered mobile services to clients in the community (e.g., testing, treatment, individual or group therapy, medication management); combined service delivery was mixed.

In free-text responses regarding program innovations, directors described an array of enhancements and innovations to their service delivery in response to the pandemic. Examples included: (1) providing a mobile health–equipped van on site from which individuals testing positive for COVID-19 could complete their telehealth visits; (2) increasing personalized outreach calls to support, check in, and link clients to services; (3) providing drive-through COVID-19 and flu testing; (4) making all services available remotely, except syringe exchanges, collecting biospecimens (e.g., finger stick rapid testing, urine collections, and blood draws), STI testing, and food assistance; (5) expanding services offered remotely, including medication inductions, peer groups, and treatment groups; (6) creation of an in-house app for requesting appointments, testing, condoms, and syringes; (7) securing grant funding to acquire and distribute smart phones for patients to use to access telehealth services; (8) quickly pivoting from nearly 100% face-to-face medical services to nearly 70% telehealth services; and (9) quickly pivoting from 100% walk-ins to appointments only.

Free text responses to the question “What do your staff need to be better taken care of by the organization?” also captured salient themes for innovations at the program level. Flexibility and accommodation for working from home, training on use of telehealth technology, childcare, reluctance to increase exposure to COVID-19, and rotating groups for coverage of in-person services were repeatedly cited by directors. Directors also noted the need to acknowledge the fatigue and burden experienced by their staff by “more mental health days/moments,” opportunities for staff to vent their exhaustion and frustrations, and creating a “staff morale” committee dedicated to staff’s well-being.

DISCUSSION

This study revealed several major findings from the perspective of program directors in both STI clinics and SSPs in the southeastern U.S., which contribute to the existing research from the viewpoint of other staff members (e.g., providers; volunteers). First, directors reported widespread change in service delivery, chiefly in reduction of in-person services and concomitant adoption of telehealth services. This is consistent with the widespread pivot to remote options seen across all sectors in 2020. Businesses sought to prevent exposure and transmission of the COVID-19 virus through social distancing, one of the only means available at the time. Moving to telehealth and combined services required significant time for providers and clinics to familiarize themselves with new platforms, regulations, procedures, and workload changes, which significantly strained personnel. Directors recognized the need for intentional steps to support staff creatively, such as increased flexibility and committees tasked specifically with promoting staff wellness.

Second, these changes unfolded differently for the two program types. SSPs mostly continued to deliver in-person services. These findings partly contrast with Wenger et. al.’s (2021) report of SSP closures in seven out of the existing nine U.S census regions, particularly in the Western and Northern U.S. Our study focused on SSPs from two U.S. census regions not included in the Wenger et al. study. Regional differences in COVID-19 response may have translated to differing levels of pressures to close or severely restrict services. However, our findings also support previous reports of resilience and adaptability among SSPs (Frost et al., 2021; J. L. Glick et al., 2022; S. N. Glick et al., 2020; Wenger et al., 2021). This is potentially attributable to their historically grassroots culture, typically small, highly dedicated staff, and minimal budgets that allow for nimble decision-making. As well, many SSPs can deliver services in outdoor settings, which reduces viral transmission risk and protects the in-person service delivery model.

Third, in contrast, STI clinics were compelled to make major changes to how they delivered care. These clinics were brick-and-mortar health care settings with larger operations and greater numbers of staff that could not relocate to an outdoor setting. Consistent with findings from a national survey of sexual health clinics (National Coalition of STD Directors, 2020), these programs significantly reduced in-person services by implementing triage procedures and launching or expanding telehealth options. Regarding PrEP, these service interruptions, followed quickly by adaptations, have been reported in more urban, higher-resourced settings that provide PrEP to underserved populations (Rosen et al., 2022). In that study, qualitative interviews of PrEP providers who transitioned to telehealth reported an overall suboptimal service provision environment for prescribing and promoting PrEP.

Fourth, across both program types, directors estimated that most clients struggled with accessing telehealth technology by phone and video, confirming that although telehealth improves access for many, substantial barriers remain for the poorest and most disenfranchised segment of the population. These findings echo others who uniformly describe a digital divide between accessibility haves and have-nots: For its many innovations in making health care more accessible, telehealth service delivery methods also amplified existing barriers to care (Ramsetty & Adams, 2020; Rosen et al., 2022). An important lesson is the opportunity for powerful, community-based participatory research to identify service delivery models that are acceptable and appeal to the most marginalized groups (Frohe, 2023).

Fifth, across both program types, directors juggled factors such as problem acuity, staff availability, COVID transmission risk, and staff willingness and comfort with technology. They also considered client access when creating policies around telehealth and combined service offerings. This complex matrix of considerations and conflicting priorities, undertaken under acute monetary and human resource limitations, exemplifies the difficulty faced by community-based organizations in pivoting day-to-day operations during a public health crisis. Both types of programs were able to make responsive, quick changes to their service delivery policies and procedures and added many innovations to their treatment delivery and staffing.

IMPLICATIONS

Disruptions to care are important to track and understand because their consequences can be significant. Because HIV and hepatitis C (HCV) testing were suspended at many SSPs, opportunities for diagnoses could be missed and lead to serious longer-term consequences (Frost et al., 2021). A simulation model of HIV transmission and PrEP initiation in Black men who have sex with men in Mississippi showed that for every 25% decrease in HIV testing and PrEP initiation, there was a 20% decrease in the number of infections diagnosed and a 23% decrease in initiation of PrEP, which led to a 15% projected increase between 2020 and 2022 in HIV incidence (Labs et al., 2022). The authors concluded that disruptions to HIV testing and PrEP access may significantly increase HIV incidence in post-pandemic years.

Similarly, keeping the doors open at SSPs is urgently important in the context of fentanyl-related mortality (Frost et al., 2022), methamphetamine injection use (Bartholomew et al., 2020; Hatch et al., 2023), and stimulant-opioid co-injection (Al-Tayyib et al., 2017; Bartholomew et al., 2020; S. N. Glick et al., 2018). SSPs serve clients who otherwise are at the margins of, or completely disconnected from, the traditional health care system. They often provide other life-saving services besides clean syringe exchange, such as food pantries, linkage to HCV and other treatments, and social services. Without access to such low barrier, community harm reduction programs, these individuals would likely be at even greater risk for negative health and social outcomes.

Finally, this study on service delivery adaptations during the COVID-19 pandemic illustrates two models of response to a public health crisis. In the event of future disruptions to services for the most marginalized populations, technology innovations may facilitate reach to many but cannot be relied upon solely. Rather, innovations in continuing in-person services may still be needed to push services to disenfranchised groups.

LIMITATIONS

Findings of this study should be interpreted in light of limitations. Data were self-reported, and therefore, subject to program directors’ inherent biases. Future studies should consider using other methods such as service utilization statistics or patient flow data to robustly triangulate findings. Additionally, our survey did not explore underlying structural or organizational mechanisms that might be hypothesized to motivate or inhibit service delivery. This study provided an uncommon look at the impact of the early and relatively momentary, pre-vaccine lockdown policies and conditions on service delivery across a large geographic region of the U.S. Findings may be less applicable to the time period following widespread vaccination and subsequent reduced need for social distancing and changes in service delivery. As findings were based on directors in six STI clinics and five SSPs in eight southeastern states, results may not generalize to community-programs in other settings and states. Finally, free text write-in responses were short, which limited our interpretation and understanding of detailed changes in service provisions that could only be gained from in-depth qualitative interviews.

CONCLUSION

Identifying strains and service gaps imposed by the COVID-19 pandemic on HIV prevention and substance use services programs will improve preparedness for future public health crises. SSPs and STI clinics demonstrated extreme resilience during a health crisis of global proportions, despite typically operating on shoestring budgets. These community service organizations were powered by deeply committed staff willing to innovate through increased flexibility in service delivery, reducing barriers to care, and creating incentives for clients. These experiences provide important lessons that may translate to the next frontier of HIV vaccine distribution.